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

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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
• cows 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

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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.)

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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

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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
• Employers willingness to make accommodations
• Opinion of the childs 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

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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
  

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National Assessment of Physicians Breast-feeding
Knowledge, Attitudes, Training, and Experience
Freed, 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

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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

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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

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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

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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!

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Correct latch

• Mother
• Mom holds breast back from areola and nipple with
  C-hold
  
• Use manual stimulation to erect the nipple
• Tickle the babys 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

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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

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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
• Babys body at breast level (boppy pillow)
• Babys head in crook of elbow
• Babys back supported with forearm
• Cup breast with free hand

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Cradle hold
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Boppy pillow
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Nursing positions

• Football hold
• Mom in same position
• Babys body and legs under moms arm
• Head snugly in moms hand with neck grasped by
  thumb and pinky and head on palm and other
  fingers
  
• Pillows under the baby (boppy)
• Avoid flexing babys head too much

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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 cant 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 babys 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 babys weight