Breastfeeding Basics: Generalist to Generalist

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Breastfeeding Basics Generalist to Generalist

• Sharon Mass, MD, FACOG
• Jenny Thomas, MD, FAAP
• Margreete Johnston, MD, MPH, FAAP

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Disclosure Slide

• Sharon Mass, Margreete Johnston, and Jenny Thomas
  have no relevant financial relationships with the
  manufacturers(s) of any commercial products(s)
  and/or provider of commercial services discussed
  in this CME activity.

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Introduction

• Breastfeeding Promotion in Physicians Office
  Practices Program Phase III aims to
• Educate and support pediatric, obstetric, and
  family medicine residents practicing physicians
  and other healthcare professionals in effective
  breastfeeding promotion and management in
  racially and ethnically diverse populations
  toward the achievement of the Healthy People 2010
  goals.
• The BPPOP III Program and this teleconference are
  supported by
• the Health Resources and Services
  Administrations Maternal
• and Child Health Bureau and the American Academy
  of
• Pediatrics.

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Healthy People 2010 recommendation

• 75 initiation in the early post-partum period
• 50 at six months of age
• 25 at one year of age

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BPPOP III Residency Curriculum

• Pilot-testing began in July of 2006 at 7 test
  sites (CA, OH, MD, SC, NC, NY, TX) and 7
  comparison sites (CA, MO, MN, NY, GA, OH, TX)
• Pilot-testing will conclude and the revised
  curriculum will be available to all residency
  programs in the fall of 2007

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Objectives

• Encourage and support breastfeeding before and
  during pregnancy
• Fit breastfeeding assessment and management into
  your office visits
• Weave a web of breastfeeding support and
  resources in your community

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ACOG Recommendation

• exclusive breastfeeding be continued until the
  infant is about six months old. A longer
  breastfeeding experience is, of course,
  beneficial
• -Educational Bulletin 258, Breastfeeding
  Maternal and Infant Aspects

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AAP Recommendation

• Human milk is the preferred feeding method for
  all infants, including premature and sick
  infants, with rare exceptions.
• Exclusive breastfeeding for the first six months
  of life
• Continuing for at least the first year of life
  with addition of solids
• Thereafter for as long as mutually desired by
  mother and child

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AAFP Recommendation

• The AAFP recommends that all babies, with rare
  exceptions, be breastfed and/or receive expressed
  human milk exclusively for about the first six
  months of life. Breastfeeding should continue
  with the addition of complementary foods
  throughout the second half of the first year.
  Breastfeeding beyond the first year offers
  considerable benefits to both mother and child,
  and should continue as long as mutually desired.
  Family physicians should have the knowledge to
  promote, protect, and support breastfeeding.
  (1989) (2001)

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Encouraging and Supporting Breastfeeding Before
and During Pregnancy

• Sharon Mass, MD, FACOG

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Alone we can do so little together we can do so
much. -Helen Keller
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Obstacles to the Support of Breastfeeding

• Lack of broad social support
• Media portrayal of bottle-feeding as norm
• Insufficient prenatal breastfeeding education
• Insufficient provider education
• Disruptive hospital policies
• Maternal employment
• Commercial promotion of formula

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Breastfeeding and the Obstetrician

• Most parents choose their method of infant
  feeding before delivery.
• Winikoff, OCampo

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Practitioner Knowledge and Attitude

• It is the role of the physician to recommend
  breastfeeding to expectant mothers.
• 88 residents
• 82 practitioners
• Training provided no or less than adequate
  preparation to support breastfeeding patients.
• 68 residents
• 79 practitioners
• Freed

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Provider Encouragement and Breastfeeding
Initiation

• Women who were encouraged to breastfeed were four
  times more likely to initiate breastfeeding than
  those that were not encouraged.
• Lu
• Percent of women who changed from bottle to
  breast after prenatal counseling
• 38 if counseled
• 8.5 if not
• Kistin

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Provider Counseling and Breastfeeding at Six Weeks

• Perception of physician recommendation
• 38 - physician recommends breastfeeding
• 62 - physician had no preference
• Breastfeeding at six weeks
• 70 who thought physician favored breast
• 54 who thought physician had no preference
• 9 who thought physician favored
  formula DiGirolomo

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So what can I, the busy ob-gyn, do?
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1. Ask early and often about breastfeeding

• Each annual GYN exam
• First prenatal visit
• Subsequent visits

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2. Examine the breasts

• Inverted nipples
• Prior surgery
• Breast asymmetry
• Tubular breasts (inadequate glandular tissue)
• Exudates/dermatitis

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3. Offer resources for prenatal education

• Books
• Classes
• Internet

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4. Delay routine postpartum procedures

• Place baby skin-to-skin
• Initiate breastfeeding in the first hour
• Delay vitamin K and eye prophylaxis
• Assist proper breastfeeding technique
• Avoid traumatic interventions (iesuctioning)

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5. Encourage the ten steps hospital policies to
support breastfeeding

• Have a written breastfeeding policy that is
  routinely communicated to all health care staff.
• Train all healthcare staff in skills necessary to
  implement this policy.
• Inform all pregnant women about the benefits and
  management of breastfeeding.
• Help mothers initiate breastfeeding within one
  hour of birth.
• Show mothers how to breastfeed and maintain
  lactation, even if separated from their infants.

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5. Hospital policies to support breastfeeding
(contd)

• Give newborn infants nothing other than
  breastmilk, unless medically indicated.
• Practice rooming in 24 hours a day.
• Encourage breastfeeding on demand.
• Give no artificial nipples or pacifiers.
• Foster the establishment of breastfeeding support
  groups.

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6. Remove formula advertising from the office
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Just give a little formula

• Youre tired, you should rest. Well feed the
  baby in the nursery tonight.
• A little formula here in the hospital wont
  hurt.

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Hospital Supplementation

• Long breastfeeding intervals OR1.1-1.3, p0.0001
• More than two bottle daily OR 1.7-4.8, p0.001
• Any supplement in the maternity ward 3.9X
  higher chance of early cessation
• Hall, Bloomquist

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Formula company discharge packs

• Decreased duration of exclusive breastfeeding
• Donnelly Cochrane review

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Risks of supplementation

• Interfere with the establishment of maternal milk
  supply (delayed lactogenesis)
• Increase risk of engorgement
• Alter infant bowel flora
• May cause nipple confusion
• Interfere with maternal-infant attachment
• Undermines maternal confidence in her ability to
  fully provide for her babys nutritional needs
• Shortened duration of EXCLUSIVE and ANY
  breastfeeding

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7. Offer post-partum resources

• Communication with other health care
  professionals
• Lactation consultants
• www.ilca.org find a lactation consultant
• Books
• Websites

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8. Know the medical management of common issues

• Perceived insufficient supply
• Engorgement
• Mastitis/Candidal infection
• Breast pain

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9. Know what products and medications are safe to
use in breastfeeding women

• Contraception
• Medications
• http//toxnet.nlm.nih.gov (LactMed database)

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Medications contraindicated in breastfeeding

• Bromocriptine
• Cocaine
• Cyclophosphamide
• Cyclosporin
• Doxorubicin
• Ergotamine

• Lithium
• Methotrexate
• Phencyclidine
• Phenindione
• Radioactive isotopes
• Radiolabeled elements

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10. Educate yourself

• ACOG/AAP Breastfeeding Handbook for Physicians
• www.aap.org
• www.acog.org
• Academy of Breastfeeding Medicine (Protocols
  Journal)
• www.bfmed.org

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Overall Conclusions

• All patients who wish to breastfeed should have
  optimal support to do so.
• It is important to offer patients a consistent
  message.
• Help patients make educated choices.
• Educate yourself.

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If you wish to go fast, go alone. If you wish
to go far, go together.

• -Old African Proverb

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Breastfeeding Management in the Office Fitting
It In!

• Jenny Thomas, MD, FAAP

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Caring for the Baby

• Use rounding as an opportunity to support,
  promote, and protect breastfeeding

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Breastfeeding is normal

• There is a reason behind everything in nature."
  - Aristotle

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The Newborn Nursery

• Take a look at your hospital policies and modify
  protocols that may interfere with breastfeeding
• Work to implement the 10 steps
• Set daily goals for mom and help her understand
  normal feeding patterns
• Involve dad

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The Newborn Nursery

• Watch output
• Recognize that jaundice is an indicator of poor
  feeding
• Understand glucose physiology and the role of
  ketone bodies in the breastfed infant
• Observe a feeding
• Ooze enthusiasm

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The Newborn Nursery

• Know warning signs of poor intake including
• Poor stool output
• Jaundice
• Nipple pain

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Getting Ready for Discharge

• Anticipate frequent feedings
• Inform mom of resources
• Provide a way of recording output and set
  expectations for adequate intake
• See back in 2-3 days

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In the Office

• Weight should be around discharge weight
• Ask about pain during feedings
• Make sure the stool is yellow
• Anticipate that the child should gain ½ ounce to
  1 ounce a day and regain birthweight by 10 days

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In the Office

• Train staff including receptionists, triage, and
  nurses
• Provide places for breastfeeding moms to feed
  their child
• Get rid of formula advertising
• Provide incentives
• Know community resources

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Back to Work suggestions for Mom

• Check into facilities at work
• Ask co-workers
• Flexible work schedules
• Breastfeed before leaving the infant and as soon
  as reunited
• Bring a picture of the baby

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Back to Work

• Advocate for insurance coverage of pumps
• Advocate for supportive legislation

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Weaving a Web of Breastfeeding Support

• Margreete Johnston, MD, FAAP

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Factors Influencing Feeding Decisions
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Community resources you can use!
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Know your community

• Where are your mothers and newborns?
• birthing centers/ referral clinics

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Think proactively

• Where do families gather with young children?
• Schools
• Playgrounds
• Churches and synagogues

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Be a part

• Prenatally, where are women receiving info on
  breastfeeding?
• TV/media community papers
• Significant others
• Caregivers

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Sources of Information
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Introduce Yourself

• Introduce yourself to obstetrical personnel.
• Avail yourself to help with breastfeeding
  problems
• Compliment your health care team on prenatal
  care.
• Positive reinforcement works

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Making It Work

• Hospitals can provide names of obstetricians with
  privileges in your area, drop a note with
  business cards
• Carve out some time in your schedule for
  education and networking, starting with rounds

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Volunteer

• Speaking at prenatal classes
• Offer in-services to hospital staff, befriend
  lactation consultants
• Meet La Leche League people, attend meetings
• Know your WIC nutritionist
• Use your personal experiences to network advocacy
  in your own practice

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Be an example for others

• Baby friendly office
• Compliment any breastfeeding wherever appropriate
• Support mothers who are in the hospital with
  nursing babies, as a professional and a resource
• Find out where pumps can be bought or rented
• Build your own library on breastfeeding
• Respect and work with cultural differences

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Clinical Faculty

• If you are affiliated with a university, offer
  in-service on AAP policies
• Breastfeeding speakers kit www.aap.org/breastfeedi
  ng
• Teach medical students and residents
  breastfeeding basics and advocacy
• Be aware of controversies and be able to discuss
  both sides of issues
• Join AAP Section on Breastfeeding

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OBSTACLES
Advertising

• Health Issues

Return to Work
Lack of Support
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Remember to thank those that Help!
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Let It Shine!

• Be proud of your breastfeeding advocacy.

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Now that you know the basics

• Please join us for the next BPPOP III
  Breastfeeding Teleconference that will focus on
  culturally effective breastfeeding care.
• If you are interested in signing up for the
  teleconference (date to be determined), please
  contact Becky Ramsey at bramsey_at_aap.org.

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Let us know how were doing

• Please visit http//www.surveymonkey.com/s.asp?u9
  29892511416 to fill out the short evaluation form
  for this teleconference. When your evaluation is
  submitted, you will be emailed your CME
  certificate for your participation in this
  educational activity.
• Thank you for participating in the BPPOP III
  Teleconference!
• If you have any questions or comments please
  contact Lauren Kotch at lkotch_at_aap.org.