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1.0 Introduction

Continued Education for Health professionals

Continued education is an important process to ensure best practice and evidence-based care. Investing in skilled infant feeding support is essential to achieving equitable health outcomes. The Baby-friendly Hospital Initiative/Baby-Friendly Initiative is an excellent way to support this.

Significant changes were made to BFHI/BFI in 2018 and in 2020 the competency verification toolkit was released. Please view this interview with Louise Dumas, MSN, Ph.D., BFI master assessor, and member of the competency verification toolkit development team. She explains the paradigm shift especially related to step 2 of the 10 steps. Click on the video below to view the interview.

BFHI updates to Step 2 and the competency verification toolkit.
© Health e-Learning-IIHL

Please review this document to better understand the changes made to the BFHI/BFI competency-based training. The practitioner needs to be able to perform professional tasks knowing the “what, why, and how” to do it. Education or training to acquire these competencies is part of the journey.

This course will cover topics that will help you in your daily work practice, whether you work in the hospital or community setting.

2.0 Protection of Breastfeeding [Domain 1]

Society is not a bystander – everyone must protect the environment in which women and parents feed their infants and demand the appropriate care, support and protection of rights. The research findings reveal the priorities of formula milk companies and how far they are prepared to go to achieve their sales and market growth. In response, we must be clear about the type of world that we stand for; what is ethical and acceptable; and where concern for our children and their futures guide and prioritize our actions today.

The International Code and WHA resolutions

In this topic, you will learn about the ExternalInternational Code of Marketing of Breastmilk Substitutes and subsequent WHA resolutions [link: https://apps.who.int/nutrition/netcode/resolutions/en/index.html](International Code). Your knowledge of the International Code will make a difference even if your role is exclusively at the bedside, clinic, or home serving expectant and new parents. Understanding the International Code will help support your daily work based on best practices.

To understand why breastfeeding needs to be protected and how the infant feeding industry uses exploitative marketing read the 28 April 2022 news release ExternalWHO reveals shocking extent of exploitative formula milk marketing[link: https://www.who.int/news/item/28-04-2022-who-reveals-shocking-extent-of-exploitative-formula-milk-marketing]. You might also find the 2021 article below of interest to share with colleagues on how the infant feeding industry uses tricks and deceit to sell its products.

ExternalOld Tricks, New Opportunities: How Companies Violate the International Code of Marketing of Breast-Milk Substitutes and Undermine Maternal and Child Health during the COVID-19 Pandemic[link: https://www.mdpi.com/1660-4601/18/5/2381/htm]

If your lives were embittered as mine is, by seeing day after day this massacre of the innocents by unsuitable feeding, then I believe you would feel as I do that misguided propaganda on infant feeding should be punished as the most criminal form of sedition, and that those deaths should be regarded as murder."
Dr. Cicely Williams, M.D., MRCP - "Milk and Murder," Singapore 1939

Subsequent relevant WHA resolutions

Subsequent relevant ExternalWorld Health Assembly (WHA) resolutions[link: https://www.who.int/teams/nutrition-and-food-safety/food-and-nutrition-actions-in-health-systems/netcode/code-and-subsequent-resolutions] carry the same status as the International Code. They help clarify and strengthen the Code and since 2016 also provide guidance on the appropriate marketing of complementary foods.

The WHA resolution 69.9 called for an end to the inappropriate promotion of all foods for infants and young children up to the age of 36 months. This was followed by the development of a document and implementation guide - PDFGuidance on Ending the Inappropriate Promotion of Foods for Infants and Young Children[link: https://apps.who.int/iris/bitstream/handle/10665/260137/9789241513470-eng.pdf], which encourages Member States to develop stronger national policies that protect children under the age of 36 months from marketing practices that could be detrimental to their health.

National implementation of the International Code

The Code forms the foundation of the protection of breastfeeding. Without it, investments in breastfeeding promotion to the public and the training of healthcare providers are eroded by the inappropriate promotion of breastmilk substitutes and conflicts of interest among healthcare workers.

[link: https://www.who.int/publications/i/item/9789240048799]

Marketing of breast milk substitutes: national implementation of the international code, status report 2022[link: https://www.who.int/publications/i/item/9789240048799]

The Code remains as relevant and important today as when it was adopted in 1981, if not more so. The Code is an essential part of creating an overall environment that enables mothers to make the best possible decisions about infant and young child feeding, based on impartial information and free of commercial influences, and to be fully supported in doing so. Protecting the health of children and their mothers from continued misleading marketing practices should be seen by countries as a public health priority and human rights obligation.

https://www.who.int/publications/i/item/9789240048799

https://www.who.int/publications/i/item/9789240048799.
© World Health Organization 2020

"While promotion of breastmilk substitutes using unethical marketing practices continues throughout the world, many countries are fighting back...The global COVID-19 pandemic created additional opportunities for manufacturers of breastmilk substitutes to exploit public fears and to promote their brands and products...32 countries have measures in place that are substantially aligned with the Code, seven more countries than reported in the 2020 report...Digital marketing platforms enable advertisers to reach beyond national borders, adding further challenges to enforcement of national laws...The number of countries with legal measures on at least some provisions of the Code now stands at 144. Legislation enacted in the past five years is generally more closely aligned with the Code than older legislation."

"This report provides updated information on the status of implementing the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly (WHA) resolutions (“the Code”) in countries. It presents the legal status of the Code, including to what extent its provisions have been incorporated in national legal measures. Given the important role of health workers in protecting pregnant women, mothers and their infants from the inappropriate promotion of BMS, the 2020 report highlights specific provisions considered to be particularly instrumental in addressing and eliminating the promotion of breast-milk substitutes, feeding bottles and teats to health workers and in health facilities, and provides an extensive analysis of legal measures taken to prohibit promotion to health workers and in health facilities."

2.1 A Code History Timeline

A Little History behind the Code

1930's

  • Dr. Cicely Williams (Paediatrician) was the first health professional to make a link between the promotion of breastmilk substitutes (BS), declining breastfeeding rates, and increased infant-young child malnutrition, morbidity, and mortality.
  • In 1939 she addressed the Rotary club in Singapore, her speech was called Milk and Murder. Sadly it took another 50 years before governments accepted breastfeeding as a topic to be actioned.

1940-50s - After World War II

  • Increased sales of infant formula, bottles, and teats.
  • Misguided perception by health professionals and the public that commercial infant milk feeding was scientifically equal to human milk.
  • This cultural perception that commercial infant milk feeding is modern is maintained today in many parts of the world through product marketing and promotion.

1960's

  • Dr. Derrick Jelliffe – an expert in infant nutrition coined the term ‘commerciogenic malnutrition’ to describe how industry marketing practices impact infant health.
  • He coined the phrase 'commerciogenic malnutrition' to refer to infant starvation caused by inappropriate promotion and use of infant formula or bottle feeding in areas with low income and poor water supplies.

1970's

  • Campaigns were started to halt the unethical promotion/marketing of infant milk.
  • The report Baby Killer was published by War on Wants which was translated by Bern Third World Action Group (AgDW) into German as “Nestlé tötet Babies” or in English “Nestle kills babies”.
  • Nestle sued AgDW (NGO) for libel and won on a technicality.
  • The judge warned Nestle to change its marketing practices and the NGO receives a token fine.
  • The long-standing Nestle boycott began and continues today.
  • In 1979, WHO and UNICEF held a joint international meeting on Infant and Young Child Feeding (IYCF).
  • The meeting included representatives from the baby milk/food industry.
  • Recommendations were made on IYCF.
  • The most significant recommendation – There should be an International Code of Marketing of infant formula and other products used as breastmilk substitutes.

1980's

  • WHO/UNICEF is charged with drafting a Code to regulate the marketing of breastmilk substitutes.
  • "May 1981: After several drafts, the Code is adopted, by resolution WHA 34.22 with a roll-call vote of 118-1. After pushing for weaker recommendations rather than a binding regulation, the US was the only country to vote against the Code’s adoption. The US business sector had successfully lobbied the administration to believe that the Code would set a precedent in allowing UN agencies to interfere with business interests".

To read more about the history of the Code you can download the handout ExternalTimeline of the International Code of the Marketing of Breastmilk Substitutes[link: https://www.aliveandthrive.org/en/resources/timeline-of-the-international-code-of-the-marketing-of-breastmilk-substitutes] from the Alive and Thrive website. There are also excellent International Code resources Externalhere. [link: https://www.aliveandthrive.org/en/bms-code]

Take the time to view this link called "ExternalPutting Babies Before Profits: The History of The Deadly Fight Against The Formula Industry.[link: https://express.adobe.com/page/uNwlQ5zsQ1Ccy/]" It traces the history from when Nestlé claims that its founder, Henri Nestlé, invented the world's first artificial infant food in 1867 to the 40th anniversary of the International Code in May 2021.

In the words of Halfdan Mahler (WHO DG 1973-88), ‘Without the NGOs, without their constant lobbying, reminding us of our duty as public health officers, even harassing us for months on end, without all that, there would have never been a Code. WHO would simply not have had the courage to get on with it.

Clip taken from the 1984 BBC/Baby Milk Action Film When Breast are Bad for Business.
© 1984 BBC/Baby Milk Action

The 1978 US Senate Hearing on the marketing of formula in developing countries and Senator Edward Kennedy cross-questioning Nestlé about its marketing of breastmilk substitutes in the developing world. This instigated the International Code of Marketing of Breastmilk Substitutes, which was adopted by the World Health Assembly in 1981. The International Code is a benchmark for good practice and is used by governments all over the world to protect infant and young child health from unethical marketing.
For more information see Externalwww.babymilkaction.org[link: http://www.babymilkaction.org]

2.2 Marketing - the role of the International Code

The evidence is strong. Formula milk marketing, not the product itself, disrupts informed decision-making and undermines breastfeeding and child health. All sectors of governments, including health, labour and trade, health professionals and their associations, investors and those with economic leverage should fulfil their responsibilities and exert their influence to insist on practices that prioritize children and families over commercial interests.

Products covered by the International Code

Despite its importance, the International Code is often misunderstood by the public, health care workers, and even policymakers. The Code concerns itself with the protection of all infants, by eliminating inappropriate commercial influences and requiring high-quality, appropriate products that are labelled for safer use by the consumer. It protects the public and the health care workers.

Products covered by the Code:
• breastmilk substitutes, including infant formula
• other milk products, foods (cereals), and beverages (teas and juices for babies), when marketed or otherwise represented to be suitable for use as a partial or total replacement of human milk up to 36 months of age.
• feeding bottles and teats/artificial nipples, as well as pacifiers ("dummies")

The Code remains as relevant today as it was 40 years ago. In recent years, some marketers of baby foods exploited the COVID-19 pandemic to promote their products by invoking unfounded fears that breastfeeding could transmit COVID-19. WHO and UNICEF guidance is clear: mothers suspected or known to have COVID-19 should continue breastfeeding.

Note the Code violations

Note the Code violations.
© Health e-Learning-IIHL

Code Violations

In the images above can you find the Code violations? Look below and you will see.


© Health e-Learning-IIHL

Key provisions related to the Code

Key provisions related to The Code

Key provisions related to The Code.
© Health e-Learning-IIHL

David Clark discusses the Code and its importance.
© Alive and Thrive

Products covered by the Code must have accurate, clear labelling for use and preparation, without any idealizing imagery or health claims. They must also indicate that breastfeeding is the ideal way to feed an infant.

Country with Code labels in law

Country with Code labels in law.
© Health e-Learning-IIHL

Country without Code labels in law

Country without Code labels in law.
© Health e-Learning-IIHL

Within health facilities, there should be no distribution of product samples or marketing materials distributed to staff or the public. Necessary products purchased for use within the facility must be purchased at market prices, with donations strictly prohibited.

Case Study

A colleague tells you that the local formula sales rep has a solution for your prenatal breastfeeding class: he has dropped off branded backpacks for each family that include coupons and very helpful information leaflets. Such a gift would likely much improve attendance at your classes. What would you do?

Consider:

  • What impact could these gifts have on your students?
  • What impact could accepting these gifts have on you as a health worker?
  • What policies might apply to this situation?
  • Where could you go for more guidance?

Health care workers and the Code

Health care workers as individuals also have responsibilities under the Code, which include ensuring that parents receive accurate, evidence-based information about breastfeeding and that parents who are breastfeeding receive individual instruction on the use of infant formula and bottles as well as avoiding any conflicts of interest with companies that are covered by the Code.

Marketing is NOT education

Manufacturers and distributors of products covered by the Code should not provide or sponsor education or training to health care providers or the public.

This is a Conflict of Interest!!!

This is a Conflict of Interest!!!

Did you know…?

The value of a gift has little impact on whether it influences the recipient. In fact, some research shows that gifts with a low value, such as pens or chocolates, are more effective at influencing future behaviour than high-value gifts. Gifts from manufacturers and distributors are always marketing and always create conflicts of interest when given to health care providers.

Identify three ways in which the parent entering this room might be harmed because the facility and/or health care provider are not following the Code.


© Michelle Pensa Branco

Health care facilities and individual health care providers have a responsibility to protect the patients that they serve and avoid conflicts of interests that may unduly influence or undermine patient trust in them.

Tip

Ensure that there is a staff member assigned to regularly 'audit' both patient and staff areas for prohibited materials (ie: company coupons, branded resources, product samples) and positive images of breastfeeding and healthy IYCF practices.

Professional and voluntary service organizations should also have specific policies to protect their members and the public from undue influence.

Case Study

You are a pediatrician. You receive a mailing at your office from your national pediatric association. Inside is this flyer.


© Health e-Learning-IIHL

  • Is this kind of contact permissible under the Code?
  • How could this event influence the care and trust of patients?
  • What steps could you take?

What should I remember?

  • The Code is an international document that is implemented through national, local, and organizational regulations and policies: it includes the provisions of the 1981 WHA resolutions and subsequent relevant WHA resolutions.
  • The Code applies to marketing, broadly defined: it does not prevent the manufacture or sale of products.
  • Which products are covered and what your responsibilities are as a healthcare worker or administrator.
  • Failing to meet your obligations as a health care provider can harm the families you are caring for.

If you would like to know more about Code Monitoring (optional)

3.0 Understanding the importance of skin-to-skin

Step 4: Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth

(New Zealand) Step 4:Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth and any opportunity thereafter.

(Canada) Step 4: Facilitate immediate and uninterrupted skin-to-skin contact at birth. Support mothers/birthing parents to respond to the infant’s cues to initiate breastfeeding as soon as possible after birth.

Birth and Breastfeeding - Initiating Early Feeds

Immediately following birth

Skin-to-skin contact between the birthing parent and infant at birth is internationally recognized as best practice based on rigorous research. In the words of Dr. Louise Dumas, "Skin-to-skin is not just something nice to do, it is something we must do!" Research shows that a minimum of 1 to 2 hours of uninterrupted from birthing parent-infant skin-to-skin contact, has a positive impact on the physiological and psychosocial aspects of the dyad, while also facilitating breastfeeding.

The recommendation for immediate, uninterrupted, skin-to-skin for the first 1 - 2 hours after birth is best practice. The key elements include:

  • No drying, place the infant widely on the mother/birthing parent's chest, with Infant's head free to move and maintain the airway, cover with a dry light blanket.
  • Observation of the mother/birthing parent and infant is key to safe skin-to-skin contact!

Take the opportunity to read the following procedural document example on safe PDFskin-to-skin contact.[link: https://courses.step2education.com/files/book/SafeSkinSkin-LD2016-September.pdf]

What does skin-to-skin look like?

  • Mother/birthing parent is lying semi-upright - neither flat nor fully sitting and is awake and responsive
  • Infant is prone ("belly down") on the mother/parent's chest, where the baby's face is easily visible to make contact and also to ensure that the nose and mouth are free from obstruction
  • Infant is covered loosely with a dry, clean blanket that does not prevent movement down to the breast or obstruct visual assessment
Photo used with permission from parent

Photo used with permission from parent.
© C. Dobrich

Photo used with permission from parent

Photo used with permission from parent.
© C. Dobrich

Photo used with permission from parent

Photo used with permission from parent.
© A. Eastgate

Photo used with permission from parent

Photo used with permission from parent

Skin to skin

If the video above doesn't play, External open YouTube link in a new window[link: https://www.youtube.com/watch?v=BAC5gPcvLJM]

Delayed cord clamping

The BFHI practices such as immediate skin-to-skin and performing all initial checks while the infant is on the mother/birthing parent's body, support delayed cord clamping.

Waiting at least 1-3 minutes after the baby's birth or until the cord itself stops pulsating has multiple benefits both in the immediate postpartum and neonatal period, in particular improving the iron status of both full- and preterm infants as they are able to receive the full complement of placental blood.

Delayed cord clamping helping babies breathe


© The Royal Women's Hospital

If the video above doesn't play, Externalopen the Youtube link in a new window[link: https://www.youtube.com/watch?v=SfeHIfGnVTU]

Research findings

  • Blood glucose at 90 minutes is significantly higher in skin-to-skin care newborns.
  • Newborn preterm infants in skin-to-skin care achieve thermo-cardio-respiratory stability within 6 hours, compared to babies in traditional incubator care who mostly do not.
  • Newborn, full-term babies who spent more than 50 minutes in skin-to-skin care are 8 times more likely to breastfeed spontaneously than infants not in skin-to-skin care.
  • Exclusive breastfeeding at 48 hours and 6 weeks postpartum and incidence of any breastfeeding at 1 and 4 months was significantly greater for infants in the skin-to-skin care groups.

3.1 Infant innate behaviours

The 9 instinctive stages

Several researchers have described this species-specific set of innate behaviors when an infant is placed in skin-to-skin contact with the birthing parent immediately following birth. It is clear that newborn babies are born with the instinct to breastfeed.

A newborn baby is born with all the necessary neurobehavioural capability to breastfeed - innate responses. The infant responses are expressed through the autonomic nervous, hormonal, and somatic systems which regulate heart rate, breathing, oxytocin and cortisol levels, and muscle movement.

The balance between these systems is very fragile and easily disturbed, particularly in the newborn period. The transition from in-utero to adaptation to life outside the uterus is often described as the sensitive period.

The baby will use olfactory and tactile cues as behavioural sequences which stimulate hand-to-mouth movements, tongue action with mouth opening, focus on the nipple and crawling towards it, massage of the breast to stimulate the nipple, head bobbing and licking at the nipple, and finally self-attachment. Widstrom et alenlightened the world to the baby's ability to perform this task without the active participation of the mother/parent.

Widstrom et al. further described these innate behaviours when newborns are in skin-to-skin contact after birth. This contact "elicits the newborn infant’s internal process to go through what could be called 9 instinctive stages: birth cry, relaxation, awakening, activity, rest, crawling, familiarization, suckling, and sleeping".

The newborn will rest throughout the first hour after birth. This Resting Stage is interspersed with the other stages. The newborn may have periods of activity, then rest, then become active again. Or the Resting Stage may occur between stages, for example, after activity and before the newborn begins to crawl.

https://www.aliveandthrive.org/sites/default/files/nine_instinctive_stages.pdf

https://www.aliveandthrive.org/sites/default/files/nine_instinctive_stages.pdf.
© Alive and Thrive

Baby-led latching

View the video below and note the following:

  • the position of mother/lactating parent and baby
  • the calming effect of this position on baby
  • the beginnings of mouthing and interest in the breast
  • the head bobbing and seeking with the tongue
  • and finally, the baby latched on and is suckling.

Did you notice the innate behaviours and instinctive stages?

3.2 Skin-to-skin and the role of the Health Worker

The role of the birth attendants

This critical period in the relationship between mother/birthing parent and infant is, in some birthing units, a high-intervention time when it should be exactly the opposite. Recall that the AAP Neonatal Resuscitation Guidelines state that all observations can take place with the infant in skin-to-skin contact with their birth mother/parent. The role of the birth attendants at this time is to support the mother/parent to provide the ideal environment for her baby to adapt to extrauterine life, orientate to the breast, and coordinate suckling.

Appropriate support is given by discussing with the mother/birthing parent, and others present, the importance of uninterrupted skin-to-skin contact. Some birth attendants tell of the mother/birthing parent and their support people being enthralled as they watch the baby move through this sequential pre-feeding behavior, not wishing to interrupt it. A little education can go a long way!

Just the thing for busy staff!

Supporting the mother/birthing parent to care for their baby with skin-to-skin contact will significantly reduce the workload of the health care staff:

  • The infant will adapt to extrauterine life quicker, reducing the risk of hypothermia or cardio-respiratory instability.
  • Glucose homeostasis is achieved quickly, reducing the risk of hypoglycemia.
  • Breastfeeding will be initiated early and successfully, with minimal input from others.
  • Breastfeeding will stimulate the release of oxytocin, contracting the uterus and reducing the risk of hemorrhage.
  • Skin-to-skin care will colonize the infant with the birthing parent's normal flora, which, when combined with breastfeeding, significantly reduces the risk of nosocomial infections.
  • Maternal self-confidence and independence will rise.

3.3 Addressing barriers to skin-to-skin

Barriers to skin-to-skin

The major barriers to skin-to-skin care (SSC) at birth are lack of personnel, time constraints, and safety concerns. Training, designated health personnel for SSC, and teamwork are the key interventions likely to improve SSC at birth.

Concern that the newborn will get cold.

  • Place newborn's abdomen directly on the mother/birthing parent's chest, without drying
  • Skin-to-skin is immediate (directly from the mother/birthing parent)
  • Newborn is extended as much as possible, so as much skin contact as possible (oxytocin)
  • Newborn is dried, especially back and head
  • Newborn is then covered with a dry blanket
  • Skin-to-skin re-warms cold babies better than in an incubator or warmer (hypothermia = 36.3 C)

Newborn needs to be examined.

  • Most examinations can be conducted with a newborn on the mother's/birthing parent's chest.
  • There is no need to move the newborn to monitor vital signs.
  • Weighing can be delayed.

Mother/birthing parent needs suturing.

  • Newborn can stay on the mother's/birthing parent's abdomen while an episiotomy is sutured.
  • Newborn can stay on the mother's/birthing parent's chest while suturing a cesarean section wound16.

Newborn needs to be bathed.

  • Delaying the first bath provides better thermoregulation and allows the vernix to remain on the skin.
  • Gently wipe the newborn dry after birth, preserving the vernix.
  • Vernix retention is associated with significantly higher skin hydration, a lower skin pH, and significantly less erythema.
  • Early bathing is associated with a significant fall in temperature.

Delivery/birthing room is busy.

  • Mother/birthing parent and newborn can be transferred to the postnatal ward while in skin-to-skin contact.

Insufficient staff to remain with the mother/birthing parent.

  • A responsible family member can stay with the mother/birthing parent and newborn.
  • Discuss routine precautions with the family member to ensure their safety.
  • Monitoring of maternal and newborn infant vital signs by staff should continue as per hospital standards.

Newborn is not alert.

  • If a newborn is sleepy due to maternal medications it is even more important that the newborn has contact as he/she needs extra support to bond and feed.

Mother/Birthing parent is tired.

  • A mother/birthing parent is rarely so tired that they do not want to hold their infant.
  • Contact with her infant can help the birthing parent to relax.
  • Review labor practices such as withholding fluid and foods, and practices that may increase the length of labor.
  • Skin-to-skin care and breastfeeding is best when the birthing parent is in a semi-reclined position; a good position for resting.

Lack of knowledge in the health professional wishing to move the infant

  • This first step following birthing has far-reaching effects on the birthing parent, infant, and breastfeeding.
  • Train all birthing room staff in the effects of immediate and undisturbed skin-to-skin contact.
  • Refer all staff to the hospital policy which they must follow. Hospital breastfeeding policies will reflect the 10 Steps to Successful Breastfeeding, including Step 4.

Resources

Skin-to-skin Contact

Skin-to-skin Contact.
© Developed by Magdalena Whoolery and Carole Dobrich. Illustrations by Angela Eastgate. May (2020)

This poster is available in multiple languages on theExternal LLLI website[link: https://www.llli.org/skin-to-skin-is-as-easy-as-1-2-3/].

3.4 The loving relationship

Bonding

This is the beginning of a loving relationship between mothers/birthing parents and their newborns. The infant appears to play his part in the establishment of these bonds by actively interacting with his parents. Following an initial cry at birth, the infant becomes quietly alert and seeks visual contact, massages the mother/the birthing parent's chest and breasts, latches, and breastfeeds. The high blood levels of beta-endorphins, oxytocin, and prolactin in both mother/birthing parent and infant facilitate falling in love.


© T. Foster

For this to occur the following factors have to be in place and considered. These are all influenced by the birth attendants.

  • the availability of the infant to their mother/birthing parent,
  • an environment conducive to mother/birthing parent and child interaction, and
  • the attitude of those present at the delivery to the appearance of the infant

What about the baby who will not be breastfed? Skin-to-skin is important for all infants, including those who are planned to be breastfed. Breastfeeding initiation is only one of the benefits of immediate and continuous skin-to-skin contact following birth.

What should I remember?

  • The interpretation of Step 4 of the Ten Steps
  • The immediate care of the newborn following birth AND where it should take place
  • The many important functions that skin-to-skin contact on the mother/birthing parent's chest has for both themself and their infant
  • How you could address the barriers to skin-to-skin care should your colleagues be concerned

Skills Competency

If you are working with families in the area of birth and immediate postpartum, please take the time to download and review the information in the skills competency. You can then ask a colleague or supervisor to confirm your competencies in this area related to knowledge, skills, and attitude.

When you have successfully completed this topic and practiced what you have learned you will be ready to do your Skills Competency. Click on the title of this box to download PDF Domain 4 Birth and Immediate Postpartum (Skin-to-skin)[link: https://static.step2education.com/docs/Skills_Competency_Domain_4_Birth_and_immediate_postpartum_skin-to-skin_USA.pdf] competency form for you to complete with your Supervisor.

4.0 Postnatal Interventions

Step 7: Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day

(Canada) Step 7: Promote and support mother-infant togetherness.

Separation of mother/birthing parent and newborn

From an evolutionary perspective, skin-to-skin care is the norm. Routine separation of the newborn from its mother/birthing parent soon after birth is unique to the 20th Century and beyond. At the risk of laboring the point, separating the mother/birthing parent and baby after birthing for any reason, other than a medical emergency, is NOT applying best practice care. All indicators of infant well-being and successful extrauterine adaptation are stabilized better and faster when the newborn is in skin-to-skin contact with its mother/birthing parent from immediately after birth for the first few hours, or at least until after the first breastfeeding.

Because of human infants' extreme immaturity at birth, infants depend on the caregiving context for relatively long periods of time, during which they require specific environmental inputs for the regulation of their biological and behavioral systems.

Note the protest response being exhibited by this newborn.

Note the protest response being exhibited by this newborn.
© Cecilia Finoli

When the mother/birthing parent and infant are separated, the infant's innate behaviors are changed. The infant firstly exhibits distress cries, followed by what is described as "protest-despair" behavior.

Separated newborns make 10 times more crying signals than babies in skin-to-skin care, and their cries have a completely different character. During the "protest" response there is intense activity seeking the mother/birthing parent, followed by "despair" behavior which sees the baby withdraw with decreased heart rate and temperature, mediated by a massive rise in stress hormones.

Maternal-neonate separation results in a physiological stress-response and has a profoundly negative impact on quiet sleep duration.

Effect on oxytocin

Oxytocin levels are highest around the time of birthing. Oxytocin cannot cross from the peripheral circulation into the brain; therefore it is only naturally occurring oxytocin released by the posterior pituitary gland that will have an effect on the mother's/birthing parent's temperament, ie. not oxytocin administered to the mother/birthing parent.

Oxytocin causes,

increased uterine contraction limiting postpartum blood loss,
the temperature of the mother's/birthing parent's breast to rise, providing warmth for the infant,
an anti-stress effect, reducing maternal blood pressure and cortisol levels and releasing gastrointestinal hormones,
a state of calmness and social responsiveness,
bonding with their infant, and enhanced maternal behaviors,
milk ejection; important at this time prior to it becoming conditioned by the suckling stimulus.

During the time the infant in skin-to-skin contact after birthing is making massage-like movements on the mother's/birthing parent's chest and breasts the maternal serum oxytocin levels rise. The infant begins these hand movements soon after birth and continues until he self-attaches and suckles.

The work of Michel Odent is well recognized by those involved in obstetrics. Odent's studies of the effects of oxytocin and other hormones of birthing are worthwhile following.

The age of cesarean sections on request, epidurals and drips of oxytocin is a turning point in the history of childbirth. Until recently women could not give birth without releasing a complex cocktail of 'love hormones'. Today, in many countries, most women have babies without releasing these specific hormones. The questions must be raised in terms of civilization. This turning point occurs at the very time when several scientific disciplines suggest that the way human beings are born has long-term consequences, particularly in terms of sociability, aggressiveness or, in other words, 'capacity to love'.

Michel Odent, 2001

Birth is a sensitive period

The first hour after birth is a sensitive period for both the infant and the mother. Through an enhanced understanding of the newborn infant's instinctive behaviour, practical, evidence‐informed suggestions strive to overcome barriers and facilitate enablers of knowledge translation. This time must be protected by evidence‐based routines of staff.

With this in mind, the importance of skin-to-skin contact for mothers/birthing parents and infants who experience assisted births appears to be even more important.

Importance of skin-to-skin following assisted birth

Importance of skin-to-skin following assisted birth.
© Cecilia Finoli

4.1 The chemistry of feeding

[link: https://www.health-e-learning.com/resources/articles/falling-in-love]

Falling in Love[link: https://www.health-e-learning.com/resources/articles/falling-in-love]

https://www.health-e-learning.com/resources/articles/falling-in-love[link: https://www.health-e-learning.com/resources/articles/falling-in-love]

Click on graphic for a larger image. https://www.health-e-learning.com/resources/articles/falling-in-love

Effect on breastfeeding

Learning is a dimension of behavior and physiology, and the human neonate has evolved to learn how to suckle when in skin-to-skin contact.

Most babies (27 out of 34) who were separated from their mothers after 19 minutes for routine weighing procedures and then returned for feeding either refused to suckle or demonstrated superficial nipple sucking techniques. The difference between the two groups (one group remained in skin-to-skin contact) inability to attach to the breast and suckle correctly for effective milk removal was significant (p>0.001).

Washing mother/birthing parent or newborn

Washing the mother/birthing parent and/or baby is also to be discouraged. Infants localize the nipple by smell and have a heightened response to odor cues in the first few hours after birth. When one of the mother's/birthing parent's breasts is washed after birthing 22 out of 30 infants preferentially self-attached to the unwashed breast.

The Calming Effect of Human Milk

ExternalThe Calming Effect of Maternal Breast Milk Odor on Term Infant: A Randomized Controlled Trial[link: https://www.liebertpub.com/doi/10.1089/bfm.2020.0116]

In particular, the olfactory system is more susceptible than the other senses at birth. In a few short minutes after delivery, the head of a human newborn spontaneously turns to the maternal chest and makes a directional leaning toward the mother's nipple to start sucking. There is proof that the odor of newborns' mothers, especially maternal milk odor, obviously and positively affects the behavior of newborns.

ExternalThe Impact of Preterm Infants' Continuous Exposure to Breast Milk Odor on Stress Parameters: A Pilot Study[link: https://www.liebertpub.com/doi/10.1089/bfm.2017.0188]

Preterm infants exposed to BM odor from their own mothers demonstrate a persistent decrease in saliva cortisol levels, which continues after termination of the intervention. This finding may suggest that exposure to own mothers' BM odor has a soothing effect on preterm infants. Further randomized controlled studies are needed to evaluate this simple, safe, and inexpensive intervention.

Suctioning of the newborn

Oral aversion as an outcome of routine oropharyngeal or gastric suctioning or intubation is often cited by clinicians as a cause of breastfeeding difficulty, but little research is available to confirm this. What the research does show is that based on a review of the literature and current national and international guidelines, the conclusion is that routine use of Oronasopharyngeal suction after birth is not indicated for vigorous, term infants with clear or meconium-stained fluid and it may actually be harmful.

Fortunately routine oral and gastric suctioning is no longer recommended, its effects proving to be harmful to more than just the infant's ability to suck.

Wiping the normal newborn's face, mouth, and nose with a towel is all that is required at birth.

Gastric suctioning, involving the passage of a tube into the neonate's stomach and aspiration of the contents, has been linked to a delay in infant pre-feeding behaviours and an increased prevalence of functional intestinal disorders in later life.

Self-test Quiz

Note on parent vs. birthing parent, adoption, different family/gender

The Baby-Friendly Hospital Initiative global documents and resources foresee a scenario where the infant is gestated and born to a woman who is also genetically their mother and who will be their parent. While this is the most common situation you will encounter, it is worth keeping mind that families are created and live together in many different ways.PDF Step 2 Education's Inclusivity Statement[link: https://static.step2education.com/m/Inclusivity_Statement.pdf]

It will not always be the case that the person who gives birth to the infant will be the one who will be their parent or the only or even primary parent who breastfeeds / chestfeeds or provides human milk. Skin-to-skin contact and early postpartum care will need to be adapted to the needs and plans of each family unit, while aiming to achieve a plan that meets global infant feeding recommendations of early initiation, exclusive breastfeeding to 6 months and continued breastfeeding to age 2 and beyond.

What should I remember?

  • where the normal place to care for a newborn is from immediately after birth and for several hours following
  • the behavioural state and physiological response of the infant who is wrapped up and separated from his/her birthing parent
  • the effect of separation of mother/birthing parent and infant, even for a short time, on his/her ability to breastfeed
  • that changing detrimental routine practices is possible when you work together

5.0 Special needs and infant challenges [Domain 6]

Challenges

When we apply the '10 Steps to Successful Breastfeeding' along with excellent prenatal care and postpartum support, we can expect that most parents:

  • are educated in breastfeeding skills and normal baby behavior,
  • have a healthy pregnancy and a normal labour without interventions, and
  • care for their babies in extended skin-to-skin contact

Our aim is for as many mothers, parents, and babies to receive all of those things to get off to the best start. For some families, that is not entirely possible and it is crucial to quickly identify those families who are going to require additional assistance from you to establish breastfeeding or chestfeeding.

Step 5. Support mothers to initiate and maintain breastfeeding and manage common difficulties

(New Zealand) Step 5: Support mothers to initiate and maintain breastfeeding and manage common difficulties, even when baby is unable to be with mother.

(Canada) Step 5: Support mothers/parents to initiate and maintain breastfeeding and manage common difficulties.

Points 4 and 5 of the Seven-point Plan for Sustaining Breastfeeding in the Community:
Point 4. Support mothers to establish and maintain exclusive breastfeeding to six months
Point 5. Encourage sustained breastfeeding beyond six months to two years or more, alongside the introduction of appropriate, adequate, and safe complementary foods.

Identified during pregnancy

Infant

  • twins, triplets, or more
  • neuromotor problems (eg. Down Syndrome)
  • facial or other abnormalities (eg cleft lip or palate)

Maternal

  • Diabetes (Type I, II, or gestational)
  • History of difficulty breastfeeding
  • History of breast reduction/surgery, chest injury, or radiation

Identified during birthing

  • intrapartum analgesics and/or anesthetics
  • birth trauma, assisted delivery (vacuum, forceps, or emergency c/section)
  • low Apgar Scores, required resuscitation
  • no or brief skin-to-skin care following birth
  • preterm (<34/6 weeks) or late-preterm birth (34/0-37/6)

Identified postpartum

  • small or large for gestational age
  • breast refusal or inconsistent ability to latch-on
  • hypoglycemia
  • hyperbilirubinemia
  • ankyloglossia
  • excessive sleepiness or irritability

When a referral is needed

  • Don't endanger breastfeeding by delaying referral.
  • Some conditions identified will require expertise beyond your own, or for a continuing period of time. Refer as early as possible to give them the best chance for breastfeeding success.
  • Early identification ensures assistance is directed where most needed.
Early support is essential

Early support is essential.
© Carole Dobrich

5.1 The 'late preterm' 'early term' baby

Infants born 34 weeks 0 days to 36 weeks 6 days gestational age are categorised as 'late preterm'. Infants born between 37 weeks 0 days to 38 weeks 6 days gestational age are categorised as 'early term'.

Definitions of gestational age periods from LPT to postterm. (Engle WA, Kominiarek M. Late preterm infants, early term infants, and timing of elective deliveries. Clin Perinatol. 2008;35(2):325&endash;341.)

Definitions of gestational age periods from LPT to postterm. (Engle WA, Kominiarek M. Late preterm infants, early term infants, and timing of elective deliveries. Clin Perinatol. 2008;35(2):325&endash;341.)

Infants born physiologically mature and capable of a successful transition to the extrauterine environment must be an important priority for the obstetric practitioner.

Late preterm and early term infants are at higher risk for short-term and long-term morbidities and mortality than term infants.

Yet those late preterm infants with no significant respiratory problems or other problems of prematurity are often cared for on the postnatal ward, with the temptation to treat them as you would a term baby. Called 'the great pretenders', these infants may present with subtle immaturity that requires a trained eye to detect, and proactive management to prevent subsequent problems.

Some problems these infants may encounter:

  • Respiratory instability and interrupted lung development
  • Poor ability to clear normal lung fluid (particularly if delivered by elective, pre-labour caesarean section)
  • Increased incidence of apnoea
  • Little respiratory reserve
  • Temperature instability
  • Less glycogen and brown fat stores available to protect against hypoglycemia
  • Reduced ability to conjugate and excrete bilirubin, increasing need for phototherapy to treat jaundice
  • Neurological immaturity
  • Poor state regulation - may go from hyper-alert to deep sleep without intervening stages
  • Easily overstimulated, then exhausted - may fall asleep before full breastfeeding taken
  • Lower tone
  • Reduced immunological competence.Keeping mother and infant together reduce the risk of infections.
  • Poor breastfeeding establishment and increased breastfeeding-associated re-hospitalisations6
  • Higher mortality throughout infancy
  • Higher incidence of mental and physical developmental delay at 24 months

Don't be complacent

These babies are NOT term babies. They may initially appear to cope well but exhibit decreasing stamina and ability after several days - watch them closely!

Remember: Late preterm = Great Pretenders

Preterm infants, rely on health care professionals to assess their growth and provide appropriate medical care and nutritional guidance. The WHO growth standards start at term and although they are recommended for preterm infants once they reach this age, they do not provide preterm infant growth assessments prior to term.

The Fenton growth chart for preterm infants has been revised to accommodate the World Health Organization Growth Standard and reflect actual age instead of completed weeks, in order to improve preterm infant growth monitoring.

Access to the Fenton growth charts can be found at External https://live-ucalgary.ucalgary.ca/resource/preterm-growth-chart/preterm-growth-chart[link: https://live-ucalgary.ucalgary.ca/resource/preterm-growth-chart/preterm-growth-chart]

Postpartum care

Initial treatment should be no different from any other infant:

  • Skin-to-skin contact immediately after birth - initial resuscitation, drying, and observations occurring on mother's chest.
  • Leave in skin-to-skin contact until after the first breastfeeding, and keep the infant skin-to-skin whenever possible.


© Health e-Learning-IIHL

Remember!

Skin-to-skin care will provide:

  • Optimal physiological stability
  • Temperature stability
  • Improved oxygen saturation and gas exchange
  • Enhanced immune protection (colonization with mother's normal flora; maternal antibody development targeted to baby's needs)
  • Decreased crying
  • Increased opportunities to breastfeed
  • Improved milk production
  • Enhanced maternal-infant bonding
  • Longer exclusive and total breastfeeding
  • Book a follow-up appointment for 24 - 48 hours after discharge for a reassessment ofthe infant and the feeding plan.

Lactation Management

The importance of breastfeeding for a preterm infant is even more significant than for full term infants. Yet it is the very nature of the immaturity of the preterm and late preterm that creates breastfeeding challenges. Poor stamina, low tone, difficulty with latch and suck all contribute.

Additional skills you may need:

how to teach hands-on pumping, and knowledge of its effect
how to teach body and jaw support during breastfeeding for an infant with hypotonia
how to teach breast compression and massage
the use of some lactation aids, eg a nipple shield (with caution) or an at-breast tube feeding device (eg SNS)

Refer early to an IBCLC for discharge planning and follow-up where feasible.

Hands-on pumping

Hands-on pumping

Hands-on pumping.
© Cecilia Finoli

Click on the link below from the Stanford School of Medicine website where you'll be able to access a 9.5 minute video that will teach you about 'hands-on pumping' and how to do it.

Externalhttp://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html[link: http://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html]

What signs of late prematurity are evident in this 35wk gestation infant?

What signs of late prematurity are evident in this 35wk gestation infant? .
© Michelle Pensa Branco

What should I remember?

  • The infant feeding cues.
  • How to teach parents to recognise milk transfer.
  • Expectations about the frequency of breastfeeding.
  • When and how to begin complementary feeding.

Skills Competency

If you are working with infants with special needs please take the time to download and review the information in the skills competency. You can then ask a colleague or supervisor to confirm your competencies in this area related to knowledge, skills, and attitude.

When you have successfully completed this topic and practiced what you have learned you will be ready to do your Skills Competency. Click on the title of this box to downloadPDF Domain 6 Helping Mothers and Babies with Special Needs [link: https://static.step2education.com/docs/Skills_Competency_Domain_6_Helping_Mothers_and_Babies_with_Special_Needs_USA.pdf]competency form for you to complete with your Supervisor.

Continued education of interest

For continued education on this topic consider the lecture CE43 Breastfeeding the Late Preterm and Early Term Infant.

5.2 Ankyloglossia

Ankyloglossia (tongue tie)

The lingual frenulum is a mucous membrane that attaches to the floor of the mouth under the tongue and stabilizes it. Ankyloglossia is a congenital anomaly characterized by an abnormally short lingual frenulum due to an excess of residual embryonic tissue. During fetal development, the tongue is fused to the floor of the mouth. During the process of apoptosis, the tongue detaches and becomes mobile. If there is incomplete detachment, this is called ankyloglossia. Since there is no consensus on diagnostic criteria across studies and the definition is not standardized, the incidence of ankyloglossia can vary from 4% to 11%.

Note the short, thick lingual frenulum restricting the degree the infant can lift his tongue.

Note the short, thick lingual frenulum restricting the degree the infant can lift his tongue.
© Carole Dobrich

A short or tight lingual frenulum can restrict tongue mobility to varying degrees and may prevent the infant from extending the tongue fully over the bottom gum line or elevating the tongue (both essential actions for breastfeeding).

Ultrasound imagery has demonstrated that in order to breastfeed effectively and comfortably, the tongue must use complex movements to create the necessary movement to extract milk without causing friction on the nipple and breast. In addition to discomfort and/or pain at the breast, other problems can be associated with tongue tie:

  • inadequate latching
  • incomplete drainage of the breast, which can lead to ductal blockages or mastitis
  • long and ineffective feedings, irritability of the baby at the breast, dissatisfaction of the baby after feedings
  • nipple injuries or infections, a feeling that the baby is biting during feeding
  • decreased milk production, and inadequate weight gain in the baby
  • early weaning from breastfeeding in the mother

While tongue tie can sometimes be assessed visually (as in the photo above), the point of attachment is not necessarily indicative of the degree to which breastfeeding is affected.

Recommendations

According to the Canadian Paediatric Society recommendations, a frenotomy is not routinely recommended in all cases of ankyloglossia. A frenotomy may be recommended when there is a clear association between a restrictive tongue-tie and major breastfeeding problems. The Academy of Breastfeeding Medicine suggests that a frenotomy should be considered when there are persistent breastfeeding problems (such as nipple pain or inadequate latch) that are not resolved with timely conservative management. Frenotomy should always be a shared decision between the health care professional and the parents.


© Carole Dobrich


© Dale Hansson


© Carole Dobrich


© Carole Dobrich

As you can see in the photos above, tongue tie can present in multiple ways and assessment must always include an oral exam and a full observation of feeding (preferably by an experienced practitioner) before making any recommendations.

Treatment

Frenotomy

Even though frenotomy is a simple surgical procedure to release the restriction, providing greater tongue movement and an improved breastfeeding outcome, parents need to be provided with evidence-based information to be able to make that informed decision. This is part of the informed consent.

The following outcomes of frenotomy have been described:

  • Reduced maternal nipple pain
  • Improved milk transfer
  • Reduced length of feeding times
  • Improved infant weight gain
  • Improved maternal breastfeeding self‐efficacy
  • Improved breastfeeding outcomes
Supportive team care

While frenotomy will correct the anatomy, breastfeeding difficulties associated with tongue tie also involve behavioural and physical adaptations that the infant (and parent) have developed while the tongue tie was restricted. Offering a team approach of trained IBCLCS, physiotherapists, and other bodyworkers will help the dyad return to a state of full functionality and comfort.

When tongue-tie is noted ...

And in the presence of breastfeeding difficulties

  • Refer the mother/lactating parent and their infant to a health professional who has experience assessing tongue ties and performing frenotomy.

Unfortunately, even when obvious breastfeeding difficulties are affecting both mother/lactating parent and baby related to tongue tie, some health professionals may still refuse to treat ankyloglossia.

What should I remember?

  • Not always necessary to treat
  • Many infants with tongue-tie will not need an intervention
  • It is important to fully assess the infant and observe and evaluate a complete feeding
  • Look at the tongue function and not just at the anatomy
  • Always start with good basic breastfeeding guidance (skin-to-skin and self-latching)
  • Provide positive lactation support
  • Try conservative methods first
  • It is still controversial
  • It is an intervention
  • Further education is needed
  • More research is needed
  • Ask the following questions “Is it causing a breastfeeding problem?”, "have other possible reasons for a breastfeeding problem been ruled out?"
    • If yes...what are the risks of not doing the procedure for the breastfeeding dyad?
    • Informed consent is essential

6.0 Managing common difficulties

Step 5: Support mothers to initiate and maintain breastfeeding and manage common difficulties

(Canada) Step 5: Support mothers/parents to initiate and maintain breastfeeding and manage common difficulties.

(USA) Step 5: Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.

Point 4 of the Seven-point Plan for Sustaining Breastfeeding in the Community: Support mothers to establish and maintain exclusive breastfeeding to six months

6.1 Engorgement

Engorgement

In this topic I'd like you to understand the difference between the normal breast fullness associated with the milk "coming in" and the pathological and preventable event which is breast engorgement.

Breast fullness

It's because of the placenta!

When the placenta is delivered the progesterone it had been producing ends.

Progesterone blocks milk production.

  • progesterone levels fall when the placenta is delivered - no longer inhibiting milk secretion
  • prolactin, which is essential to 'make milk' was already in high concentration in the mother/lactating parent's blood stream
  • lactose secretion into the alveoli of the breast increases, osmotically drawing in water to increase milk volume

There is also a marked increase in blood flow and lymphatic activity in the breast. These changes will occur whether breastfeeding is initiated or not.


© Photo: Tracey Foster

Secretory activation (lactogenesis II) occurs biochemically at about 30 - 48 hours postpartum. The clinical onset experienced as 'the milk coming-in' is reported to occur around postpartum Day 2 - 3, with wide individual variation (1hr - 6 days).

Stage II lactogenesis (secretory activation) starts with copious milk production after delivery. With the removal of the placenta at delivery, the rapid drop in progesterone, as well as the presence of elevated levels of prolactin, cortisol, and insulin, are what stimulate this stage. Usually, at days 2 or 3 postpartum, most women experience swelling of the breast along with copious milk production. In primiparous women, the secretory activation stage is slightly delayed, and early milk volume is lower. Lower milk volume is also observed in women who had cesarean births compared with those who delivered vaginally. Late onset of milk production has also been seen in women who have had retained placental fragments, diabetes, and stressful vaginal deliveries.

Signs and Symptoms

Increasing milk volume is reported as:

  1. breast tingling
  2. breast fullness
  3. milk leakage
  4. physical appearance of milk
  5. change in infant swallowing pattern while feeding, and cues to feed.

These are all normal and manageable events. Frequent, effective milk removal will make this transition comfortable while meeting the changing needs of the infant.

Engorgement

Engorgement is ...

...the swelling and distension of the breast, usually in the early days of initiation of lactation, caused by vascular dilatation as well as the arrival of the early milk.

However, ...

Breast engorgement is not an inevitable part of early lactation. It is a distinct condition that can share some of the same clinical features as mastitis spectrum disorders.

Engorgement causes:

  • pain, discomfort, and sometimes misery for the mother/lactating parent

If not effectively treated it can result in a mastitis spectrum disorder:

  • blocked ducts
  • mastitis
  • low milk supply
  • premature weaning

This preventable condition should be rare in units that implement good breastfeeding standards.

Signs and Symptoms

If normal breast fullness progresses to engorgement the signs and symptoms include:

  • swollen breasts; tight, shiny skin
  • generalized pink or redness of both breasts
  • mild to severe pain
  • heat is increased in both breasts
  • difficulty latching baby effectively and achieving milk removal
  • mild pyrexia (fever)

Some of the early postpartum engorgement symptoms may appear similar to those of early inflammatory mastitis. However, postpartum engorgement results from the secretory activation (lactogenesis II) stage of lactation and is related to interstitial oedema and hyperemia (congestion).
It is bilateral in presentation and includes breast pain, firmness, and swelling occurring generally around 3 and 5 days postpartum. On rare occasions, it may be as late as day 9 or 10 (delayed lactogenesis II) and, therefore a delayed presentation.

Cause

  • Milk stasis in the breast
    • poorly latched infant, or ineffective suckling
    • reduced breastfeeding?
    • giving additional fluids to baby, that delay feeding cues
    • using pacifiers/dummies to delay feeds
    • 'skipping' feeds, particularly night feeds
    • not expressing when breastfeeding is ineffective
  • Overhydration of IV fluids during labor
  • Low serum albumin

Why does this happen?

When one or more of the changes that occur at secretory activation is abnormal it creates a spiral of events.

  • delayed, ineffective, or infrequent milk removal => blockage of capillaries and slowed venous return => breast swelling and tissue oedema => difficult milk removal ... and so on.
  • breast swelling and tissue oedema (from overhydration with IV fluids in labor) => difficult milk removal => blockage of capillaries and slowed venous return => tissue oedema ...

Engorgement can be prevented by implementing good breastfeeding practices.

      • Minimize use of intravenous fluids during labour
      • early initiation of breastfeeding - more breastfeeding in the first 48 hrs is associated with less engorgement?
      • baby well latched to the breast
      • frequent feeds day and night
      • finish feeding on one breast before offering the other side
      • if baby not feeding, hand express every few hours from the time of birth


      © Photo: UNICEF


      © Photo: Carole Dobrich


      © Photo: Tracey Foster


      © Photo: Tracey Foster

      Don't be fooled

      Breast fullness is normal. Engorgement is not.

      Engorged, painful breasts are not a sign of a good milk supply. It usually indicates that breastfeeding practices have been poorly initiated, and proactive management will be required to retrieve the situation.

      Breast engorgement is common, but preventable in most cases.

      Clinical Management

      This painful condition can be resolved with diligent attention to:

      • Effective removal of milk
        • Use reverse pressure softening of the areola and if necessary hand expression or a manual pump to remove small volumes of milk before the infant latches as this can help facilitate physiological milk transfer.
        • Encourage the mother/lactating parent to breastfeed her baby often.
          • Encourage rooming in, breastfeeding/chestfeeding and avoid pumping where possible
          • Ensure the infant is well latched onto the breast.
          • Allow the baby to feed as long as he will on one side before offering the other side, optimizing drainage.
        • Hand express milk, if necessary.
          • If the baby is not transferring milk effectively or the dyad is separated
          • After feeding: If breasts are still uncomfortably tight, express enough to achieve comfort.
            If the baby does not breastfeed on the second side, hand express milk from that side until comfortable to prevent engorgement from getting worse.
        • When breasts are particularly full, stimulate a milk ejection by gentle massage/compression. Apply gentle compression anywhere on the breast with the palm of the hand. This gentle pressure may help the milk flow freely from the nipple without having to hand express when the mother/lactating parent is experiencing a lot of pain.
        • Try lymphatic drainage to alleviate oedema and consider using ice for symptomatic relief.

      There is some evidence to suggest that some treatments may be promising for the treatment of breast engorgement, such as cabbage leaves, cold gel packs, herbal compresses, and massage, but more studies are needed for the true effect of these interventions to be known.

      Will expressing increase milk production?

      Ideally, milk production will increase daily until peak milk volume is reached in the early weeks postpartum.

      Until engorgement is resolved:

      • breastfeed to meet the infant's needs (effectively and frequently)
      • if breasts are still uncomfortably full, hand express until comfortable (not empty!)
      • between feeds when breasts are uncomfortably full, hand express until comfortable (not empty!)

      Milk removal in addition to the immediate needs of the baby should only be enough to achieve breast comfort. Overdoing milk expression now will not make up for less milk removal later and may create unnecessary difficulties.

      As venous congestion reduces and the infant's needs increase, additional milk removal will not be required and the breast will tailor milk production to the infant's needs.

      Reassure the mother/lactating parent that this management will assist in faster resolution of her engorgement. Failure to diligently attend to these strategies will prolong the discomfort, initiate involution, and risk low breastmilk supply.

      • Reduce tissue swelling
        • A Cochrane Review of management of breast engorgement? found:
          • For breast hardness, cold gel packs may be more effective than routine care.
          • There is no difference between treatment with cold packs or cabbage leaves. Both were equally effective in relieving pain but there was no strong evidence that interventions resolved symptoms faster than with no treatment.
          • Acupuncture gave a greater improvement in symptoms in the days immediately after the treatment.
        • The underlying principle for the use of cold is to initiate vasoconstriction, decreasing venous congestion and reducing interstitial oedema.
          • Depending on the degree of engorgement, the cold compresses may need to be replaced frequently (e.g. 20 mins on, 20 mins off, and repeat several times)
          • Apply cold compresses to both breasts immediately after breastfeeding/expressing.
        • Certain non-steroidal anti-inflammatory drugs are very effective.

      Therapeutic ultrasound was found to be of no benefit in a randomized, controlled, double-blind trial.

      There is insufficient evidence from trials to support the widespread implementation of a particular treatment for breast engorgement. At the same time, treatments such as cold packs, massage, herbal compresses or cabbage leaves applied to the breast may be soothing, are unlikely to be harmful, are inexpensive and readily available.

      Heat or cold?

      Heat increases blood flow to the breast and the movement of fluid into the tissues to further exacerbate the engorgement. Avoid standing under a hot shower or soaking the breasts in warm water during this period of engorgement.

      Cold reduces the blood flow to the breast reducing swelling (interstitial fluid causing edema flows away from the breast via the lymphatic system).

      Mother/lactating parents usually prefer the feeling of cold, but it is important to individualize your management and be responsive if a mother/lactating parent finds this to be unpleasant.

      Areolar oedema/edema

      When breast engorgement is so severe that the areolar is edematous, latching the baby onto the breast for effective breastfeeding is impossible. Methods have been described to assist the movement of this interstitial fluid to make latching possible.

      Read this interesting article

      Click on the following link and read the 2021 study ExternalEffectiveness of Reverse Pressure Softening of Areola in Women with Postpartum Breast Engorgement.[link: https://medicopublication.com/index.php/ijpot/article/view/14513/13148]

      Print out the handout on ExternalReverse Pressure Softening [link: https://kellymom.com/bf/concerns/mother/rev_pressure_soft_cotterman/]by Jean Cotterman and file it in your Workbook.

      Share these papers with your colleagues who may be working with women experiencing this type of engorgement. Ask the mother/lactating parents about their feelings about the usefulness of this technique. When you are proficient at it you will be able to describe its application over the phone to mother/lactating parents with difficulty at home.

      Additional strategies include

      • lie mother/lactating parent on their back and using light stroking movements, very gently move the fingers along the breast away from the nipple, towards the axilla; aiding lymphatic drainage
      • baby has to be ready to feed immediately after this drainage because the fluid will return very quickly
      • hand express if the baby not available to suckle. DO NOT use a breast pump ... this increases the edema.

      PDFABM Clinical Protocol #20: Engorgement, Revised 2016[link: https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/20-engorgement-protocol-english.pdf]

      The Basics of Breast Massage and Hand Expression from Maya Bolman

      What should I remember?

      • How secretory activation is initiated.
      • The difference between normal breast fullness and breast engorgement.
      • Breastfeeding practices which increase or decrease the likelihood of engorgement.
      • Management to assist the resolution of engorgement.
      • What will happen if engorgement is not quickly and effectively resolved.
      • Have an awareness of areola edema and overactive milk production.

      6.2 Hyperlactation

      Hyperlactation

      Oversupply - too much milk!

      In everyday language, the issue of "too much milk" may be referred to as overproduction, overproduction syndrome, or an overabundant milk supply. In lactation literature, overactive production by the milk-producing glands during lactation may also be called hyperlactation or hyperlactation syndrome.

      Hyperlactation, also termed hypergalactia or ‘‘oversupply,’’ is the production of breast milk in excess of the volume required for growth of healthy infant(s) based on international standards.

      Parents with oversupply are usually very uncomfortable with large, swollen breasts, leaking milk, and an abundant milk supply. The baby may appear to gulp milk during feeding or develop poor breastfeeding technique, slipping off the nipple in an attempt to not have to consume so much.

      But why does it happen? Breastfeeding mismanagement can contribute to why this might occur. It can be self-induced by the mother/parent concerned about possibly not enough milk and therefore stimulates the breasts and/or takes herbal galactagogues to produce more milk than the infant requires. It can also occur when health care professionals through their recommendations contribute to an excessive milk production. Recommending pumping in addition to breastfeeding, and galactagogues may be appropriate in certain situations yet without close follow-up and guidance about cessation, this if not closely monitored can lead to iatrogenic hyperlactation. Idiopathic hyperlactation refers to a mother/parent with a high rate of milk production with no clear etiology. With guidance, health professionals can help with prevention by using good counselling skills about breastfeeding and encouraging breastfeeding self-efficacy.

      Signs and Symptoms of Hyperlactation

      Signs and Symptoms of Hyperlactation that may be experienced by the breastfeeding/chestfeeding dyad.

      Mother/lactation parent

      Excessive breast growth during pregnancy >2 cup sizes
      Persistent or frequent breast fullness
      Breast and/or nipple pain
      Copious milk leakage
      Recurrent plugged ducts
      Recurrent mastitis
      Nipple blebs
      Vasospasm

      Infant

      Excessive weight gain
      Difficulty achieving a sustained, deep latch
      Fussiness at the breast
      Choking, coughing, or unlatching during feeds
      Breast refusal
      Clamping down on the nipple/areola
      Short feedings
      Gastrointestinal symptoms (e.g., spitting up, gas, reflux, or explosive green stools)


      Leaning back in the laid back position such as in this image (using gravity) may help the infant cope better with the milk flow and volume.

      Leaning back in the laid back position such as in this image (using gravity) may help the infant cope better with the milk flow and volume.

      Clinical management

      Management of hyperlactation.

      • Block feeding for 24-48 hours under close supervision by experienced lactation support professional.
      • Herbal remedies may include sage, jasmine flowers, and chasteberry to reduce milk production.
      • Prescription medications may include pseudoephedrine and oral contraceptives (oestrogen) under medical supervision.
      • Dopamine agonists such as bromocriptine or cabergoline can possibly be utilized under medical supervision if hyperlactation persists despite all other interventions.
        • CAUTION as these medications have a long half-life, there are concerns about the side effects, and can lead to suppression of lactation.

      What is Block Feeding?

      Block feeding is to restrict breastfeeding to one breast for a set number of feedings or a set amount of hours and then change to the other breast for a set number of feedings or a set amount of hours.

      "Close monitoring on an individualized daily or weekly basis can help ensure adequate infant growth and reduce maternal complications. Block feeding must be discontinued in the event that milk production falls below the infant’s needs."

      [link: https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/1746-4358-2-11]

      Full drainage and block feeding method (FDBF)[link: https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/1746-4358-2-11]

      van Veldhuizen-Staas described the full drainage and block feeding method (FDBF) in the publication called ExternalOverabundant milk supply: An alternative way to intervene by full drainage and block feeding[link: https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/1746-4358-2-11]. Take the opportunity to review this article.

      Herbal therapies

      There are a number of herbal therapies suggested for decreasing milk production. Many are anecdotal without readily available published research. Research has found that jasmine flowers used topically were an effective and inexpensive method of suppressing puerperal lactation and could be used as an alternative in situations where cost and nonavailability restrict the use of dopamine agonists.It is important to remember there are also traditional or cultural treatment or practices families might use.

      [link: https://www.bfmed.org/assets/DOCUMENTS/PROTOCOLS/Protocol%20%2332%20-%20English%20Translation.pdf]

      ABM Clinical Protocol #32: Management of Hyperlactation[link: https://www.bfmed.org/assets/DOCUMENTS/PROTOCOLS/Protocol%20%2332%20-%20English%20Translation.pdf]

      Take the opportunity to read, print out or save the PDF - PDFABM Clinical Protocol #32:Management of Hyperlactation[link: https://www.bfmed.org/assets/DOCUMENTS/PROTOCOLS/Protocol%20%2332%20-%20English%20Translation.pdf] and keep it for future reference. It is for the medical profession yet has lots of helpful information.

      What you should remember

      • Hyperlactation can be self-induced, iatrogenic, or idiopathic.
      • Prevention is the first step when possible
      • Block feeding with close supervision
      • Dopamine agonists should be reserved for cases that do not resolve with other treatments and used with caution and close suppervision.

      7.0 Supplementation

      Step 6 of the Ten Steps to Successful Breastfeeding (revised 2018):

      Step 6: Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.

      (Canada) Step 6: Support mothers/parents to exclusively breastfeed for the first six months unless supplements are medically indicated.

      (New Zealand) Step 6: Avoid giving breastfed newborns any food or fluids other than breastmilk, unless clinically indicated.

      Point 4 of the Seven-point Plan for Sustaining Breastfeeding in the Community:

      Point 4. Support mothers to establish and maintain exclusive breastfeeding to six months

      Human milk substitutes

      Human milk substitutes (including infant formula, water, or glucose water) interfere with the infant's ability to learn to breastfeed and the establishment of lactation. There is a significantly higher rate of premature weaning amongst infants who are given human milk substitutes in the early postnatal days.

      Colostrum is essential for gut protection, growth, and repair as well as the establishment of the bifidobacterium environment. Colostrum aids the expulsion of meconium which reduces enterohepatic circulation of bilirubin. Human milk substitutes do none of these things.

      [link: https://feedthebabyllc.com/wp-content/uploads/2013/02/formulaprepstepbystep.pdf]

      Preparing powdered human milk substitutes as safely as possible[link: https://feedthebabyllc.com/wp-content/uploads/2013/02/formulaprepstepbystep.pdf]

      Click on the title above. This links to a leaflet for mothers/parents that describes, with very good graphics, how to safely prepare human milk substitutes. Read the leaflet, print it out, and file it.

      Go through the leaflet or a similar one that your hospital or clinic may use, as you demonstrate to a mother/parent how to prepare the formula. Then, most importantly, ask for a return demonstration on making up another bottle of formula, confirming that the instructions are understood at each step of the process.

      Note the minimum temperature of the water at the time the powdered formula is added - this minimum temperature is necessary to kill bacterial contaminants (70 degrees Celsius or 158 degrees Fahrenheit). The prepared formula must be cooled before giving to the infant.

      Self-test quiz

      The decision to introduce any supplement other than human milk is a serious one that must weigh the risks of infant formula feeding and the benefits of breastfeeding should be weighed against the risks posed by the presence of the specific condition listed. These are based on the PDFWHO's recommendations.[link: https://apps.who.int/iris/bitstream/handle/10665/69938/WHO_FCH_CAH_09.01_eng.pdf] This document called PDFMedical Indications for Supplementation by the Breastfeeding Committee of Canada[link: https://breastfeedingcanada.ca/wp-content/uploads/2021/04/Medical-Indications-for-Supplementation-April-14.pdf] may also be helpful in guiding decision-making about supplementation.

      Infant Indications

      Infants with specific inborn errors of metabolism (eg: classic galactosemia, maple syrup urine disease, phenylketonuria) will require lifelong special diets, including specialized infant formula. In the case of phenylketonuria, partial breastfeeding is possible and should be encouraged. Lactating parents should be encouraged to maintain their milk supply through the planning so that they have all options open to them as their infant's feeding plan is finalized.

      Infants with very low birth weight (<1500g) or who are before 32 weeks gestational age may require donor human milk until their parent can produce their full intake and may also require some specific nutrient fortification.

      Infants at risk of hypoglycemia and who fail to respond to human milk feeding may require short-term supplementation with human milk substitutes. Donor human milk should be offered wherever possible in these cases.

      Maternal Indications

      There are few medications routinely administered to healthy adults of child-bearing age that pose a risk to the breastfeeding infant. Where there are concerns, safe alternatives often exist or dosing and treatment length can be adapted to minimize the risk while maintaining some or complete breastfeeding.

      If treatment can be delayed, an older infant will generally be more able to metabolize any medications that pass through the milk and also be less severely impacted by reduction or elimination of breastfeeding.

      A few drugs and treatments, such as cytotoxic chemotherapy and radioactive iodine are firm contra-indications regardless of the age or amount of breastfeeding. Some recreational drugs, but not all, are also an absolute contraindication, such as cocaine and heroin. If you are interested to learn more you can listen to this conversation with Dr. Lisa Graves "ExternalPregnancy and postpartum substance use[link: https://www.youtube.com/watch?v=25oGaoPnNHg]"

      Pregnancy and substance use.
      © Health e-Learning-IIHL

      Supplementing the breastfed infant

      When breastfeeding alone is insufficient or temporarily not possible, the choice of supplement should be, in order of preference:

      1. The mother's/parent's own expressed milk, if it is available and suitable.
      2. Donor human milk - from another healthy mother/parent or human milk bank
      3. Commercial infant formula

      PDFInformal (Peer-to-Peer) Milk Sharing: The Use of Unpasteurized Donor Human Milk[link: http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/HealthPromotion/InformalMilkSharing_PracticeResource.pdf]

      How much supplement should be given?

      Your goal is to give the infant as much as he would normally have taken at the breast. ie 2 - 10ml per feed in the first 24 hours; 5 - 15ml per feed in the second 24 hours; 15 - 30ml per feed between 48 and 72 hours of age and 30 - 60ml per feed from 72 - 96 hours of age.

      How should this supplement be given?

      Tube-device at the breast, cup feeding, finger-feeding, syringe feeding, spoon feeding, dropper feeding, and bottle feeding are all alternatives available, with bottle feeding being the least desirable for promoting normal infant feeding behaviours.

      The following methods are detailed in the following topic pages.

      • Feeding-tube device at the breast
      • Cup feeding
      • Finger feeding
      • Bottle feeding

      Drip drop feeding

      What effect do supplements have?

      The WHO strategy states that infants who are not breastfed should receive special attention from health systems as they constitute a group at risk for growth and health problems.

      Short-term effect on the mother/lactating parent

      A loss of maternal self-confidence occurs when supplements are given without a valid medical indication.

      The reduced breast stimulation and reduced milk removal that occurs as a result of the infant being given supplements results in

      • An increased incidence of breast engorgement, and
      • More severe engorgement can cause breast involution and the failure of adequate lactation. Early, frequent milk removal is pivotal to the success of breastfeeding in the coming weeks.
      • Shorter duration of lactational amenorrhoea

      Short-term effect on infant health

      Infant ability to suck at the breast can be disturbed as they learn a different sucking technique.

      Supplements change the normal flora of the intestine, increases gut permeability and decreases gut motility.

      Commercial infant milk can be contaminated during manufacture and preparation, and the feeding implements can introduce another source of infection.

      Protective properties in human milk, such as lactoferrin, are inactivated by commercial infant milk.

      Effect on digestion and absorption

      Commercial infant formula is poorly digested and absorbed compared to human milk as

      • There is a normal immaturity of digestion and absorption at birth
      • Human milk contains enzymes to aid digestion (eg lipase) that are not in infant formula
      • Human milk macronutrients are in easily digested form,unlike the macronutrients in infant formula
      • Absorption of minerals is enhanced by human milk 'transporters'

      Effect on serum glucose levels

      Serum glucose levels normally drop to their lowest levels at about 2 hours of age, stimulating the infant's physiology to mobilize other sources of energy ensuring euglycemia is achieved and maintained for up to 24 hours, irrespective of oral intake.

      Giving babies glucose water or commercial infant formula interferes with this normal physiological process and may result in further interventions being required.

      Effect on jaundice

      Likewise the normal physiology of bilirubin metabolism is interrupted when artificial supplements are given. Reduced breastfeeding frequency and supplementation with water or glucose water have been associated with increased serum bilirubin concentrations in the first 5 days of life Lack of early feeding delays passage of meconium and increases enterohepatic reabsorption of bilirubin.

      Increased breastfeeding is the best way to treat the additional insensible water loss that is caused when phototherapy is required.

      Effect on atopic disease

      Even just one or two commercial infant milk feeds at this time may result in the development of cow's milk intolerance or cow's milk allergy, which will become symptomatic later in infancy.

      Effect on breastfeeding

      The use of supplements during the hospital stay (and afterwards) is closely associated with earlier cessation of exclusive breastfeeding and earlier weaning.

      Breastfeeding is negatively affected when formula is used, even in hospitals where educational materials, counseling, support and policies are generally favorable to breastfeeding. Research was conducted in a unit where nursing staff attitudes regarding breastfeeding were very positive with more than 80% reporting discussing the advantages of breastfeeding routinely with mothers. However, 77% of mothers had started bottle-feeding 2 to 3 weeks after birth, the majority (93%) remembered which brand of formula was used to supplement their baby in hospital and most were using that brand.

      Parents may interpret the use of formula as an endorsement by hospital staff, despite clear verbal messages promoting breastfeeding.

      But the mother/parent requested a supplement ...

      Lack of understanding of normal newborn behavior, volume of human milk required in the early days and maternal fatigue are the major reasons mothers give for requesting a supplement.

      Education about newborn behavior and the importance of giving their infant only human milk change parental expectations and decrease requests for supplements.

      But what about maternal fatigue ...

      Time for some brainstorming!

      Brainstorm with your colleagues ways of supporting a tired mother/parent in hospital who has requested a supplement, or who, in the community setting, is wanting to give supplements to change the baby's behavior.

      Unit Activity

      Review your Unit's policy on supplementation AND common practices of the staff. Ensure that there are very clear policy guidelines for when a supplement is medically indicated. Discuss with your colleagues the implications for the dyad should they not follow this policy. You can review thePDF ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017[link: https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/3-supplementation-protocol-english.pdf].

      Do you have an "Informed Consent" form to ensure mothers/parents are aware of the risks of infant formula for non medical reasons?

      What should I remember?

      • the medically valid reasons for the use of human milk substitutes
      • the best choice of supplement when indicated, in order of preference
      • how best to give a supplement when it is required
      • how much supplement to give according to the age of the infant
      • the effects of supplements on the infant's health, the mother/lactating parent, and their ongoing breastfeeding relationship

      Self-test quiz

      Skills Competency

      If you are working with families needing to supplement their infants, please take the time to download and review the information in the skills competency. You can then ask a colleague or supervisor to confirm your competencies in this area related to knowledge, skills, and attitude.

      When you have successfully completed this topic and practiced what you have learned you will be ready to do your Skills Competency. Click on the title of this box to download Domain 6 Teaching formula preparation, supplementation, and feedingPDF [link: https://static.step2education.com/m/b/es/c/competencies_supplementation-formula_EN.pdf]competency form for you to complete with your supervisor.

      7.1 Feeding-line device at the breast or chest

      There are various types of feeding-line devices commercially available; they can also be improvised. The supplemental milk is contained in a soft pouch or bottle, and a length of fine, soft tubing reaches from the milk receptacle to the breast at the nipple/areolar complex.


      © Carole Dobrich


      © Carole Dobrich

      As the baby suckles at the breast with the feeding line also in his mouth, milk is removed from both the breast and the feeding-line device. This is an excellent method of providing supplemental milk:

      • avoids any possibility of suck confusion
      • stimulates milk production
      • enhances the infant's suck vigor by creating a steady milk flow, and
      • lessens the likelihood of breast refusal

      When to choose an at-breast feed line

      It may be very useful for:

      • newborn requiring supplementation for medical reasons
      • mothers/parents with a chronic low supply failing to thrive infants who are still willing to breastfeed
      • infants with low tone (primary hypotonia or secondary due to underfeeding)
      • some cases of breast refusal in the older infant who is frustrated with a slow milk flow

      Clinical tip

      Newborns learn that the breast is the place which provides all their needs. An at-breast feed line can rescue a breastfeeding relationship which is threatened by poor infant-breast association.

      Consider a feed line as a first choice rather than a last resort and become proficient with its use so that you can confidently assist mothers.

      How to use a tube-feeding device at the breast

      Assemble what you need

      • The feeding line device, assembled
      • The supplement
      • An alert baby who is willing to latch to the breast

      Applying the feeding tube

      7.2 Cup feeding

      Cup feeding is easy to perform by parents or health professionals. This method of supplementation causes infants minimal exhaustion and they quickly learn to lap or sip the milk from the cup.

      When a newborn cannot breastfeed cup feeding activates similar muscles to those used during breastfeeding much better than if bottle fed, and is therefore a better temporary substitute for breastfeeding.

      Preterm infants who are cup fed are more likely to maintain physiological stability including oxygen saturation, and be exclusively breastfed at hospital discharge, at 3 months of age and at 6 months of age than preterm infants who received bottles for required supplements.

      Father cup feeding his baby.

      Father cup feeding his baby.
      © McBeth used with permission

      When to choose cup feeding

      Cup feeding would be the first choice for an infant who requires supplemental feeding away from the breast, either because they are unable to achieve an effective latch or because they are separated from their lactating parent.

      How to cup feed

      Equipment

      • A small cup with a smooth edge
        • a plastic cup can be shaped slightly during feeding
        • a small glass, eg. a shot glass, is also quite suitable
        • cups for the purpose of cup-feeding babies are available commercially
      • the necessary supplement
      • a receiving blanket or something to wrap the baby in

      How to cup feed

      Special thank you to Magdalena Whoolery and Julie Fogarty for developing this poster

      Special thank you to Magdalena Whoolery and Julie Fogarty for developing this poster

      7.3 Finger Feeding

      Finger feeding involves the infant sucking on the 'feeder's' finger with a source of supplement being given alongside the finger as the infant sucks well.

      It is an alternative feeding method when an infant is unable to breastfeed.

      It can also be used for modification of an inappropriate sucking technique.

      In a NICU...

      Finger feeding is an effective way to increase sucking abilities, accelerate the transition to breastfeeding, and shortens the duration of hospitalization in preterm infants.

      The finger-feeding technique was shown to be a better feeding transition method regarding efficacy when compared with the cup feeding method, due to lower milk loss and fewer complication episodes.

      Finger feeding can be considered as an alternative to cup feeding.

      Finger feeding is easily taught to parents who can continue at home if necessary.

      When to consider finger feeding

      Finger feeding may be considered when:

      • the infant is unable to grasp the breast
      • the infant is refusing the breast
      • the infant is rousable but too sleepy for cup feeding
      • the mother/parent who has severely damaged nipples requiring an alternative feeding method during the healing process
        • this is helpful to the mother/parent and may also serve as a suck therapy for the infant during this time
      • as a 'pre-breastfeed' enticer for infants suffering from confusion or dysfunctional suck problems.

      How to finger feed

      Infant being finger fed human milk in an upright position

      Infant being finger fed human milk in an upright position.
      © J & B Eastgate

      Equipment

      • Milk receptacle or Syringe and/or feeding tube
        • feeding tube with one end placed in a milk receptacle (cup, open bottle, or bottle with teat upside down) OR
        • regular or periodontal curved tip
      • Supplement (human milk, or if unavailable commercial infant formula)
      • Pillow or towel roll
      • Gloves (for all except the infant's own parents)

      Preparation

      Wash hands. Health professionals don gloves. (Parents need not use gloves)

      Warm the supplement and pour into the milk receptacle or draw it up into the syringe. If a feeding line is being used - place it in the milk receptacle and tape distal end (tape is not always needed) to finger. If a syringe is being used attach the tube (be very careful with using a syringe).

      NEVER force the milk into the infant's mouth, allow the infant to suck in the milk, and explain this to the parents

      Support the infant on a pillow or on the lap of the feeder person.

      Utilize the same positioning principles as used when feeding at the breast:

      • Infant well supported down the back
      • Infant's body in alignment with his head; neck slightly extended

      Technique

      • The feeder uses their finger with the nail-side down and the soft pad of the finger to the palate.
      • The feeder's finger begins curled. Use the knuckle to gently stimulate the top lip and encourage tongue protrusion and gape.
      • Uncurl the finger under the top lip and introduce it along the palate.
      • Keep finger directly down midline during feeding.
      • Once sucking has commenced, insert the finger with the feeding tube or the syringe tip against the feeder's finger. (Note: if the feeding tube is being used it can also be gently slid in the corner of the mouth while the infant is sucking on the finger)
      • GENTLY push very small amounts of milk (approx 0.5ml) into the infant's mouth to stimulate continued sucking only if needed.
      • Follow infant's lead with sucking bursts - only push milk in when infant is sucking if needed, or stimulate suck recommencement by massaging the palate.
      • Suction generated by the infant's sucking will sometimes draw the milk from the feeding receptacle.

      8.0 Closing session

      Thank you for participating in MA03. We hope you have found it interesting, and that it has revitalized your desire to provide the best care for mothers/parents and infants.

      Take home messages

      • The BFHI/BFI initiative is an excellent way to support best practices and evidence-based care.
      • The infant feeding industry uses exploitative marketing and breastfeeding needs to be protected.
      • As health professionals, we have an obligation to meet our responsibilities under the International Code.
      • Skin-to-skin saves lives.
      • Mother/birthing parent and baby should NOT be separated after birth for any reason, other than a medical emergency.
      • Frenotomy should be considered when breastfeeding problems persistent that are not resolved with timely conservative management.
      • The decision to introduce any supplement other than human milk is a serious one and the risk-benefit must be weighed.
      • Cup, finger, and at-breast supplementation are alternatives to bottle feeding.
      • Hospital and community health practices have a significant impact on the success of breastfeeding.
      • Implementing the Ten Steps to Successful Breastfeeding or the Seven Point Plan to Protect, Promote and Support Breastfeeding ensures the best care is given to families.

      Your assessment quiz

      Now it is time to complete your assessment quiz. You will have 3 attempts and need a passing grade of 80%

      Your certificate

      Have you passed the Assessment Quiz yet? If you have Congratulations! You can now collect your Certificate and display it at your place of work.