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1.0 Why Breastfeeding is Important

Breastmilk and breastfeeding are not "special" - breastfeeding is just normal.

While breastfeeding is only normal, it is incredibly important for all humans.
Breastmilk is the natural first food for babies, with breastfeeding being the natural means of delivery of this food source. Breastmilk is the only single food that can meet ALL of the nutritional needs of a human for at least 6 months, and this is at a time when that human is growing at the fastest rate he will ever grow after birth.

When another source of milk or method of feeding is considered, the growth, health, development, and all other short- and long-term outcomes of the infant should be compared to 'the norm'. In this topic you will learn about the differences in outcomes according to feeding decision.

Breastmilk ensures normal growth and health by:

  • the completeness of its composition and the superiority of each of those components for growth and development (biochemistry); and
  • the ability of breastmilk to kill or inactivate pathogens, cause the infant to resist disease and allergies, and stimulate the infant's own immune defences (immunology)

How an infant is fed will have a life-long impact

Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice.1

AAP Breastfeeding Task Force

A kangaroo and her joey - There is no mammal species on earth, other than humans, that would trust the growth, development and health of their young to the milk of another species.

A kangaroo and her joey - There is no mammal species on earth, other than humans, that would trust the growth, development and health of their young to the milk of another species. .
Image © D.Fisher, IBCLC

What would you say?

A mother, pregnant with her second baby, says to you “I breastfed my first baby for 6 weeks then gave him infant formula. He's a beautiful, healthy little boy today. Is breastfeeding really worth all the effort it takes?

Notes

  1. # Section on Breastfeeding (2012) Breastfeeding and the use of human milk.

1.1 Biochemistry

Exclusive breastfeeding for the first 6 months of life provides all the nutrients and water that an infant needs to grow and develop. After 6 months, other nutritionally adequate and safe foods should be added to the infant's diet, with breastfeeding continuing to 2 years of age or beyond.1

The composition of breastmilk is relatively constant with minimal fluctuations caused by maternal diet, even when the mother's food intake is inadequate (eg famine). 2
Unlike the nutrition received by the fetus through the placenta, the nutrition received by breastfed infants is not dependent on the status of maternal metabolism.

For her own well-being a well-nourished woman should aim to consume an additional 500 kcal per day in the form of nutritious snacks. 3 Additional fluid requirements are met by recommending drinking sufficient water to avoid thirst. Consuming volumes of water in excess to needs will NOT increase breastmilk production. 4 5

a. Protein

Human milk contains approximately 9g/L of protein, decreasing as lactation progresses. 6 This is less than measured protein in cows milk, however it is of higher biological value and, obviously, perfect for a human infant. 7

Whey proteins form the predominant proteins in breastmilk - approximately 60%. Casein forms the remaining 40%. These values are approximate... some texts showing the ratio may be between 80:20 at different stages of lactation to 50:50 (in very late lactation).

The high concentration of whey proteins are digested quickly and easily in the infant's stomach. Breastmilk casein has a mainly nutritive function, providing minerals and essential amino acids to the infant.

Proteins in breastmilk also have other functions such as:

  • essential amino acids for growth
  • protective factors (eg. immunoglobulins, lactoferrin, etc.)
  • carriers for hormones (eg. thyroxine, cortisone-binding proteins)
  • carriers for vitamins (eg folate, Vit D, Vit B12 binding proteins)
  • enzymatic activity (eg amylase, lipase)
  • growth factors (eg insulin-like growth factor, epidermal growth factor)

Did you know...?

The high concentration of whey proteins and the soft, flocculent curds formed by breastmilk casein is the reason why breastfed babies do not get constipated. If a mother is concerned her baby might be constipated it is important to investigate the cause, because this is NOT normal for the (exclusively) breastfed baby.

Cow milk casein (the predominant protein in cow's milk) forms a tough, less digestible curd.


In the Journals

Several observational studies have shown an association between a high protein intake (>15 energy %) early in life and an increased risk of developing obesity and thereby non-communicable diseases (NCDs) later in life.
...
It is also plausible that an important reason for the slower growth in breast-fed infants is the lower content of protein breastmilk, but other qualities of breastmilk could also play a role.

A high intake of protein, especially dairy protein [in infant formula], stimulates the growth factors insulin-like growth factor (IGF-I) and insulin, and it has been suggested that the lower risk of NCDs in breast-fed infants is mediated through a regulation of IGF-I. 8

Nutr Metab Cardiovasc Dis. 2012;22(10)


Workbook Activity 1.1

This is the first of your Workbook Activities. Have you printed your Workbook yet? If not, return to the course information page, click on the link and print the Workbook. Fill out the activities as you progress through this course.

b. Carbohydrates

Lactose (milk sugar) is the principle carbohydrate in human milk. Lactose is the most stable component of mature breastmilk. Lactose is synthesized in the mother's breast and broken down by the enzyme lactase in the baby's small intestine.
The enzyme lactase breaks lactose into glucose and galactose, ready for absorption into the blood stream.

The role of lactose:

  • The rapid increase of lactose levels in colostrum at secretory activation (the milk 'coming in', also referred to as lactogenesis II) causes osmotic drawing of water into the breast secretion resulting in copious breastmilk production.
  • Provides energy to the body - and particularly to the rapidly growing infant brain.
  • Enhances absorption of calcium and iron.
  • Galactose is ultimately essential for development of central nervous system.

There have been around 130 different oligosaccharides (short chains of sugar molecules) identified in human milk.9 These important sugars comprise up to 1.2% of mature human milk, compared to only 0.1% of cow's milk. Their role is in protection of the infant from infections.

Food for thought...

At a concentration of 70g/L, human milk has the highest concentration of lactose of all the mammalian milks. Have you ever wondered why? Could it be because the human brain has the MOST growth of all mammal species to accomplish over the next two years and lactose contains elements essential to brain growth?

Consider what effects a lactose-free artificial infant formula could have on the infant fed on it. Discuss this with your colleagues.


Workbook Activity 1.2

Complete Activity 1.2 in your workbook.

c. Milk Lipids (fats)


Properties of milk lipids:
  • provide around half of the energy (kilojoules) in breastmilk
  • essential for the synthesis and development of retinal and neural tissues
  • are a rich source of the essential fatty acids linoleic acid and alpha-linolenic acid and their long-chain derivatives arachidonic acid (AA) and docosahexaenoic acid (DHA). DHA is essential for the developing visual system.

Milk lipids are the most variable constituent of human milk.

This variability is directly related to the amount of milk held in the breast at that time .
Milk removed when the breast is fullest has a low concentration of fat. Fat concentration increases in a linear fashion as more and more milk is removed. 10


© Dr Jacqueline Kent, Biochemistry and Molecular Biology, The University of Western Australia

Illustrated is a series of samples from an expression collected in 1mL fractions. The fat is seen as small clumps of white towards the top of each tube.
The samples are, in order from left to right, a fore-milk sample (hand-expressed), a stimulation sample (the first milk removed by the breast pump), 7 samples collected during the expression, and a final sample hand-expressed after pumping. The initial sample is 5.6% cream (fat) and the final is 18.3% cream (fat).

For this mother this represents a change in degree of breast fullness from 0.55 (about half full) to 0.0 (well-drained).11


Workbook Activity 1.3

Complete Activity 1.3 in your workbook.

Foremilk vs Hindmilk

Many misunderstandings surround the use of these terms. The milk available at the beginning of a breastfeed is sometimes known as foremilk, and hindmilk is often used to describe the milk consumed by the infant at the end of the breastfeed.

The only difference between foremilk and hindmilk is in fat content, with foremilk having a lower fat content than hindmilk at a given breastfeed. You have just learned that the fat content increases in a linear fashion as milk is removed from the breast during that breastfeed, therefore, the change from foremilk to hindmilk is not defined. Use of the terms 'foremilk' and 'hindmilk' may be misrepresentative.

Breastmilk storage capacity

Breastmilk is stored in the alveoli of the breast, and storage capacity of the breast is unique for every woman and every breast. Some mothers may have a large storage capacity, while others may have a very small capacity, and most women have differing capacity in each breast.12,13,14 You cannot accurately judge a woman's breast capacity visually - don't assume that a large breasted woman has a large capacity.

For a mother who has a large storage capacity the milk received by her baby while the breast is at its fullest will be low in fat. After breastfeeding several times the volume in the breast will be reduced and the fat content of subsequent feeds will be much higher. However, for the mother with a small storage capacity, her baby may remove all or most of the breastmilk at most feeds. The fat content of breastmilk at each feed will be similar.

Clinical Tip

Mothers should follow their baby's feeding cues. The mother with the smaller breastmilk storage capacity will find her baby will cue to feed frequently. The mother with the larger storage capacity may find her baby takes larger feeds and requests fewer feedings. Both babies may consume similar amounts of breastmilk over a 24-hour period and both will grow equally as well. Scheduling feeding may work for some babies but cause other babies to be very unhappy and cause failure to thrive.

Cholesterol

The level of cholesterol in breastmilk remains constant (10-20mg/dL) despite dietary manipulation of the mother's cholesterol intake. There is negligible cholesterol in artificial infant formula.

Cholesterol is required to build and maintain cell membranes. Amongst other important tissues it is involved in laying down the myelin sheath which covers the axons of nerve cells in the rapidly growing brain and spinal cord. Multiple sclerosis, a problem of myelinisation, is much more prevalent in countries where artificial infant feeding is common. 15,16

The high level of cholesterol in breastmilk appears to have a 'programming' effect on infants, protecting them from detrimental effects in later life, with adults who were artificially-fed having significantly higher total cholesterol levels and incidence of coronary heart disease. 17 18 19

d. Vitamins

Vitamin A
  • necessary for vision and maintenance of epithelial structures
  • adequate stores laid down in the fetal liver during the last trimester
  • human milk is an excellent source of vitamin A20
Vitamin D
  • synthesized in the skin from cholesterol on exposure to UVB radiation (sunshine)
  • stimulates intestinal absorption and renal reabsorption of calcium and phosphorus
  • involved in bone resorption and bone formation
  • fetal stores of Vitamin D in infants born to mothers with normal status may be depleted by 2 months of age in the absence of any exposure to sunlight
  • breastmilk is a negligible source (20 IU/L) for a recommended need of 400 IU per day 21
  • supplementation is recommended for infants who are unlikely to receive adequate Vitamin D from natural sources
Vitamin E
  • mature human milk meets the daily recommended intake
Vitamin K
  • prothrombin, coagulation Factors VII and IX and some plasma proteins are vitamin K-dependent proteins. These are blood clotting factors.
  • Vitamin K (phylloquinone) levels in human milk vary considerably depending on maternal diet. Maternal supplementation of 5mg/day increases breastmilk concentration to levels which provide the infant's daily requirement.
  • Vitamin K synthesis by bacteria in the large intestine in the first week of life provides insufficient levels for the fully breastfed infant because the predominant gut bacteria (bifidobacteria) does not synthesize Vitamin K.
  • Once only intramuscular injection of Vitamin K is recommended for all infants at birth. No other supplementation is required.
Vitamin B
  • Most B vitamins are in appropriate concentrations in breastmilk.
  • Where a mother is deficient in B vitamins, supplementing the mother will ensure her breastmilk levels are appropriate.22
    Precaution should be taken with Vitamin B6 as mega-doses (ie 600mg/day) have been shown in some studies to reduce maternal prolactin levels, and therefore their breastmilk supply. Usual supplement is 25mg per day . Mothers with a long-term history of oral contraceptive use may be deficient in Vitamin B6.
  • A strict maternal vegan diet without B12 supplementation has resulted in serious infant morbidity. 23 24 Likewise mothers with gastric bypass surgery are also at risk of Vitamin B12 deficiency. 25 Mothers and infants in this situation should be under the care of a medical and nutrition team.
Vitamin C
  • Vitamin C in breastmilk correlates with maternal intake.26
    Levels in breastmilk remain within a normal range, regardless of maternal 'mega' supplementation.

e. Minerals

Concentration of minerals in human milk appears to be quite low, however they have a very high bioavailability and their interrelationship with other nutrients may affect their absorption, metabolism and excretion.

Calcium

Lactating women are often advised to take a calcium supplement or to increase, above normal, their intake of calcium-rich foods. However, in a large study of a group of women in Cambridge UK27 there was no correlation found between calcium intake (ranging from 600 to 2300mg/day) and the amount of calcium in their breastmilk.28

The infant's daily requirement for calcium is adequately met by breastmilk. Bone growth in the infant is unaffected by maternal supplements.

Maternal bone mineral density is not affected adversely by breastfeeding, or enhanced by calcium intake above normal levels. Within 3 months of weaning bone mineral density in breastfeeding women has returned to normal, or is even enhanced.27,29Breastfeeding decreases incidence of osteoporosis in post-menopausal women30 and parity with prolonged total duration of breastfeeding has no detrimental effect on bone mineral density.31

Iron

  • levels relatively low but highly bioavailable to infant - five-fold more efficient absorption from human milk than from cows milk32
  • breastmilk iron levels are NOT correlated with maternal iron status - levels in breastmilk remain within a normal range even when the mother is anemic33
  • the presence of high lactose and Vitamin C levels in breastmilk also aid its absorption
  • iron supplements for term infants during the first 6 months of exclusive breastfeeding is unnecessary.34
    Complementary foods after 6 months of age should include iron-rich foods. Some infants who continue to be exclusively breastfed for much longer than 6 months may maintain an adequate iron status - biochemical analysis on an individual basis may be indicated.35

Iodine

  • required for synthesis of thyroid hormones that are required for brain development during fetal and early postnatal life
  • iodine deficiency is a leading cause of brain damage
  • breastmilk levels vary widely according to geographic region and maternal intake
  • supplementation of women during pregnancy and lactation in iodine-deficient areas will reverse this leading cause of mental impairment32

f. Water

Breastmilk contains a high percentage of water. When babies have unrestricted access to the breast they DO NOT need additional water, even in hot climates. Giving water or other fluids such as teas, will decrease the infant's desire to breastfeed decreasing nutrient intake and breastmilk synthesis, and increasing the infant's risk of infections.

The taste of breastmilk

The flavour (flavor) of breastmilk is affected by the foods in the maternal diet. This daily variation in flavour can help the infant to become used to the tastes of the family foods and ease the transition to these foods when complementary feeding begins.36
Artificial infant formula tastes the same for every feed.

Dietary advice

What should I remember?

  1. the effect maternal diet has on breastmilk composition.
  2. proteins: several functions, including immunological protection.
  3. carbohydrates: the enzyme that breaks down lactose and the two components that are absorbed; the function of those two components.
  4. lipids: control of levels in breastmilk; functions in infant.
  5. bioavailability as it relates to vitamins and minerals; know when supplementation is required.
  6. period of time that breastmilk alone will meet all of the infant's nutritional needs.

Self-test Quiz

Notes

  1. # World Health Organization (2002) Complementary feeding: Report of the global consultation, and summary of guiding principles for complementary feeding of the breastfed child
  2. # Neville MC (2001) Anatomy and Physiology of Lactation
  3. # Picciano MF (2003) Pregnancy and Lactation: Physiological Adjustments, Nutritional Requirements and the Role of Dietary Supplements
  4. # Dusdieker LB et al. (1990) Prolonged maternal fluid supplementation in breast-feeding.
  5. # Dusdieker LB et al. (1985) Effect of supplemental fluids on human milk production.
  6. # Riordan J (2005) Breastfeeding and Human Lactation
  7. # Hale TW et al. (2007) Textbook of Human Lactation
  8. # Michaelsen KF et al. (2012) Amount and quality of dietary proteins during the first two years of life in relation to NCD risk in adulthood.
  9. # McVeagh P et al. (1997) Human milk oligosaccharides: only the breast
  10. # Daly SE et al. (1993) Degree of breast emptying explains changes in the fat content, but not fatty acid composition, of human milk
  11. # Kent J (2005) Personal communication
  12. # Engstrom JL et al. (2007) Comparison of milk output from the right and left breasts during simultaneous pumping in mothers of very low birthweight infants.
  13. # Ramsay DT et al. (2005) Anatomy of the lactation human breast redefined with ultrasound imaging
  14. # Cox DB et al. (1997) Studies on Human Lactation: The Development of the Computerized Breast Measurement System
  15. # Pisacane A et al. (1994) Breastfeeding and multiple sclerosis
  16. # Conradi S et al. (2013) Breastfeeding is associated with lower risk for multiple sclerosis.
  17. # Das UN (2003) A perinatal strategy to prevent coronary heart disease
  18. # Martin RM et al. (2005) Breastfeeding and atherosclerosis: intima-media thickness and plaques at 65-year follow-up of the Boyd Orr cohort
  19. # Owen CG et al. (2008) Does initial breastfeeding lead to lower blood cholesterol in adult life? A quantitative review of the evidence.
  20. # Fujita M et al. (2011) Vitamin A dynamics in breastmilk and liver stores: a life history perspective.
  21. # Gallo S et al. (2013) Effect of different dosages of oral vitamin D supplementation on vitamin D status in healthy, breastfed infants: a randomized trial.
  22. # Allen LH (2012) B Vitamins in Breast Milk: Relative Importance of Maternal Status and Intake, and Effects on Infant Status and Function
  23. # Codazzi D et al. (2005) Coma and respiratory failure in a child with severe vitamin B12 deficiency
  24. # Allen LH (2008) Causes of vitamin B12 and folate deficiency.
  25. # Grange DK et al. (1994) Nutritional vitamin B12 deficiency in a breastfed infant following maternal gastric bypass
  26. # Tawfeek HI et al. (2002) Effect of maternal dietary vitamin C intake on the level of vitamin C in breastmilk among nursing mothers in Baghdad, Iraq.
  27. # Prentice A (2000) Calcium in pregnancy and lactation
  28. # Kent JC et al. (2009) Why calcium in breastmilk is independent of maternal dietary calcium and vitamin D.
  29. # Kovacs CS (2005) Calcium and bone metabolism during pregnancy and lactation
  30. # Schnatz PF et al. (2010) Effects of age at first pregnancy and breast-feeding on the development of postmenopausal osteoporosis.
  31. # Lenora J et al. (2009) Effects of multiparity and prolonged breast-feeding on maternal bone mineral density: a community-based cross-sectional study.
  32. # Picciano MF (2001) Nutrient Composition of Human Milk
  33. # Shashiraj et al. (2006) Mother\'s iron status, breastmilk iron and lactoferrin--are they related?
  34. # Yang Z et al. (2009) Prevalence and predictors of iron deficiency in fully breastfed infants at 6 mo of age: comparison of data from 6 studies.
  35. # Griffin IJ (2001) Iron and Breastfeeding
  36. # Beauchamp GK et al. (2009) Early flavor learning and its impact on later feeding behavior.

1.2 Immunology

At birth, the baby's skin and gut is sterile, but is quickly colonized by the bacterial flora of those with whom he comes in contact.

Clinical Tip:

A simple strategy to ensure the baby's skin is colonized by the flora common to his mother is to limit the handling of the newborn by health care workers until after the mother and baby have been together, in skin-to-skin contact, for a number of hours. Prolonged skin-to-skin contact also reduces the risk of the baby acquiring nosocomial infections.
Careful attention to hand hygiene is essential when it becomes necessary for staff members to handle the baby.

Soon after birth, the infant's gut is colonised by potentially harmful aerobic bacteria. The environment quickly changes as harmless anaerobic bacteria take over. Breastmilk supports this development of a protective anaerobic flora which may function as probiotics. Artificially-fed babies are colonized by aerobes and other anaerobes in addition to bifidobacteria, with a predominance of enterococci and enterobacteria. Clostridia, Enterococci, E. Coli and Bacteroides are also a common part of the gut flora of the artificially fed. 1

Protective components of breastmilk

Proteins

Immunoglobulins

Immunoglobulins are present in human milk. The special structure secretory IgA (sIgA) is the main immunoglobulin . Concentration in colostrum is particularly high to provide immediate protection for the infant entering a world of microbes.

  • sIgA protection is 'targeted' against organisms with which the mother, and consequently her baby, come into contact, killing the offending pathogen
  • sIgA coats the infant's intestine preventing adherence of pathogens, blocking them from getting onto and into the infant's tissues
  • sIgA encourages the growth of the normal, non-virulent gut bacteria.

Lactoferrin

  • has antibacterial (to gram-positive and gram-negative), antiviral and antifungal (Candida albicans) effects
  • promotes the growth of intestinal epithelium

Alpha-Lactalbumin

  • antiinfective and immunostimulatory functions
  • forms a complex that induces apoptosis (= cell death) of all malignant cells tested, but not normal cells - known as HAMLET (human alpha-lactalbumin made lethal to tumour cells) 2

Lysozyme

  • this enzyme effectively attacks E. coli in concert with lactoferrin and sIgA

Carbohydrates

Oligosaccharides

  • prebiotic effect - produce an increased proliferation of bifidobacteria and lactobacilli (probiotics) which are not digested in the infant's small intestine, but enter the colon as intact, large carbohydrates that are then fermented by the resident bacteria.
  • block receptors on epithelial surfaces by resembling binding sites for bacteria, sweeping the bacteria from the gut with them as they are eliminated
  • defend infants against pathogens that cause otitis media, respiratory tract infections, urinary tract infections, diarrhoea.

Lipids and milk fat globules

Fatty acids and monoglycerides attack or neutralise G lamblia, Entamoeba, E coli, and Shiga-like toxins.

Cellular components

The neutrophils and macrophages in breastmilk most likely protect the maternal breasts.

Lymphocytes in breastmilk are absorbed and may possibly confer immunological information to the baby.

Other protective factors

Breastmilk contains a myriad of other factors that work to protect and enhance the development of the breastfed child, including nucleotides, defensins, cytokines, hormones and growth factors, anti-secretory factor, anti-inflammatory components, soluble CD14 and soluble Toll-like Receptor, etc.

Workbook Activity 1.4

Complete Activity 1.4 in your workbook.

Take a minute to reflect...

Breastmilk truly is a living food that is unique to each mother and baby. While artificial infant milk is life-saving for some babies, for the majority, it is an inferior source of food and protection.

What should I remember?

  • Breastmilk is not just for nutrition
  • There are many components which prevent and fight infections - know the main protective factors
  • Artificial infant milk does not contain any immunological properties

Self-test Quiz

Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column

Notes

  1. # Hanson L (2004) Immunology of Human Milk: How breastfeeding protects babies
  2. # Lonnerdal B et al. (2003) Nutritional and physiologic significance of alpha-lactalbumin in infants

1.3 Relative risks

A little statistics...

Relative risk (RR) is a ratio of the probability of a disease, in this case, occuring in the experimental group (ie artificially-fed) versus the control (breastfed) group. The equation to work it out is: RR = Probability in experimental group divided by Probability in control group.

For example: If the probability of an infant contracting diarrhoea in the first month of life is 1% when breastfed, but 14% if artificially-fed then the RR=14. An artificially-fed infant has 14 times the risk of getting diarrhoea in the first month of life compared to the risk for a breastfed infant.


Clinical Note:

To obtain true and fair scientifically-relevant results in research studies, the researcher must compare the variable being studied to the norm. For example: compare state of disease in adults who smoke (variable), to state of disease in adults who do not smoke (the norm). Results are then written up as a change from the norm - ie 'incidence of lung cancer is increased in those who smoke by X.'

Breastfeeding is normal and breastfed babies enjoy a NORMAL state of health. Studies of infant health are notoriously reported incorrectly, making statements that equate to 'Breastfed babies are healthier' whereas correct scientific language should read 'Artificially-fed babies are sicker'.

Whenever you discuss feeding outcomes with your colleagues or with parents, ensure you are speaking factually using breastmilk and breastfeeding as the norm.

Acute diseases attributable to artificial feeding

Diarrhea, otitis media and pneumonia


The relative risk of developing diseases throughout life for artificially-fed as compared to human milk-fed infants.1
0 - 1 month 1 - 12 months 1 - 6 years
Diarrhea 14 4 - 10
Otitis media 8.6 3.3 - 4.3
Respiratory illness 3.3 - 4.3

Urinary Tract Infection

Significant increase in UTI amongst artificially-fed infants in Sweden; this protection for the breastfed infant persisted after weaning.2

Necrotising Enterocolitis

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in the NICU, with often devastating consequences.The key risk factors leading to NEC are prematurity, formula feeding, intestinal ischemia, and bacterial colonization.3 The mortality rate (15%-25%) for affected infants has not changed appreciably in 30 years.

Septicemia and Meningitis

Neonatal septicemia and meningitis is associated with severe morbidity and high mortality rates. Artificially fed infants in neonatal intensive care units, and artificially fed infants in developing countries, are most at risk.

A comparison of risk of sepsis in babies in neonatal intensive care units:4

Postnatal Age Breastmilk Fed Artificial Milk Fed
first 10 days 5% 10%
11 - 24 days 9% 20%
25 - 38 days 0% 15%

Non-communicable diseases attributable to artificial feeding

Type 1 Diabetes Mellitus (Insulin-dependent diabetes)

Type 1 diabetes is an auto-immune disease determined by a combination of genetic and environmental factors.

  • general population risk of developing Type 1 diabetes = 0.4%
  • when a first-degree relative is affected = 6%

Environmental factors provide the trigger that causes a child to develop diabetes.

There are several hypotheses as to what these environmental factors are:

  • early exposure to cow's milk protein
  • introduction to solid food before 3 months
  • not having all the protective benefits of breastmilk

Meta-analyses of the published research found a strong link between early introduction of artificial milks and the development of Type 1 diabetes:

  • exposure to cow's milk in the first 3 months 5 6 7
  • weaning before 3 months 8
  • no-breastfeeding, while breastfeeding for more than 12 months was protective 9
  • being artificially fed at the time solid foods are commenced 10

The cycle of diabetic risk

Mothers who have type 1 diabetes are more likely to artificially feed their infants.11 Cesarian section birth, prematurity and unstable condition of baby at birth are among the reasons given for this occurrence. Breastfeeding duration is likely to be shorter amongst this group of mothers with breastfeeding <4 weeks being associated with overweight at age 2 years.12

Can you see how the risk of type 1 diabetes can spiral through the generations? The birth and post-birth circumstances and management of the diabetic mother can lead to an intervention (ie. infant being not-breastfed/early exposure to cow's milk protein in artifical infant milk) which triggers the infant to later develop diabetes.

Would mothers put their baby at risk if they knew this?
What can you do at your workplace to help break this cycle?

Type 2 Diabetes and Metabolic Syndrome

The mechanism is not entirely understood, however, studies report that formula-fed infants have higher basal and post-prandial concentrations of insulin and neurotensin. 13 14
Being formula-fed in infancy is associated with later development of type 2 diabetes and/or metabolic syndrome. 15 16 17

Celiac Disease

Some developed countries are reporting an 'epidemic' of celiac disease in children less than 2 years of age. 18
Celiac disease is an autoimmune enteropathy. Genetic susceptibility and dietary exposure to gluten are necessary for it to occur.

Artificial feeding increases the incidence 4-fold, as well as causing an earlier onset.

Being breastfed during the introduction of gluten-containing foods has a significant protective effect.19,20

Experiencing infectious diseases early in life increases the risk for later celiac disease.18 As already noted, artificially fed infants experience significantly more early-life infections.

The current recommendation to prevent the development of celiac disease is for children to be breastfed exclusively for 6 months and for breastfeeding to continue while, and for several months after, gluten is introduced into the diet.

Obesity

Obesity is a serious condition that leads to chronic diseases such as heart disease, diabetes, hypertension, some cancers and an earlier death. Prevention of obesity starts at birth and is greatly influenced by the feeding method chosen.

Breastmilk contains an appetite regulator, leptin. Artifically-fed infants have half the normal serum leptin. 21 Low serum leptin directly predicts high BMI in childhood.22

Artificial feeding is significantly correlated with obesity in childhood and adulthood. 23 24 25 26

Closely associated with childhood obesity:

  • early weaning to artificial infant formula
  • introduction of artificial infant formula before 6 months of age while breastfeeding
  • introduction of solid foods at or before 4 months27

Childhood Cancer

Fortunately childhood cancers are rare; unfortunately the child who was artificially-fed is at increased risk.

Being artificially fed is linked to development of the following cancers: 28 29

  • acute lymphoblastic leukemia (leukaemia) 30
  • lymphomas - Hodgkin's and non-Hodgkin's31
  • neuroblastomas
  • rhabdomyosarcoma32

Inflammatory Bowel Diseases

  • Ulcerative colitis
  • Crohn's disease

The causes of these conditions are multifactorial. However, being artificially fed in infancy is directly related. 33 34

Allergic Responses

Cow's milk is the most common single allergen affecting infants. The proteins in cow's milk are the allergen, NOT lactose. Standard infant formulas are made from cow's milk.

Asthma, eczema, urticaria, rhinitis, failure-to-thrive, colic, chronic respiratory disease, gastro-oesophageal reflux and gastro-intestinal disease are all examples of conditions caused by an allergy or intolerance to cow's milk protein.

Compared to breastfed infants, artificially-fed infants have a significantly higher incidence of all forms of atopy. 35 Feeding soy-based artificial baby milk, compared to standard cow's milk-based artifical baby milk does not reduce the risk. 36

The recommendation for atopy and asthma prevention still focuses on avoidance of tobacco smoke exposure and food allergens during the first 4 months of life, and to breastfeed the infant.37

Workbook Activity 1.5

Complete Activity 1.5 in your workbook.

Intelligence

The brain of the newborn infant continues to develop rapidly after full term birth, doubling in size by one year of age. The brain growth in the preterm infant is even more rapid and therefore has an even greater potential to be harmed by inappropriate nutrition.

Since Lucas in 1992 38 was able to demonstrate an intellectual deficit caused by artificial infant formula feeding, there have been numerous research papers confirming those findings. 39 40

Assessment of children at 6.5 years of age reveals:

  • exclusive artificial feeding, or early introduction of artificial infant formula, contributes significantly to 41

    • reduced total IQ
    • reduced verbal IQ
    • reduced performance IQ

Think about it

If you search the medical and scientific journals using search terms such as IQ, visual development, motor development, verbal skills, etc and link them to feeding method in the first 12 months of life you'll receive literally thousands of hits. The effect of first food on the development of the brain has been intensely studied.

While the previously discussed acute and chronic conditions affect a percentage of children, development of the immature brain affects EVERY child. ie EVERY child fed on artificial infant formula will have their IQ reduced from their potential.

Do parents know this? If they did would they choose this option for their child lightly?

Some infants have to be fed artificially, and therefore it is of critical importance that the researchers continue their search so that these children are not further disadvantaged. The formula manufacturers quickly add the latest finding into their formulas; however, to date, no additiive has prevented this damage to the IQ of the artificially-fed infant.

Sudden Infant Death Syndrome (SIDS)

Over the past 30 years deaths from SIDS has been significantly reduced by sleeping infants on their backs on a safe sleep surface and avoidance of cigarette smoke. Researchers have now been able to demonstrate that artificial feeding causes SIDS. 42

Artificial feeding at one month of age was associated with double the risk for SIDS. 43 The majority of babies older than one month who died of SIDS were fed artifical formula. 44 45 46

A meta analysis of 23 SIDS studies revealed 19 studies which found artifical feeding increased SIDS. The combined analysis indicated that artificially-fed infants were twice as likely to die from SIDS. 44

'Breastfeeding' is being recommended by major SIDS Prevention councils around the World.47

Maternal Health

The health benefits of breastfeeding are not limited to the infant. The breastfeeding mother also receives significant protective effects with all the following being significantly more common in women who artificially feed their infants:
  • breast cancer
  • premenopausal ovarian cancer
  • Type 2 diabetes mellitus
  • hypertension
  • myocardial infarction
  • anemia

SUMMARY

Artificial feeding is detrimental to infant health because it:

  1. does not provide optimal nutrition; increasing the risk of non-communicable diseases

  2. does not provide the many special, unique protective factors, both antibody and non-antibody, found in human milk; increasing the risk of acute and chronic infectious diseases

  3. exposes the infant to bacterial pathogens in other food sources

Think about it:

Most new parents do not know of the research that clearly demonstrates these poor health and developmental outcomes from artificial feeding. As a health professional do you feel it is fair to withhold this information from parents who generally just want to do the best thing for their children?

Who do you think is being protected when this information is not shared with parents?
Who stands to lose by withholding this information?
Who stands to gain by withholding this information?


But we shouldn't make mothers feel guilty!

Click on the icon above to read an article about making mothers feel guilty.

What would you say?

Well, have you thought about what you would say now if a mother said to you,
"Is breastfeeding really worth all the effort it takes?"

In Module 3 you'll learn that discussing specific effects of breastfeeding and artificial infant formula feeding is required of you. However, the next module will help you to see how you can discuss this topic (and many others) giving

  • accurate, factual information,
  • that the mother will be able to understand in the context of her situation,
  • while building the mother's confidence to make decisions that suit her situation, and
  • that she feels supported to carry out.

What should I remember?

  • the absence of breastmilk properties is the first contributing factor to disease processes
  • the exposure to artificial substances such as artificial infant milk has a strong association with acute and chronic illness
  • the acute conditions which are associated with infant formula feeding
  • the chronic conditions which are associated with infant formula feeding
  • there is a positive correlation between artificial infant formula feeding rates and the incidence of infant mortality and morbidity in every country in the World

Self-test Quiz

Assessment Quiz

When you are happy that you've understood all the information in this topic you will be ready to complete the Module 1 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 1.

Notes

  1. # Heinz (2001-02) Heinz Sight: Infant Nutrition Newsletter
  2. # Marild S et al. (2004) Protective effect of breastfeeding against urinary tract infection
  3. # Yeo SL (2006) NICU update: state of the science of NEC.
  4. # el-Mohandes AE et al. (1997) Use of human milk in the intensive care nursery decreases the incidence of nosocomial sepsis
  5. # Patelarou E et al. (2012) Current evidence on the associations of breastfeeding, infant formula, and cow\'s milk introduction with type 1 diabetes mellitus: a systematic review.
  6. # Kostraba JN et al. (1993) Early exposure to cow's milk and solid foods in infancy, genetic predisposition, and risk of IDDM.
  7. # Gerstein HC (1994) Cow's milk exposure and type 1 diabetes mellitus. A critical overview of the clinical literature.
  8. # Perez-Bravo E et al. (1996) Genetic predisposition and environmental factors leading to the development of insulin-dependent diabetes mellitus in Chilean children
  9. # Malcova H et al. (2006) Absence of breast-feeding is associated with the risk of type 1 diabetes: a case-control study in a population with rapidly increasing incidence
  10. # Frederiksen B et al. (2013) Infant Exposures and Development of Type 1 Diabetes Mellitus: The Diabetes Autoimmunity Study in the Young (DAISY).
  11. # Hummel S et al. (2007) Breastfeeding habits in families with Type 1 diabetes
  12. # Hummel S et al. (2008) [Breastfeeding in women with gestational diabetes]
  13. # Lucas A et al. (1980) Breast vs Bottle: endocrine responses are different with formula feeding
  14. # Salmenperä L et al. (1988) Effects of feeding regimen on blood glucose levels and plasma concentrations of pancreatic hormones and gut regulatory peptides at 9 months of age: comparison between infants fed with milk formula and infants exclusively breast-fed from birth.
  15. # Plagemann A et al. (2012) Early postnatal life as a critical time window for determination of long-term metabolic health.
  16. # Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries
  17. # Horta BL et al. (2007) Evidence on the long term efects of breastfeeding:systematic review and meta-analyses
  18. # Myléus A et al. (2012) Early infections are associated with increased risk for celiac disease: an incident case-referent study.
  19. # Ivarsson A et al. (2013) Prevalence of childhood celiac disease and changes in infant feeding.
  20. # Akobeng AK et al. (2006) Effect of breast feeding on risk of coeliac disease: a systematic review and meta-analysis of observational studies
  21. # Savino F et al. (2004) Breast-fed infants have higher leptin values than formula-fed infants in the first four months of life
  22. # Savino F et al. (2013) High serum leptin levels in infancy can potentially predict obesity in childhood, especially in formula fed infants.
  23. # Baker JL et al. (2004) Maternal prepregnant body mass index, duration of breastfeeding, and timing of complementary food introduction are associated with infant weight gain.
  24. # Kalies H et al. (2005) The effect of breastfeeding on weight gain in infants: results of a birth cohort study
  25. # Li C et al. (2005) Additive interactions of maternal prepregnancy BMI and breast-feeding on childhood overweight
  26. # Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries.
  27. # Pearce J et al. (2013) Timing of the introduction of complementary feeding and risk of childhood obesity: a systematic review.
  28. # Shu XO et al. (1999) Breast-feeding and risk of childhood acute leukemia
  29. # Martin RM et al. (2005) Breast-feeding and childhood cancer: A systematic review with metaanalysis
  30. # Crouch S et al. (2012) Infectious illness in children subsequently diagnosed with acute lymphoblastic leukemia: modeling the trends from birth to diagnosis.
  31. # Rudant J et al. (2011) Childhood Hodgkin\'s lymphoma, non-Hodgkin\'s lymphoma and factors related to the immune system: the Escale Study (SFCE).
  32. # Lupo PJ et al. (2013) Allergies, atopy, immune-related factors and childhood rhabdomyosarcoma: A report from the children\'s oncology group.
  33. # Frolkis A et al. (2013) Environment and the inflammatory bowel diseases.
  34. # Hansen TS et al. (2011) Environmental factors in inflammatory bowel disease: a case-control study based on a Danish inception cohort.
  35. # Friedman NJ et al. (2005) The role of breast-feeding in the development of allergies and asthma
  36. # Ram FS et al. (2002) Cow's milk protein avoidance and development of childhood wheeze in children with a family history of atopy.
  37. # Lau S (2013) What is new in the prevention of atopy and asthma?
  38. # Lucas A et al. (1992) Breast milk and subsequent intelligence quotient in children born preterm
  39. # Jedrychowski W et al. (2012) Effect of exclusive breastfeeding on the development of children\'s cognitive function in the Krakow prospective birth cohort study.
  40. # Brion MJ et al. (2011) What are the causal effects of breastfeeding on IQ, obesity and blood pressure? Evidence from comparing high-income with middle-income cohorts.
  41. # Gustafsson PA et al. (2004) Breastfeeding, very long polyunsaturated fatty acids (PUFA) and IQ at 6 1/2 years of age.
  42. # Hauck FR et al. (2011) Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis.
  43. # Vennemann MM et al. (2009) Does breastfeeding reduce the risk of sudden infant death syndrome?
  44. # McVea KL et al. (2000) The role of breastfeeding in sudden infant death syndrome
  45. # Alm B et al. (2002) Breastfeeding and the sudden infant death syndrome in Scandinavia, 1992-95
  46. # Horne RS et al. (2004) Comparison of evoked arousability in breast and formula fed infants.
  47. # Young J et al. (2012) Responding to evidence: breastfeed baby if you can--the sixth public health recommendation to reduce the risk of sudden and unexpected death in infancy.

2.0 Communication Skills

Information cannot be effectively received, transferred or exchanged without using good communication skills. Good communication skills will enhance your relationships with friends, family, colleagues and the families you work with.

When working with women respect for the women's own thoughts, beliefs, and culture are a part of good communication. When you share information with a mother and demonstrate that respect she will gain the confidence to make the decisions that are right for her and her family.

You can use communication skills to:

  • Listen and learn about the woman's beliefs, level of knowledge and her practices

  • Build her confidence and praise practices that you want to encourage

  • Offer information

  • Suggest changes the woman could consider if changes are needed


© DIAC Images creative commons


Good communication skills results in the person with whom you are having a conversation:

  • developing trust in you
  • confiding in you
  • reflecting on their personal predicament
  • problem-solving for themselves
  • accepting the outcome of their actions
  • being empowered in other spheres of their life

Lack of communication skills results in the person with whom you are having a conversation:

  • distrusting you
  • treating you as an authority figure (may not disclose crucial information)
  • dwelling on the problem
  • allowing you to provide a 'solution' to their situation
  • being resentful of the outcome of your instructions
  • may cause further feelings of 'uselessness' or 'dependence', being unable to deal with future problems

Workbook Activity 2.1

Complete Activity 2.1 in your workbook.

Personal Qualities

You will need to develop a trusting relationship with the women, men and families you are assisting at this important stage of their life. Carl Rogers, a world-renowned psychotherapist, described three qualities essential to constructive communication: genuineness, non-possessive love and empathy. Communication skills, without the presence of these three factors, are associated with harmful therapist-client interactions.

Genuineness

The first of these is genuineness. Sometimes called congruence, it means being honest and open - what you really are without front or façade. The genuine person knows it is impossible to be completely self-revealing, but is committed to a responsible honesty and openness with others.

Non-possessive love

Also referred to in some texts as 'unconditional positive regard', but probably meaning more than this phrase allows. 'Non-possessive love' refers to your ability to accept, respect and support another person in a non-paternalistic way. This includes all of the client's frailties and weaknesses, as well as their strengths and positive qualities.

The 'love' you exhibit has the characteristics of patience, fairness, consistency, rationality and kindliness. It encourages freedom.

Empathy

Empathy refers to the ability to really see and hear another person and understand that person from their perspective. 'Putting yourself in their shoes.' Psychologists describe the Apathy-Empathy-Sympathy continuum.

Apathy Empathy Sympathy
"Yes, well mothers are constantly tired." "Broken nights can be very tiring." "I don't know how you cope with being woken so often."
"There's nothing wrong with breastmilk." "You're worried your breastmilk may be too thin." "It's so scary when all your baby has is your milk."

Apathy is a lack of feeling, while sympathy is 'feeling for' another person. Empathy is 'feeling with' the other person. Empathy involves experiencing the feelings of another without losing one's own identity. If you lose the ability to separate your own feelings from the feelings of another person, you are no longer empathetic.

Practise makes perfect!

Communication skills are not something to be turned on and turned off at particular times. Develop your skills talking with your family and friends - practise them all the time.

What should I remember?

  • what you will achieve by using good communication skills in your interactions with mothers
  • the outcome when you use good communication skills; and the corollary when you don't
  • the difference between apathy, empathy and sympathy

Self-test quiz

Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column

2.1 Non-verbal

You will have heard the phrase “ It's not what you say, it's the way you say it! ” .
Verbal communication allows you to express yourself, while nonverbal communication enhances and reinforces the effect of your spoken word.

Nonverbal communication is a reliable indicator of the real feelings.

Consider how the mother will interpret these messages.

The mother is sitting in a chair breastfeeding her baby. In each situation the health care worker says, “Good morning. How is breastfeeding going?

  • Health care worker stands over the mother.
  • Health care worker sits behind desk, writing in notes at the same time.
  • Health care worker checks her watch as she asks the question.
  • Health care worker is holding a stack of files in her hands.
  • Health care worker moves mother's clothing aside and touches her breast and jiggles baby's chin.

Are you really listening?

Hearing and effective listening are not the same thing.
To be a good communicator you must first pay attention to the speaker (the mother). Your posture, eye contact, gestures, facial expressions and short responses are all nonverbal cues that help the mother to understand whether you are following her conversation.

Posture

  • Relaxed alertness.
  • Body leaning slightly forward.
  • Face the other squarely and be at eye level.
  • Maintain an open posture (no crossed arms or legs).
  • Position yourself at an appropriate distance. This is influenced by cultural and individual differences. Both too near and too far positioning causes anxiety. Generally, in Western cultures, about one metre (3 feet) is about right.

Appropriate body motion

Movements should be in response to what the speaker is saying. Lack of movement signifies the listener is controlled, cold, aloof and reserved. Sometimes the listener may be so in tune with the speaker that their gestures synchronise.

Eye contact

Eye contact allows the speaker to appraise your receptiveness, and allows you to 'see' if there are deeper meanings than those being expressed. Eye contact involves softly focusing on the speaker's eyes, occasionally shifting the gaze from her face to other parts of her body, a gesturing hand for example, and then back to the face and eye contact once again.

Repeatedly looking away from the speaker, staring at her constantly or blankly, or looking away as soon as she looks at you are examples of poor eye contact.

Consider cultural differences. For example Australian aboriginal people prefer to avoid direct eye contact.

Minimal encouragers

Minimal encouragers are simple responses that indicate you are 'with them'. They aid the speaker to continue speaking, but don't direct the flow of the conversation. They are usually sprinkled throughout a conversation.

Examples are: mm-hmm, yes, right, I see, then?, go on, yeah, etc... They shouldn't imply agreement or disapproval.

Non-distracting environment

  • pleasant, uncluttered room
  • turn off television or intrusive music
  • do not allow phone calls to interrupt the conversation
  • in hospital setting, curtain off the mother's bed; put Do Not Disturb sign on door
  • in an office: place chairs away from desk, avoid having a desk between you
  • be aware of the mother's need for privacy, seeking a private area or asking others to leave if necessary

Time

The way a person perceives time, structures their time and reacts to time is a powerful communication tool. How you and your conversational partner react to punctuality and a willingness to wait will have an impact on your communication. How long are you or they prepared to listen?
Also consider the timing of your conversation as it relates to other activities for both parties.

Non-verbal communication is two-way

While you are ensuring that your nonverbal communication is congruent with your message and demonstrating effective listening, don't neglect to read the communication signs being given by your conversational partner.
Note all of the aspects of non-verbal communication being exhibited in this photograph. Did you notice the body motion? Note the eye contact between the two.

Note all of the aspects of non-verbal communication being exhibited in this photograph. Did you notice the body motion? Note the eye contact between the two.

Workbook Activity 2.2

Complete Activity 2.2 in your workbook.

What should I remember?

  • all facets of nonverbal communication
  • consider the immediate environment
  • consider the implications of time and timing

Self-test Quiz

2.2 Listening skills

Listening skills involve

  • Reflecting back what you have understood the mother said.
  • Appropriate questioning.

Reflective listening

Reflective listening communicates to the mother your interpretation of what she has said and how she feels, and does so in a way that demonstrates understanding and acceptance.

Paraphrasing

Paraphrasing typically explains or clarifies what was said. A good paraphrase is succinct, cutting directly to the message and is restated the way you understood the message. Paraphrasing is not parroting (or copying). Parroting stifles conversation, paraphrasing contributes to the communication between people.

An example:

Mother: “I love my baby and I love breastfeeding her. My mother says it's the best thing for babies. But I'm so tired every day from getting up for the night feeds. I just wish my husband could give her a bottle sometimes.

Health care worker: “Breastfeeding is good, but you think you might begin giving her bottles of formula.

At this point the mother will either agree or she'll disagree and clarify her intent.

Applying paraphrasing more often in our everyday conversations would improve the fluency and accuracy of what was said and what was understood to have been said.

Paraphrasing exercise

Reflecting feelings

You don't have to state the mother's feelings if it isn't appropriate. However, you must be aware of what they are.

How do you correctly interpret her feelings?

Try these tips.

  • Sometimes they may be spoken and leave you in no doubt: “ I felt so angry when he said that to me.
  • You may need to infer it from the content: “ I spent two hours yesterday when I was really busy helping her to breastfeed. Now she's artificially feeding, and says she was going to when she got home anyway.
  • Observe her body language. Much of your understanding of body language is 'innate'; something you pick up during a lifetime of interpersonal relationships. However, there is still so much you could learn. This is beyond the scope of this course but you will find it very rewarding if you pursue this interesting topic.
  • How would you be feeling in that situation? Each person's emotional experience is unique, but by applying the previous points and thinking about how you would feel you can have a fairly good guess. If you reflect that feeling, eg. “ That's so frustrating ” , she will either agree readily or tell you how she actually feels.

Appropriate questioning

Consider the following conversation:

Health worker: Good morning. Are you feeling well today?
Mother: Yes. I'm well.
Health worker: Is baby feeding OK?
Mother: Yes.
Health worker: Are you having any problems?
Mother: No.

Now consider how it could have been more productive.

Health worker: Good morning. How are you feeling?
Mother: I'm feeling well. Thank you.
Health worker: Tell me about how you are feeding your baby.
Mother: I breastfeed often during the day, and give him a bottle at night.
Health worker: What made you decide to give a bottle at night?
Mother: He wakes up at night, so I don't think my milk is strong enough to satisfy him.

Do you see how questions that require only a one-word answer (closed questions) limit the amount of information you receive, while open questions encourage more conversation?

We often rely on questions excessively and use them poorly. Questions usually focus on our own intent, perspective, and concerns rather than on the mother's orientation. When that happens, questions are a barrier to communication.

About questioning

Closed questions
A closed question can be answered with either a single word or a short reply, eg yes/no. Closed questions direct the conversation, keeping control of the conversation with the questioner, and should therefore rarely be used.
Because these questions are so directed, the mother may reply with what she thinks you want to hear for fear of getting the question wrong. eg. “ How many times a day do you feed him?
Closed questions are useful for starting a conversation while retaining control, “ It's great weather, isn't it? ” and for facts, “ What was your baby's birth weight? ” “ How old are your other children?

Open questions
Open questions deliberately seek longer answers, asking the mother to think and reflect, before responding with opinions and feelings. The control of the conversation moves to the respondent.
The question should be designed to help her to clarify her own problem, rather than provide information for the interviewer. “ How do you feel your baby is latching when you use the nipple shield? ”, “ How could you keep your other children busy while baby is feeding?

Ask only one question at a time - and not too many even then.

Converting closed to open questions

What should I remember?

  • the two aspects of listening skills
  • the goal of paraphrasing, and how to paraphrase
  • the best use of closed and open questions

2.3 Building confidence

In topic 3 you will learn how nurturing maternal self-efficacy and self-confidence influences mothers to breastfeed their infants for much longer. Your communication skills can help the mother to feel good about herself and confident in her role as a mother. Confidence can help a mother to carry out her decisions and to resist pressures from other people.

To build confidence the mother must feel

  • that you accept her and her decisions without judgment;
  • that you notice and praise what she is doing right, and
  • you offer additional information in an easily understood manner that will allow her to make her own informed decisions.

Acceptance

Acceptance of a person's actions or beliefs is the starting point of any relationship.

Accepting what a mother says helps her to trust you and encourages her to continue the conversation. Accepting what a mother says is not the same as agreeing that she is right. You can accept what she is saying and give correct information later.

Which one of these statements demonstrates acceptance?

Mother: “I give my baby a bottle each night because he was waking up.
Health worker: “It's normal for babies to wake at night. That's not a reason to give a bottle.
Health worker: “That might stop him waking up at night.
Health worker: “Getting up to settle a baby at night is very tiring.

The first response disagreed with the mother. The second response agreed with the mother even though the information was incorrect. The third response demonstrates acceptance of her statement without either agreeing or disagreeing.

Acceptance statements quiz


Choose the response that demonstrates acceptance of the mother's statement.

Avoiding judgmental words

Words that may sound like you are judging include: right, wrong, well, bad, good, enough, properly, adequate, problem, still.
Words like this can make a woman feel that she has a standard to reach or that her baby is not behaving normally. Examples: "Is your baby latching properly?", "Does he have enough wet and dirty nappies/diapers?".

The mother may hide how things are going if she feels she is being judged. In addition, the mother and the health worker may have different ideas about what "properly" or "enough" means. It is more helpful to ask open questions such as "How do you feel he is going with latching now?", "Could you describe his wet and dirty nappies/diapers to me?"

Practice avoiding judging words

Acknowledge what is right

Notice and praise what the mother and baby are achieving. This is very important. Always look for, and comment on, what is good.
An example might be to comment that it is good to see she responds to early feeding cues, or that her baby opens his mouth really well just before latching.

Use language that is easily understood

Regardless of the mother's educational level, using simple language and avoiding medical terms or jargon provides greater clarity and better understanding.

Using simple language

Provide relevant information

Additional ideas and options can be added to the ones the mother has already tried or knows about. Limit your suggestions to only a few that would be relevant to her. Don't overwhelm her with information. Use phrases such as: “How would you feel about...?” or “Some recent research shows that... Could this apply in your situation?

Your aim is to ensure the mother has enough information to make an informed decision. The mother solves her own problem.

If you've applied the communication skills discussed so far you may find that the mother has already found her own solution. Sometimes just a good listener who can accurately reflect her feelings and provides a well-organized summary is sufficient for her to see her situation in a new light.

Workbook Activity 2.3

Complete Activity 2.3 in your workbook.

What should I remember?

  • WHAT you say and HOW you say it affects a mother's self-confidence
  • how to phrase sentences to reflect acceptance without judgment
  • praise is important
  • how to provide additional information in a manner that is easily understood and leads to informed decision-making

2.4 An example

An example of good communication skills

Mother: My child won't eat even though she is eight months old. She is only breastfeeding.
Health Worker: It is wonderful that you are breastfeeding - that's still her best food. (approval) But you are right to offer her other food too. (agreement)
Mother: I give her porridge in her bottle but she spits it out and cries.
Health Worker: I see (acceptance, no criticism). What have you thought of doing? (exploring)
Mother: Well, I tried not breastfeeding her so much but she cried too much.
Health Worker: She really likes your breastmilk - she's a clever girl! (approval) How does she act when the other children are eating? (open question)
Mother: She cries and reaches for their food, but she is still too little for the foods they are eating.
Health Worker: So she is eager to eat with the other children (summarising). Have you tried preparing food for her specially? Or feeding her while the others are eating? (offering ideas)
Mother: Do you mean cooking her special meals? I am really very busy.
Health Worker: Of course you are! (accepting) Some mothers cook all the vegetables and then just take some out, remove the skins and mash them. Then they can spoon feed the baby while the others are eating whole vegetables. (offering ideas)
Mother: Well, I could try that. It doesn't sound like a lot of extra work. (mother makes decision)
Health Worker: You mentioned using a bottle? (exploring)
Mother: I know I shouldn't, but sugar water keeps her quiet when I'm cooking.
Health Worker: It's difficult to get everything done (accepting), but I agree that the bottle isn't the best solution. (agreement, no criticism)
How would you feel about giving her a piece of soft chapati or fruit to try her teeth on while you are cooking? (offering ideas)
Mother: Well, perhaps (mother making decision). But won't she choke on these things? I thought babies needed to drink.
Health Worker: You're right, they do need drinks (agreement) but just your breastmilk. That gives all the sugar and water they need (information). Now that she sits alone, she can start learning about your family food, too.
Mother: Should I go on giving her porridge?
Health Worker: Yes, that's very good food, especially with some mashed pumpkin or mashed banana added. (information).
Bottles are not the best way to feed babies (correct by giving information, not criticism).
She might enjoy porridge more from a spoon or cup (offering ideas).
They are easier to keep clean than a bottle anyway (information).
So, how do you think you can best feed your daughter now? (checking)
Mother: Well, let's see. I will go on breastfeeding and giving her porridge. I could add some fruit or pumpkin, and mashed beans and vegetables that the others are eating. Did you say I can give her some chapati? (shows understanding)
Health Worker: Yes, that's fine.

Good counselling makes a mother more confident and readier to learn. Notice that the healthworker responded to the mother's concerns. She came back to correct the mistakes of the bottle and the sugar water but gave information in a gentle way that did not criticise the mother. She checked that the mother understood what to continue doing and what to change.

(Counselling scenario adapted from WHO Counselling Course, Helen Armstrong)

Assessment Quiz

When you are happy that you've understood all the information in this topic you will be ready to complete the Module 2 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 2.

3.0 Pregnancy Care

Baby Friendly Step 3 and Point 3

Step 3 of the Ten Steps to Successful Breastfeeding, and Point 3 of the Seven-point Plan for Sustaining Breastfeeding in the Community both state:
Inform all pregnant women about the benefits and management of breastfeeding.

Australia: Point 3 - Inform women and their families about breastfeeding being the biologically normal way to feed a baby and about the risks associated with not breastfeeding

The prenatal discussion should cover

  • the importance of exclusive breastfeeding for the first 6 months,
  • the health associations of breastfeeding
  • the risks of artificial feeding, and
  • basic breastfeeding management.

Pregnant women of 32 weeks or more gestation should confirm that the health associations of breastfeeding and implications of not-breastfeeding have been discussed with them, including at least two of the following:

  • infant nutrition,
  • disease protection,
  • maternal-infant bonding,
  • health benefits to the mother, and
  • that they have received no group education on the use of infant formula.

They should be able to describe at least two of the following breastfeeding management topics:

  • importance of rooming-in,
  • importance of feeding on demand,
  • how to assure enough milk, and
  • positioning and attachment.
(Source: The Global Criteria for the WHO/UNICEF Baby Friendly Hospital Initiative)1

I want to know everything!

I want to know everything!
© Trisku


Workbook Activity 3.1

Complete Activity 3.1 in your workbook.

Some of these topics we've already covered, the remainder will be covered in following modules. Review the Topic 1.3 Relative Risks to ensure that you are confident to talk to mothers about risks of artificial feeding as well as the 'benefits' of breastfeeding.

Broaching the topic

Consider how you would continue the discussion following the mother's reply to the following questions.

Health worker: How are you going to feed your baby?
Mother: I'm going to bottle feed.

OR

Health worker: Are you going to breastfeed?
Mother: Yes.

These are closed questions and don't allow you to broaden the discussion without it being challenging to the mother, regardless of her response.

Health worker: What are your thoughts on breastfeeding?

This open question will give you the opportunity to discuss any barriers that the woman may see to breastfeeding, or to discuss problems she may have had with previous breastfeeding and to begin discussion of the topics listed above.

It is also implicit in the question and following conversation that you consider breastfeeding to be relevant. The importance of the health care provider's attitude is significant when we find that a woman's attitude to breastfeeding has been shown to correspond closely to that of her health care provider. 2

Discussing breastfeeding with pregnant women needn't take more than a few minutes at each visit. For example, at the first visit...

Health worker: What changes have you noticed in your body so far?
Mother: My breasts have grown so much. I need to buy new bras! What's causing that?
Health worker: Your breasts are preparing themselves for breastfeeding your baby, growing extra milk-making ducts. Look, here's a diagram of what is happening inside your breasts.

At this point you could give her some more information on how her breasts will make and release her breastmilk according to how often her baby feeds. In just a few minutes you've covered how to assure enough milk and importance of feeding on demand, without it becoming a 'lecture' for the mother.

A little bit of information given like this at each visit normalises breastfeeding as a part of childbearing and motherhood. At a later visit, closer to 32 weeks when you feel you've gradually covered all the information necessary and answered any questions raised, you could spend more time confirming the mother's understanding of breastfeeding.

Audit tool

Does your clinic have a method that records that all the topics listed above have been discussed with all pregnant women? If not, a sample checklist is available from Baby Friendly UK. Clicking on the icon to the left will take you to their checklist. Another sample checklist, developed by WHO/UNICEF is available by clicking PDFhere.

Don't force a premature, un-informed decision

Many health units ask the pregnant mother what her feeding intention is early in pregnancy prior to providing education.

It is not reasonable to expect anyone to make an informed decision without information.

Once the mother has given an answer, particularly if she chose artificial feeding, education about breastfeeding is frequently withheld.

Think about the impact such a simple question, asked at the wrong time, could have.

Do you really need to ask her at all? After she's learned about normal birth and cesarean delivery do you ask her which one she will have? Why not? Why should it be different with infant feeding?

When the mother does not breastfeed

There are circumstances when breastfeeding is contraindicated. Be aware that this could be a difficult emotional situation for the mother, requiring thoughtful counseling. Some of these circumstances include:
  • Infant conditions:
    • classic galactosemia
    • maple syrup urine disease
  • Mother:
    • cytotoxic chemotherapy
    • addicted to illegal drugs
    • HIV positive, when safer alternatives are available for her infant
    • radio-active iodine-131 precludes breastfeeding for about 2 months. This should be avoided given that safer alternatives are available.
One-on-one education about the preparation of artificial feeds is to be given at the time of need.

One-on-one education about the preparation of artificial feeds is to be given at the time of need.


  • Other conditions may require the mother to temporarily withhold her breastmilk, or the infant to receive only limited amounts of breastmilk in conjunction with a specialized formulation.
    • some maternal medications; most medications have alternatives that are safe during lactation
    • very low birth-weight or very preterm infants
    • infants with phenylketonuria; with careful monitoring
    • infants with hypoglycemia that does not respond to breastfeeding or breastmilk feeding; though due to the seriousness of this condition intravenous therapy is preferred management.

A mother may also choose not to breastfeed for reasons of her own. It is important that the mother receives the education already mentioned and is aware of the short- and long-term effects of artificial milks on her child before she makes this decision.

Breastmilk substitutes

The choice of a breastmilk substitute should be made in conjunction with a pediatrician or other health professional who will have responsibility for the infant's health and growth. Factors such as a family history of allergies, weight gain issues and feeding difficulties with other siblings will guide this choice and the choice of feeding implements. The mother should bring these with her to the hospital or clinic so that she can learn how to prepare them and feed her infant while being supervised.

A large American study reported more than 3/4 of mothers using breastmilk substitutes did not receive instruction on formula preparation or storage from a health professional. 3

A systematic review of the literature from the United Kingdom described errors in reconstitution of breastmilk substitutes by parents, with a tendency to over-concentrate feeds, though under-concentration also occurred. 4

Infants fed a breastmilk substitute that is not prepared in a safe manner are prone to:

  • hypernatremic dehydration,
  • malnutrition,
  • obesity, and
  • gastrointestinal infections. 5

Because of the frequency and seriousness of these errors, instruction on formula preparation, storage and safe feeding practices must be given individually to the parents by a health professional at the time they need it . This teaching is not effective when given prenatally. Topic 7.5.4 details how to teach this skill.

The WHO Code on the Marketing of Breastmilk Substitutes precludes group instruction of this important skill. Likewise it stipulates that instruction is to occur after the infant is born, at the time of need. 6

What should I remember?

  • Step 3 (BFHI) and Point 3 (Plan for the Community)
  • the 3 important breastfeeding knowledge areas which must be covered with all pregnant women
  • using open questioning and conversation techniques which can open discussion about infant feeding
  • when breastfeeding is contraindicated
  • when artificially-feeding parents are to receive instruction on infant formula preparation

Skills Competency #1

Communicating with pregnant women about infant feeding

Linked here is the first of 4 Skills Competencies every staff member must successfully complete to meet the staff education requirements of the Baby Friendly Initiative. Before doing this first competency you may wish to complete the whole course, ensuring you have the evidence-based knowledge to discuss the topics you must discuss with the mother and any other issues the mother may raise.


Notes

  1. # World Health Organisation et al. (1992) Global Criteria fort he Baby-Friendly Hospital Initiative
  2. # Lu MC et al. (2001) Provider encouragement of breast-feeding: evidence from a national survey
  3. # Labiner-Wolfe J et al. (2008) Infant formula-handling education and safety.
  4. # Renfrew MJ et al. (2003) Formula feed preparation: helping reduce the risks; a systematic review.
  5. # Egemen A et al. (2002) A generally neglected threat in infant nutrition: incorrect preparation of infant formulae.
  6. # World Health Organization (2008) The International Code of Marketing of Breast-Milk Substitutes: frequently asked questions. Updated version 2008

3.1 The feeding decision

What is most influential?

Several studies have noted that women may decide on how they will feed their baby either before pregnancy or during the first trimester. These decisions are formed as a product of their demographics and the culture in which they live.

Demographic data, such as age, ethnicity, social class, education, etc may be used to predict feeding decisions. There is limited ability to change these factors.

Psychosocial variables, however, can also have a significant impact, and these can be targetted with education.
Researchers found that maternal attitudes are better predictors of feeding method than are sociodemographic factors, 1 and that a woman's prenatal intention was a stronger predictor than the standard demographic factors combined. 2 Fathers' attitudes also influence maternal decisions.3,4

In a study of women who were already breastfeeding 95.5% gave breastmilk as being better for the baby as the major reason they chose to breastfeed, with convenience for the mother another common reason. Another researcher 5 explored why both breastfeeding and artificial formula-feeding mothers chose their method of feeding. They found ...

  • Mothers chose to feed artificial infant formula

    • not because they embraced artificial infant formula-feeding, rather that they rejected breastfeeding
    • found breastfeeding embarrassing
    • feared the pain or discomfort
    • felt it limits freedom and social life
    • were concerned that the father would not be involved
    • but acknowledged that human milk is better for the baby
  • Mothers who chose to breastfeed had the following in common

    • a positive attitude toward breastfeeding and human milk
    • considered human milk to be healthier or 'better' for babies than artificial infant formula
    • felt breastfeeding was more natural
    • felt it resulted in better bonding or closeness with the baby
    • and their self-confidence was linked to longer duration of breastfeeding

Both breastfeeding and artificial infant formula-feeding mothers felt that their chosen feeding method was the most convenient.

How can we influence the decision?

In the community

Community health promotion activities that present breastfeeding as a natural, healthy, and normal way to feed a baby can influence society opinion. As a member of that society the mother and her support people will also be influenced.

What can your hospital do?

Consider forming a small group that is interested in health promotion activities. How could you go about increasing public acceptance of breastfeeding as the normal way to feed infants? Some ideas could include:
  • Becoming involved in ExternalWorld Breastfeeding Week[link: http://worldbreastfeedingweek.org/] promotions, with displays not only at the hospital but in shopping precincts, libraries and other public places.
  • Use social media avenues to connect with your community. What social media does your target-group use? Could your Unit have an official 'twitter' account, or a blog? Does your hospital have a Facebook account? If there are popular bloggers writing on parenting issues in your area could you write articles for them to post?
  • Be prepared to make public statements whenever any topic about breastfeeding is raised in the media, eg breastfeeding in public, workplace reforms, etc. Make your hospital the 'go to' place whenever the media wants expert opinion on breastfeeding topics.
  • Offer consultancy services to government departments that fund health promotion activities.
  • What other ideas can you think of? Please share them in the General Forum.

Prenatal education

The attitude of the health care provider to breastfeeding strongly influences the pregnant woman's attitude. Women who are encouraged to breastfeed by their doctor, nurse or midwife are four times more likely to initiate breastfeeding than women who do not receive their encouragement. 6

Play your part...

This is an indication of the mother's respect for her health provider's opinion. The responsibility rests on your shoulders to be a positive influence on pregnant women at a time when they are so open to receiving information.
You have a very important role to play in encouraging a positive breastfeeding attitude.

If your health care district runs pre-conception classes this is an ideal opportunity to have a major influence on women and their partners.

Early in their pregnancy, and continue throughout pregnancy:

  • Provide information about the recommended length of time to breastfeed exclusively (ie 6 months), and in total (up to 2 years and beyond). 7
    Mothers who know the scientific recommendation are more likely to set that as their breastfeeding goal.
  • Include the mother's support people, particularly the father, but also the mother's mother and mother-in-law when giving education, both face-to-face and in classes. 8 9
    Having their support for breastfeeding makes a significant difference to initiation and duration of breastfeeding.
  • Discuss how to provide breastmilk during times of separation.10 11 9
    Feelings of being 'tied' to the baby, or not knowing how they could breastfeed when they return to the workforce, can cause some mothers to not begin breastfeeding or to wean very early.
  • Increase maternal confidence and self-efficacy. 12

Provide a supportive environment for breastfeeding in the hospital. Mothers say it is important that nurses discuss breastfeeding and watch them breastfeed. Having a Lactation Consultant review them also positively influences mothers' self-confidence.

Guilt and not breastfeeding

This is a good opportunity for you to re-read about how feelings of guilt develop around the infant feeding decision. Understanding this will assist you to communicate effectively with pregnant women.

What should I remember?

  • The factors which most influence a woman's infant feeding decision
  • The prenatal circumstances which can positively influence maternal attitude towards breastfeeding
  • Your role as a health professional in modelling a positive breastfeeding attitude to all women
  • Be proactive - you will make a difference!

Self -test quiz

Notes

  1. # Dungy CI et al. (1994) Maternal attitudes as predictors of infant feeding decisions
  2. # Donath SM et al. (2003) Relationship between prenatal infant feeding intention and initiation and duration of breastfeeding: a cohort study
  3. # Sencan I et al. (2013) Factors influencing breastfeeding duration: a survey in a Turkish population.
  4. # Freed GL et al. (1993) Effect of expectant mothers' feeding plan on prediction of fathers' attitudes regarding breast-feeding
  5. # Brodribb W et al. (2007) Identifying predictors of the reasons women give for choosing to breastfeed.
  6. # Lu MC et al. (2001) Provider encouragement of breast-feeding: evidence from a national survey
  7. # Wen LM et al. (2012) Awareness of breastfeeding recommendations and duration of breastfeeding: findings from the Healthy Beginnings Trial.
  8. # Tarrant RC et al. (2010) The prevalence and determinants of breast-feeding initiation and duration in a sample of women in Ireland.
  9. # Ismail TA et al. (2013) Intention of pregnant women to exclusively breastfeed their infants: The role of beliefs in the theory of planned behaviour.
  10. # Plewma P (2013) Prevalence and factors influencing exclusive breast-feeding in Rajavithi Hospital.
  11. # Ladomenou F et al. (2007) Risk factors related to intention to breastfeed, early weaning and suboptimal duration of breastfeeding.
  12. # Leahy-Warren P et al. (2013) Factors influencing initiation and duration of breast feeding in Ireland.

3.2 The barriers

Barriers to breastfeeding can be divided into 3 main categories:

  • societal barriers, such as attitudes of the general population, the mother and her support networks. These are influenced by commercial interests, among other things.
  • institutional barriers,caused by health policies or professionals that lack breastfeeding management skills
  • postnatal perceptions of ability to continue breastfeeding. The mother's lack of knowledge of normal newborn behaviour, breastfeeding management and a need or expectation to work away from her baby influence this perception.

Mothers identified these barriers, with the top 3 being 1

  • breastfeeding in public
  • management of breastfeeding by their health professional, and
  • trying to combine breastfeeding and working

Workbook Activity 3.2

Complete Activity 3.2 in your workbook.

Addressing societal barriers

Worldwide campaigns, eg. World Breastfeeding Week, a WABA initiative; the Global Strategy for Infant and Young Child Feeding, a WHO/UNICEF initiative, as well as national and local initiatives attempt to influence community attitudes.

National program to influence community attitudes.       The Ad Council, USA

National program to influence community attitudes. The Ad Council, USA

from San Diego County Breastfeeding Coalition

from San Diego County Breastfeeding Coalition

Acceptance of breastfeeding in public is a reflection of community attitudes.

Discomfort in public breastfeeding is reported by many women and is noted as a significant barrier. Targeting this area specifically, organizations have developed public service announcements for various media.

Some countries and States have had to go to the extreme step of legislating for a mother's right to breastfeed her baby wherever she and her baby are when her baby requires feeding.


What can you do to influence community attitudes?

Before you can address barriers that mothers will have to overcome, you will need to understand what they are. Surveying the mothers and their relatives and friends that you meet in your unit could give you a starting point. From there, a small but enthusiastic committee could brainstorm ideas for local and community activities to address these concerns.

Share your findings in the forum.

Health provider knowledge, skills and management

A common complaint from women is the amount of conflicting advice they receive from their health care providers. Also some of that advice may be detrimental to ongoing breastfeeding success.


Step 1 and Point 1

Step 1 of the Ten Steps to Successful Breastfeeding and Point 1 of the Seven Point Plan for Sustaining Breastfeeding in the Community both state:
Have a written breastfeeding policy that is routinely communicated to all staff

A regulatory policy, such as the policies implemented by health care institutions, limit the discretion of individuals or compel certain types of behavior. That is, you have a legal requirement imposed on you by your employer to follow the policy. It is not a personal decision whether you will follow or ignore certain aspects of a policy.

A policy that has been developed to support evidence-based, best-practice principles not only prevents conflicts in care, but is your protection should anything untoward occur.

Display the Policy in the most common languages spoken.

Display the Policy in the most common languages spoken.
© D.Fisher, IBCLC


The policy is to be displayed in all areas that serve mothers and babies. It should cover all Ten Steps to Successful Breastfeeding in hospitals or all of the Seven Point Plan.

Baby Friendly Step 2 and Point 2

Step 2 of the Ten Steps to Successful Breastfeeding and Point 2 of the Seven Point Plan for Sustaining Breastfeeding in the Community both state:
Train all health care staff in skills necessary to implement this breastfeeding policy
Congratulations on joining the ever-growing group of skilled and knowledgeable health professionals who protect, promote and support breastfeeding mothers and babies!

Education of health professionals using the curriculum developed for Step 2 of the Baby Friendly Hospitals Initiative produced staff who were significantly more knowledgeable about breastfeeding, had more positive attitudes and were more likely to employ correct practices for the promotion of exclusive breastfeeding.2,3 Another study showed that mothers who birthed in hospitals that had a high compliance to Baby Friendly Steps initiated breastfeeding in greater numbers and breastfed for longer than those in non-Baby Friendly hospitals.4

Support your colleagues

ALL of your colleagues want to do what is best for both mother and baby. Encourage those colleagues who are unsure of current, evidence-based practices to complete an educational program such as this one. It will help them to achieve their goal, and benefit mothers and babies.

Postnatal perceptions

Educating mothers about maintaining milk supply and normal newborn behaviour will be discussed as you work through this course.

Breastfeeding and separations

An increasing number of women must spend time away from a baby or child who is still in the age range prior to earliest age of weaning ... ie the first two years. Returning to the paid workforce is the most common reason for regular separation of mother and baby, and a common reason given for premature weaning.

Leaving her baby to go to work can be a highly stressful time for the mother. She will need to consider the physical and emotional effects of separation for long or short periods of time.

Continuing to provide breastmilk can

  • present many challenges,
  • help her to maintain an emotional connection to her baby, despite her physical absence,
  • help prevent the many acute illnesses associated with group child care,
  • make breastfeeding when they are reunited a very special and close time.

Your professional role is to

  • Educate her on the value of continuing to provide breastmilk for her baby, despite separation.
  • Discuss the issues she will need to address to be successful.
  • Provide her with contacts for peer-support services, to talk with other women in her situation.
  • Inform the mother of her right to breastfeed, and what workplace legislation will protect her right.

Do some action research

Ask your colleagues, friends and the mothers you meet who continued to breastfeed until their baby was at least 12 months old what they did during periods of separation. You are likely to get many unique ideas which you can share with pregnant women.

Workbook Activity 3.3

Complete Activity 3.3 in your workbook.

Breastfeeding in special circumstances

Most women will be healthy, having no special needs regarding breastfeeding, and will be able to breastfeed without difficulty.

When a referral is needed

In some of the circumstances described the mother will need the help of other health professionals, such as a psychologist, or a lactation consultant, or a doctor, and perhaps referral to a peer-support group. Does your Unit have a procedure in place to ensure the mother is aware of these other services and able to access them?

What should I remember?

  • The main barriers that mothers face when breastfeeding.
  • Methods to address these barriers.
  • The mothers that will require extra counseling or referral to other health care professionals to assist them to breastfeed successfully.

Notes

  1. # McIntyre E et al. (2001) Attitudes towards infant feeding among adults in a low socioeconomic community: what social support is there for breastfeeding?
  2. # Gupta A et al. (2002) Training in Baby Friendly Hospital Initiative
  3. # Owoaje ET et al. (2002) Previous BFHI training and nurses' knowledge, attitudes and practices regarding exclusive breastfeeding
  4. # Merten S et al. (2005) Do baby-friendly hospitals influence breastfeeding duration on a national level?

3.3 Physical preparation

What physical preparation should mothers do?

The old texts abound with advice on nipple preparation techniques. Studies from the 1970s all found that any physical preparation of the nipples is entirely unnecessary and should NOT be recommended.

  • Inverted nipples: Treatment of inverted or non-protractile nipples during pregnancy using Hoffman's nipple stretching exercises and/or breast shells makes NO difference to the nipples compared to a group who had no intervention. Women in the intervention groups were more likely to not initiate breastfeeding or wean early. Therefore this practice is not to be recommended. 1

  • Expressing colostrum: Routine expression of colostrum is likewise not necessary and could cause anxiety in women who are not comfortable handling their breasts in this manner, or in those who are unable to express colostrum - a fact which is not related to ability to produce breastmilk postnatally.
    However, antenatal expression and collection of colostrum may be recommended for certain maternal or newborn medical reasons. 2 This ready supply of colostrum brought to the hospital when the mother births may be sufficient if a supplement is necessary.
    It also provides an ideal opportunity to teach mothers how to hand express, a skill they will need to learn anyway.

Prenatal breast examination

While there is no physical preparation necessary for breastfeeding, examination of the breasts during a routine prenatal check-up can reveal information that could assist with the care of the mother and baby postnatally, and it provides an opportunity to discuss breastfeeding and any concerns the mother may have.
Have the mother in a sitting position.

The breast is composed of glandular tissue (functional tissue), fibrous tissue and fatty tissue. Breast size is variable between women, and even in the same woman. The amount of fatty tissue present largely determines breast size. Glandular tissue influences size to a lesser degree.

The glandular tissue begins to function as a milk producing gland during pregnancy. The duct system and terminal milk-producing buds, called alveoli, proliferate during the first half of the pregnancy. Breast size increases for most women during this time.

Under the influence of the hormone prolactin, small amounts of colostrum are produced. Pregnancy progesterone inhibits full milk production. Breastmilk is synthesised and stored in the alveoli and travels through the duct system towards the nipple openings.

The nipple is in the centre of the areola and the least important structure of the breast during breastfeeding, being merely the structure through which the ends of the ductal system pass. Unfortunately, it is often the most commented on by the mother's advisors, forecasting success or failure of breastfeeding on the size and erectile nature of the nipple, which of course is incorrect.

The areola may darken during pregnancy. Montgomery's follicles are tiny glands that have a pimple-like appearance on the areola and become more prominent during pregnancy. These follicles may secrete an oily substance, and some secrete tiny droplets of milk. Maternal areola odor is produced which enhances the newborn's sucking activity.3 Washing the breasts before feeding is not recommended as it washes away these protective secretions, and the important prefeeding stimulus provided by the unique smell.

Inspection

  • Size and shape: Breasts and nipples come in an infinite variety of sizes and shapes. Breast size is not related to milk production. Remember, it's breastfeeding, not nipple feeding. A 'different' nipple shape could provide mother and baby with a challenge - the key is to achieve good latch to the breast.
  • Asymmetry: Most women have asymmetrical breasts. Marked asymmetry should be noted, but no further action is necessary. If the smaller breast is felt to be hypoplastic, it is helpful to note that one breast can produce sufficient breastmilk for the baby.
  • Large breasts: Some women with very large breasts may like to discuss their feelings about their breasts and what breastfeeding is going to mean to them. Knowing how to help this mother to feed easily and discreetly could be the significant factor in her infant feeding decision.
  • Skin appearance: The skin should appear smooth without thickening or dimpling, which, while rare in women of child-bearing age, could indicate an underlying tumour. Skin conditions such as psoriasis, dermatitis or bacterial or herpetic lesions should also be noted, and treated.
  • Scarring: Record the position and reason for surgical or injury scars noting their potential to impact on breastfeeding (eg. breast reduction surgery, areola incision, burns etc).
A prenatal examination of the breasts can give you a lot of useful information.

A prenatal examination of the breasts can give you a lot of useful information.
© Goldfarb Breastfeeding Clinic

Palpation

Take this opportunity to discuss and demonstrate breast self-examination as a routine breast screening technique for breast cancer, but one which can also be useful to detect blocked ducts during lactation.

Workbook Activity 3.4

Complete Activity 3.4 in your workbook.

Record-keeping

It is important to record the signs and symptoms you noted at this examination. Later in the pregnancy the mother could be referred to a Lactation Consultant to discuss any issues which may impact on breastfeeding, such as breast reduction, augmentation, or if the mother has a concern about her capability to breastfeed. A medical review is indicated for other abnormalities noted.

Markedly small or asymmetrical breasts may, or may not, make breastfeeding difficult. Postnatally, routine procedures should readily identify babies who are receiving insufficient breastmilk. However, a note in the mother's chart will alert staff to remain vigilant.

The power of words.

It's often been commented that the most important organ for successful breastfeeding is the brain. There are essential hormones released here, but of MORE importance is the belief by the mother that she can breastfeed. A positive attitude by all her health care providers is essential to prevent self-doubt limiting the mother's potential.

Be aware of the words you use and the impact they have on a mother's self-confidence.

What should I remember?

  • Prenatal preparation of the breasts and nipples is not necessary
  • Breasts and nipples are all different and usually have no impact on breastfeeding ability or milk production
  • The normal physiologic changes to the breasts during pregnancy
  • How to note and record anomalies of a breast examination

Self-test Quiz

Assessment Quiz

When you are happy that you've understood all the information in this topic you will be ready to complete the Module 3 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 3.

Notes

  1. # MAIN Collaborative Group Preparing for Breast Feeding (1994) Treatment of inverted and nonprotractile nipples in pregnancy
  2. # Cox S (2006) Breastfeeding with Confidence
  3. # Schaal B et al. (2006) Human breast areolae as scent organs: morphological data and possible involvement in maternal-neonatal coadaptation

4.0 Birthing and Physiology

The benchmark outcome of pregnancy is the normal vaginal birth of the baby, without any medical or pharmacological intervention and without complication for either mother or baby, followed by the baby being able to latch and breastfeed well.
This may not be achievable for some women for whom the availability of skilled medical, nursing and pharmacological assistance is essential, but it is possible for the majority of women in the World.

Normal labor is a fragile entity. Once intervention occurs then a cascade of interventions inevitably follow.1

Kroeger, 2004

Health care professionals have a responsibility to support and facilitate normal birthing. What happens to the mother during birthing has far-reaching effects on her relationship with her baby, her ability to breastfeed and the health of the mother and her child.

Poster available for purchase from NHS, UK

Poster available for purchase from NHS, UK

Lactation physiology

Lactogenesis is the making of breastmilk. There are three distinct phases. 2

  1. Secretory differentiation commences during pregnancy.
    • also known as lactotgenesis I (LI)
    • pregnancy hormones promote cell differentiation and growth of milk ducts and stimulate mammary cells to prepare to synthesise milk
    • most women will see some evidence of a milky secretion (colostrum) from their breasts during their pregnancy

  2. Secretory activation. The initiation of lactation begins biochemically around 30 - 40 hours after birth.
    • also known as lactogenesis II (LII)
    • changes occur as a result of endocrine function, entirely dependent on the right mix of hormones:
      • progesterone levels drop as a result of the removal of the placenta, AND
      • prolactin levels are high as they are at the time of birthing, in the presence of
      • normal insulin, thyroid hormones and glucocorticoids
    • the mother experiences the sensation of the milk 'coming in' around 70 hours after birth

  3. Lactogenesis III (LIII) is the maintenance of ongoing lactation.
    This autocrine function is dependent on frequent, effective removal of milk from the breasts.

Workbook Activity 4.1

Complete Activity 4.1 in your workbook.

What could delay or inhibit secretory activation?

Hint: Remember it's an endocrine function, therefore consider hormonal causes.

  • Accidents at birthing may cause endocrine disruption of lactogenesis. For example:
    • retention of a functional portion of the placenta that continues to secrete progesterone, 3
    • a haemorrhage severe enough to cause Sheehan's syndrome (pituitary gland necrosis). 4
  • A delay is common in women with insulin-dependent diabetes mellitus 5
  • Up to 80% of mothers of very premature infants have difficulty establishing lactation. 5
  • There is an increased incidence after assisted deliveries. 6
    Finding the cause of this delay and relating it to the physiology of lactogenesis has led researchers to look at the effect of stress.

Stress and breastfeeding

High stress levels are correlated with high cortisol levels. Cortisol in normal concentrations, is necessary to initiate secretory activation successfully.

  • Markers of both fetal and maternal stress during labor and delivery are associated with delayed breast fullness.7
  • Maternal stress seems to interfere with the release of oxytocin causing poor milk removal, and a newborn who experienced stress during labor and delivery may be too weak or too sleepy to latch on and suckle effectively.8
  • Onset of lactation occurred later in women who had higher cortisol levels. Primiparous women had higher levels than multiparous women. Stress during labor and/or delivery is likely to be a significant risk factor for delayed onset of lactation.9

What should I remember?

  • that interventions in labor have far-reaching effects on mother and infant
  • the 3 stages of lactation
    • when each commences
    • what controls their initiation or, in the case of LIII, what maintains it
    • the timing of their occurrence
  • the factors that can interfere with secretory activation

Self-test quiz

Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column

Notes

  1. # Kroeger M et al. (2004) Impact of Birthing Practices on Breastfeeding: Protecting the Mother and Baby Continuum
  2. # Czank C et al. (2007) Hormonal control of the lactation cycle
  3. # Anderson AM (2001) Disruption of lactogenesis by retained placental fragments
  4. # Kilicli F et al. (2013) Sheehan\'s syndrome.
  5. # Hartmann P et al. (2001) Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity
  6. # Dewey KG et al. (2003) Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss
  7. # Chen DC et al. (1998) Stress during labor and delivery and early lactation performance
  8. # Dewey KG (2001) Maternal and fetal stress are associated with impaired lactogenesis in humans
  9. # Grajeda R et al. (2002) Stress during labor and delivery is associated with delayed onset of lactation among urban Guatemalan women

4.1 The first hours

Promotional poster - from Baby Friendly UK

Promotional poster - from Baby Friendly UK

The benefits to the mother of immediate breastfeeding are innumerable, not the least of which, after the weariness of labour and birth, is the emotional gratification, the feeling of strength, composure, and the sense of fulfillment that comes with the handling and suckling of the baby.1

Ashley Montague, 1978

Baby Friendly Step 4

Step 4 of the Ten Steps to Successful Breastfeeding states:

"Help mothers to initiate breastfeeding within a half-hour of birth."

This step is now interpreted as:

Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognize when their babies are ready to breastfeed, offering help if needed. 2

Immediately following birth

At the time of birth 90% of newborns do not need assistance to begin breathing and will benefit from being placed in skin-to-skin contact on the mother. 3

  • Immediately dry newborn and move him/her onto mother's abdomen in skin-to-skin contact.
  • In this position:
    • Baby can be covered with dry linen to maintain temperature,
    • upper airway can be cleared by wiping the mouth and nose, and
    • respiration and heart rate can be assessed and monitored.

The first breastfeed

Read this great article!

What happens now is truly a miracle to watch! Click on the icon on the left to read this paper, then file it in your Workbook. If you are in contact with colleagues who are with birthing mothers, share it with them too.

Several researchers have described this species-specific set of innate behaviors when baby is placed in skin-to-skin contact with the mother immediately following birth. It is clear that newborn babies are born with the instinct to breastfeed.4,5,6,7


© R.Cantrill, IBCLC

Research findings

  • Blood glucose at 90 minutes is significantly higher in the skin-to-skin care newborns. 8
  • 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. 9
  • 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. 10
  • Exclusive breastfeeding at 48 hours and 6 weeks postpartum 11 and incidence of any breastfeeding at 1 and 4 months 8 was significantly greater for infants in the skin-to-skin care groups.

The role of the birth attendants

This critical period in the relationship between mother and baby is, in some birthing units, a high-intervention time when it should be exactly the opposite. Recall that the AAP Neonatal Resuscitation Guidelines 3 state that all observations can take place with infant in skin-to-skin contact with his mother. The role of the birth attendants at this time is to support the mother 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, and others present, the importance of uninterrupted skin-to-skin contact. Some birth attendants tell of the mother and her 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 to care for her baby with skin-to-skin contact will significantly reduce the workload of the health care staff looking after her.
  • The infant will adapt to extrauterine life more quickly, reducing any risk of hypothermia or cardio-respiratory instability.
  • Glucose homeostasis is achieved quickly, reducing risk of hypoglycemia.
  • Breastfeeding will be initiated early and successfully, with minimal input from others.
  • Breastfeeding will stimulate the release of oxytocin, reducing the risk of maternal hemorrhage.
  • Skin-to-skin care will colonize the baby with the mother's normal flora, which, when combined with breastfeeding, significantly reduces the risk of nosocomial infections.
  • Maternal self-confidence and independence will rise.

Addressing barriers to skin-to-skin

Concern that the baby will get cold.

  • Dry the baby and place in skin-to-skin contact on mother's chest.
  • Put a dry cloth or blanket over both the mother and the baby.
  • If the room is cold cover the baby's head with a bonnet to reduce heat loss.
  • Babies in skin-to-skin contact have higher temperature than those dressed and better temperature regulation than those under a heater or in incubator care. 12 13

Baby needs to be examined.

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

Mother needs suturing.

  • Baby can stay on mother's abdomen while an episiotomy is sutured.
  • Baby can stay on mother's chest while suturing a cesarean section wound.14

Baby needs to be bathed.

  • Delaying the first bath provides better thermoregulation and allows the vernix to remain on the skin.
    • Gently wipe the baby dry after birth, preserving the vernix.
    • Vernix retention is associated with significantly higher skin hydration, a lower skin pH and significantly less erythema. 15
    • Early bathing is associated with a significant fall in temperature. 16

Delivery room is busy.

  • Mother and baby can be transferred to the postnatal ward while in skin-to-skin contact.

Insufficient staff to remain with the mother.

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

Baby is not alert.

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

Mother is tired.

  • A mother is rarely so tired that she does not want to hold her baby.
  • Contact with her baby can help the mother 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 mother is in a semi-reclined position; a good position for resting.

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

  • This first step following birthing has far-reaching effects on mother, baby 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.

Workbook Activity 4.2

Complete Activity 4.2 in your workbook.

Maternal-infant bonding

This is the beginning of a loving relationship between the parents and their newborn. 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's chest and breasts and latches and breastfeeds. The high blood levels of beta endorphins, oxytocin and prolactin in both mother and infant facilitate falling in love.17

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 his/her parents,
  • an environment conducive to parent and child interaction, and
  • the attitude of those present at the delivery to the appearance of the infant17

What about a baby to be artificially fed?

Skin-to-skin time with mother is equally important for EVERY baby. In Topic 4.3 Postnatal interventions, you will read the effects of separating mothers and newborns - facilitating breastfeeding is only one of many, many benefits of skin-to-skin contact.

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's chest has for both her and her infant
  • how you could address the barriers to skin-to-skin care should your colleagues be concerned

Self-test quiz

Notes

  1. # Montague A (1978) Touching: The Human Significance of the Skin
  2. # World Health Organization (2006) Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Intergrated Care
  3. # Kattwinkel J et al. (2010) Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
  4. # Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed
  5. # Widstrom AM et al. (1990) Short-term effects of early suckling and touch of the nipple on maternal behaviour
  6. # Varendi H et al. (1998) Soothing effect of amniotic fluid smell in newborns
  7. # Mattos-Graner RO et al. (2001) Relation of oral yeast infection in Brazilian infants and use of a pacifier
  8. # Moore ER et al. (2012) Early skin-to-skin contact for mothers and their healthy newborn infants.
  9. # Bergman NJ et al. (2004) Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns
  10. # Gomez Papi A et al. (1998) Kangaroo method in the delivery room for full-term babies
  11. # Thukral A et al. (2012) Early skin-to-skin contact and breast-feeding behavior in term neonates: a randomized controlled trial.
  12. # Carfoot S et al. (2005) A randomised controlled trial in the north of England examining the effects of skin-to-skin care on breast feeding.
  13. # Fransson AL et al. (2005) Temperature variation in newborn babies: importance of physical contact with the mother.
  14. # Smith J et al. (2008) The natural caesarean: a woman-centred technique.
  15. # Visscher MO et al. (2005) Vernix caseosa in neonatal adaptation.
  16. # Bergstrom A et al. (2005) The impact of newborn bathing on the prevalence of neonatal hypothermia in Uganda: a randomized, controlled trial.
  17. # Attrill B (2002) The assumption of the maternal role: a developmental process

4.2 Labor interventions

The care a mother experiences during labor and birthing can affect breastfeeding and how she cares for her baby. Birth practices that help the mother to feel competent, in control, supported and ready to interact with her baby include:

  • Emotional support during labor
  • Freedom of movement during labor
  • Offering light foods and fluids during labor
  • Avoidance of unnecessary caesarean section
  • Early mother-infant contact
  • Facilitating the first feed

Consideration of the following facts is important when labor interventions are considered:

Analgesia during labor

The most commonly used intrapartum analgesics are potent narcotics which have the potential to block the newborn's normal reflexes to suckle at the breast within the first hour after birth. When opiates must be used shorter-acting opiates are preferred.

  • Fentanyl, sufentanil and remifentanil are all short-acting.
  • Morphine has a short half-life (1.5 - 2 hrs) and does not have an active metabolite.
  • Meperidine (Pethidine/Demerol) is associated with a greater incidence and duration of respiratory depression, cyanosis and bradycardia in neonates. It is metabolized to the active metabolite normeperidine (norpethidine) which has a long half-life (63 hours in the neonate). Meperidine/Pethidine reaches its highest levels in the fetus 2 to 3 hours after administration, however normeperidine/norpethidine levels continue to rise the longer it is until birth. Normeperidine/norpethidine still has half the pharmacological activity of meperidine/pethidine.
  • Butorphanol (Stadol) and Nalbuphine (Nubain) interfere with fetal heart rate monitoring. Observe mother and baby for psychotomimetic reactions.

How long will the effects of meperidine/pethidine be experienced by the newborn baby?

It takes approximately 5 half-lives for a substance to reach insignificant serum (blood) concentration. How long will it take the newborn baby to clear normeperidine and its effects from his system?

Multiply 63 hours by 5 times; then divide by 24 to have your answer in days.

Other forms of analgesia such as inhaled nitrous oxide, paracervical block, pudendal block and local perineal anaesthesia expose the infant to minimal quantities of medication and may be an alternative to intravenous narcotics or epidural analgesia.

Neuraxial pain relief (epidural/spinal)

Anesthetics such as lignocaine and bupivacaine are commonly administered via the epidural route to mothers in labor to provide pain-free birthing. This local anesthetic is almost always combined with narcotics such as morphine, fentanyl or sufentanil, providing a rapid onset of pain relief while reducing the intensity of immobility for the mother.

While epidurals in labor provide greater pain relief than non-epidural methods, they are also associated with:1

  • longer first and second stages of labor,
  • maternal fever
    • followed by septic work-up of infant, and maternal/infant separation, and possibly antibiotic therapy
  • a drop in blood pressure
    • fluid 'loading' used routinely; commonly associated with postnatal breast engorgement and additional weight loss in the infant during the first two days
  • problems passing urine
  • decrease in oxytocin levels during labor, necessitating an increased use of oxytocin augmentation
  • an increased incidence of fetal malposition,
  • an increased need for instrumental vaginal delivery
  • the mother being unable to move for a period of time after the birth, and
  • the possibility of a postdural puncture headache2 palliatively treated by horizontal bed rest, and usually further medical intervention.
  • decreased oxytocin and prolactin levels on Day 2 postpartum.3
Medications administered via epidural or spinal routes rapidly enter the maternal circulation, are measurable in the fetal circulation within 10 minutes4 and may persist for up to 3 days in the newborn.5

Is breastfeeding affected?

Yes and no!

The risk of associated interventions (eg assisted delivery, etc) make breastfeeding more challenging.

Infant behavior is adversely affected when high doses of analgesia, or repeated doses over a longer duration, are used. This is minimised when
  • the dose used is low (eg less than 150mcg Fentanyl)
  • motor block is minimized
  • longer duration and repeated dosing are avoided.
Breastfeeding is not affected when the mother's motivation to breastfeed is high and she is well-supported. However, the subtle changes in infant behavior may be sufficient to challenge a less-committed mother.

Did you know?

Another side effect of epidural administration is the fall in maternal serum beta endorphins.6 Beta-endorphins are a naturally occurring opiate that, like other opiates, act as an analgesic, inducing feelings of pleasure, euphoria, and dependency or, with a partner, mutual dependency.

  • levels increase throughout pregnancy; high levels at the end of pregnancy are associated with a decreased need for intrapartum analgesia.7 Such high levels help the laboring woman to transmute pain and enter the altered state of consciousness that characterizes an undisturbed birth.8
  • Beta-endorphins are found in colostrum; it is thought they contribute to postnatal fetal adaptation, to overcoming birth stress, to the postnatal development of several related biologic functions of breastfed infants and may persist for up to 3 days.9,5,10,11

Cesarean (caesarean) section

How it was ...

Cesarean birth is often associated with delayed skin-to-skin contact between mother and baby and longer time to first breastfeed.

  • Rowe-Murray et al (2002)12 reported a significant delay in initiating breastfeeding compared with women giving birth vaginally, with or without instrumental assistance.
  • Shawky & Abalkhail (2003)13 found caesarean section delivery to be significantly related to earlier cessation of breastfeeding.
  • Leung et al (2002)14 identified caesarean delivery was a risk factor for not initiating breastfeeding, for breastfeeding less than 1 month, and it remained a significant hazard against breastfeeding duration.

Don't forget the effects of the operation itself: an abdominal incision, pain, restricted movement, intravenous therapy, a urinary catheter, analgesics for several days, restricted oral intake and any complications arising from these interventions. Rooming-in is more difficult, at least initially.

The baby has an increased risk of respiratory problems, and is subjected to suctioning of mouth and oropharynx. Some units purposely separate the post-cesarean delivered baby from its mother for "observation" for several hours and may perform routine heel prick blood tests. Due to separation and the desire of the staff to let the mother 'rest', the baby may be given formula supplements.

All of these factors have the potential to limit the frequency, effectiveness and, ultimately, duration of breastfeeding.

Interesting research

An interesting study15 looked at whether the hormonal patterns of oxytocin, prolactin and cortisol differed between women delivered by emergency cesarean section or vaginally, and if those patterns showed any relation to the duration of breastfeeding. They found that the mothers birthing vaginally had significantly more oxytocin pulses on Day 2 than the cesarean section mothers. Furthermore, the cesarean section women lacked a significant rise in prolactin levels at 20-30 min after the onset of breastfeeding. They were able to link the oxytocin pulsatility on Day 2 to the duration of exclusive breastfeeding.

How it should be ...

Hospitals practicing Step 4 of the 10 Steps to Successful Breastfeeding are diligent at ensuring a minimum disruption to this important bonding and breastfeeding step. 16

Many hospitals support the newly delivered infant being dried and placed directly on the mother's chest for skin-to-skin contact while the obstetrician completes the surgery. The infant will remain here throughout the recovery and mother's transfer to the ward.

The ideal cesarean

The Natural Caesarean. A wonderful way to support the mother and respect the baby when birth is by caesarean. This 12 minute video is from Youtube. (Some hospitals block youtube - view from a home computer)

Pregnancy classes

What is included about birthing interventions in the curriculum of the pregnancy classes where you work? Do all pregnant women know the effects of interventions on themselves and their baby? Do they have to give consent prior to any of these procedures? How well informed is this consent?

Form a group to review the pregnancy class curriculum.

Assisting a mother following an assisted delivery

  • Initiate skin-to-skin contact as soon as possible
    • immediately following vaginal delivery if baby does not require advanced life support.
    • as soon as possible if caesarean section under epidural or spinal analgesia. Many hospitals facilitate this while the surgeon closes the wound.
    • as soon as the mother is responsive if caesarean section under general anaesthetic. Place baby in skin-to-skin contact with father or other close family until mother available.
    • If contact must be delayed initiate skin-to-skin contact at the earliest opportunity.
  • Facilitate breastfeeding as soon as possible.
    • The mother does not need to be able to sit up, to hold her baby, or meet other mobility criteria in order to breastfeed.
    • It is the baby that is finding the breast and suckling.
    • As long as there is a support person with them, the baby can be in skin-to-skin contact in preparation for breastfeeding even if the mother is drowsy from anesthesia.
  • Help the mother find a comfortable position.
    • The 'biological nurturing' position (mother semi-reclined) is comfortable for mothers, best for skin-to-skin contact and facilitates infant self-attachment to the breast.
    • Side-lying in bed. This position helps to avoid pain in the first hours and allows breastfeeding even if the mother must lie flat after spinal anesthesia.
    • Sitting up with a pillow over the incision or with the baby held along the side of her body with the arm closest to the breast.
    • Lying flat with the baby lying on top of the mother.
  • Facilitate rooming-in with assistance, until mother is able to care for baby.

Workbook Activity 4.3

Complete Activity 4.3 in your workbook.

What can you do?

  • Prenatal parent preparation. Discuss ways to cope with pain and discomfort of labor, and the risks and benefits of interventions.
  • Provide a supportive environment for birthing - lessens need for analgesia and assisted delivery.
  • Be prepared to allow extra time and assistance to establish breastfeeding and bonding following intrapartum medications and assisted delivery.

What should I remember?

  • all interventions in labor carry a risk for both mother and infant which must be weighed against the need for the intervention
  • how intrapartum drugs affect the infant
  • measures you can take to limit the deleterious effects of intrapartum interventions

Self-test quiz

Notes

  1. # Anim-Somuah M et al. (2005) Epidural versus non-epidural or no analgesia in labour.
  2. # Vincent RD et al. (1998) Epidural Analgesia During Labor
  3. # Jonas K et al. (2009) Effects of intrapartum oxytocin administration and epidural analgesia on the concentration of plasma oxytocin and prolactin, in response to suckling during the second day postpartum.
  4. # Rosenblatt DB et al. (1981) The influence of maternal analgesia on neonatal behaviour: II. Epidural bupivacaine
  5. # Sepkoski CM et al. (1992) The effects of maternal epidural anesthesia on neonatal behavior during the first month
  6. # Raisanen I et al. (1984) Pain and plasma beta-endorphin level during labor
  7. # Dabo F et al. (2010) Plasma levels of beta-endorphin during pregnancy and use of labor analgesia.
  8. # Buckley S (2002) Ecstatic Birth: The Hormonal Blueprint of Labor
  9. # Ombra MN et al. (2008) beta-Endorphin concentration in colostrums of Burkinabe and Sicilian women.
  10. # Zanardo V et al. (2001) Labor Pain Effects on Colostral Milk Beta-Endorphin Concentrations of Lactating Mothers
  11. # Zanardo V et al. (2001) Beta Endorphin Concentrations in Human Milk
  12. # Rowe-Murray HJ et al. (2002) Baby Friendly Hospital Practices: Cesarean Section is a Persistent Barrier to Early Initiation of Breastfeeding
  13. # Shawky S et al. (2003) Maternal factors associated with the duration of breast feeding in Jeddah, Saudi Arabia
  14. # Leung GM et al. (2002) Breast-feeding and its relation to smoking and mode of delivery
  15. # Nissen E et al. (1996) Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by caesarean section or by the vaginal route
  16. # Smith J et al. (2008) The natural caesarean: a woman-centred technique.

4.3 Postnatal interventions

Separation of mother and newborn

From an evolutionary perspective skin-to-skin care is the norm. Routine separation of the newborn from its mother soon after birth is unique to the 20th Century. At the risk of laboring the point, separating the mother and baby after birthing for any reason, other than 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 from immediately after birth for the first few hours, or at least until after the first breastfeed.

When mother 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. 1

Separated newborns make 10 times more crying signals than babies in skin-to-skin care, and their cries have a completely different character. 2 3 During the "protest" response there is intense activity seeking the mother, followed by "despair" behavior which sees the baby withdraw with decreased heart rate and temperature, mediated by a massive rise in stress hormones. 4

Maternal-neonate separation results in a physiological stress-response and has a profoundly negative impact on quiet sleep duration.5

Note the protest response being exhibited by this newborn.

Note the protest response being exhibited by this newborn.
Photo © T.Young, RM


Maternal separation may be a stressor the human neonate is not well-evolved to cope with and may not be benign.5

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 temperament, ie. not oxytocin administered to the mother.

Oxytocin causes6,7

  • increased uterine contraction limiting postpartum blood loss,
  • the temperature of the mother'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 chest and breasts the maternal serum oxytocin levels rise.8 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. In 2001 he wrote:

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'. 9

Odent, 2001

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

[link: http://www.health-e-learning.com/resources/articles/34-falling-in-love]

Falling in Love[link: http://www.health-e-learning.com/resources/articles/34-falling-in-love]

Click on the icon on the left and read the article.

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.1

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 two groups (one group remained in skin-to-skin contact) in ability to attach to the breast and suckle correctly for effective milk removal was significant (p>0.001).10

Washing mother or newborn

Washing the mother 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 breasts is washed after birthing 22 out of 30 infants preferentially self-attached to the unwashed breast.11

Breast odours from the mother exert a pheromone-like effect at the newborn's first attempt to locate the nipple. Newborns are generally responsive to breast odours produced by lactating women. Olfactory recognition may be implicated in the early stages of the mother-infant attachment process, when the newborns learn to recognize their own mother's unique odour signature.12

Winberg, 1998

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.

Fortunately routine oral and gastric suctioning is no longer recommended, it's effects proving to be harmful to more than just the infant's ability to suck.13

Wiping the normal newborn's face, mouth and nose with a towel is all that is required at birth.14

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 behaviours15 and an increased prevalence of functional intestinal disorders in later life.16

Workbook Activity 4.4

Complete Activity 4.4 in your workbook.

Group Activity

Form a small group and firstly compare your lists of the benefits of keeping mothers and babies together in skin-to-skin contact (Workbook activity 4.2), then examine the interruptions to this that you each identified in Workbook activity 4.4.

Together, look at each interruption separately and develop strategies for change to prevent these separations.

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 mother
  • the baby's role in causing an oxytocin response in the mother and the effect this has on her
  • the effect of separation of mother and baby, even for a short time, on his/her ability to breastfeed
  • that changing detrimental routine practices is possible when you work together.

Self-test quiz

Assessment Quiz

When you are happy that you've understood all the information in this topic you will be ready to complete the Module 4 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 4.

Notes

  1. # Alberts JR (1994) Learning as adaptation of the infant.
  2. # Michelsson K et al. (1996) Crying in separated and non-separated newborns: sound spectrographic analysis
  3. # Christensson K et al. (1995) Separation distress call in the human neonate in the absence of maternal body contact
  4. # Bergman N (2003) Humans and Kangaroos: A Biological Perspective
  5. # Morgan BE et al. (2011) Should neonates sleep alone?
  6. # Mattos-Graner RO et al. (2001) Relation of oral yeast infection in Brazilian infants and use of a pacifier
  7. # Uvnas-Moberg K (1998) Oxytocin may mediate the benefits of positive social interactions and emotions
  8. # Matthiesen AS et al. (2001) Postpartum maternal oxytocin release by newborns: Effect of infant hand massage and sucking
  9. # Odent M (2001) New reasons and new ways to study birth physiology
  10. # Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed
  11. # Varendi H et al. (1994) Does the newborn baby find the nipple by smell?
  12. # Winberg J et al. (1998) Olfaction and human neonatal behaviour: clinical implications
  13. # Clifford M et al. (2010) Neonatal resuscitation.
  14. # Kelleher J et al. (2013) Oronasopharyngeal suction versus wiping of the mouth and nose at birth: a randomised equivalency trial.
  15. # Widstrom AM et al. (1987) Gastric suction in healthy newborn infants. Effects on circulation and developing feeding behaviour
  16. # Anand KJ et al. (2004) Gastric suction at birth associated with long-term risk for functional intestinal disorders in later life

5.0 Breastfeeding the Baby

There is no knowledge or skill more important for you to possess and pass on to mothers than how to position their babies for comfortable latching and efficient milk transfer. If positioning and latching isn't correct then breastfeeding isn't working at all. When a mother is confident her baby is breastfeeding well there's very little else she needs to know to be successful.

Mothers who have the confidence to breastfeed their babies find it an empowering experience. Teaching by 'hands-off' methods will enhance the mother's confidence when her baby achieves good latch.

When should baby be fed?

The best time to commence feeding an infant is when he first exhibits cues that he is ready to feed. When early cues are ignored the infant's behaviour will progressively become more agitated until he is crying, making latching more difficult. If the feed is further delayed the infant may tire quickly and feed poorly once feeding is finally offered.

Early feeding cues

  • mouthing and non-nutritive sucking - the infant moves his mouth in a searching or sucking manner
  • subtle body movements, wriggling
  • rooting when face touched
  • hand-to-mouth movements, with or without sucking on hand
(Note: the infant may progress through these signals very quickly - immediate attention to these signals will meet the baby's needs and initiate a more effective breastfeed)
Newborn displaying early feeding cue.

Newborn displaying early feeding cue.
© D.Fisher, IBCLC

Answering baby's cues

Workbook Activity 5.1

Complete Activity 5.1 in your workbook.

It's a team effort!

The team consists of the mother and the baby. Supporters of the team include the baby's father, the mother's other relatives and friends, and her health care providers.

  • The mother's role is to position the baby to facilitate the breastfeeding reflexes.
  • The baby's role is to be free to respond to the stimulation of those reflexes. If not interfered with the baby's reflexes will cause him to latch perfectly to the mother's breast and suckle effectively.
  • Your role is to guide the mother to position the baby so that the baby's reflexes are stimulated - not to either do it for the mother and baby, nor to tell the mother how she should latch the baby.

Preparing to guide the mother

Expensive teaching aids aren't necessary to demonstrate good positioning and latch. Common positioning and latching problems can be avoided by using these simple strategies.

  • Demonstrate positioning using a doll. This is an effective visual aid.
  • Ask the mother to try to swallow when her head is turned to one side, or when her head is tilted forward. This demonstrates how difficult it would be for baby to swallow if he had to turn his head or flex his neck to latch.
  • Ask the mother suck on her own thumb. Firstly have her put her thumb midway into her mouth and suck, then move the thumb back to the junction of the soft and hard palate and suck. Ask her to compare the effort required to keep the thumb in her mouth in both positions and the different tongue action necessary in each position. This may help the mother to understand the importance of facilitating a deep latch where her nipple will move to the back of the baby's mouth to prevent undue pressure on the nipple.
  • Show the mother a photograph of a baby who is well positioned and latched to the breast. Be very discerning though - there are many posters available that show poorly latched infants.

What's your practice like?

How do you assist a mother to position and latch her baby? How often do you achieve this being totally 'hands off'? Note the number of times the mother latches her baby well herself after your 'hands off' instructions, and the number of times you give hands-on assistance. Think about why you are needing to do it for her, or giving her significant assistance. Reflect on ways to reduce the number of times hands-on assistance is necessary.

How would you feel about benchmarking your results against those of several of your colleagues? Get a small group together that you feel 'safe' with and keep your individual statistics for a month, then compare them. Explanations for unsuccessful cases can be discussed together.

What should I remember?

  • Ways to teach and pass on knowledge without touching
  • Variations of early feeding cues
  • A baby who is crying in hunger is detrimental to breastfeeding

5.1 Positioning Principles

It's fundamental!

The mother provides the position. The baby does the latching (attaching).

Mother and baby

Observation of experienced mothers will reveal that they adopt a myriad of positions for breastfeeding throughout the day, even walking. A breastfeed may last from a few minutes up to an hour. And the mother will repeat this many times a day for at least a year. Your guidance to her is simply to adopt a position that will facilitate the baby's feeding reflexes, will avoid muscle strain and in which she is comfortable.

Reclining positions are comfortable and facilitate rest while feeding. This is the best position for mothers during the learning period.

Biological nurturing position

Current studies have demonstrated that the position that maximizes the release of pre-feeding neonatal primitive reflexes is when the mother is laid back semi-reclining with the infant prone on her chest.
This position has become known as the biological nurturing position. 1

The biological nurturing position facilitates the baby's sensory input and maintains positional stability as a result of the prone body position of the baby acting as a gravity pull towards the mother. The infant is able to use his hands and feet to push off his mother's abdomen and thrust himself toward the breast. He will lift his head up into extension to allow his chin to push forward into the breast and prepare for latch.
Biological nurturing positioning

Biological nurturing positioning.
© D.Fisher, IBCLC

Biological nurturing position

Biological nurturing position.
© K.Small


Workbook Activity 5.2

Go to your workbook and complete Activity 5.2

What about other positions?

The principles remain the same for all positions. Ensure that the infant has:

  • Sensory input: Babies depend on smell and chest-to-chest contact to initiate their feeding behavior.

The unwashed breast has a unique and individual odor that stimulates prefeeding activity and delays crying in the baby. 2 Only if necessary a drop of milk may be expressed and wiped over the mother's nipple and areola to stimulate this reflex (the infant can smell his mother very easily so don't waste time doing this when the baby is frantically seeking to latch).

Skin-to-skin contact (ie baby and mother unrestricted by clothing from the waist up) is best in the early days or when experiencing any latching difficulties. When baby and mother are clothed (light clothing, no blankets or other restrictions) is also effective allowing the baby to orientate and focus. This position calms the baby and initiates his seeking behaviours.

  • Positional stability: Positional stability is necessary for the baby to control his body and head movements. There are three aspects to this stability...
A stable base : in human anatomy terms that base is provided for the head by the shoulder girdle.
Proximal stability : infant's head and neck in alignment and supported, and
Midline symmetry : ie. the muscles on either side of the spine are experiencing equal movement.

Full chest-to-chest contact, with arms and legs free to move, achieves this. Light pressure to hold baby close to mother's chest is needed. This is best achieved by gravity in the biological nurturing position, and by having the mother's hand on the infant's back in other positions.
Cross cradle hold

Cross cradle hold.
© D.Fisher, IBCLC

Underarm hold

Underarm hold.
© D.Fisher, IBCLC


Cradle hold

Cradle hold.
© D.Fisher, IBCLC

Side lying

Side lying.
© D.Fisher, IBCLC


Closely examine each of the photographs above noting:

  • Is there adequate sensory input? chest to chest and baby held firmly against mother's body?
  • Is base stabilised? check for support across back and between shoulder blades
  • Is there proximal stability? neck and head supported NB** NEVER hold the back of the baby's head at any time during positioning, latching and feeding
  • Is there midline symmetry? baby's head and neck aligned with his spine; one arm on either side of breast
  • Is chin firmly applied to breast, nose free to breathe?
  • Is mother relaxed and well supported?
  • Is mother's arm supporting baby held comfortably, with relaxed wrist and fingers?

The Principles of Positioning

Workbook Activity 5.3

Complete Activity 5.3 in your workbook.

Start at the beginning

Do you see some mothers who are struggling with breastfeeding - they feel awkward and unsure how to hold the baby; maybe the baby's responses seem confused?

Rather than rush in with an intervention, suggest that the mother lie back slightly and bring her baby onto her chest. Encourage her to talk to him to help calm them both. It won't be long before he "bobs" his head seeking her breast. She can assist to free his arms or support his head if he needs guidance.
No interference, maximum opportunity for baby and mother to perform at their best!

(This is best in skin-to-skin for a newborn, however, it can be very successful for the older baby who has becomes confused and is also effective when infant clothed, but not restricted by blankets.)

Positioning and latching - baby-led

View the video below. When you do note:
  • the position of mother and baby
  • the calming effect of this position on baby
  • the beginnings of mouthing and interest in the breast
  • the keen interest in the breast as soon as colostrum had been wiped onto the breast (note: this was probably not necessary to do - baby was already showing interest)
  • the head bobbing and seeking with the tongue
  • finally the baby latched and suckling.


© Denise Fisher

What should I remember?

  • The importance of the mother's position in providing the basis for the baby's position.
  • The BEST position for baby and mother when learning to breastfeed.
  • Techniques which provide a stable base, proximal stability and midline symmetry.
  • How to apply the same principles to all positions which the mother may use.

Self-test Quiz

Click and drag the missing words below into their correct place

The missing words are: alignment chin gravity odour pre-feeding prone raise reflexive shoulders skin-to-skin smell turned

To assist the mother and baby to achieve successful breastfeeding, you will need an understanding of all the factors which facilitate the best circumstances:

  • A newborn baby's feeding behaviour is instinctive and __________.
  • The baby's sense of __________ will direct him towards the __________ of his mother's breast.
  • When the mother is semi-reclined her baby will be __________ on the front of her body. This natural biological nurturing position releases many primitive neonatal reflexes which stimulate __________ behaviour.
  • Baby's position firmly against mother's chest is maintained primarily by __________, though the mother may support her baby's back and __________ to provide stability.
  • The infant's head and neck need to be in straight __________. The infant will not be able to latch effectively if his head is __________ to the side.
  • Once the correct position has been achieved, the infant will __________ his head and reach for the breast.
  • His __________ will touch the breast first and make an indent in the breast.
  • When an infant is having latching difficulties the first suggestion to make to the mother is to place her infant __________ on her chest.

Notes

  1. # Colson S et al. (2008) Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding.
  2. # Doucet S et al. (2007) The "smellscape" of mother's breast: effects of odor masking and selective unmasking on neonatal arousal, oral, and visual responses.

5.2 Breastmilk transfer

Obviously the goal of breastfeeding is to achieve milk transfer from mother to baby.

Breastmilk transfer occurs by:

  1. positive pressure as the milk ejection reflex (MER) forces milk from storage in the alveoli towards the nipple, and
  2. negative pressure, created in the baby's mouth, drawing the milk from the breast into the oro-pharynx.1

Understanding the anatomy


© Health e-Learning

Imagine the functional tissue of the breast as like a large bunch of grapes. The grapes are linked by thin stalks to thicker stalks and thicker stalks again as more sections of grapes join it, until there is one thick stalk.

A grape represents an alveolus (pl. alveoli) which holds the breastmilk. The stalks are the ductules and lactiferous ducts through which the milk passes, and the whole bunch of grapes represents one lobe of functional breast tissue. Each breast contains about nine lobes.2


The lactocytes, columnar epithelial cells that make up the alveolus, synthesise the breastmilk which is then stored in the lumen.

Each alveolus is surrounded by a basket-like weave of myoepithelial cells, muscle cells. Contraction of the myoepithelial cells constricts the alveoli, forcing the breastmilk into the ducts and towards the nipple where the baby can remove it.


© Health e-Learning


Workbook Activity 5.4

Complete Activity 5.4 in your workbook.

Milk ejection reflex

In response to stimulation around the nipple/areola area a surge of oxytocin is released from the posterior pituitary gland. It travels via the blood stream to both breasts causing the myoepithelial cells surrounding the alveoli to contract. Sometimes this can be so forceful as to cause the milk to drip or even squirt from the nipple.

This is called the milk ejection reflex (MER).


© Health e-Learning

MER can be quite forceful.

MER can be quite forceful.
© A.VerSteeg


When the MER has been stimulated mothers may describe the sensation as

  • a sharp, momentary pain in the breast, or
  • a fullness or tightness of the breasts, or
  • a tingling sensation inside the breast, or
  • there may be no sensation at all.

It can be seen to be functioning when milk drips or squirts from the breast. If the baby is suckling at the time you'll notice a change in suck pattern to a suck / swallow / breathe / suck / swallow / breathe pattern with swallows about every second. This vigorous sucking from increased milk flow may last 1.5 - 2 minutes. You may hear the baby gulping the larger volume of milk too.

As the effect of oxytocin wears off the alveoli and ductal system, milk which is not removed by the infant (or by expressing) moves back up the ductal system to the alveoli once more.

Take home message:

Milk transfer is dependent on milk ejection! No MER = Hungry baby

Important

Many mothers do not feel the milk ejection at all, and rarely is it felt in the first few days postpartum despite it functioning quite well. Prior to the milk 'coming in' the change in the baby's suckling is also not noticeable.

In multiparous women involution pain is felt more acutely during milk ejection. (Why?)

Negative pressure transfer

The mouth of the newborn is ideally suited to suckling at the breast. The tongue grasps the breast tissue and the lips create a seal around the areola. Negative pressure in baby's mouth draws the breast into position and maintains it there forming a teat of soft breast which completely fills the mouth. The small mandible fits closely against the breast, allowing the baby's nose to be free for breathing, while the buccal fat pads in their cheeks prevent the cheek from 'collapsing' in during suckling.

Negative pressure is created in the sealed mouth when the back of the tongue drops in response to the increased milk flow at milk ejection. There is a coincident lowering of the soft palate. The intra oral vacuum is at its greatest when the tongue is fully lowered prior to swallowing. It is this negative pressure which draws the breastmilk from the nipple into the baby's mouth.

Workbook Activity 5.5

Complete Activity 5.5 in your workbook.

What should I remember?

  • The two mechanisms which are required for milk transfer during breastfeeding - describe each.
  • The hormone which stimulates the milk ejection reflex.
  • The mechanism and function of the milk ejection reflex.
  • The changes which occur in the mother and the infant during MER.

Self-test Quiz

Notes

  1. # Ramsay D et al. (2004-09-10) Ultrasound imaging of the sucking mechanics of the breastfeeding infant
  2. # Geddes DT (2007) Inside the lactating breast: The latest anatomy research

5.3 Assessing breastfeeding

The five-step process

Wolf and Glass1 suggest a five-step assessment/evaluation process:
  1. Gather information and plan for the visit
  2. Feeding observation
  3. Exploration of strategies for improvement
  4. Develop an action plan
  5. Communication of results

1. Gather information and plan for the visit

Review pertinent information including mother's/infant's chart, notes from telephone conversations, notes from referral source, etc, prior to meeting with the mother and infant.

Planning includes assembling any items and equipment you expect to use during the assessment (eg. comfortable chair for mother, clean gloves in case oral examination required, etc.).

2. Feeding observation

Breastfeeding observation entails three parts:
  • General observation: general interaction between the mother and infant. Health of mother, health of baby, health of the mother's breasts.
  • Naturalistic observation: observation of a portion of a usual breastfeeding. This is best performed without intervention from the assessor.
  • Elicited observation: observation of the outcome of suggested modifications (eg changes to position, attachment, etc.).

Use your communication skills

It can help to put the mother at ease if you explain that you would like to watch the baby feeding, rather than saying you are watching what the mother is doing. And don't forget to praise the mother for something she is doing that is good.

What is involved in a 'naturalistic observation'?

A naturalistic observation implies you observe what naturally happens, prior to any interventions.

Mother's and baby's position

  • Do the mother and baby appear comfortable and relaxed?
  • Is the baby well positioned?
    • Good sensory input: breast wasn't washed prior to feeding; baby in firm contact with mother chest-to-chest, either no clothing or minimal clothing between them.
    • Good positional stability: a stable base; proximal stability; midline symmetry

Latching

  • Did mother position baby, then allow baby to latch himself? If not, why not? eg. breast may have needed to be shaped; is the mother controlling the baby's latching?
  • Where is baby's chin? Is it firmly applied to the breast? Is the baby's nose free to breathe without the need to hold the breast tissue away? Exceptions only with very large, soft pendulous breasts.
  • Is baby's mouth very wide open with both lips flanged outwards? Exceptions to this are in mothers with soft, elastic breast tissue where a baby can achieve a deep latch with lots of breast tissue and not need to continue the wide gape throughout the feed.
  • Can you see more areola visible above the top lip than beneath the bottom lip (or, if areola small, another sign that the baby has a large amount of breast tissue in mouth).

Really important!

One author 2 viewed the positioning and latching procedures adopted by mothers with painful nipples and concluded that the whole process from pre-feeding behaviors to the suck rhythm need to be assessed.

Observe the moment of latching of the baby to the breast and as much of the feed as you can, then be there again to observe the nipple as it leaves baby's mouth.

Sucking pattern

  • When first latched was sucking rapid for up to a minute? This is a stimulation pattern to elicit the milk ejection reflex.
  • After about a minute (or less) did sucking settle into a regular, slower suck/swallow/breathe/suck/swallow/breathe pattern with some short pauses? This is a nutritive sucking pattern. You should also hear baby swallowing milk; milk may leak from the other breast; or mother may report feeling the milk ejection reflex.
  • What are baby's jaw movements like? They should be 'deep' movements visible right up to the temporo-mandibular joint below the ears.
  • How long did the nutritive sucking pattern persist? Milk ejection usually lasts about 2 minutes and therefore the nutritive sucking pattern should last about that long. (Note that prior to the milk 'coming in' the nutritive pattern will be briefer, with swallows less frequent.)
  • What happened after the nutritive sucking pattern stopped? Sucking usually returns to the short, quick stimulation pattern again with smaller jaw movement, fewer swallows and longer resting pauses.
  • Was the nutritive pattern repeated? It may not be as noticeable subsequently, but this cycle is usually repeated as baby stimulates a second or more milk ejections during one breastfeed.

How was the breastfeed completed?

  • Did the baby fall asleep at the breast being completely satiated, or detach himself contented, or wanting more milk from the other breast, or did the mother remove the baby when she felt he'd had enough?

What did the nipple look like as it came out of the baby's mouth?

  • Observe the nipple immediately when it comes out of the baby's mouth. It should look very similar to its pre-feeding state. There should be NO ridging or 'squashed' appearance or white compression lines.

How did it feel?

  • Of course you will ask the mother how it feels at each stage, and also observe her for signs of anxiety or pain.
  • In the first few days for the first minute or less she may describe it as painful, but settles to be pain free quickly. This initial pain is called 'nipple stretch pain' and occurs as the nipple and areola form the teat. Breastfeeding may 'tug' but for the majority of mothers it should not be painful.

Ideal teaching opportunity

Don't keep this knowledge to yourself!
The mother and baby will be leaving your care very soon. It is of profound importance that the mother knows what to look for when baby is breastfeeding so she is reassured that baby is breastfeeding well.

Simplify this checklist, putting emphasis on the position/latch and that she can recognize the nutritive suck (baby swallowing milk).

Workbook Activity 5.6

Complete workbook activity 5.6

Observation skills

Look closely at these photos, noting all the details of positioning and latch.
When you are ready, answer the response activity below.


© D.Fisher IBCLC


© D.Fisher IBCLC


3. Exploration of strategies for improvement

  • The development of hypotheses for improving the feeding interaction based on history and observations.
  • Discussion with mother of hypotheses generated, including pros and cons of various methods for improving the feeding outcome.
  • Testing of agreed strategies.

If the strategy involved a practical skill (eg. change of position, using a feeding aid, etc.) a return demonstration with the mother implementing the change unassisted will give you both the confidence that it is achievable.

4. Develop an action plan

Using all gathered data, hypotheses and strategies, develop an action plan for feeding management that is agreed upon between yourself and the mother.
Record this in the mother's file and give a copy to the mother or write a list for her to refer to at home.
If you are working with a mother with a young baby remember that feeding at this stage is dynamic; be prepared to review and revise your plans frequently - at least daily.

5. Communication of results

  • Discuss findings and action plans with the mother. The language used to describe the situation is extremely important. The assessor should take great care to avoid terminology that blames, negatively characterizes, or labels the mother or infant.
  • Review plans with the mother to assure that the plan is achievable and agreeable to all parties.
  • Document the outcomes of the assessment and evaluation.
  • Communicate findings to key healthcare providers in accordance with their need for further care of the mother and baby if in hospital; or mother's consent to release information in the community. Clearly identify and refer any items that need further medical evaluation.1

Observation skills

Look carefully at this baby breastfeeding and complete the response activity below.


© Photo copyright UNICEF C107-5

Workbook Activity 5.7

Complete Activity 5.7 in your workbook.

Make your work easy!

A thorough assessment of a breastfeeding session with each mother at least every 24 hours while she is in hospital, will ensure potential problems are identified early and prevented. Please make this a priority when you plan your work schedule for your shift.

What should I remember?

  • A logical progression to each breastfeeding assessment.
  • How to conduct the assessment in a manner that supports the mother's self-confidence.
  • The mother is the person who must be able to implement any changes required; the importance of knowing she understands and is willing and able to implement the action plan.
  • How early, careful and thorough breastfeeding assessments result in more capable, self-confident mothers.

Assessment Quiz

When you are happy that you've understood all the information in this topic you will be ready to complete the Module 5 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 5.

Skills Competency #2

Observing, assessing and assisting breastfeeding

When you have successfully completed this Module and applied what you have been learning to your practice with mothers and babies you will be ready to complete your Skills Competency. Click on the title of this box to download Observing, assessing and assisting breastfeeding competency form for you to complete with your Supervisor.

Notes

  1. # Wolf LS et al. (1992) Assessment and Management: Feeding and Swallowing Disorders in Infancy
  2. # Blair A et al. (2003) The relationship between positioning, the breastfeeding dynamic, the latching process and pain in breastfeeding mothers with sore nipples.

6.0 A time to learn

Currently in developed countries many mothers have little experience of caring for babies and children before they have their own first child. Health education is an important role for health professionals. Antenatal education and postnatal support significantly increases the incidence of breastfeeding initiation and exclusive breastfeeding to six months.1,2,3

How to provide education effectively

The perinatal period is filled with so many new experiences for women, and postnatal hospitalisation is short, therefore it is important to target educational interventions effectively. It is not effective to just give educational materials, either antenatally or postnatally, without a discussion with the mother of their contents.

Asking people direct questions about how they learn leads towards four primary processes being involved in an overlapping way.

These can be summarized as follows:

  1. wanting to learn (motivation, thirst for knowledge)
  2. learning by doing (practice, trial and error)
  3. learning from feedback (midwife/nurse's comments, seeing the results)
  4. digesting (making sense of what has been learned)

Asking people further questions about where and when they learn reveals that most people consider they learn best:

  • at their own pace (allow plenty of time for questions, return demonstrations, etc)
  • at times and places of their own choosing (privacy may be important, or when less tired)
  • often with other people around, especially fellow learners (a group of new mothers, or her partner)
  • when they feel in control of their learning

Workbook Activity 6.1

Complete Activity 6.1 in your workbook.

Individuals also have an inclination to a preferred style of learning experience.

  • Auditory learners use their sense of hearing as their primary means of absorbing information eg. discussions, hearing of others' experiences, story telling.
  • Visual learners relate to pictures, demonstrations, videos and written materials.
  • Kinesthetic (kinaesthetic) learners like activities which involve them fully eg. practicing the skill taught, return demonstrations, etc.

Clinical application

Educational materials should be presented in a variety of formats. For example:

To teach a mother how to position and latch her baby to the breast

  • she may view a video with other mothers (pre/postnatal)
  • discuss a leaflet showing the technique (pre/postnatal)
  • be given a demonstration using a doll (pre/postnatal)
  • be supervised privately as she positions and latches her baby and receives feedback from her health carer, as well as seeing and feeling her baby well latched and suckling. (postnatal)

Postnatal education

When all the information required to be covered in Step 3 and Point 3 (see 3.0 Pregnancy Care) is covered during the prenatal period, the emotion-laden postnatal period can be used more effectively for

  • practical help - eg. positioning, latching, breast expression
  • educational messages about feeding patterns, maintaining exclusive breastfeeding, baby behavior, recognizing abnormalities, and
  • psychological support.

Learning happens best when...

  1. the mother is needing/wanting to know
  2. the information is presented in a manner which encompasses her learning style
  3. she receives feedback that allows her to digest (or reflect) on what she has learned

What should I remember?

  • The effective learning circumstances for most people.
  • When and where mothers are likely to prefer to learn.
  • How to apply effective learning style to your workplace.

Self-test quiz

Notes

  1. # Lumbiganon P et al. (2012) Antenatal breastfeeding education for increasing breastfeeding duration.
  2. # Kupratakul J et al. (2010) A randomized controlled trial of knowledge sharing practice with empowerment strategies in pregnant women to improve exclusive breastfeeding during the first six months postpartum.
  3. # Su LL et al. (2007) Antenatal education and postnatal support strategies for improving rates of exclusive breast feeding: randomised controlled trial

6.1 Practical skills

Baby Friendly Step 5 and Point 4

Step 5 of the Ten Steps to Successful Breastfeeding, and Point 4 of the Seven-point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Care Settings both require health care professionals to teach women about the maintenance of breastfeeding.
Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants .
Support mothers to initiate (establish) and maintain (exclusive) breastfeeding (to 6 months). United Kingdom, Canada, New Zealand

Inform women and their families about the management of breastfeeding and support them to establish and maintain exclusive breastfeeding to 6 months. Australia
As well as assisting mothers to breastfeed their infant, as in the previous topic, these Points/Steps require staff to teach mothers the techniques of manual expression of breastmilk.

Expressing breastmilk

All mothers are to be taught how to hand express their breastmilk. Many mothers will also have a manual or electric breast pump they intend to use and you may like to see that they know how to use it correctly too.

Hand expression is a simple, cost-free and effective method of milk removal.1,2

Hand expressing

Many mothers prefer hand expression rather than using a pump because:

  • Hands are always with you, and there are no parts to lose or break.
  • Hand expression can be very effective and quick when the mother is experienced.
  • Some mothers prefer the skin-to-skin stimulation from hand expression rather than the feel of plastic and sound of a pump.
  • Hand expression is usually gentler than a pump, particularly if the mother's nipple is sore.
  • There is less risk of cross-infection since the mother does not use equipment that may be difficult to clean effectively.
  • There is no cost.

Even a mother who does own a pump may have more success hand expressing

  • to collect small volumes of colostrum antenatally, anticipating a postnatal medical problem, or
  • to get just a few drops of milk to entice baby to latch, or
  • to apply to a damaged nipple, or
  • to remove just enough milk to allow her baby to latch to her engorged breast, or
  • to relieve the discomfort from an engorged breast, or
  • to clear a blocked duct, or
  • to obtain milk for her baby who is unable to breastfeed, or
  • to obtain milk for her baby when they are separated, or
  • to obtain milk to pasteurize for her baby if she is HIV positive.

Hand expressing is THE most effective and least wasteful method for collecting colostrum.

Workbook Activity 6.2

Complete Activity 6.2 in your workbook.

Don't underestimate the value of hand expressing

This is important for you to know and to share with mothers who may need to be pumping for whatever reason in the weeks ahead:

Breastmilk production at week 8 postpartum is significantly increased when mothers

  • hand express 5 or more times per day in the first 3 days
  • combine hand expressing and pumping after secretory activation (hands-on pumping)1

How to hand express

  • Preparation
    • Mother should wash her hands;
    • Prepare a clean wide-necked receptacle for the milk - a medicine cup, tea cup or bowl may be appropriate depending on volume expected.
  • Technique
    • Mother may sit or stand comfortably - possibly where she can rest her arm or lean forward slightly over the container;
    • Gently massage the breasts, running hands over the nipple and areola to stimulate the milk ejection reflex;
    • Position the first finger and thumb on opposite sides of the nipple, at about the edge of the areola or about 2.5cm (1") from the base of the nipple;
    • Push directly back towards the chest wall, then compress the breast between finger and thumb, and follow through by moving the pressure towards the nipple without sliding the fingers on the skin of the breast;
    • It may take a minute or so to stimulate the milk ejection. Milk only flows easily during a milk ejection so continue expressing while milk flow is good for approx 2-3 minutes. Colostrum is quite viscous, so be patient;
    • Swap breasts and repeat. The mother may like to do this on each breast several times;
    • Stop expressing when milk flow slows to drips or the goal has been achieved (eg. areola is softened enough for infant to latch, or volume needed is achieved).
    Note: 1. the finger and thumb placement; 2. the pressure back towards the chest wall before, 3. compressing the breast tissue between finger and thumb.

    Note: 1. the finger and thumb placement; 2. the pressure back towards the chest wall before, 3. compressing the breast tissue between finger and thumb.
    © E.Grunis, IBCLC


    Video © Australian Breastfeeding Association. Used with permission.

    Pumping breastmilk

    There are many different types of breastpumps available on the market. All staff must be aware of the safety issues surrounding each pump, including adequate cleaning, and its correct use. Either get other competent staff to demonstrate its use, or ask the company representative to give a short educational session for the staff.

    Manual and electric pumps can be equally as effective - the mother will need to consider cost and skills required to use each piece of apparatus. For example, some manual pumps can cause wrist strain which may exacerbate carpel tunnel syndrome; other mothers prefer the versatility of carrying a manual pump to work; electric pumps are very efficient for long term expressing circumstances.

    Who is best to demonstrate pump usage to mothers?

    The pump company representative's job is to sell more pumps and encourage as many mothers as possible to use their pumps for as long as possible. Your role is to show a mother how to safely use a pump for only as long as it is absolutely necessary.

    Do not ask the company representative to speak to mothers about their pump.

    [link: http://newborns.stanford.edu/Breastfeeding/MaxProduction.html]

    Do you assist mothers who need to pump long-term?[link: http://newborns.stanford.edu/Breastfeeding/MaxProduction.html]

    Mothers who need to pump regularly for their infants often have difficulty maintaining an adequate milk supply. This is because they depend on the breast pump alone to remove milk. By combining pumping and hand expressing mothers have been able to more than double the amount of milk removed at each session, continuing to stimulate and maintain an excellent milk supply.

    Watch the video linked to the title of this box. The techniques you will learn will benefit the mothers in your care. (Note also the demonstration of breast massage and compression).

    Storing breastmilk for a healthy baby

    If the mother is not going to use the expressed milk within the next few hours, store it safely. Glass and plastic containers with lids are suitable for use, as are breastmilk storage bags.

    There should be a means of noting the time and date of expressing the breastmilk on each container. For hospital use the identity of the mother and baby should also be clearly written.

    • All storage equipment will be thoroughly clean.
    • Refrigerate milk that will not be used within the next few hours.
    • Freeze milk that will not be used within two days.
    Storing Breastmilk for a Healthy Baby 3 4 5
    Breastmilk status Room temperature 26°C or lower Refrigerator (5°C or lower) Freezer
    Freshly expressed into container 6 - 8 hours;
    when refrigerator available store milk there
    < 72hrs
    store at back where coldest
    2 weeks freezer compartment inside refrigerator (-15C);
    3 months in freezer section of refrigerator with separate door (-18C);
    6 - 12 months in deep freeze (-20°C or lower)
    Previously frozen; thawed in refrigerator, but not warmed 4 hours or less;
    that is until the next feeding
    24 hours Do not refreeze
    Thawed outside refrigerator in warm water For completion of feeding 4 hours or until next feeding Do not refreeze
    Infant has begun feeding
    (ie. contact with baby's mouth)
    Only for completion of feeding Discard Discard

    Note: Chilled breastmilk may be safely stored at 15°C for up to 24 hours. This is the temperature maintained in an insulated container with a freezer block, eg blue ice. 6

    Activity

    Locate the guidelines to hand expressing and safe breastmilk storage that is provided for mothers in your Unit. Discuss this leaflet with each mother and give her a copy as she is taught this essential skill. Keep a copy of the leaflet in your Workbook.

    If there are no guidelines in your Unit for hand expressing and safe breastmilk storage:
    Form a small group to research and develop a suitable leaflet in conjunction with the relevant stake holders.

    Using the expressed breastmilk

    The order in which to use expressed breastmilk is

    1. First choice: All milk expressed in the first 4 days (colostrum); assures baby receives the antibody-rich colostrum as soon as possible
    2. Second choice: Freshly expressed milk prior to refrigeration; fresh breastmilk has the most active protective properties
    3. Third choice: Refrigerated breastmilk, using the oldest first; decreases the need to freeze milk, which has a greater effect on immunological properties
    4. Finally: Frozen breastmilk that has been stored the longest; to reduce the need to discard milk that has passed the use-by date

    Skills Competency #3

    Hand expressing and safe milk storage

    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 Hand expressing and safe milk storage competency form for you to complete with your Supervisor.

    Supporting mothers who are separated from their infants

    There may be many reasons a mother is unable to be with her infant at all the times the infant requires breastfeeding. These could include:
    • infant or mother requiring hospitalization (eg neonatal intensive care; medical or surgical event for mother or infant)
    • maternal appointments (eg dentist, solicitor, etc)
    • maternal work commitments
    • or perhaps just a child-free day of leisure for the mother.

    Occasional separations are usually easily handled by having some breastmilk already stored in the refrigerator or freezer for the child-carer to give to the infant.

    Employment and breastfeeding

    An increasing number of women spend large amounts of time away from a baby or child who is still in the age range prior to earliest age of weaning ... ie the first two years. Returning to the paid workforce is the most common reason for regular separation of mother and baby, and a common reason given for premature weaning.

    Leaving her baby to go to work can be a highly emotional time for the mother. Continuing to provide breastmilk can

    • present many challenges, but also
    • help her to maintain an emotional connection to her baby, despite her physical absence,
    • avoid the acute and chronic illnesses associated with artificial infant formula, and
    • make breastfeeding when they are reunited a very special, and close time.

    During the prenatal period you can guide mothers by

    • educating them on the value of continuing to provide breastmilk for baby, despite separation.
    • discussing the issues she will need to address to be successful.
    • providing her with contacts for peer-support services, to talk with other women in her situation.
    • informing mothers of their right to breastfeed, and what workplace legislation will protect her right.

    Enlisting her support network will assist the mother to meet her breastfeeding goals. An encompassing approach including her family, the child carer, her work colleagues and employer will provide support beneficial to continuing to provide breastmilk during periods of separation.

    Prenatal preparations

    There are numerous challenges mothers will face, many unique to individuals. Addressing the foreseeable challenges is best begun during pregnancy.

    • Discuss with her employer

      • working shorter hours each day, or less days per week, at least initially
      • bringing her baby to her for breastfeeding, or her going to her baby
      • a venue that will be suitable for her to use to pump, or breastfeed
      • the advantages to her employer of her continuing to breastfeed, particularly that her child will suffer less illnesses, requiring her to have less absences from work
      • If necessary, inform her employer of her legislated rights.
    • Choosing her potential child carer

      • one who has knowledge of breastmilk storage and care, and supports exclusive breastmilk-feeding for the first 6 months
      • proximity to either her home, or her place of work, with possibility of going to or having baby come to her during the period
    • Will she need to pump her breastmilk?

      • Begin researching pumps to find one that will suit her.
      • Where will she keep her pumped breastmilk?
      • (Don't forget to share the information about ensuring a continued good breastmilk production by hand expressing colostrum and combined hand and pump milk removal next.)

    What should I remember?

    • Teaching hand expression of breastmilk is an essential part of protecting, promoting and supporting breastfeeding.
    • The effect of hand expressing colostrum and hands-on pumping on milk production.
    • The potential circumstances that may lead to expressing of breastmilk.
    • How to hand express and teach this skill to mothers.
    • The safe storage times and temperatures for each breastmilk status.
    • The order in which to use expressed breastmilk.
    • How you can support mothers who must be separated from their infants.
    • To complete the Hand Expressing competency.

    Self-test quiz

    Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column

    Notes

    1. # Morton J et al. (2009) Combining hand techniques with electric pumping increases milk production in mothers of preterm infants.
    2. # Becker GE et al. (2011) Methods of milk expression for lactating women.
    3. # Academy of Breastfeeding Medicine Protocol Committee et al. (2010) ABM clinical protocol #8: human milk storage information for home use for full-term infants (original protocol March 2004; revision #1 March 2010).
    4. # National Health and Medical Research Council (2012) Infant Feeding Guidelines: Information for health workers
    5. # Slutzah M et al. (2010) Refrigerator storage of expressed human milk in the neonatal intensive care unit.
    6. # Hamosh M et al. (1996) Breastfeeding and the working mother: effect of time and temperature of short-term storage on proteolysis, lipolysis, and bacterial growth in milk.

    6.2 Breastfeeding messages

    Baby Friendly Step 8

    Step 8 of the Ten Steps to Successful Breastfeeding summarizes the basis of breastfeeding management in recognising an infant's total needs. It states:
    Encourage breastfeeding on demand.

    How often should a baby breastfeed?

    • How much milk is available for baby?
      A mother's unique breast capacity and rate of milk synthesis dictates how much milk she has available in the breast at each feed.
    • How hungry is baby?
      The degree of hunger dictates how much the baby will take at each feed, and how frequently he will return for more milk.
    These are both physiological states that cannot be manipulated.

    Kent et al (2006) 1 in their study of 71 thriving, exclusively breastfed babies ranging in age from 1 to 6 months, found:

    • they averaged 11 feeds (range 6 - 18) per 24 hrs.
    • 10 of the babies always fed from both breasts per feed;
    • 19 babies always fed from one breast per feed;
    • the majority of babies sometimes fed from one and sometimes fed from both breasts;
    • 2/3 of babies fed at night, and consumed 20% of their total daily intake at this time.
    These researchers concluded that all mothers and babies are unique and mothers should respond to their babies' cues rather than striving to be average.

    Babies' feeding cues:

    • Early cues
      • wriggling, moving arms or legs
      • rooting, fingers to mouth
    • Mid cues
      • fussing, squeaky noises
      • restless, crying intermittently
    • Late cues
      • full cry, aversive screaming pitch, turns red
    Newborn exhibiting a late feeding cue

    Newborn exhibiting a late feeding cue


    So what should I tell a mother?

    Responding to her baby's early feeding cues will ensure baby is fed as often as necessary for her baby.

    Is the baby getting enough breastmilk?

    Before you can answer this question you need to know how much breastmilk is normal at the various stages of lactation. The average is as follows: 1 2 3

    Age of baby 24hr volume Infant intake
    Note:
    Individual breastmilk intake (and therefore production) does not significantly change between 1 and 6 months of age
    Day One 37ml (range: 7 - 123ml)
    (av:1+oz)
    few drops - 5ml/feed
    Day Two 84ml (range: 44 - 335ml)
    (av: 3.75oz)
    5 - 15ml/feed
    (1 teaspoon - 1/2 ounce per feed)
    Day Three 408ml (98 - 775ml)
    (13+oz)
    15 - 30ml/feed
    (1/2 - 1oz per feed)
    Day Five 705ml (452 - 876ml)
    (av: 23.5oz)
    depends on feeding frequency, volume available and infant appetite
    1 - 6 months 780ml (500 - 1350ml)
    (av: 26oz)
    30ml - 135ml/feed (6 - 18 feeds/day)
    (1 - 4.5oz/feed)

    The colostrum received by the baby in the first few days contains highly concentrated immunoglobulins and other protective factors (1.2 Breastmilk Immunology). Also, babies are usually born somewhat 'waterlogged' and therefore a few days of low oral intake assists the infant to clear the excess fluids. The baby is in more need of immunological protection than nutrition in the first few days.

    Physiologically the newborn's stomach is not able to hold volumes larger than this. At birth the gastric wall is non-compliant and non-relaxing, which, when combined with the hypomotility of the duodenum, results in early satiety and frequent regurgitation in the first few days.4


    Workbook Activity 6.3

    Complete Activity 6.3 in your workbook.

    Observations to make to ensure good intake

    In the first 3 days postpartum it can be assumed that the intake is adequate if the baby is positioned well, latches well and sucks actively.
    After secretory activation (average range of clinical onset is 50-73 hrs postpartum) 5 it is essential that mothers know how to recognize signs that their baby is feeding well.

    As you assess breastfeeding each day, teach the mother to:
    • observe the sucking pattern. Baby should be seen to move from a quick suck:suck:suck pattern (a stimulation pattern) to a slower suck:swallow:breathe:suck:swallow:breathe pattern (the nutritive pattern) which is sustained for 2 to 3 minutes. Baby may pause after this and repeat the pattern again. Observation of this pattern confirms milk transfer is occurring.
    • observe the urine and stool output. It will indicate intake: If it's coming out, it must have gone in!
    • after most feeds the baby will appear satiated
    • baby's mucous membranes will be moist

    Normal output table

    Age Urine output Stool output
    0 - 24 hours one wet nappy/diaper one or more meconium stools
    24 - 48 hours two wet nappies/diapers one or more meconium stools/possible transitional stool
    48 - 72 hours three wet nappies/diapers transitional stool
    from Day 4 onwards 6 - 8 thoroughly wet nappies/diapers, with clear urine soft, yellow, curdy (at least daily, preferably more frequent) until about 6 weeks

    #1 Rule of infant output - If it's coming out it must have gone in!

    It is important for parents to understand this concept. Teach them that the volumes going in as intake will be reflected in output as urine and stool.
    Describe the amounts that are displayed in the table above so that parents have a realistic expectation.

    Exception: the baby is being given fluids other than breastfeeding

    How do mothers receive this information?

    Is this information routinely given to ALL mothers? It is critical to the well-being of her baby. If you aren't able to identify when a mother has had this information discussed with her, form a group to develop a protocol to ensure this safeguard is put in place as soon as possible.

    Is it the same for bottle-fed babies?

    Yes, on the whole it is. All babies should be fed when they cue to feed, and be allowed to finish the feed when they choose to, ie. not forced to finish all the formula or breastmilk in the bottle.
    Urine and stool output is also an excellent guide to intake sufficiency for babies fed with a bottle, though those receiving breastmilk substitutes will have a firmer stool and be prone to constipation.

    Twins, or more!

    Like most mothers, mothers of multiples choose to breastfeed because breastmilk is known to provide better nutrition and health for their babies. Prenatal counseling of mothers of multiples significantly increases the initiation and duration of breastfeeding.6 Attendance at 'mothers of multiples' support group meetings is also associated with increasing the duration of breastfeeding.

    Can mothers produce enough milk for multiples?

    Yes. The more often and effectively breastmilk is removed from the breast, the more milk will be produced. All mothers should be taught this principle, but it is even more relevant to the mother of multiples.

    Studies7 of milk production in mothers of multiples found that the mothers of exclusively breastfed three-month-old twins were producing between 2.2 - 3.4 litres (73 - 113oz.) of breastmilk per 24 hours, while a mother of exclusively breastfed 2½ month old triplets produced 3.08 litres (~103 oz). This compares with studies of breastmilk production for singletons of 750 to 1100 ml (25 - 36oz.) per 24 hours.8

    Assisting breastfeeding

    There are several issues that should be addressed, namely education about breastfeeding, working with the mother to find the positions that work for her, discussing how she will cope with fatigue and the extra workload, and increasing her food intake to maintain her health.

    • Find an appropriate long couch or bed that provides space on each side of the mother for her to place essentials or place a baby down while she is attending to another baby.
    • Use a firm pillow or foam that will not sink during feeds.
    • The newborn may perform better with breastfeeding if the mother feeds each baby individually during the early learning phase. This allows her the opportunity to bond and learn about each baby's breastfeeding needs and abilities.
    • When breastfeeding two babies at the same time
      • initially the mother will require competent assistance to help with positioning her babies, ensuring correct latch and effectiveness of feedings
      • encourage and assist the mother to experiment with which baby to latch first, which positions are best at different times of the day, whether to always feed together or sometimes feed separately, whether to keep one breast per baby or swap them each feed, etc to see what works best for her
    • For triplets, two babies can be fed at the same time, then the third baby feeds from both breasts. At subsequent feeds the babies are rotated.
    • Encourage the mother to ask for and accept help from family and friends who have offered assistance so she can concentrate on her task of breastfeeding and caring for the babies, and herself.
    Breastfeeding twins

    Breastfeeding twins

    Beginning complementary foods

    Baby Friendly Point 5

    Point 5 of the Seven-Point Plan is concerned with maintaining exclusive breastfeeding until 6 months, and continued breastfeeding with the addition of appropriate complementary foods after 6 months of age.

    (Canada: Step 8: Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.)
    Encourage exclusive and continued breastfeeding (beyond six months)(to two years), with appropriately timed introduction of (adequate and safe) complementary foods.
    Developmental readiness:
    • the infant is not functionally ready to take complementary foods earlier than 6 months of age.
    • At, or soon after 6 months, strengthening of the infant's musculature allows him to independently control his head and sit up.
    • The development of fine motor coordination of more distal muscles, including the tongue and lips and their function of bringing in and manipulating more solid food in preparation for swallowing, is indicative of his ability to handle these foods at this age. 9

    Physiological readiness:
    • Coincidentally, at around 6 months of age, most infant's energy needs for growth and development are beyond the provision of breastmilk alone and appropriate complementary foods are required to provide additional calories and nutrients for future growth.10

    The MOST important food

    Breastmilk exclusively meets the nutrient requirement of well, full-term infants for the first 6 months of life.

    Between 6 and 24 months of age is a critical time for promotion of optimal growth, health and behavioral development with longitudinal studies demonstrating this is the peak age for growth faltering, deficiencies of certain micronutrients, and common childhood illnesses.

    The World Health Organisation 11 recommends the following guiding principles for appropriate complementary feeding to ensure nutritional well-being continues once complementary feeding begins:

    • continue frequent, on demand breastfeeding until two years old or beyond;
    • start at six months with small amounts of foods and increase gradually as the child gets older
    • practise responsive feeding. Feed child slowly and patiently, encouraging them to eat but do not force them, talk to the child and maintain eye contact;
    • practise good hygiene and proper food handling.

    Baby-led or mother-led eating?

    Traditionally in developed countries the recommended approach to complementary feeding tends to be in a structured fashion of food preparation (puree or mash), mother-directed using a spoon.

    However, there are a growing number of parents practicing baby-led weaning. This is an alternative method for introducing complementary foods to infants in which the infant feeds themselves hand-held family foods at mealtimes instead of being spoon-fed by an adult. Mothers who use this method are generally very satisfied, while health professionals express concern at the risk of choking.12

    Weaning

    Breastfeeding and breastmilk continues to provide protection and growth factors as well as being a quality food source for as long as the child is breastfed. There is no stage of lactation where breastmilk stops having these beneficial effects.

    • The introduction of complementary foods from 6 months of age is the beginning of the weaning process.
    • The weaning process can take as long as the mother and baby want it to take, but infants should continue to receive breastmilk until they are a minimum of 12 months and preferably 2 years old.

    Despite health professionals having this knowledge, the number of babies who are being exclusively breastfed at 6 months of age, and the number of babies receiving any breastmilk at 12 months of age is much less than it should be in most countries.

    Weaning too early

    Have you thought about how you could influence mothers in your area?

    Brainstorm some ideas with your colleagues and implement them. Examples could be a poster that simply states “Breastmilk only to 6 months; Breastmilk plus family foods to 2+ years.” Sometimes a simple statement such as that is all the mother needs to know. However, you could also address education about artificial feeding and talk to mothers about the barriers they may see to continuing to provide breastmilk.

    What should I remember?

    • The infant feeding cues.
    • The variation in milk production and infant intake in the first 5 days.
    • The expected infant output which indicates adequate intake.
    • How to teach mothers to recognise milk transfer.
    • Expectations for mothers about the frequency of breastfeeding.
    • When and how to begin complementary feeding.
    • The minimum age an infant should be weaned completely from breastmilk.

    Self-test quiz

    Notes

    1. # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
    2. # Riordan J (2005) Breastfeeding and Human Lactation
    3. # Saint L et al. (1984) The yield and nutrient content of colostrum and milk of women from giving birth to 1 month post-partum
    4. # Zangen S et al. (2001) Rapid maturation of gastric relaxation in newborn infants
    5. # Perez-Escamilla R et al. (2001) Validity and public health implications of maternal perception of the onset of lactation: an international analytical overview
    6. # Friedman S et al. (2004) The effect of prenatal consultation with a neonatologist on human milk feeding in preterm infants.
    7. # Saint L et al. (1986) Yield and nutrient content of milk in eight women breast-feeding twins and one-woman breast-feeding triplet.
    8. # Kent JC et al. (2004) Frequency, volume and fat content of breastfeeds of exclusively breastfed babies
    9. # World Health Organization (2001) Report of the expert consultation of the optimal duration of exclusive breastfeeding
    10. # Dewey K (2003) Guiding Principles for Complementary Feeding of the Breastfed Child
    11. # World Health Organisation (2010) Infant and young child feeding - Fact sheet N,.342
    12. # Cameron SL et al. (2012) Healthcare professionals\' and mothers\' knowledge of, attitudes to and experiences with, Baby-Led Weaning: a content analysis study.

    6.3 Normal growth

    Physical growth is measured by weight, length (height) and head circumference. Regular weighing is part of most Western well-baby care systems. Growth charts are used universally in pediatric care.1 Growth charts are used to plot the infant's data for comparison with expected growth in each of these parameters.

    Growth charts plot a curve of the median, then plot the highest and lowest curves of normal growth on either side. The most common ones in use have percentile curves.

    • The 3rd percentile reflects that 3% of children are either at or below this line.
    • The 97th percentile indicates that 97% of children will be either at or below that line.
    • The 50th percentile is the median and 50% of children will be either equal to or below this curve; likewise 50% of children will be either equal to or above this curve.

    Look at the movie not the photo

    Plotting of a child's data on one occasion in time has limited value. The important information is what happens to that child's data over time.

    • is the child's data continuing to cross through curves, or
    • is the child's data tracking normally along an upward curve, even if it is the 3rd percentile?

    Weighing of babies is not an innocuous procedure

    Researchers have found that clinic visits often focused around the weighing of the baby with little attention being given to discussing other child care matters.2 It was noted that the interpretation of an acceptable weight gain was reduced to the expectation that the plotted weight should mirror one of the curves on the growth chart.
    Mothers in this study, and others, 3 were found to change their feeding practices at the expense of breastfeeding to increase weight gain to stay on or exceed a growth curve.

    ... the routine of weighing risks becoming a ritual practice with potential to undermine infant nutrition rather than a supportive means to encourage the best care possible for individual babies. ” (p94) 2

    Before weighing a baby:

    • ask the mother if she has any concerns about her baby.
    • discuss the baby's breastfeeding behavior and intake of complementary foods (if age appropriate)
    • ask about the baby's output - urine and stooling.
    • observe the achievement of age-appropriate developmental skills.
    • observe the baby's general condition: skin turgor, color, adipose distribution (particularly as the mother takes the baby's clothes off in preparation for weighing).

    Surprised?

    Absolutely NOT!!!
    The weight readout on the scale should not come as a surprise to you if you have had a good discussion with the mother about those factors before weighing baby.

    Workbook Activity 6.4

    Complete Activity 6.4 in your workbook.

    Before weighing this exclusively breastfed Papua New Guinean baby would you anticipate having any concerns? If not, why not?

    Before weighing this exclusively breastfed Papua New Guinean baby would you anticipate having any concerns? If not, why not?
    Photograph © D.Fisher, IBCLC

    What influences movement through growth curves?

    A variation from a growth curve is only one observation. Further history-taking, other observations, investigations or time may be required before a definitive explanation can be given.

    Reasons data may fluctuate:

    • Data is plotted on a growth chart based predominantly on artificially-fed children. (Ensure you are using the WHO growth charts) Artificially-fed babies have a markedly different, and therefore abnormal, growth trajectory.
    • Child was born large, but is genetically determined to be slighter - or vice versa.
    • Child has had a temporary illness, losing weight which will be quickly regained when healthy again.
    • Inadequate nutritional sustenance to support growth; or excessive, but poor quality foods causing obesity.
    • Chronic illness that prevents normal growth.

    WHO Child Growth Standards

    The WHO growth charts provide a single international standard that represents the best description of physiological growth for all children from birth to five years of age and establishes the breastfed infant as the normative model for growth and development.

    Print a copy of the percentile charts PDFBOYS weight-for-age[link: http://www.who.int/entity/childgrowth/standards/cht_wfa_boys_p_0_6.pdf] and PDFGIRLS weight-for-age[link: http://www.who.int/entity/childgrowth/standards/cht_wfa_girls_p_0_6.pdf]. File in your workbook.

    Accurately weighing an infant

    In comparing balance, spring and electronic scales most studies found greatest accuracy using electronic scales, with newer scales being more accurate than older scales. Scales should be regularly re-calibrated.

    For greatest accuracy:

    • weigh the infant on the same set of scales each time
    • weighing procedure to be performed by the same person at each visit, using their usual technique
    • weigh the baby at approximately the same time of day
    • weigh the baby at the same time in relation to a feed, eg. straight after feeding
    • weigh the baby naked. Weighing baby with a diaper/nappy or clothed results in larger discrepancies.
    • take time to concentrate on accurately plotting the weight. One study4 found >28% of points were plotted inaccurately.

    What should I remember?

    • Normal infant growth occurs within a range.
    • All infant measurements should be plotted using the WHO Child Growth Standards.
    • Consider weight as one useful measurement of progress.
    • The growth trajectory of the healthy breastfed infant is the norm for all infants.
    • The important techniques which make weighing as accurate as possible.

    Self-test Quiz

    Notes

    1. # de Onis M et al. (2004) Worldwide practices in child growth monitoring
    2. # Sachs M (2006) Routine weighing of babies: does it improve feeding and care?
    3. # Behague D (1993) Growth monitoring and the promotion of breastfeeding.
    4. # Cooney K et al. (1994) Infant growth charts

    6.4 Sleep

    Rooming-in in Hospital

    Baby Friendly Step 7

    Step 7 of the Ten Steps to Successful Breastfeeding states:
    Practice rooming in - allow mothers and infants to remain together 24 hrs/day.

    In their research to support the inclusion of this Step, UNICEF1 found that when mothers and infants were separated, infants

    • breastfed less frequently,
    • secretory activation was evident later
    • clinical jaundice was more common
    • weight gain per day was statistically less.

    Babies cared for in nurseries had more crying episodes (and were therefore more stressed) and were responded to less frequently.

    24-hr rooming in resulted in mothers experiencing the same number of hours total sleep as the separated dyads, infants spent 33% of the time in quiet sleep compared with only 25% in the nursery group and there was no difference in daytime alertness in the two groups.

    This suggests that rooming-in does not greatly alter maternal sleep and it improves infants' sleep.

    Workbook Activity 6.5

    Complete Activity 6.5 in your workbook.

    Addressing the barriers

    This Step can be difficult to implement in places where a well-baby nursery has traditionally been utilized for procedures on infants, and separations from mothers.
    Suggestions that have worked for others include:
    • staff education. Unless all the staff are convinced that rooming-in is beneficial to the mothers and babies in their care, there will be some resistance and many mixed messages given to parents. To 'mother the mother' while she is in hospital is a natural response from nurses and doctors.

    • parent education. Initially parents may have an expectation that their infant will be cared for in a night-nursery overnight, and taken away for all procedures. Mothers may even express trepidation about having their baby in their room overnight while they sleep. Parenting classes, posters in prenatal clinics and all staff giving the same message about the benefits of rooming-in can change these expectations.

    • call me. Give explicit instructions to all mothers to ring their call bell when baby needs attention - give this message with genuine meaning and a smile. Mothers often report that they didn't want to disturb the nurse, and therefore their experience could be one of feeling unsupported and afraid.

    • supporting an exhausted mother. Long labor, instrumental birth, cesarean birth, unwell from non-birthing reasons, noisy wards, never-ending interruptions ... fatigued mothers are very common.
      • Teaching settling techniques such as skin-to-skin care, breastfeeding lying on her side, and rocking and patting the infant are all excellent skills the mother will need when she is at home.
      • Encouraging the mother's support person to remain with her can be a very enjoyable experience for the new family, and give the mother a peaceful rest. This is family-centered care.2
      • Implementing an afternoon 'rest time' with a darkened room, no 'hospital-reason' interruptions and no visiting is often appreciated.
      • Clustering her nursing care and medical care needs to limit interruptions.
      • Asking mothers to use their call bell when they are awake so that vital signs observations or other procedures can be done then.

    • using procedures as education times. Babies cry less when being held or breastfed during procedures such as heel stick. When hearing checks, bathing, weighing, newborn examination, etc are performed in the mother's room it's the perfect time to educate the parents about each of these.

    • staffing allocation. Concern that there is not enough staff is usually not borne out. Parent education is more efficient and effective, and staff time is not used pushing babies to and from the nursery. No staffing for a well-baby nursery is required.

    • mother assistants. Suitably qualified volunteers to watch over a baby at the mother's bedside when she needs to leave the room (eg a mother who smokes) or baby just needs patting to sleep with mother in bed resting.

    • record all separations. Recording the length and the reason for each separation could help some staff to identify unjustified separations, and also highlight genuine barriers that the unit can address.

    • be alert for exceptions. This Step will not be appropriate for every baby or every mother. Stay vigilant to the infants and mothers who require additional supervision.

    Is this your problem?

    If mother-infant separations are too common in your unit gather a small group of colleagues to address the issues. Start by gathering data on the current situation. Then develop a survey for parents and staff to identify the barriers they see. Once you have identified them you will be able to work with your group and colleagues to address each issue.

    Sleep

    Of all the parenting issues discussed in New Mothers' groups, the number of night wakings their baby has must nearly top the list. Today's parents have busy daytime lives, many employed outside the home, and having a good night's sleep is highly desirable.
    Lay opinion all too frequently recommends interventions such as sleeping the baby in another room and not responding to feeding cues, or giving infant formula as the late evening feed, or beginning complementary foods well before the recommended age.

    So, what's wrong with these suggestions? First, let's look at what is normal behavior.

    What's normal?

    Initially wakefulness and feeding are closely related.

    • During the first 24 hours the newborn spends the first 2 hours awake and alert, and breastfeeding. After the initial few days most babies will sleep a total of about 16 hours a day.

    • By 3 weeks of age the average length of the longest sleep is about 3.5 hours. By 6 weeks of age some babies are having up to 6 hours in one sleep. As a circadian rhythm develops the longest sleep tends to be at night.

    • The cumulative hours of sleep per day slowly decreases to 14-15 hours by 3 months and 13-14 hours by 6 months of age. 3

    The natural course of settling is seen to proceed over the first 6 months, but even after that age increased waking occurs in up to 42% of children who have already shown the capacity to sleep through the night. 3 Two thirds of babies breastfeed at night, and have their biggest feed at this time consuming 20% of their total daily intake. 4

    How can I use this knowledge to help parents?

    Knowledge of what is normal behavior is reassuring to parents.
    Nighttime feeding is necessary for adequate growth and development for MOST babies - very few babies will sleep more than 6 hours without needing to breastfeed during the first few months.

    Tips to share

    • observe baby for signs of tiredness and respond to them immediately
    • have a quiet period before settling the baby to sleep, avoiding stimulating interactions and noises
    • many babies like to breastfeed to sleep, and are easily transferred to their sleep surface once asleep
    • when putting a baby down to sleep stay with the baby until he moves from the rapid eye movement stage from which he is easily roused, into the deep sleep stage where he is more likely to stay asleep regardless of movement and noises around him.
    • A daytime nap for the mother while her baby is asleep will help her avoid exhaustion.
    Encourage parents to accept that night-waking is normal behavior and not to have expectations that their baby will be any different.5

    Sleep in the home situation

    The lay suggestions to increase nighttime sleeping quoted in the last section all increase the risk of Sudden Infant Death Syndrome (SIDS) for the infant.

    Sleep location

    The SIDS associations and pediatric societies both advise that infants sleep in the same room as a responsive adult for all their sleep periods - daytime too.
    • Room sharing, particularly when the infant sleeps in close proximity to the mother, has been found to reduce the risk of SIDS.
    • It is unclear why this is so, but hypothesized that air movement, human movement and noises all keep the infant from falling in to a 'too deep' sleep from which it is difficult to arouse. 6
    • Striking temporal overlap (synchronicity) in infant and mother arousals has also been described.7 This means that mothers and their infants spend more time in the same sleep stage, creating an awareness of the infant's condition. It also assists mothers to cope with broken sleep - the infant isn't rousing the mother at a time when she is in in her quiet sleep phase.
    • An adult is able to supervise the infant's sleep to recognize and respond quickly to infant distress or other concerns.
    • Breastfeeding is facilitated with minimal disruption to mother and infant. Exclusive breastfeeding before hospital discharge is significantly greater when mothers room-in.8

    Breastfeeding to prevent SIDS

    The SIDS associations and pediatric societies both advise mothers to exclusively breastfeed their young infants to reduce the risk of Sudden Infant Death Syndrome (SIDS).
    • Formula feeding is associated with increased risk of SIDS. 9
    • Giving infants formula or solid foods in an attempt to increase sleeping hours will reduce their need to breastfeed, reducing the mother's milk supply.
    • At 2-3 months formula-fed infants are significantly more difficult to rouse than breastfed infants - this is the peak time for SIDS. 10
    • Formula feeding increases the risk of infection, which is one cause suggested for these deaths. 11 12 13
    • Breastfeeding is more easily achieved when the infant sleeps in the same room.
    • By being able to respond to early feeding cues, before crying, the infant will breastfeed in a calm state from which it is easier to settle.

    What should I teach the parents going home with baby?

    • Coping strategies for handling night waking
      • Sleep baby in same room, in close proximity to mother.
      • Keep lights dim and avoid stimulating baby when he wakes to feed at night.
      • Respond quickly to early feeding cues before baby is wide awake and crying.
      • Take some time during the day to have a nap at the same time baby does.
      • Night-waking is a normal part of childhood growth and development. Accept it.
    • Breastfeeding is another important strategy to reduce the risk of SIDS.
    • Always have baby sleep in a safe sleeping situation in close proximity to a responsive adult.

    What should I remember?

    • The detrimental effects of separating mothers and newborns.
    • The advantages to maternal education, bonding, breastfeeding and self-efficacy from 24-hour rooming-in.
    • How normal sleep patterns progress from birth to older infant.
    • The important points in handling night-waking.
    • How sleep location and infant feeding type affect incidence of SIDS.

    Self-test Quiz

    Notes

    1. # Child and Adolescent Health and Development (CAH) (1998) Evidence for the ten steps to successful breastfeeding
    2. # Johansson M et al. (2013) Fathers want to stay close to their partner and new baby in the early postnatal period: the importance of being able to room in after a surgical birth.
    3. # de Weerd AW et al. (2003) The development of sleep during the first months of life
    4. # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
    5. # McGuire E (2013) Maternal and infant sleep postpartum.
    6. # Hauck FR et al. (2011) Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis.
    7. # McKenna JJ et al. (1994) Sleep and arousal, synchrony and independence, among mothers and infants sleeping apart and together (same bed): an experiment in evolutionary medicine
    8. # Jaafar SH et al. (2012) Separate care for new mother and infant versus rooming-in for increasing the duration of breastfeeding.
    9. # Zotter H et al. (2012) Breast feeding is associated with decreased risk of sudden infant death syndrome.
    10. # Horne RS et al. (2004) Comparison of evoked arousability in breast and formula fed infants.
    11. # Saadi AT et al. (1999) The protective effect of breast feeding in relation to sudden infant death syndrome (SIDS): I. The effect of human milk and infant formula preparations on binding of toxigenic Staphylococcus aureus to epithelial cells.
    12. # Gordon AE et al. (1999) The protective effect of breast feeding in relation to sudden infant death syndrome (SIDS): II. The effect of human milk and infant formula preparations on binding of Clostridium perfringens to epithelial cells.
    13. # Gordon AE et al. (1999) The protective effect of breast feeding in relation to sudden infant death syndrome (SIDS): III. Detection of IgA antibodies in human milk that bind to bacterial toxins implicated in SIDS.

    6.5 Psychological support

    Maternal self-confidence and self-efficacy

    Researchers confirm self-confidence and self-efficacy to be major predictors of breastfeeding success. Studies in Denmark, 1 USA, 2 3 Australia, 4 5 New Zealand, 6 Canada 7 and China 8 have all found mothers who have confidence in their ability to breastfeed and mothers with high breastfeeding self-efficacy significantly more likely to breastfeed.

    Negative influences on self-confidence and self-efficacy include:

    • A lack of education about breastfeeding was identified by several of the researchers mentioned above.
    • Health professional attitudes and actions in regard to breastfeeding. At 12 weeks postpartum mothers are much more likely to be breastfeeding if they reported having received encouragement from their clinician to breastfeed. 2
    • Health care professionals giving inaccurate or inconsistent advice .
    • Some hospital routines are also potentially detrimental to breastfeeding. 7

    Influencing self-confidence and self-efficacy

    Include breastfeeding education in:

    • community awareness programs,
    • prenatal classes,
    • prenatal health care provider visits, and
    • postnatally

    Integrate self-efficacy enhancing strategies, improve the quality of healthcare delivered and increase a new mother's confidence in her ability to breastfeed.5

    Identifying and supporting mothers who exhibit signs of anxiety also increases breastfeeding duration and exclusivity in affected women. 9

    Support from the mother's partner or a nonprofessional greatly increases the likelihood of positive breastfeeding behaviors. 7

    Never underestimate the role of the father in supporting breastfeeding.

    Never underestimate the role of the father in supporting breastfeeding.
    © WIC program, USA

    The power of words

    Many clinicians will tell you that breastfeeding is a confidence game.

    Prof Hartmann in his studies of breast growth and development from preconception to weaning noted one woman in their study had no breast changes during her pregnancy. She went on to successfully breastfeed her baby. Prof Hartmann commented that she was successful because no one at any time suggested to her that she might have a problem.

    Similarly a woman who exclusively breastfed her triplets for 6 months said that she did it because no one told her she might not be able to, and that had it been suggested she probably wouldn't have had the confidence to even try.

    Mothers have reported losing self-confidence to breastfeed from someone commenting about their 'flat' nipples, or small breasts, or red hair, or fair skin, or ability to hold the baby.

    Impatience is another factor identified by mothers trying to learn a new skill. Taking the baby from the mother and having him/her settle immediately demonstrates to a mother her lack of skill, and perhaps to an anxious mother, that the baby may 'prefer' someone else.

    Be aware at all times of how your seemingly innocent comments and actions can affect maternal confidence.

    With such short hospital stays it's important for the mother to assume all care of her infant as soon as she is physically able to, with nurses or midwives available to coach her when needed, providing positive feedback at every opportunity.

    Think positive. Sound positive.

    It's the little things that count.

    What should I remember?

    • Education about breastfeeding is integral to self-confidence and self-efficacy.
    • Health professional encouragement is vital to maternal self-confidence
    • Include the father or mother's support people in education
    • Encourage independence in baby care, with help when required

    Self-test Quiz

    Notes

    1. # Kronborg H et al. (2004) The influence of psychosocial factors on the duration of breastfeeding
    2. # Taveras EM et al. (2003) Clinician support and psychosocial risk factors associated with breastfeeding discontinuation
    3. # Chezem J et al. (2003) Breastfeeding knowledge, breastfeeding confidence, and infant feeding plans: effects on actual feeding practices
    4. # Creedy DK et al. (2003) Psychometric characteristics of the breastfeeding self-efficacy scale: data from an Australian sample
    5. # Blyth R et al. (2002) Effect of maternal confidence on breastfeeding duration: an application of breastfeeding self-efficacy theory
    6. # Vogel A et al. (1999) Factors associated with the duration of breastfeeding
    7. # Dennis CL (2002) Breastfeeding initiation and duration: a 1990-2000 literature review
    8. # Loke AY et al. (2013) Maternal Breastfeeding Self-Efficacy and the Breastfeeding Behaviors of Newborns in the Practice of Exclusive Breastfeeding.
    9. # Adedinsewo DA et al. (2013) Maternal Anxiety and Breastfeeding: Findings from the MAVAN (Maternal Adversity, Vulnerability and Neurodevelopment) Study.

    6.6 Discharge planning

    The goal of discharge planning is two-fold

    • to prevent common problems, and
    • to enhance maternal self-esteem and self-confidence1

    It is the duty of care of the health professionals caring for the mother-baby dyad to ensure that all mothers know how to recognise wellness in their baby and adequate transfer of milk and to react quickly when anything abnormal occurs.

    Preventing common problems

    Timing of follow-up

    Routine follow-up with a qualified health care provider must be confirmed with the parents prior to discharge. A suggested Clinical Practice Guideline recommends the following appointment schedule:2

    Age of infant at discharge Should be seen by
    Before 24hr old 72 hrs (3 days)
    From 24 - <48 hrs 96 hrs (4 days)
    From 48 - 72 hrs 120 hrs (5 days)
    For some newborns discharged before 48 hours, 2 follow-up visits may be required, the first visit between 24 and 72 hours and the second between 72 and 120 hours.

    Critical warning signs

    The 3 Red Flags!

    Optimal birth circumstances and good postnatal breastfeeding care will significantly reduce the incidence of infant problems. Each of these signs is an indicator that there may be a breastfeeding problem or something more serious.
    Any of these signs need immediate medical attention.

    #1. Baby's output is less than expected.

    Review the output table in 6.2 Breastfeeding Messages

    Do all mothers have a copy of that table to take home?

    Output is a direct indicator of intake - ensure that you can accurately describe normal urine and stool output of the breastfed infant. There are visual aids available to show parents what to expect.

    Ask about the pinkish/rusty stain on a nappy/diaper which is urates in urine. This is normal until baby is 72 hours old (3 completed days). Secretion of urates in urine is a direct function of the serum uric acid concentration (ie blood levels). It is normal to see urates on a nappy/diaper with a scant volume of urine until Day 4. As the milk intake increases on Day 4 urates should no longer be seen.

    A note of caution to health professionals who provide only telephone consultations ... your image of a wet nappy/diaper, or a reasonable bowel action may not match the mother's impression. Urine should be clear and each nappy/diaper heavy. Although not a pleasant image, it is helpful to describe a 'handful' size as being a good volume of stooling. This is a very clear picture and will help the mother understand that scant frequent stainings are inadequate.

    If there is any doubt at all you must organize for the baby to have medical review urgently.

    #2. Breastfeeding is painful.

    Breastfeeding should not be painful.

    Pain during feeding, misshapen or damaged nipples or pain continuing after the feeding are all indicators that baby is poorly latched and milk transfer will be compromised. A hot or inflamed painful breast is a sign of severe engorgement, or mastitis with reduced milk transfer as a result. Painful breastfeeding is abnormal!

    Immediately seek help from an expert in breastfeeding.

    #3. Increasing jaundice

    Jaundice is a physiological state and is an expected developmental state for the majority of breastfed babies. Jaundice peaks at about Day 3 then gradually fades over the next few weeks. Jaundice should not be seen below the level of the umbilicus.

    Increasing jaundice causes sleepiness and poor feeding; conversely, poor feeding causes increased jaundice.

    Teach parents to check for jaundice by observing their baby in natural daylight and putting finger pressure on their baby's forehead, upper chest, arms, abdomen and upper legs, and observe for blanching.

    Instruct parents that increasing jaundice or jaundice at or below nipple line is to be reported immediately to their baby's health professional.

    Return for immediate assessment

    • Urine and stool output less than normal or urates persist after the 3rd completed day
    • Nipple damage, pain; painful or inflamed breasts
    • Increasing jaundice

    Workbook Activity 6.6

    Complete Activity 6.6 in your workbook.

    These signs or symptoms are the most important for the parents to remember and seek help with if they develop.

    Some instructions are very complicated and often confuse education about breastfeeding with Red Flags, for example, telling parents to count a minimum number of feeds per day, or to be concerned about sleepy babies. If these markers become a problem then one or more of the Red Flags will also be evident.

    Succinct instructions will more likely be remembered by parents. Ensure they know how to seek urgent review from their health care provider whenever any one or more of those points are abnormal.

    Contraception

    Preventing an unwanted pregnancy is important to women, and adequate child-spacing is important to the mother's health and the health of the new baby. Breastfeeding is also of paramount importance to the health of both mother and baby.

    It is preferable for the mother to recover her nutritional status following the demands of pregnancy and lactation. Recovery of these stores prior to a subsequent pregnancy is important for her health - a recuperative period of less than 6 months between the end of breastfeeding and the next pregnancy is associated with depletion of maternal nutrient stores.3

    Mothers therefore require counselling on selection of a contraceptive method that is

    • highly effective in preventing pregnancy, and
    • does not interfere with breastfeeding.

    The Lactational Amenorrhea Method (LAM) of contraception has been extensively studied and found to be more effective than the progestin-only contraceptive pill. Additionally all forms of hormonal contraceptive have the potential to adversely affect breastfeeding.

    Using the Lactational Amenorrhea Method of contraception

    Using the Lactational Amenorrhea Method of contraception.
    Graphic © Health e-Learning


    [link: http://www.waba.org.my/resources/lam/FBPF.htm]

    Contraception for breastfeeding mothers[link: http://www.waba.org.my/resources/lam/FBPF.htm]

    To read more about other contraceptive methods during lactation click on the icon on the left, print the page and file it with your course notes. From this page you'll find further links and references.

    The quality of contraceptive/fertility counselling given to a woman significantly influences its effectiveness. When giving advice about any contraception ensure you understand it completely.

    Workbook Activity 6.7

    Complete Activity 6.7 in your workbook.

    Consolidating learning

    Practical skills should be reinforced by educational materials which must be

    • accurate,
    • consistent within themselves and with previous verbal teaching,
    • written at an appropriate reading-age, and
    • free from commercial advertising.

    Resource materials for mothers

    Form a group to look at ALL the materials that are given to mothers. Each one should be discussed and explained to the mother as it is given. Are all the materials necessary? Are all staff familiar with the materials?

    "The critical warning signs" handout is the most important - does it stand out from the brochures? Perhaps you could start a working group to design/update this vital parent information page?

    Discharge packs DO influence actions, particularly in regard to breastfeeding. Artificial formula company sponsored packs reduce the likelihood of exclusive breastfeeding4 and therefore for the health and safety of mother and baby they should not be distributed by any health care facilities.

    Referral to mother-to-mother support network

    Baby Friendly Step 10 and Point 7

    Step 10 of the Ten Steps to Successful Breastfeeding, and Point 7 of the Seven-point Plan for Sustaining Breastfeeding in the Community state:
    Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
    Point 7: Promote co-operation between health care staff, breastfeeding support groups and the local community.

    Attendance at mother-to-mother support groups or follow-up by peer counselors has demonstrated significant increases in maintaining exclusive breastfeeding.5,6 7 Strategies that depend mainly on face-to-face support appear more effective than those that rely primarily on telephone contact. 8 Parents should be given information about the location and availability of these services with encouragement to use the services.

    How is the information provided?

    Does your Unit have a list of all the available breastfeeding support groups and networks in your area? Is it up-to-date with current phone numbers and meeting places and dates? Are representatives from these groups welcome to meet with mothers in your Unit?


    © Australian Breastfeeding Association

    What should I remember?

    • The 3 critical warning signs that indicate potential infant danger.
    • The consequences of these warning signs if left unattended.
    • The contraceptive choices and actions which can be offered safely for breastfeeding mothers.
    • How to contact your local mother-to-mother support group.

    Self-test Quiz

    Assessment Quiz

    When you are happy that you've understood all the information in this topic you will be ready to complete the Module 6 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 6.

    Notes

    1. # Friedman MA et al. (2004) Discharge criteria for the term newborn.
    2. # AAP Subcommittee on Hyperbilirubinemia (2004) Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation
    3. # Merchant K et al. (1990) Maternal and fetal responses to the stresses of lactation concurrent with pregnancy and of short recuperative intervals.
    4. # Donnelly A et al. (2004) Commercial hospital discharge packs for breastfeeding women
    5. # Thomson G et al. (2013) Callers\' attitudes and experiences of UK breastfeeding helpline support.
    6. # Sudfeld CR et al. (2012) Peer support and exclusive breastfeeding duration in low and middle-income countries: a systematic review and meta-analysis.
    7. # Hoddinott P et al. (2006) Effectiveness of a breastfeeding peer coaching intervention in rural Scotland
    8. # Sikorski J et al. (2004) Support for breastfeeding mothers

    7.0 Infant Challenges

    Infant risk factors

    Being able to identify and target your expertise to the mothers and babies who are at most risk of problems has become increasingly more important as nurse/midwife workload increases. The ideal would be to have mothers who:

    • are educated in breastfeeding skills and normal baby behavior,
    • have a healthy pregnancy and a normal labor without interventions, and
    • whose newborn is cared for with extended skin-to-skin contact.

    However, that scenario isn't possible for every mother and therefore it is very important that you can quickly identify those mothers and infants who are going to require additional assistance from you to establish breastfeeding.

    Consider the infants who fall into the following categories, and allot additional time to assist their mothers.

    Identified during pregnancy

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

    Identified during birthing

    • mother received intrapartum analgesics and/or anesthetics
    • birth trauma, assisted delivery (vacuum, forceps or emergency c/section)
    • low Apgar Scores, required resuscitation
    • no or short skin-to-skin care following birth
    • preterm or late-preterm birth

    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 these mothers and babies as early as possible to give them the best chance for breastfeeding success.

    Early identification ensures assistance is directed where most needed.

    Early identification ensures assistance is directed where most needed.

    7.1 Late preterm; Non-latching

    The 'late preterm' baby

    Infants born 34 weeks 0 days to 36 weeks 6 days gestational age are categorised as 'late preterm'. 1

    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 2 3 4
      • 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 3
    • less glycogen and brown fat stores available to protect against hypoglycaemia 2 5
    • reduced ability to conjugate and excrete bilirubin, increasing need for phototherapy to treat jaundice 2 3
    • neurological immaturity 2
      • poor state regulation - may go from hyper-alert to deep sleep without intervening stages
      • easily overstimulated, then exhausted - may fall asleep before full breastfeed taken
    • lower tone
    • reduced immunological competence. 2 3 6 Keeping mother and infant together reduces risk of nosocomial infections.
    • poor breastfeeding establishment and increased breastfeeding-associated rehospitalisations 6 7 8 9
    • higher mortality throughout infancy 6 10
    • higher incidence of mental and physical developmental delay at 24 months 3 11

    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

    Postpartum care

    Initial treatment should be no different from any other infant:

    • Skin-to-skin contact immediately after birth - initial resuscitation, drying and observations occuring on mother's chest
    • Leave in skin-to-skin contact until after the first breastfeed

      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 breastmilk production
      • enhanced maternal-infant bonding
      • longer exclusive and total breastfeeding
      all of which are even more important to be achieved quickly for these infants.
    • Delay all routine procedures (eg. vit K injection, eye prophylaxis, hepatitis B vaccine, weighing) until baby stable, settled and after first breastfeed as these procedures increase crying, depleting metabolic reserves and disrupting breastfeeding behaviours. Most can be carried out while skin-to-skin with mother if hospital routine is not flexible.

    The first 12 - 24 hours

    • Close observation of the infant should continue for at least the first 12 - 24 hours. Each institution will have their own protocol, however the mother should never be excluded. Skin-to-skin care with the mother is still the best way to stabilize and protect the infant and should be overtly encouraged, even if the infant is in the NICU for observation.
    • Encourage 24-hour rooming-in. Stable, healthy babies can stay with the mother even while receiving intravenous therapy or phototherapy.

    Discharge planning

    • Develop a feeding plan in conjunction with the mother. Ensure she understands the plan and the rationale behind it.
    • Provide this plan to her in written format after discussion, and send a copy to her outpatient health care provider.
    • It will include
      • response to early feeding cues,
      • frequency of feeding for her infant,
      • signs of good milk transfer while sucking,
      • how to increase milk transfer if indicated (breast compression and massage),
      • how to increase milk production if indicated (hand expressing and hands-on pumping),
      • expected urine and stool output.
      • how and when to supplement if this has already been initiated.
    • Book a follow-up appointment for 24 - 48 hours after discharge for reassessment of baby and 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. 9 12 13 14

    Use skilled resources

    If you have a Lactation Consultant on your staff, refer the mother and baby to her for initial assessment of their needs and the development of a unique breastfeeding plan in conjunction with the mother and her postnatal nurse or midwife.
    The lactation consultant will also be able to teach you any additional clinical skills required should you be unsure of any of them.

    Ensure the mother knows not only how to implement the following, but also why it is important.

    • use skin-to-skin care and biological nurturing postioning extensively (maintaining physiological stability, stimulating neonatal feeding reflexes).
    • respond immediately to early feeding cues, leaving nappy/diaper changing until after feeding (due to baby's low energy reserves).
    • hand express colostrum then use hands-on pumping when milk is 'in' after every breastfeeding attempt initially (ensure adequate stimulation of milk supply).
    • breastfeed 2 - 3 hourly (small frequent feeds easier on small stomach capacity reducing overdistension; increased sleepiness causes baby to not wake to feed as often as needed).
    • and, of course, to seek immediate medical review for any of the 3 danger signals that all mothers are taught before discharge home: ie
      • urine output less than normal
      • increasing jaundice
      • painful or damaged nipples

    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 or an at-breast tube feeding device (eg SNS)

    Workbook Activity 7.1

    Complete Activity 7.1 in your workbook.

    [link: http://newborns.stanford.edu/Breastfeeding/MaxProduction.html]

    Hands-on Pumping[link: http://newborns.stanford.edu/Breastfeeding/MaxProduction.html]

    Click on the title or icon above to go to the Standford 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.
    What signs of late prematurity are evident in this 35wk gestation infant?

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

    What should I remember?

    • Late preterm is not full term even if appearing to be well.
    • The signs and symptoms that indicate baby's condition and progress.
    • How skin-to-skin care affects this group of infants.
    • Breastfeeding management which minimises energy usage, enhances milk transfer and protects milk supply.

    Self-test quiz

    The Non-latching Baby

    There are many reasons for a newborn not to latch or latch poorly and breastfeed ineffectively. The following have been associated with sub-optimal breastfeeding behaviors on Day 3 postpartum:15

    • condition at birth compromised (trauma, intrapartum drugs, resuscitation required)
    • pacifier/dummy use
    • flat or inverted nipples
    • breastfeeding delayed for up to 48 hours, and
    • primiparous mothers.

    It has been demonstrated that forcing the baby to the breast can abolish the rooting reflex and disturb placement of the tongue. A healthy baby should have the opportunity of showing hunger and optimal reflexes, and attach to its mother's breast by itself. 16

    Read this Externalshort article[link: http://www.health-e-learning.com/resources/articles/37-when-the-back-of-the-babys-head-is-held-to-attach-the-baby-to-the-breast] that describes the detrimental effects of a hand placed on the back of the baby's head during latching.

    Your first responsibility

    A newborn who shows no inclination to breastfeed is abnormal until proven otherwise.

    The most important concern when a baby is not exhibiting this expected reflex is to rule out infant morbidity. Observe the infant's vital signs and organize a pediatric review if any abnormality is detected. Conditions such as unexpected respiratory distress syndrome, Group B strep infection, sepsis, hypoglycaemia, etc may first present as a baby not exhibiting the normal feeding reflexes.
    We also know that it could be as a result of intrapartum drugs or the birthing experience, and the baby just needs more time, but don't assume that until you have eliminated the more sinister causes.

    Principles of management

    The aim of your plan is to:

    1. protect the baby: this not only means to ensure the physical well-being of the infant (nutrition and warmth), but includes protecting the baby from unnecessary supplementation before it is indicated.
    2. protect the lactation: until such time as baby is suckling well
    3. treat the mother with sensitivity; emotionally she may be feeling guilty or rejected by her infant.

    The Action Plan

    Re-establish skin-to-skin care on mother's chest if this had been interrupted. This baby should have A LOT of time in this position. Encourage the mother to adopt the laid back position of Biological Nurturing to stimulate pre-feeding behaviours.

    Teach the mother about the early feeding cues, ie. wriggling, mouthing, bringing hand to mouth, rooting. Ensure she knows to facilitate feeding immediately the baby shows these cues

    Smear the areola with breastmilk (the smell of the breast guides the baby towards it). Trickle small amounts of breastmilk into the corner of the infant's mouth as he lies near the breast.

    Avoid stressful events/procedures and handle the baby with care ie. don't force the baby to the breast or hold the infant's head in an attempt to hasten latching.

    From 0 to 24 hours old

    • continue to observe the baby's vital signs regularly and observe for symptoms of hypoglycemia (blood testing not indicated if asymptomatic). Initiate pediatric review if outside the range of normal.
    • reassure the mother and be patient
    • hand express breastmilk each time baby tries unsuccessfully to breastfeed. Finger-feed, spoon feed or slowly trickle the tiny volumes into the corner of the baby's mouth from a syringe if the baby is swallowing OK.
    • hand expressing should have commenced within 6 hours of birthing (preferably earlier) and regularly at least 3 hourly thereafter (up to 5 hour break overnight). 17 While the baby's condition should not deteriorate due to lack of feeding in this first 24 hours, giving the baby the expressed milk makes common sense.

    From 24 to 48 hours old

    • continue in skin-to-skin care
    • continue regular observations of vital signs and for signs of hypoglycemia.
    • attempt to rouse and interest baby in breastfeeding every 3 hours.

      If unsuccessful:
    • Feed the baby! with the expressed breastmilk.
      Average breastmilk volume intake in the second 24 hours is 5 - 15ml per feed with a 24 hour total volume of 84ml. This should be your goal.
      • cup, finger or spoon feed 18 the breastmilk to the baby. 19 Giving more than 2 supplements using a bottle can lead to discontinuation of exclusive, and any, breastfeeding. 20
      • continue regular hand expressing or pumping at least 8 times per 24 hours.
      • refer mother and baby to a Lactation Consultant for evaluation.

    From 48 to 72 hours old

    • Continue all strategies as above
    • Average total volume of breastmilk taken is 400ml (13.5oz) per day, or about 15 - 30ml/feed - depending on the volume the mother is able to express each time.

    From Day 5

    • Secretory activation (lactogenesis II) should have occurred by now
    • Continue all strategies as above
    • The breast may need to be softened by expressing a little milk prior to attempting to latch21
    • Average daily volume of breastmilk consumed from Day 5 is ~700ml (~24oz). Some babies may settle and thrive on less, some may require more.

    (The recommended daily volumes are taken from the average volume taken at the breast by the well, full-term baby. Refer to the table in topic 6.2 .)

    Note: Never underestimate the significance of skin-to-skin contact to trigger instinctive reflexes and enhance recovery.
    Cup feeding is a good alternative when an infant is unable to suckle.

    Cup feeding is a good alternative when an infant is unable to suckle.
    © A.Hunt, IBCLC

    Some general tips
    If you can identify a reason for non-latching it is easier to target the cause.
    For example:
    • flat, inverted or non-protractile nipples
      • try pulling the nipple out with gentle suction from a pump, or the mother may be able to evert the nipple or make it more erect by stimulation
      • shape the breast for the baby and hold that shape until the baby is well-established suckling
      • a thin silicone nipple shield may be useful, though milk transfer is very poor prior to secretory activation
    • baby attempts to latch but has uncoordinated latch
      • skin-to-skin and biological nurturing facilitating normal reflexes
      • avoid all use of artificial nipples (teats/dummies/pacifiers)
      • encourage baby to suck well on finger, rewarding good sucking action with expressed breastmilk
      • slip finger out and breast into mouth when baby establishes good sucking pattern
    • sleepy baby (usually as a result of intrapartum medications or birth trauma)
      • attempt to wake for feeds
      • give expressed breastmilk via finger feeding to ensure baby has sufficient calories for energy (sleepy babies will often still suck on a finger while too drowsy to latch to breast)
      • patience - s/he will become more alert eventually
    • physical issues (eg torticollis, fractured clavicle, ankyloglossia, facial asymmetry, cleft palate, etc)
      • refer to specialists for treatment; refer to lactation consultant for feeding plan
      • concentrate on establishing a good breastmilk supply

    Does your Unit have a policy on the non-latching baby?

    Review the policy. Is it current, using up-to-date research to support the recommendations? If not, form a small group to research the topic then draft a policy that you present to your colleagues (midwifery, nursing and medical). Ensure all staff are familiar with the policy to avoid conflicting information and management strategies.

    Workbook Activity 7.2

    Complete Activity 7.2 in your workbook.

    Breast refusal in the older baby

    Babies may be fussy at the breast and refuse to breastfeed for a period of time. Before 12 months of age this is rarely due to the infant choosing to wean.

    Determine that it actually is breast refusal. Mothers sometimes misinterpret an older baby's quicker more efficient feeding, or a decreased need for breastmilk when complementary foods are introduced, as breast refusal. During very hot weather baby may not feed during the heat of the day, but will feed well in the evening or during the night. Other reasons may be pain, forceful MER/low supply, flavour changes and sucking confusion.

    Management strategies for the older baby

    • Record a comprehensive history, including specifics on breastfeeding behavior and urine and stool output prior to this episode. Record the change in behavior and baby's current output.
    • Do an assessment of the baby including weight, length, head circumference, attainment of appropriate developmental milestones, observation of alertness and general health. If there are signs of delayed growth or ill health, refer the baby to a doctor.
    • Observe a breastfeed, or attempted breastfeed. (Review Topic 5.2 Assessing Breastfeeding)
    • If refusal persists for more than one or two missed feeds

      • the mother should express her milk to maintain her milk supply
      • use the expressed milk or donor breastmilk to feed baby, preferably using a cup
      • use donor breastmilk or artificial infant formula if baby refuses the breastmilk
      • a medical review of the baby is indicated if baby won't feed at all

    Detective work is needed!

    This is a distressing time for the mother, who may be feeling variously angry, rejected, worried, disappointed and bewildered. Good counseling skills will help you to empathize with the mother and work together through a comprehensive history-taking to find a reason for the baby's behaviour. If you can determine the cause you can then direct your management strategies more effectively.

    General guidelines include:

    • patience; avoid trying to force the baby to breastfeed or displaying anxiety or anger during attempts
    • encourage lots of skin-to-skin time in bed together or sharing a bath. Don't expect the baby to breastfeed ... but it just might happen
    • observe the environment - avoid distractions such as other children, toys, television, etc. Choose a dimly lit room and play some relaxation music.
    • attempt breastfeeding when baby is nearly asleep or just beginning to wake up
    • offer the breast instead of pacifier/dummy, and when infant starts thumb sucking
    • suggest baby be cup fed rather than bottle fed when separated from the mother
    • suggest the use of a tube feeding device at the breast instead of bottles if supplements were being given
    • give written instructions and supervise the mother using alternative feeding methods until she feels confident doing it herself.

    What should I remember?

    • Protect the baby. Protect the lactation. Support the mother.
    • Be a detective to determine possible cause of non-latch or refusal.
    • Know the protocol to follow for a non-latching infant in the first 24 hrs after birth and for each day until secretory activation.
    • Encourage patience.

    Self-test quiz

    Give your response

    Notes

    1. # Engle WA (2006) A recommendation for the definition of "late preterm" (near-term) and the birth weight-gestational age classification system.
    2. # Hughes A et al. (2014) Late preterm birth is associated with short-term morbidity but not with adverse neurodevelopmental and physical outcomes at 1 year.
    3. # Baumert M et al. (2011) [Late preterm infants--complications during the early period of adaptation].
    4. # Resch B et al. (2011) Are late preterm infants as susceptible to RSV infection as full term infants?
    5. # AAp Committee on Fetus and Newborn (2011) Postnatal glucose homeostasis in lat preterm and term infants
    6. # Machado LC Júnior et al. (2014) Late prematurity: a systematic review.
    7. # Radtke JV (2011) The paradox of breastfeeding-associated morbidity among late preterm infants.
    8. # Vessière-Varigny M et al. (2010) [Breastfeeding in a population of preterm infants: a prospective study in a university-affiliated hospital].
    9. # Cleaveland K (2010) Feeding challenges in the late preterm infant.
    10. # Tomashek KM et al. (2007) Differences in mortality between late-preterm and term singleton infants in the United States, 1995-2002.
    11. # Woythaler MA et al. (2011) Late preterm infants have worse 24-month neurodevelopmental outcomes than term infants.
    12. # Meier P et al. (2013) Management of breastfeeding during and after the maternity hospitalization for late preterm infants.
    13. # Ahmed AH (2010) Role of the pediatric nurse practitioner in promoting breastfeeding for late preterm infants in primary care settings.
    14. # Walker M (2008) Breastfeeding the late preterm infant.
    15. # Dewey K (2003) Guiding Principles for Complementary Feeding of the Breastfed Child
    16. # Widstrom AM et al. (1993) The position of the tongue during rooting reflexes elicited in newborn infants before the first suckle
    17. # Furman L et al. (2002) Correlates of lactation in mothers of very low birth weight infants
    18. # Kumar A et al. (2010) Spoon feeding results in early hospital discharge of low birth weight babies.
    19. # Morton J et al. (2013) Five steps to improve bedside breastfeeding care.
    20. # Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding
    21. # Cotterman J (2004) Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement

    7.2 Hypoglycemia; Jaundice

    Pathologic Neonatal Hypoglycemia

    Physiology

    The term hypoglycemia refers to low blood glucose concentration. The body, and particularly the brain, requires a source of energy to function. Glucose is an important source of energy.

    There are two times of crisis in the neonates life regarding energy (glucose) needs. Both crises are managed by the infant'snormal metabolic adaptation using alternative fuel sources. (ie gluconeogenesis and glycogenolysis)
    1. The first crisis occurs after birth when the cord stops pulsing and the maternal supply of glucose to the newborn is discontinued. 1 2
      • blood glucose concentration reaches its nadir in the first 1 - 2 hours
      • blood glucose concentration then rises to a steady state within 2 - 3 hours
      • feeding the infant may cause small transient rises in blood glucose concentration, but it is not feeding that maintains euglycemia
    2. The second crisis will occur if lactation is delayed. 3 4 5
      • Fat breakdown occurs, releasing ketone bodies that provide glucose-sparing fuel to the neonatal brain, protecting neurologic function.
    Transient hypoglycemia in the early neonatal period is a common adaptive phenomenon as the newborn changes from the fetal state of continuous transplacental glucose consumption to intermittent nutrient supply following cessation of maternal nutrition at birth.
    In the term, healthy newborn this dynamic process is self-limiting and is not considered pathologic.6

    Routine glucose screening

    Clinically significant (ie pathologic) hypoglycemia does NOT occur in well, full term babies. The baby's physiology protects him against this by using metabolic processes to maintain steady-state glucose concentration. 7 2

    Unnecessary routine screening results in the misidentification and misdiagnosis of neonates captured while experiencing the normal, self-correcting physiologic blood glucose nadir.

    Following this unforgiveable error, further surveillance and unnecessary, aggressive treatment interventions will follow that are harmful to the neonate's normal adaptive processes and interferes with breastfeeding, further risking the infant's health.

    Routine glucose screening is poor practice!

    Routine glucose screening is poor practice!


    Unnecessary interventions

    Routine hypoglycemia screens, treatments, and interventions in the healthy infant are not evidence-based. 6 8
    The practice contributes to increased stress for the parents and infant, unnecessary painful procedures for the infant and causes a serious disruption of the initiation process and duration patterns of lactation.

    Diagnosing pathologic neonatal hypoglycemia

    Prolonged hypoglycaemia, sufficiently severe to cause neurological signs, is called pathologic neonatal hypoglycemia.
    Diagnosis is made when
    • neurological signs are present, and
    • blood glucose concentration is low. 9

    This is a very serious condition which could lead to neurological impairment.

    Which infants are at risk?

    Consider which infants may have metabolic stressors or immaturity that could affect the normal release of glucose in the first hours following birth, or ketone body metabolism later.
    Infants at risk of symptomatic hypoglycemia include: 10
    1. Infants of diabetic mothers - hyperinsulinemia as a result of poor maternal control during pregnancy will cause hypoglycemia until stabilised.
    2. Infants who are preterm or late preterm with metabolic immaturity.
    3. Infants who have few fat reserves, eg small for gestational age infants
    4. Infants who have experienced severe stress, eg. perinatal stress, cold stress, sepsis7

    Infants in these categories require frequent observation for neurological signs and blood screening for glucose concentration at intervals according to evidence-based medical protocols.

    Clinical signs to observe for:

    The most important observation you will make is the infant's level of consciousness. Disturb the infant - if he wakes easily, great! If he doesn't: pick up the infant, talk to him, wake him up. A limp infant you cannot wake is a bad sign.

    Other clinical manifestations7

    • irritability, tremors, jitters
    • tachypoena (rapid respiration)
    • exaggerated Moro reflex
    • high-pitched cry
    • lethargy, limpness, hypotonia
    • apnea or irregular breathing
    • cyanosis
    • hypothermia, temperature instability
    • poor or inadequate sucking reflex
    • vasomotor instability
    • seizures

    But of course ...

    ALL infants will be observed for clinical signs - not only those 'at risk'.
    ANY infant who exhibits any of these neurological signs will require urgent referral for medical review and blood glucose estimation.

    Workbook Activity 7.3

    Complete Activity 7.3 in your workbook.

    You can prevent pathologic hypoglycemia!

    Placing ALL newborns in skin-to-skin care with their mother from immediately after birth and for as long as possible, preferably at least the first day of life, will:
    • stabilise the infant's temperature (no requirement to burn fat for heat)
    • stabilise the infant's cardio-respiratory system
    • stimulate metabolic adaptation
    • initiate the first phase of the enteric nervous system (facilitating intestinal function)
    • reduce stress (release of cortisol initially causes a surge in blood glucose concentration, then a fall)
    • facilitate early and frequent breastfeeding (preventing the delay in lactation which would precipitate the infant's second energy 'crisis')
    as well as preventing other risk factors for hypoglycemia, such as nosocomial infections. 11

    While this won't, unfortunately, eliminate hypoglycemia, it will prevent it from developing in a significant number of infants.

    This is really important!

    It's worthwhile repeating: The BEST way for you to prevent hypoglycaemia in the infants you care for is by placing baby in skin-to-skin contact with his mother immediately after birth, and for as long as possible.

    Share your thoughts in the forum about how this simple, no-cost practice helps prevent hypoglycemia.

    What about early feeding?

    Facilitation of early and frequent breastfeeding is strongly encouraged. However, exogenous glucose, such as from colostrum (or infant formula in the bottle-fed), is not essential to maintain normal glucose concentration in the first 24 hours.

    Healthy, full-term infants do not develop symptomatic hypoglycemia in the first 24 hours simply as a result of underfeeding. 12

    Frequent, effective breastfeeding will, however, be protective after the first 24 hours. Beginning breastfeeding soon after birthing will ensure the infant is breastfeeding well and maternal lactation is becoming established by the time the infant is dependent on this source of energy.

    Workbook Activity 7.4

    Complete Activity 7.4 in your workbook.

    Clinical management of pathologic hypoglycaemia

    Inadequately treated symptomatic hypoglycemia has such a serious outcome that pediatricians agree that
    the clinician should not rely on oral feeding (eg breastmilk or infant formula) for the correction of symptomatic hypoglycemia 12 and “ symptomatic hypoglycemia should always be treated with a continuous infusion of parenteral dextrose . 10,7

    During medical management breastfeeding should continue uninterrupted. The goal is to have an infant who suckles effectively at the breast and a mother's milk supply that is able to meet his needs when IV therapy is discontinued.

    • continue breastfeeding, and skin-to-skin contact during treatment
    • do not give water, glucose water or formula to the breastfed infant
    • continue breastfeeding while weaning baby from IV glucose, monitoring carefully

    Extend your knowledge

    Go to the PDFAcademy of Breastfeeding Medicine[link: http://www.bfmed.org/Media/Files/Protocols/Hypoglycemia_Revised2014_English.pdf] and read this protocol on Hypoglycemia. File it in your workbook.

    Unit Activity

    Access your Unit policy on the management of hypoglycemia. Using this excellent PDFChecklist published by Baby Friendly UK[link: http://www.unicef.org.uk/Documents/Baby_Friendly/Guidance/hypo_policy.pdf] and the Academy of Breastfeeding Medicine protocol you have already printed, assess the quality of your policy. Is it up-to-date and evidence-based? If not, form a working group to revise it, present it at a Unit meeting and implement it.

    What should I remember?

    • How euglycemia is maintained in the first 24 hours, regardless of oral intake.
    • The effect of unnecessary blood glucose monitoring on the full-term, healthy infant.
    • The infants who are 'at-risk' of pathologic neonatal hypoglycemia.
    • How to recognise signs of pathologic hypoglycemia.
    • The best practice management to prevent symptomatic hypoglycemia for all infants.
    • How to support breastfeeding during medical management of pathologic hypoglycemia.

    Self-test quiz

    Jaundice

    The most common paediatric condition encountered in the first week is hyperbilirubinaemia. It is so common that it is termed "Physiological Jaundice" and reflects the normal physiological changes that occur as the neonate adapts to extrauterine life.

    Normal serum bilirubin levels

    The neonate is more susceptible to high serum bilirubin levels because13

    1. there is increased breakdown of fetal erythrocytes. This is the result of the shortened lifespan of fetal erythrocytes and the greater number of erythrocytes in neonates.
    2. liver excretory ability is low because of the relative immaturity of the liver.

    At birth neonates have a low serum bilirubin. The normal pattern is for a rise to a peak by the third day of life, followed by a plateau and drop in levels, or, for ⅔ of babies, a gradual rise to another peak on about the 10th day. After this the levels gradually drop until about the third week of life. (An exception to this is found in babies of Asian origin whose Day 3 levels peak nearly twice as high as found in non-Asian babies).

    In some mothers, unidentified factors present in her breastmilk may contribute to increased enterohepatic circulation of bilirubin with harmless jaundice persisting for many weeks. This is an extension of physiologic jaundice known as breastmilk jaundice. No special treatment is required and continued breastfeeding is recommended. 14



    Diagram © Health e-Learning

    Food for thought

    The physiology of the breastfed baby is the norm, and the standard that science strives to achieve for those infants artificially-fed.

    Serum bilirubin has an antioxidant effect which it is thought cmpensates for the relative deficiency of endogenous antioxidants in newborns. While excessive serum bilirubin is dangerous, lower levels with a slow decline must have a purpose.

    Causes of abnormal bilirubin levels

    • Abnormal weight loss : A weight loss of more than 7% in both artificially fed and breastfed infants is associated with higher serum bilirubin concentrations. Inadequate intake causes
      • retention of meconium and reabsorption of previously excreted bilirubin back into the blood stream.
      The cycle is then likely to continue as raised serum bilirubin causes sleepiness and poor feeding, decreased intake and further reabsorption of bilirubin.

    • Hemolytic processes : Blood group incompatibilities (Rh, ABO, and others) may increase bilirubin production through increased haemolysis. Nonimmune haemolytic disorders (spherocytosis, G-6-PD deficiency) also may cause increased jaundice through increased haemolysis.

    • Non-hemolytic processes : A number of other nonhaemolytic processes can increase serum bilirubin levels. Accumulation of blood in extravascular compartments (cephalhaematomas, bruising, occult bleeding) may increase bilirubin production as the blood is absorbed and degraded. Increased bilirubin production also is seen in infants with polycythemia and in infants of mothers with diabetes. Increased reabsorption of bilirubin from the bowel leading to elevated bilirubin levels is seen in infants with bowel obstruction or ileus.

    Physical appearance

    Jaundice has a cephalocaudal (or cephalopedal) ie head to toe progression; it is evident first in the face, gradually becoming visible on the trunk. Jaundice seen below the level of the umbilicus and on the extremities reflects increasingly higher serum bilirubin levels. Jaundice disappears in the opposite direction.
    Daylight on a clear day provides the best lighting for evaluation. Pressure applied on the skin using the finger pad will blanch the skin revealing the underlying colour.

    Non-invasive transcutaneous measurement of bilirubin is a reliable screening method for identifying infants who need additional work-up. 15 Laboratory measurement of bilirubin is indicated if jaundice involves the lower body and extremities. 14

    Transcutaneous bilirubin monitoring is non-invasive.

    Transcutaneous bilirubin monitoring is non-invasive.


    Management of hyperbilirubinemia

    Prevention of hyperbilirubinemia due to inadequate intake involves early recognition of risk factors, good teaching and supervision of breastfeeding, and mothers who are able to recognize that good transfer of breastmilk to the infant is occurring.

    Optimal breastfeeding behaviors results in lower serum bilirubin concentration in the first 5 days: 14

    • initiation of breastfeeding in the first hour after birth
    • continuous rooming-in with unlimited access to the breast
    • a breastfeeding frequency of 10 to 12 times per day
    • prompt responses to early hunger cues, and
    • absence of all supplementation.

    Ensure adequate intake for the infant:

    • assess breastfeeding effectiveness
    • stimulate and support an adequate milk supply
    • frequent breastfeeds; 8-12 per 24 hrs
    • offer supplemental feeds of expressed breastmilk, if necessary
    • artificial infant formula is given only in the absence of adequate breastmilk volumes
    When phototherapy treatment is required:
    • offer emotional support to the mother while her baby is receiving treatment
    • continue all of the above feeding measures (additional insensible water loss will be met by breastmilk)
    • Do NOT give water supplementation (increases serum bilirubin)

    One of the Red Flags

    Increasing jaundice is one of the 'Red Flags' you will discuss with all mothers prior to their discharge from hospital. (see 6.6 Discharge Planning )

    Ensure that every mother knows

    1. that a degree of jaundice is normal in breastfed infants
    2. how to assess the level of jaundice in their infant
    3. that increasing jaundice after Day 3 MUST be reported immediately to their health care practitioner
    4. any jaudice below the level of the nipple line should be immediately reported to their health care practitioner.
    5. that high levels of jaundice are very dangerous, and therefore don't delay reporting it.

    Workbook Activity 7.5

    Complete Activity 7.5 in your workbook.

    Extend your knowledge

    Read and print the AAP Policy ExternalPhototherapy to Prevent Severe Neonatal Hyperbilirubinemia in the Newborn Infant.[link: http://pediatrics.aappublications.org/content/128/4/e1046.full]

    This protocol from the Academy of Breastfeeding Medicine is also excellent: PDFGuidelines for Management of Jaundice in the Breastfeeding Infant Equal to or Greater Than 35 Weeks’ Gestation [link: http://www.bfmed.org/Media/Files/Protocols/Protocol%2022%20Jaundice.pdf]

    Unit activity

    What is your Unit's policy on prevention, recognition and management of jaundice? Discuss the Unit policy with your colleagues, comparing it to the AAP recommendations and other evidence-based articles. Particularly note the importance of continued, frequent, effective breastfeeding in the prevention and management of jaundice.

    What should I remember?

    • Jaundice is a normal physiological process in the well full-term baby (physiological jaundice)
    • The potential risk factors for problematic jaundice
    • The optimal management that prevents an abnormal pattern of jaundice
    • The importance of and what to teach mothers about jaundice before they are discharged with their babies.

    Self-test quiz

    Click and drag the missing words below into their correct place

    The missing words are: breastfeeding breastmilk physiological supplementation tenth third

    __________ jaundice is normal in most newborns. Bilirubin rises to a peak on the __________ day of life, followed by a further rise until the __________ day for most breastfed infants. A harmless form of jaundice that persists for many weeks is termed __________ jaundice.
    Prevention of hyperbilirubinemia is focused on frequent, effective __________ and the absence of all __________.

    Notes

    1. # Hawdon JM (2010) Best practice guidelines: Neonatal hypoglycaemia.
    2. # Cornblath M et al. (2000) Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds
    3. # Hawdon JM et al. (1992) Patterns of metabolic adaptation for preterm and term infants in the first neonatal week.
    4. # Edmond J et al. (1985) Ketone body metabolism in the neonate: development and the effect of diet.
    5. # Cotter DG et al. (2011) Obligate role for ketone body oxidation in neonatal metabolic homeostasis.
    6. # Haninger NC et al. (2001) Screening for hypoglycemia in healthy term neonates: effects on breastfeeding
    7. # Wight N et al. (2014) ABM Clinical Protocol #1: Guidelines for Blood Glucose Monitoring and Treatment of Hypoglycemia in Term and Late-Preterm Neonates, Revised 2014.
    8. # Committee on Fetus and Newborn et al. (2011) Postnatal glucose homeostasis in late-preterm and term infants.
    9. # Hawdon JM (1999) Hypoglycaemia and the neonatal brain.
    10. # Jain A et al. (2010) Hypoglycemia in the newborn.
    11. # Csont GL et al. (2014) An evidence-based approach to breastfeeding neonates at risk for hypoglycemia.
    12. # Eidelman AI (2001) Hypoglycemia and the breastfed neonate
    13. # Cohen RS et al. (2010) Understanding neonatal jaundice: a perspective on causation.
    14. # Gartner LM (2001) Breastfeeding and jaundice
    15. # Panburana J et al. (2010) Accuracy of transcutaneous bilirubinometry compare to total serum bilirubin measurement.

    7.3 Supplementation

    Baby Friendly Point 5 and Step 6

    Step 6 of the Ten Steps to Successful Breastfeeding, and Point 5 of the Seven-point Plan for Sustaining Breastfeeding in the Community state:
    Step 6: Give newborn infants no food or drink other than breastmilk, unless medically indicated.
    Point 5: Encourage exclusive and continued breastfeeding (beyond six months) (to two years or more), with appropriately-timed introduction of (adequate and safe) complementary foods.

    In-hospital breastmilk substitutes

    Breastmilk 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 mothers whose infant's were given breastmilk substitutes in the early postnatal days. 1 2

    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.

    Breastmilk substitutes impair these processes. They also fill the infant's stomach lessening the urge to breastfeed. As a result, breastmilk intake is minimal ...

    • increasing breastfeeding problems, 3
    • decreasing the likelihood of a return to exclusive breastfeeding
    • decreasing the duration of breastfeeding, 3 4 5 1 and
    • the cycle of delayed initiation of lactation has the propensity to cause further use of breastmilk substitutes. 6

    Reasons proferred for the giving of post-breastfeed supplements, or additional bottles of water, glucose water or artificial infant milk have included:

    • the infant is sleepy and has not had 8 feeds in the first 24 - 48 hours (see 7.2 Breast refusal for how to manage this)
    • to give the mother a rest
    • because the mother doesn't have her milk 'in' yet
    • to calm a crying infant
    • to prevent hypoglycemia
    • to reduce jaundice, or to prevent dehydration in a baby under phototherapy lights

    None of these reasons are indications for giving supplements, with some having the opposite effect to the result desired.

    Medical indications for supplementation

    The World Health Organization states that there are few medical indications that may require individual infants to be given fluids or food in addition to, or in place of, breastmilk. Whenever stopping breastfeeding is considered, 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. The following circumstances may be considered:

    Infant conditions:

    • These infants should receive only specialized infant formula:
      • infants with specific inborn errors of metabolism; eg classic galactosemia, maple syrup urine disease, phenyloketonuria (some breastfeeding possible with careful monitoring)
    • These infants should continue to receive breastmilk, but may require other food in addition for a limited time:
      • infants with very low birth weight (<1500g) or who are born preterm (before 32 weeks gestational age)
      • infants at risk of hypoglycemia due to impaired metabolic adaptation or increased glucose demand and who fail to respond to optimal breastfeeding or breastmilk feeding (eg. prematurity, small for gestational age, have experienced significant intrapartum hypoxic stress, or are ill or mother is diabetic)

    Maternal conditions:

    • HIV infection. Individualized assessment required that includes the availability of counseling and support, and that infant formula feeding will be acceptable, feasible, affordable, sustainable and safe (AFASS). (See topic 8.5 Medical and Surgical Issues for managment of maternal HIV)
    • Temporary infant formula feeding may be necessary when
      • the mother is taking medication which is contraindicated when breastfeeding, and for which there is no safe alternative. Rarely are there no safe alternatives, however cytotoxic chemotherapy is one example.
      • the mother abuses drugs such as heroin, cocaine, amphetamines, cannabis, alcohol etc. Seek individual counseling for mothers in these instances to assess their dependency and the needs of their infant.

    Adapted from ExternalWHO/UNICEF: Acceptable medical reasons for use of breast-milk substitutes. 2009[link: http://whqlibdoc.who.int/hq/2009/WHO_FCH_CAH_09.01_eng.pdf?ua=1]

    Protect breastfeeding

    When breastfeeding is temporarily delayed or interrupted for any reason

    Supplementing the breastfed infant

    When breastfeeding alone is insufficient or temporarily inappropriate, the choice of supplement should be, in order of preference:
    1. The mother's own expressed breastmilk, if it is available and suitable.
    2. Donor breastmilk - from another healthy mother or human milk bank
    3. Protein hydrolysate formula. This type of formula is preferable to standard formula for the breastfed infant as it is hypoallergenic, reduces bilirubin levels more rapidly 7 and is more likely to be seen by the parents for what it is - a temporary medicine until such time as the infant can resume exclusive breastfeeding.

    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 between 48 and 72 hours of age and 30 - 60ml from 72 - 96 hours of age. (refer to the table found in 6.2 Breastfeeding Messages )

    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 and is unacceptable in Baby Friendly organisations.

    The following methods are detailed in the following pages.

    Feeding-tube device at the breast

    Cup feeding

    Finger feeding

    Bottle feeding (this topic includes a Competency form)

    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.

    Review 1.0 Why Breastfeeding is Important to refresh your memory regarding the short- and long-term effects of infant formula feeding.

    Short-term effect on the mother

    A loss of maternal self-confidence occurs when supplements are given without a valid medical indication. 8

    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, which 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 9

    Short-term effect on infant health

    Infant ability to suck at the breast can be disturbed as s/he learns a different sucking technique.10

    Supplements change the normal flora of the intestine, 11 12 increase gut permeability and decrease gut mobility.

    Artificial infant milk can be contaminated during manufacture and preparation, and the feeding implements can introduce another source of infection. 13

    Protective properties in breastmilk, such as lactoferrin, are inactivated by artificial infant milk. 14

    Effect on digestion and absorption

    Artificial infant formula is poorly digested and absorbed compared to breastmilk as

    • there is a normal immaturity of digestion and absorption at birth
    • breastmilk contains enzymes to aid digestion (eg lipase) that are not in infant formula
    • breastmilk macronutrients are in easily digested form, unlike the macronutrients in infant formula
    • absorption of minerals is enhanced by breastmilk '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 a euglycemia is achieved and maintained for up to 24 hours, irrespective of oral intake.15
    Giving babies glucose water or artificial 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.16 Lack of early feeding delays passage of meconium and increases enterohepatic re-absorption of bilirubin.

    Increased breastfeeding is the best way to treat the additional insensible water loss that is caused when phototherapy is required.17

    Effect on atopic disease

    Even just one or two artificial baby 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.18,19

    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.2 20 21

    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.22 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 requested a supplement ...

    Lack of understanding of normal newborn behavior, volume of breastmilk 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 breastmilk 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 in hospital who has requested a supplement, or who, in the community setting, is wanting to give supplements to change her baby's behavior.

    Human Immunodeficiency Virus (HIV)

    • Exclusive breastfeeding to 6 months of age, combined with antiretroviral therapy has a low risk of mother-to-child transfer of HIV. 23 24 25 26

    Exposure to cow's milk protein and other foods damages the permeable infant gut allowing transfer of the HIV virus. 27 Unless it is known, without doubt, that a mother is HIV negative then there is a likelihood the baby may suffer serious morbidity and eventual mortality from giving a breastfed infant just one supplementary bottle.

    Workbook Activity 7.6

    Complete Activity 7.6 in your workbook.

    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 them, the mother and the baby should they not follow this policy.

    Do you have an "Informed Consent" form to ensure mothers are aware of the dangers of infant formula?

    [link: http://www.bfmed.org/Media/Files/Protocols/Protocol%203%20English%20Supplementation.pdf]

    Extend your knowledge[link: http://www.bfmed.org/Media/Files/Protocols/Protocol%203%20English%20Supplementation.pdf]

    Click on the icon or wording above to open and read the Protocol for the Hospital Guidelines for the use of Supplementary Feedings.
    Print it out and file it in your Workbook.

    What should I remember?

    • the medically valid reasons for the use of breastmilk 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 and their ongoing breastfeeding relationship
    • be aware of the legal implications of giving infant formula with no valid medical indication
    • safe preparation of infant formula

    Self-test quiz

    Notes

    1. # Lakati AS et al. (2010) The effect of pre-lacteal feeding on full breastfeeding in Nairobi, Kenya.
    2. # Parry JE et al. (2013) Predictors and consequences of in-hospital formula supplementation for healthy breastfeeding newborns.
    3. # Isenalumhe AE et al. (1987) Prelacteal feeds and breast-feeding problems.
    4. # Hossain MM et al. (1992) Prelacteal infant feeding practices in rural Egypt.
    5. # Pérez-Escamilla R et al. (1996) Prelacteal feeds are negatively associated with breast-feeding outcomes in Honduras.
    6. # Ahmed FU et al. (1996) Prelacteal feeding: influencing factors and relation to establishment of lactation.
    7. # Gourley GR et al. (1992) The effect of diet on feces and jaundice during the first 3 weeks of life.
    8. # Gagnon AJ et al. (2005) In-hospital formula supplementation of healthy breastfeeding newborns
    9. # McNeilly AS (2001) Neuroendocrine changes and fertility in breast-feeding women
    10. # Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding
    11. # Edwards CA et al. (2002) Intestinal flora during the first months of life: new perspectives.
    12. # Guaraldi F et al. (2012) Effect of breast and formula feeding on gut microbiota shaping in newborns.
    13. # Holy O et al. (2014) Cronobacter spp. as emerging causes of healthcare-associated infection.
    14. # Wharton BA et al. (1994) Faecal flora in the newborn. Effect of lactoferrin and related nutrients
    15. # Eidelman AI (2001) Hypoglycemia and the breastfed neonate
    16. # Gartner LM (2001) Breastfeeding and jaundice
    17. # de Carvalho M et al. (1981) Effects of water supplementation on physiological jaundice in breast-fed babies
    18. # Wegienka G et al. (2006) Breastfeeding history and childhood allergic status in a prospective birth cohort
    19. # MacIntyre EA et al. (2010) Early-life otitis media and incident atopic disease at school age in a birth cohort.
    20. # Chantry CJ et al. (2014) In-Hospital Formula Use Increases Early Breastfeeding Cessation Among First-Time Mothers Intending to Exclusively Breastfeed.
    21. # Biro MA et al. (2011) In-hospital formula supplementation of breastfed babies: a population-based survey.
    22. # Reiff MI et al. (1985) Hospital influences on early infant-feeding practices.
    23. # Thakwalakwa C et al. (2014) Growth and HIV-free survival of HIV-exposed infants in Malawi: A randomized trial of two complementary feeding interventions in the context of maternal antiretroviral therapy.
    24. # Horvath T et al. (2009) Interventions for preventing late postnatal mother-to-child transmission of HIV.
    25. # Iliff PJ et al. (2005) Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival.
    26. # Coovadia HM et al. (2007) Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study.
    27. # Smith MM et al. (2000) Exclusive breast-feeding: does it have the potential to reduce breast-feeding transmission of HIV-1?

    7.3.1 Feeding-line device at the breast

    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.

    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.

    It

    • avoids any possibility of suck confusion,
    • stimulates the mother's breastmilk 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 with a chronic low supply (ie. due to infant poor feeding or conditions such as hypoplasia)
    • 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

    Insufficient milk flow will very quickly cause the infant to lapse into non-nutritive sucking or display breast refusal behaviour.
    Newborns imprint 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
    • hypoallergenic tape
    • the supplement
    • an alert baby who is willing to latch to the breast

    Preparation

    • It is assumed you will have already discussed everything about the need for supplementation and what and how it will be given with the mother and the infant's doctor.
    • Warm the milk to be used as a supplement.
    • Prime the tubing with the supplement milk, either by gravity or by vacuum (suction).

    Technique

    • Tape the distal end of the tubing to lie alongside the mother's nipple, with tape away from where baby will latch. The tubing is best placed on the breast to be just above the corner of the infant's mouth, not in the middle of the top lip.
    • Latch the baby as usual, ensuring the soft tubing passes into baby's mouth as he latches to the breast. (Instruct the mother to visualise that the tubing will be running alongside the length of the nipple so it sits in the groove of the tongue during sucking.
    • Breastfeed as usual.
    • Milk flow can be controlled by

      • raising the milk container; the flow of the supplement is easier to initiate and requires less suction to maintain flow,
      • lowering the milk container; the flow will be slower, requiring greater suction from the baby, or
      • clamping the tubing off initially, encouraging baby to remove as much breastmilk from the breast as possible before unclamping the supplement.
    At-breast supplemental feeding line.

    At-breast supplemental feeding line.

    7.3.2 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. 1
    Preterm infants who are cup fed are more likely to maintain physiological stability including oxygen saturation,2 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. 3

    When to choose cup feeding

    Cup feeding would be the first choice for any infant who was not able to achieve suckling at the breast or for a newborn not yet established at breastfeeding who is separated from his mother.

    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

    Preparation

    • Two thirds fill cup with slightly warmed supplement
    • Baby must be alert and showing an interest in feeding
    • Wrap baby well to prevent cup being knocked by his hands
    • Sit baby comfortably upright on your lap

    Technique

    • Rest the rim of cup on baby's bottom gum
    • Tip the cup until milk just reaches rim of cup
    • DO NOT pour milk into baby's mouth
    • Leave cup in position when baby pauses and is not drinking
    • Continue to tip cup to keep milk at rim of cup

    Baby will quickly learn to sip or lap milk from the cup.

    Father cup feeding his baby.

    Father cup feeding his baby.

    Notes

    1. # Franca EC et al. (2014) Electromyographic analysis of masseter muscle in newborns during suction in breast, bottle or cup feeding.
    2. # Marinelli KA et al. (2001) A comparison of the safety of cupfeedings and bottlefeedings in premature infants whose mothers intend to breastfeed
    3. # Yilmaz G et al. (2014) Effect of cup feeding and bottle feeding on breastfeeding in late preterm infants: a randomized controlled study.

    7.3.3 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 inappropriate sucking technique.

    In a NICU...

    Breastfeeding rates on discharge home increased by 30% when this NICU replaced bottle feeding with finger feeding for their preterm babies.1

    Finger feeding can be considered as an alternative to cup feeding.2

    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 has severely damaged nipples requiring rest during healing process - this is helpful to the mother 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

    Equipment

    • Syringe
      • regular or periodontal curved-tip, OR
      • feeding line attached to syringe or other milk receptacle
    • Supplement
    • Pillow or towel roll
    • Gloves (for all except infant's own parents)

    Preparation

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

    Warm the supplement and draw it up into the syringe. If a feeding line is being used - attach line to milk receptacle and tape distal end to finger.

    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 nail-side down and soft pad of 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 syringe tip against the feeder's finger. (Note: If feeding tube were being used this would have been taken into mouth with finger)
    • Push very small aliquots of milk (approx 0.5ml) into infant's mouth to stimulate continued sucking.
    • Follow infant's lead with sucking bursts - only push milk in when infant is sucking, or stimulate suck recommencement by massaging the palate.
    • Suction generated by infant's suck will sometimes draw the milk from the feeding receptacle.

    Important tip!

    The infant oral cavity is very sensitive. Fingers come in all different shapes and sizes so to avoid confusion and desensitization of the infant, limit the number of different people who perform this procedure.

    Parents are very capable of taking on this task and teaching them will ensure consistency of technique and give them confidence.

    A nice job for Dad!

    A nice job for Dad!
    © H.Darby, dad

    Notes

    1. # Oddy WH et al. (2003) Implementing the Baby Friendly Hospital Initiative: the role of finger feeding.
    2. # Marmet C et al. (2000) Assessing infant suck dysfunction: case management.

    7.3.4 Bottle feeding

    Bottle feeding should be a last choice for a breastfed infant.

    It is only a feeding method, unlike breastfeeding which is a complete physiological, psychological and nutritional experience. Bottle feeding undermines breastfeeding success.

    The physical act of bottle feeding is very different to the normal action which occurs during breastfeeding. Artificial nipples/teats are less elastic than a mother's breast. The infant's tongue works in an up-and-down piston motion during bottlefeeding 1 and overuses the buccinator and orbicularis oris muscles, while deactivating the masseter muscle. 2 3 4
    Bottle feeding creates repeated airway closure during swallowing. Rapid milk flow results in more frequent swallowing and less opportunities for breathing. 5

    When to use bottle feeding

    Bottle feeding may be considered when the mother:
    • is unable to breastfeed for medical reasons or her infant's medical condition precludes breastfeeding ability.
    • chooses to use a bottle for supplementation - with adequate education about impact on breastfeeding and health risks associated with bottle use.
    • weans her infant when milk is still a major part of the diet.

    Considerations when bottle feeding a breastfed infant

    • Use a straight bottle rather than a bent bottle.
    • Choosing a teat/artificial nipple: 6
      • Use a long teat/artificial nipple. 7 (Tip reaches near to junction of soft and hard palates at back of mouth, where the tip of breast nipple would come to.)
      • A medium-wide base. (Taken into mouth up to screw cap reminds baby to have a wide-open mouth.)
      • Use a slow-flow artificial nipple/teat. Requires baby to suck well to obtain the milk.) A medium-flow artificial may be required for an infant with low tone. nipple.
      • Choose a soft artificial nipple/teat. (Texture closer to breast nipple)
      • Rationale:
        • Don't use artificial nipples that have a short, narrow shaft and a very wide base. They force the baby to make a tight mouth around the narrow shaft. This short shaft is forward in the baby's mouth changing the tongue position and action.

    Bottle feeding technique

    • Position the baby so that he is sitting upright. Support the baby's back, neck and base of head with the forearm and hand. Hold the bottle horizontally removing the pressure from gravity. (Kassing (2002) 8 cautions against the mother and/or caregiver using an arm or the crook of an elbow to support the baby's neck, because there is a greater tendency for the baby to lean back a bit rather than remaining upright.)
    • Stimulate the rooting reflex using the tip of the artificial nipple brushed gently on the baby's lips. When baby opens his mouth very wide slide the tip of the teat under the top lip, wait for the baby to grasp and draw the entire artificial nipple into his mouth right up to the cap. (By stimulating the rooting reflex and waiting for a wide gape, you are simulating what will occur when breastfeeding.)
    • Keeping baby upright, tilt the bottle just enough to keep the artificial nipple filled with milk. As the bottle empties take care not to hyper-extend the baby's neck.
    • Closely observe baby for full duration of the feeding. Slow the feed, or pause it if the baby is showing early signs of distress. These signs can be very subtle: frowning, wide-eyed, fist clenching, etc. Baby should not get to the stage where he is gulping, or not pausing to take a breath, or becoming cyanosed.

    Assess a bottle feed


    © B.Ash, IBCLC


    © B.Ash, IBCLC


    What is the difference?

    Good bottle feeding practices are essential

    A sound nutritional foundation for growth of the child is laid down during the first two years. A critical aspect of care to ensure bottle-fed infants receive appropriate nutrition during this time is to ensure the infant's caregivers receive education on the importance of proper feeding.
    Positive nurturing and infant feeding are closely aligned. Encourage the bottle feeding mother to make the feeding experience an enjoyable one for her infant by responding to feeding cues promptly, holding her infant during feeding, using an appropriate nipple/teat for milk flow and not forcing the infant to consume more than he wants. Discuss observations the mother can make that indicate:
    • early feeding cues,
    • infant pleasure (or stress) during the feed,
    • adequate intake such as
      • signs of satiety
      • normal bowel actions,
      • expected urine output, and
      • appropriate weight gain (neither excessive, nor inadequate).

    Preventable dangers

    In a 2008 study 9 more than 3/4 of mothers reported they did not receive instruction on artificial formula preparation from a health professional. Consequently many mothers did not follow safe practices when preparing their infant's formula feeds.

    • Dangers of incorrect preparation
      • gastrointestinal infection, serious illness and death from:
        • contamination from unhygienic practices contaminating feeding implements
        • contamination from bacteria found in the powdered formula when purchased (eg Cronobacter sakazakii) 10
        • contaminated water supply.
    • Incorrect reconstitution - a commonly found error:
      • over-dilution causes poor weight gain and inadequate intake of calories and nutrients
      • under-dilution causes hypernatremic dehydration, diarrhea and excessive intake of calories.
    • Over-feeding and under-feeding by caregivers must also be addressed.
      Volume of intake guidelines are available from various sources, however parents should be encouraged to use these as only a guide. Encourage feeding to be initiated when the infant cues and ended by the infant when satiety is indicated. A responsive caregiver is able to observe the infant's behavior so that the infant remains comfortable. The focus is on reading the infant's needs rather than consuming a predetermined volume of milk.
      • over-feeding causes 'food battles' and obesity,
      • under-feeding causes poor growth and development
      • both under- and over-feeding cause failure to thrive and malnutrition

    Contamination of powdered infant formula

    Cronobacter spp and Salmonella enterica bacteria have been cultivated from freshly opened tins of powdered infant formula and is a risk for ALL powdered milks. 11

    Cronobacter species are opportunistic pathogens, and a mortality rate of 40 to 80% is found when contaminated infant formula is given to susceptible infants. This pathogen can cause a range of serious diseases such as meningitis, septicemia, necrotizing enterocolitis, and brain abscesses and has been responsible for a variety of sequelae such as quadriplegia. 12

    Because it is not possible to produce sterile powdered infant formula it is recommended to use a sterile liquid preparation for newborns less than 1 month of age and preterm or sick infants.

    Preparing breastmilk substitutes safely

    Click on the title above. This links to a leaflet for mothers that describes, with very good graphics, how to safely prepare breastmilk substitutes. Read this leaflet, print it out and file it in your Workbook.

    Go through this leaflet, or a similar one that your hospital or clinic may use,13 as you demonstrate to a mother how to prepare the formula. Then, most importantly, ask her to show you how she would do it by making up another bottle of formula, confirming that she understands 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 Celcius or 158 degrees Fahrenheit)

    What should I remember?

    • the different oral actions that occur during bottle feeding and breastfeeding
    • the type of bottle and teat/artificial nipple to use when a breastfed infant is being bottle fed
    • how to teach a safe bottle feeding technique that encourages positive parenting skills
    • the preventable dangers inherent in bottle feeding
    • how and why to effectively and clearly teach safe preparation of breastmilk substitutes and safe bottle feeding techniques to caregivers

    Skills Competency #4

    Teaching formula preparation and feeding

    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 Teaching formula preparation and feeding competency form for you to complete with your Supervisor.

    Notes

    1. # Weber F et al. (1986) An ultrasonographic study of the organisation of sucking and swallowing by newborn infants.
    2. # Franca EC et al. (2014) Electromyographic analysis of masseter muscle in newborns during suction in breast, bottle or cup feeding.
    3. # Inoue N et al. (1995) Reduction of masseter muscle activity in bottle-fed babies.
    4. # Gomes CF et al. (2006) Surface electromyography of facial muscles during natural and artificial feeding of infants
    5. # Mathew OP (1991) Breathing patterns of preterm infants during bottle feeding: role of milk flow.
    6. # Peterson A et al. (2009) Breast and Bottle: Reaching Your Breastfeeding Goals
    7. # Noble R et al. (1997) Therapeutic teat use for babies who breastfeed poorly
    8. # Kassing D (2002) Bottle-Feeding as a Tool to Reinforce Breastfeeding
    9. # Labiner-Wolfe J et al. (2008) Infant formula-handling education and safety.
    10. # Siqueira Santos RF et al. (2013) Screening for Cronobacter species in powdered and reconstituted infant formulas and from equipment used in formula preparation in maternity hospitals.
    11. # Holy O et al. (2014) Cronobacter spp. as emerging causes of healthcare-associated infection.
    12. # Norberg S et al. (2012) Cronobacter spp. in powdered infant formula.
    13. # World Health Organisation (2007) How to prepare formula for bottle-feeding at home

    7.4 Crying baby

    My baby cries a lot. What should I do?

    Babies cry to express a need, and the cry of the baby causes the parent to respond.

    Babies who cry frequently are perceived as 'fussy' and are more likely to be fed solid foods before 4 months 1 2 or given a pacifier/dummy.

    Using counseling skills techniques, listen to what the mother is saying and try to determine a cause. Observe her interaction with her baby and what settling techniques she is using. Watch the baby breastfeeding and examine the baby. If necessary, refer to a doctor for further assessment.

    Build the mother's confidence

    • Listen and accept the mother's feelings
    • Reinforce what the mother and baby are doing right; what is normal
    • Give information relevant to this mother
    • Give practical help

    Some suggestions that may help

    • Hold her baby skin-to-skin against her chest; her warmth, smell and heartbeat will help to soothe him.
    • Offer her breast to her baby: he may be hungry, thirsty or in need of suckling for a sense of security; some babies will settle quickly when offered a 'nearly-empty' breast when not hungry.
    • Attend to baby's comfort: change nappy/diaper; check baby is not too warm nor too cold; etc
    • Talk to, sing, rock the baby while holding close. Gently swinging the baby sideways (ie from ear to ear) helps settle quicker than backwards and forwards movement.
    • Stroking or baby massage with oil may help.
    • Involve the mother's support people in the discussion so they understand that supplements aren't the solution to this problem.
    • Suggest use of a baby sling/pouch for the mother to be able to continue other tasks or ask that someone else carry and comfort the baby for a period of time, giving the mother a break.
    • Encourage involvement in a mother-to-mother support group where mothers can share experiences and concerns.
    • Investigate the mother's intake of caffeinated drinks and smoking - both of which are associated with crying and unsettled babies.
    • Suggest a 24-48 hr diary of the infant's behaviour - this may help you determine a link to a time of day or activity and help the mother's perception of the crying.

    To swaddle or not to swaddle?

    A crying baby needs comfort and reassurance.
    Some cultures use swaddling methods and this practice has made its way into many modern parenting styles. The adult observes that the infant becomes calm, quiet and less likely to disturb themselves with jerky movements.
    • swaddling increases intrathoracic pressure which, in turn, decreases pulmonary functional residual capacity. 3
    • swaddling decreases spontaneous cortical arousals and autonomic control in newly swaddled sleeping infants - similar responses are observed in victims of sudden infant death. 4
    • swaddling has been associated with injury and death 5
    • swaddling is associated with hip dysplasia6

    Be cautious not to look for a quick fix. A 'good' baby is not a sleeping baby. Be a detective to help determine the existence of an underlying organic cause of the unsettled behaviour and reassure the mother.

    Some babies may benefit from gentle swaddling. Carefully explain the correct application of this technique and discourage its use completely after the newborn begins to roll over.

    Swaddled infant

    Swaddled infant


    Be alert!

    A crying baby causes strong emotional responses in people so be alert to the mother's state of mind and ability to cope. This may be a desperate plea for more professional help, not just settling tips.

    Pacifiers/Dummies

    Baby Friendly Step 9 and Point 4

    Step 9 of the Ten Steps to Successful Breastfeeding, and Point 4 of the Seven-point Plan for Sustaining Breastfeeding in the Community state:
    Point 4:
    Support mothers to initiate (establish) and maintain (exclusive) breastfeeding (to 6 months). United Kingdom, Canada, New Zealand

    Inform women and their families about the management of breastfeeding and support them to establish and maintain exclusive breastfeeding to 6 months. Australia

    Step 9: Give no artificial nipples/teats or dummies/pacifiers to breastfeeding infants.

    Sucking and breastfeeding

    • The suckling technique used during breastfeeding is completely different to the action of sucking used on a bottle teat or non-nutritive sucking on a pacifier/dummy.
      Babies are thought to 'imprint' latching and suckling skills from their earliest experiences. 7 When artificial teats/dummies are their predominant feeding experience, learning to latch and use a correct sucking technique is difficult.

    • Pacifiers/dummies stifle early feeding cues and are often used to delay breastfeeding and reduce the time spent at the breast. This will have a significant impact on the control of milk synthesis and potential to decrease milk supply.
      Studies of full term newborns and preterm infants demonstrate reduced duration of exclusive breastfeeding when pacifiers are used extensively and/or more than a few supplements are given using bottles. 8,9 10 11

    • Teats and pacifiers are reservoirs for infection which adheres easily to the surface. 12 13
    • Pacifiers are associated with an increase in otitis media, 14 dental caries 15 and dental malocclusion. 16,17

    • A literature review examining the effect of restricted pacifier use noted no effect on exclusive breastfeeding at 4 months of age, however was not able to assess the short-term difficulties faced by mothers, nor the long-term effect of pacifiers on infant's health. 18
    • Some studies have found that of the infants who died of SIDS fewer were given a pacifier to settle and therefore some recommend the use of pacifiers for the prevention of sudden infant death syndrome (SIDS). 19 The explanation offered, that an infant sucking on a pacifier during the night has more spontaneous arousals, has been shown not to occur. 20

    Should a mother wish to use a pacifier it's use should be guided by 21 ...

    • do not commence use until breastfeeding well established, eg 4 - 6 weeks or longer
    • only use it at the time the infant is put down to sleep - if rejected by infant do not force
    • when the pacifier falls out during the infant's sleep it is not to be reinserted.

    Workbook Activity 7.7

    Complete Activity 7.7 in your workbook.

    When crying is excessive

    The most common causes of excessive crying are

    • immaturity in the first 7-8 weeks of life
    • lactose malabsorption,
    • colic, and
    • gastroesophageal reflux disease

    Lactose malabsorption/overload

    This is primarily a condition of overload of large volumes of breastmilk in the gut which exceeds the ability of lactase to split it. Undigested lactose osmotically draws in fluid from the abdominal cavity where it ferments in the presence of the gut bacteria.

    Presentation

    Onset is usually in the first few weeks of life, but could present later if mother changes her feeding style.

    • Baby
      • usually thriving baby, putting on weight very well
      • frequently distressed and has inconsolable crying
      • short sleeps followed by waking in pain
      • frequently sucking fist for comfort
      • draws knees up to chest while crying
      • flatulence ++
      • many nappies/diapers per day soaked with clear urine
      • frequent, watery, copious, green-ish and/or frothy stools
    • Mother
      • has a copious breastmilk supply and a large breastmilk storage capacity
      • offers baby both breasts at most breastfeeds, taking baby off first breast after a measured amount of time, rather than when it feels 'drained'
      • may feel the baby's 'fist sucking' indicates hunger and breastfeeds baby again; usually from breast not (or least) suckled at the previous feed
      • may feel she has an inadequate supply because of his frequent feeding and crying
      • may be concerned baby has a gastrointestinal infection because of the unusual stool appearance

    Management

    • Reassure mother of the volume and suitability of her breastmilk for her baby.
    • Discuss with her the signs that indicate the infant is in good health.
    • Encourage breastfeeding from only one breast over a period of time, determined individually. eg. One mother may repeatedly breastfeed from only her left breast for a 2-4 hours time period. Every time baby indicates a need to suckle during that time he will be put to the left breast and receive breastmilk that has an increasing fat content as that breast is progressively drained. This will slow the gastric emptying, and usually the infant will take less breastmilk when the breast is less full; both factors resulting in less lactose being transferred rapidly into the small intestine. For the next 2-4 hour block of time, the infant may only feed from the right breast, and so on until the problem is resolved. Mothers will be able to determine by trial and error the most appropriate time period for each breast.
    • Frequency of breastfeeding is not restricted. All feeding cues during the set time period are responded to with the same breast.
    • Care of the breast not being suckled may involve gentle expressing or releasing enough milk for comfort and applying ice packs to prevent engorgement. This can be done while the infant is feeding on the other breast.
    • Resolution of the infant's symptoms is usually rapid - within 48 hours, although it could take up to a week.
    • A return to two-sided breastfeeding may be indicated in time as milk volume settles and gut maturity improves, either for most feeds or perhaps only evening feeds.

    Colic

    Infants who have colic cry excessively without an identifiable need. They are difficult to console and provoke much parental anxiety. Sleep is interrupted for both infant and caregiver, and mothers experience increased risks of breastfeeding failure, postpartum depression, and marital conflict.
    When infants cry excessively, they are at a much greater risk of child abuse. Parents become desperate for resolution and accept advice and therapies from a wide variety of resources. 22 23

    Eglash 24 considers pure colic to be a patterned daily behavior of crying that a parent can predict will occur and stop at certain times, and the baby is fine at other times of day. This health care provider does not expect a change in maternal diet to help, the condition being self-limiting by about age 3 months.

    A tea containing camomile and other herbs had a degree of effectiveness, however the volume required to be given to the infant to obtain this effect was excessive and therefore not recommended.

    Acupuncture, likewise, was not found to be effective. 25

    A pilot study 26 found a significant decrease in crying and increase in sleeping in colicky infants receiving cranial osteopathic manipulation. Larger studies are required to confirm the effectiveness of this intervention.

    Administration of probiotics was initially felt to be helpful, however in larger studies was found to be ineffective. 27 28

    Reviews of the research 24 29 examining pharmaceutical, naturopathic and behavioral techniques for their effectiveness in reducing colic are only able to recommend a low-allergen maternal diet as having any effect on the breastfed baby. Only one pharmaceutical agent (dicyclomine) was found to be any more effective than a placebo, and due to serious side effects it is no longer recommended.

    Management

    1. Refer for medical review to exclude pathology
    2. Low-allergen diet for the mother may result in some improvement
    3. Infant and parent support measures

    Gastroesophageal Reflux

    Gastroesophageal reflux occurs when stomach contents reflux into the esophagus/oesophagus and out the mouth, resulting in regurgitation, or spitting up, and vomiting. This condition is very common and is caused by the sphincter at the top of the infant's stomach having not yet become efficient at retaining the stomach contents. Most babies with this condition are happy and continue to thrive, outgrowing the worst of it around 6 months of age.

    Gastroesophageal Reflux Disease

    Gastroesophageal Reflux Disease (GERD, GORD) occurs when the constant refluxing of stomach contents causes burning and ulceration of the esophagus and sometimes aspirates into the lungs. This medical condition will be diagnosed and treated by the infant's doctor.

    Breastfeeding Management

    • Breastfeed the infant in an upright position, at least 30o elevation of the head above the stomach.
    • Some babies will want to breastfeed very frequently, as the breastmilk eases the pain by neutralizing stomach acid.
    • Cow milk protein allergy is frequently associated with GERD. A trial of maternal low-allergen diet is recommended.30

    What should I remember?

    • Crying is an expression of a need.
    • The pros and cons of pacifier use and how and when to safely use one should the parents wish to
    • Some practical suggestions to settle the infant's crying.
    • The possible underlying causes of excessive crying.
    • The breastfeeding management strategies which may assist lactose overload symptoms.
    • Excessive crying not relieved by practical suggestions is a marker requiring medical review.

    Self test quiz

    Notes

    1. # Wasser H et al. (2011) Infants perceived as fussy are more likely to receive complementary foods before 4 months.
    2. # Karacam Z (2007) Factors affecting exclusive breastfeeding of healthy babies aged zero to four months: a community-based study of Turkish women
    3. # Thach BT (2009) Does swaddling decrease or increase the risk for sudden infant death syndrome?
    4. # Richardson HL et al. (2010) Influence of swaddling experience on spontaneous arousal patterns and autonomic control in sleeping infants.
    5. # McDonnell E et al. (2014) Infant Deaths and Injuries Associated with Wearable Blankets, Swaddle Wraps, and Swaddling.
    6. # Clarke NM (2014) Swaddling and hip dysplasia: an orthopaedic perspective.
    7. # Woolridge MW (1986) The 'anatomy' of infant sucking.
    8. # Maastrup R et al. (2014) Factors associated with exclusive breastfeeding of preterm infants. Results from a prospective national cohort study.
    9. # Karabulut E et al. (2009) Effect of pacifier use on exclusive and any breastfeeding: a meta-analysis.
    10. # Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding
    11. # Collins CT et al. (2004) Effect of bottles, cups, and dummies on breast feeding in preterm infants: a randomised controlled trial
    12. # Comina E et al. (2006) Pacifiers: a microbial reservoir
    13. # da Silveira LC et al. (2009) Biofilm formation by Candida species on silicone surfaces and latex pacifier nipples: an in vitro study.
    14. # Salah M et al. (2013) Recurrent acute otitis media in infants: analysis of risk factors.
    15. # Congiu G et al. (2013) Early childhood caries and associated determinants: a cross-sectional study on Italian preschool children.
    16. # Bueno SB et al. (2013) Association of breastfeeding, pacifier use, breathing pattern and malocclusions in preschoolers.
    17. # Urzal V et al. (2013) Oral habits as risk factors for anterior open bite in the deciduous and mixed dentition - cross-sectional study.
    18. # Jaafar SH et al. (2012) Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding.
    19. # Hauck FR et al. (2005) Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis
    20. # Hanzer M et al. (2009) Pacifier use does not alter the frequency or duration of spontaneous arousals in sleeping infants.
    21. # American Academy of Pediatrics (2012) Policy statement on Breastfeeding and the use of human milk
    22. # Abacı FB et al. (2013) Psychosocial status and quality of life in mothers of infants with colic.
    23. # Fireman L et al. (2006) Colic
    24. # Crotteau CA et al. (2006) Clinical inquiries. What is the best treatment for infants with colic?
    25. # Skjeie H et al. (2013) Acupuncture for infantile colic: a blinding-validated, randomized controlled multicentre trial in general practice.
    26. # Hayden C et al. (2006) A preliminary assessment of the impact of cranial osteopathy for the relief of infantile colic
    27. # Anabrees J et al. (2013) Probiotics for infantile colic: a systematic review.
    28. # Sung V et al. (2014) Treating infant colic with the probiotic Lactobacillus reuteri: double blind, placebo controlled randomised trial.
    29. # Garrison MM et al. (2000) A Systematic Review of Treatments for Infant Colic
    30. # Heine RG (2006) Gastroesophageal reflux disease, colic and constipation in infants with food allergy

    7.5 Inadequate weight gain

    Inadequate weight gain, or failure to thrive (FTT) is a sign of poor health that is caused by other factors. It's not a condition in its own right.

    Definition of failure to thrive (FTT)

    In the younger baby weight loss of >7 - 10% of birthweight, or failure to regain birthweight by the second week is considered abnormal.

    In the older baby it may be defined in several ways

    • an infant whose weight or height for age is less than the 3rd or 5th percentile
    • an infant whose weight for age falls through 2 major percentile curves on their growth chart
    • weight less than 80% of ideal body weight for age

    Review the WHO Child Growth Standards as covered in Topic 6.3 . It is important to have a good understanding of normal growth and to be competent to recognise sub-optimal growth patterns.
    All infant measurements should be plotted on these charts only.

    Cause of failure to thrive

    • poor absorption and/or the inability to use absorbed nutrients, or
    • increased metabolic demands, (eg heart disease, undiagnosed infection, etc) or
    • inadequate energy intake from

      • an insufficient supply of breastmilk, or
      • regulation of breastfeeding such that the baby is unable to take sufficient breastmilk, or
      • inability of the baby to suckle effectively at the breast.

    What to do about excessive newborn weight loss

    All newborns lose weight after they are born regardless of whether breastfed or formula-fed. Mean weight loss of between 5.5% for infants optimally breastfed and born in a Baby Friendly designated hospital, 1 and 7% is considered normal.
    This weight loss is attributed to the infant correcting his fluid status in the first 24 hours. Infant weight loss is greater than the average when mothers receive 1200ml or more intravenous fluids in the 2 hours prior to birthing. In these cases it is suggested that the infant's weight at 24 hours should be the benchmark against which further weight recordings are compared. 2

    History and examination

    A good history followed by examination of the mother and infant should allow you to identify why the infant is losing weight. You may identify maternal medical, surgical or medication-use reasons, however the most common reason will be that the infant has not been breastfeeding frequently or effectively enough.

    Management

    Encourage:
    • extended skin-to-skin care (hours at a time)
    • responding immediately to the earliest feeding cues
    • good, deep latch and effective suckling
    • observe for milk transfer (ie swallowing appropriate to the volume of intake expected by age)
    Other tips to improve breastmilk production and transfer include:
    • breast compression while breastfeeding
    • hand expressing between breastfeeds (give the milk to baby via cup, spoon or finger-feed)
    • hands-on pumping if secretory activation (lactogenesis II) has occurred
    • (refresh your memory of hand expressing and hands-on pumping at Topic 6.1)
    Supplementing
    Additional supplementation (with artificial infant formula) may be required if the above measures do not result in an improvement.
    Refer to Topic 7.3 on how to supplement.

    The volume of supplement given should be individualized to the infant's immediate needs and age. Thoughtful supplementation can rescue a dangerous situation and support the mother to continue to successfully breastfeed. Thoughtless supplementation can cause further ill health for the infant and risk the success of breastfeeding.

    What to do when you suspect FTT

    Record a thorough history

    Your routine history intake form should allow you to identify issues that may be significant, eg. gestational age at birth, weight at birth, weight at hospital discharge, interventions in birthing, early postnatal breastfeeding history, jaundice, ill health since birth, maternal medical, surgical, obstetric and lactation history, etc. [Discuss in the forums or with your colleagues why each of these could be significant.]

    • If the mother has been concerned about her baby's growth, ask her what actions she has taken to date; eg. doctor review, pumping additional breastmilk, using breast compression, taking a galactagogue, giving supplements, etc.
    • Ask the mother to describe typical breastfeeding behavior.

      If necessary prompt the mother to include:

      • type of feeding cues and her response to them,
      • describe when the baby feeds, not just how many times per day or night,
      • baby's behavior before, during and after breastfeeds,
      • the mother's active involvement, eg. waking baby to feed, delaying feeding to fit a schedule or her busy lifestyle, stimulating baby to continue to breastfeed, stopping baby after a time-limit, etc.
    • Ask the mother about complementary foods, or other fluids given to baby, or the use of a pacifier - How much? How often? Why? ...
    • Ask her to describe her baby's urine and stool output in a typical day. It would be an advantage if you could see a wet and a dirty diaper/nappy.
    • Ask her to describe her baby's temperament. If crying behavior sounds excessive, ask for a more detailed description of frequency and type.
    • Ask her about her baby's recent state of health.
    • Does she give the baby any medications (prescription or non-prescription), vitamins, 'tonics', etc?
    • If you don't already have it, plot as many weight and length measurements onto the WHO Growth Chart as the mother is able to provide you with. From this you will be able to determine a trend.
    • Ask about her recent state of health, medications (prescription and non-prescription) and postpartum recovery, particularly her lochia. [Why ask about lochia?]
    • Ask her about the growth patterns of her other children, if applicable. If they followed a similar growth pattern did she do anything to try to influence it? Was it successful?
    • Social issues could be significant: if appropriate, ask about the family structure, their living conditions, stressors, other children. Observe the interaction between mother and baby during your consultation - also other relationships if someone else has accompanied the mother.

    Examination of the baby

    Observe the baby naked.

    Ask the mother to lie the infant down and undress him/her (reducing chance of distress caused by unfamiliarity). Observation should include the infant lying flat on his back (if tolerated), turned gently from one side to the other, and laid prone with head turned to face both sides.

    • Behavioral state, and transition between states. Reaction to being undressed, laid down flat, picked up and cuddled/soothed by mother.
    • Muscle tone and position that the infant assumes (well flexed, partially flexed, extended, hyperextended, head turned one particular direction exclusively)
    • Shape of the infant's head particularly noting presence of forceps or vacuum marks (first few weeks), cephalhaematoma, asymmetry.
    • Skin: turgor, subcutaneous fat, rashes, integrity, bruises; color - jaundice (extent); pale; mottled; cyanosis - where, what precipitated it
    • Mucous membranes: color, moisture, inflammation, integrity, infection
    • Respiratory effort, presence of sweating; response to exertion
    • Does the infant feel hot (febrile), or unusually cool to touch?
    • If you have received instruction on how to assess for intact cranial nerves, note your findings. Note facial movement and symmetry.
    • Weigh the infant. (Review the information in Topic 6.3 ) - Length and head circumference could also be recorded if you have an accurate means of doing so.
    Oral assessment
    • Response to stimulation of rooting reflex
    • Visual examination - size, shape of tongue; uvula (bifid or not); intact palate, labial and lingual frenulum, condition of mucous membranes (moist/dry; candida; etc)
    • Suck assessment - (only perform after instruction and supervision by experienced practitioner) feeling for intact palate (hard and soft), notches on palate, shape of palate, grooving of tongue, tongue action during sucking (or preventing sucking)
    Observe a breastfeed - if the infant is not in immediate danger, observation of a breastfeed is essential. (Review Topic 5.2 )
    • Note position adopted by mother and how she holds her baby
    • Note sucking pattern and ability - Note: Sucking will be sub-optimal and with notable non-nutritive sucking. Observing the feeding process will help determine whether poor sucking caused the failure to thrive or whether the failure to thrive is the end result of another cause. Milk supply is usually compromised too due to the poor feeding, so this needs to be assessed and addressed.

    As the mother prepares to breastfeed ask permission to examine her breasts, looking for marked differences in size, hypoplasia, state of health of the breasts and nipples and surgical scars.

    Modelling observational skills

    By following the flow of the consultation above, (until you assessed the cranial nerves or performed the oral assessment) you were modelling to the parents good general observational skills.
    If you also talked with the parents as you made each observation you will be giving them the confidence to be objective in their observations of their baby too, preventing unnecessary anxiety but ensuring prompt attention is sought when needed.

    RED FLAG

    If the infant appears ill (pale, lethargic, sunken fontanelle, poor skin turgor, minimal urine output, hot or cool to touch) organise for the infant to be seen by a doctor urgently or for immediate transfer to hospital.

    Workbook Activity 7.8

    Complete Activity 7.8 in your workbook.

    Test weighing

    Some practitioners find test weighing a baby to determine the volume of breastmilk received at a single breastfeed to be beneficial, while other practitioners do not.

    This procedure must be used sensitively and its limitations explained to the mother:

    • From one test weigh it is not possible to conclude how much milk the baby is consuming in a 24-hour period,
    • nor how much milk is available for the baby in the breast either at this feed or for the 24-hour period.
    Accurate test weighing requires quality, digital scales that are sensitive to within 2g and are re-calibrated regularly. The infant is weighed immediately before and again after breastfeeding without removing any of the clothing or wraps the baby was in at the first weighing. The difference between the second weight and the first weight is an indication of how much breastmilk the baby consumed.

    Accuracy is dependent on attention to weighing technique.

    Management

    Management of failure to thrive in a breastfed baby requires a multidisciplinary team approach. The ultimate goal is to have baby exclusively breastfeeding and gaining weight normally.

    Parent education and counseling

    While the management below is focussed on clinical issues, your communication skill and care and understanding for the parents is as important an aspect of the consultation as getting nutrients into the baby. You must build trust and understanding between you and the parents.

    Step 1

    The first action you will take is to discuss with the mother the importance of having her baby reviewed by the baby's doctor. This is important, even if you think it is a feeding problem that you can resolve that has caused the problem. The infant has been compromised and needs a medical review.

    Step 2

    Next, feed the baby! The normal range of daily intake of breastmilk by healthy infants aged from 1 month to 6 months is 500ml - 1350ml (17oz - 44oz), with the average being 780ml (26oz) irrespective of the infant's weight or age. This volume is consumed over 11 feeds a day (range 6-18). Infants generally consume significantly more breastmilk during the morning and nighttime breastfeeds than during the day and evening breastfeeds.3

    The baby will need supplementation. Determining how much milk to supplement will depend firstly on the infant's condition, and secondly on how much is required to produce a normal urine and stool output and consistent weight gain.

    The infant's stomach will be unaccustomed to large volumes of milk. Introducing frequent small volumes of supplement will prevent overdistention and possible vomiting. Bear in mind the very wide range of normal - being pedantic about a set volume to be consumed at a predetermined number of feeds without considering what is normal is not helpful to the mother or baby. Individualize your care!

    Be very careful that you don't jeopardise breastfeeding completely with a management plan that doesn't take normal breastfeeding physiology into consideration.

    A quick calculation

    Let's look at that from a practical viewpoint.

    Total daily intake = approx 800ml
    8 feeds/24 hrs = 100ml/feed
    11 feeds/24 hrs = 70ml/feed
    12 feeds/24 hrs = 65ml/feed

    The volume of supplement will be a portion of these total feed amounts. Some babies wake frequently because they are hungry. Other babies have no energy reserves so they are very difficult to rouse and will feed poorly when woken.

    The supplement is to enhance the infant's current intake, not to act as a total replacement feed.

    What supplement shall I use?

    The aim is for the infant to have as much of his mother's breastmilk as is available, while ensuring the infant receives sufficient nutrition to correct the deficit and permit normal growth. Sometimes the mother's milk supply is still adequate to meet her baby's needs - correcting poor positioning may be all that is required.

    Choose the appropriate supplement and method of delivery according to the information in 7.3 Supplementation

    • ONLY if baby is >6 months - commence complementary foods, replacing nutrient-poor foods with nutrient-dense, high calorie foods if necessary.

    When to supplement

    With the information you have gained during your history-taking and clinical examination you should be able to decide whether the baby needs supplementing after all breastfeeds, or only from the afternoon, or even just the evening feeds as most mothers have fuller breasts in the morning.

    Individualise your care

    No two babies will be in the same situation therefore every strategy you and the parents devise will be unique. Don't look for a 'solution' you can apply in every situation.

    Step 3

    You must also determine and treat the cause, if possible. Is the cause maternal or infant in origin?

    • Protect the milk supply - insufficient breastmilk supply is addressed in Topic 8.4
    • Inability of the infant to suckle effectively at the breast could be caused by poor positioning and poor latching, or by ineffective suckling. Positioning and latch is well within your area of expertise, however you may need to refer the infant with poor suckling ability to a lactation consultant, pediatric speech therapist or other appropriate specialist.
    • Restrictive scheduling of breastfeeding, excessive non-nutritive sucking (pacifier or dummy use), denial of night-feeding, etc is addressed by education and discussion of normal behavior with the parents. Encourage the mother to join mother-to-mother support groups.
    • The management of the infant with poor absorption of nutrients or increased metabolic demands will be managed by a medical specialist.

    Step 4

    Follow-up. It is absolutely essential that the parents are competent, and feel confident, to observe their infant, recognise a problem early and seek assistance at any time.

    To this end you will discuss with them ...

    • Observation of infant's output. Baby must have at least 5 thoroughly wet with clear urine nappies (diapers) per day; stooling should be regular and copious. Keeping a feeding and output diary will provide them and you with accurate information on which to base changes to the management plan.
    • Observation of infant's appearance. Baby should be bright-eyed and alert, and skin should not be pale.
    • Observation of infant's behavior. Baby should be active, alert and happy for some time each day, waking for feeds and feeding enthusiastically.

    How soon and frequently you follow-up will depend on the baby's condition. Daily phone follow-up could be indicated to get reports on feeding and output, with a weight check again in two or three days if output was satisfactory until then. Revise the plan as necessary with the ultimate goal to have the baby fully breastfed and thriving.

    Workbook Activity 7.9

    Complete Activity 7.9 in your workbook.

    What should I remember?

    • The signs of failure to thrive.
    • The possible underlying causes of poor weight gain.
    • The significant history information which will help to identify the cause of the problem.
    • The steps to appropriate management of failure to thrive.

    Self-test quiz

    Assessment Quiz

    When you are happy that you've understood all the information in this topic you will be ready to complete the Module 7 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 7.

    Notes

    1. # Grossman X et al. (2012) Neonatal weight loss at a US Baby-Friendly Hospital.
    2. # Noel-Weiss J et al. (2011) An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss.
    3. # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day

    8.0 Maternal Challenges

    Maternal risk factors

    As with infant risk factors, early identification of the dyads that are at risk of premature weaning allows you to allocate your time appropriately to get the best outcome for mothers and babies in your care.

    Identified during pregnancy

    • breast or nipple abnormalities
    • previous breast surgery
    • poor lactation history
    • acute or chronic illnesses
    • obesity
    • pregnancy-induced hypertension
    • social issues - poverty, lack of support, lack of child-rearing knowledge

    Identified during birthing

    • intrapartum analgesics or anesthetics
    • assisted delivery - forceps or vacuum
    • perineal trauma - large episiotomy
    • surgical delivery
    • post-partum haemorrhage

    Identified postpartum

    • severe engorgement
    • painful, cracked or bleeding nipples
    • late-onset of secretory activation (lactogenesis II)
    • persistent breast pain
    • mastitis
    • insufficient milk supply
    • postnatal depression
    • rigid parenting philosophy

    These lists are not complete - every mother has her own, individual issues or obstacles to overcome. Your skills and knowledge, support, understanding, acceptance and good communication skills may be sufficient to help some mothers make possible what they never dreamed they could.

    The career you have chosen is infinitely variable, challenging and rewarding. I hope you are able to feel the privledge it is to be able to have a positive influence on the lives of women and children.

    Just out of interest ...

    Pick a random shift you have worked recently and look at the list of mothers and their infants allocated to your care. Was your time spent proportionately more on the mothers who had risk factors for breastfeeding difficulty?

    When a referral is needed

    As for the baby with risk factors, don't endanger breastfeeding by delaying referral to a professional who can provide the acute and/or ongoing assessment and guidance appropriate to their condition.
    Early referral can prevent problems which may be impossible to retrieve if left too long.
    Knowledge and help is now available for nearly all problems you'll encounter.

    Knowledge and help is now available for nearly all problems you'll encounter.

    8.1 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

    Secretory activation (lactogenesis II) occurs biochemically at about 30 - 48 hours postpartum. 1 2 3 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) . 4

    It's because of the placenta!

    When the placenta is delivered the progesterone it had been producing is stopped.
    Progesterone blocks milk production.5
    • 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's blood stream
    • lactose secretion into the alveoli of the breast increases, osmotically drawing in water to increase milk volume 6
    There is also a marked increase in blood flow to the breast. These changes will occur whether breastfeeding is initiated or not.

    Review this in Topic 4.0

    Signs and Symptoms

    Women report knowing their milk is 'in' by the following signs and symptoms:

    1. breast tingling
    2. breast fullness
    3. milk leakage
    4. physical appearance of the 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 for the mother, while meeting the changing needs of the infant.

    Engorgement

    Engorgement causes:
    • pain and misery for the mother
    If not effectively treated results in:
    • blocked ducts
    • mastitis
    • low milk supply
    • premature weaning
    This preventable condition should be rare in units that implement good breastfeeding standards.
    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. 7
    However, ...
    Breast engorgement is not an inevitable part of early lactation.

    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 ...
    • I'm sure you 'get the picture' now.

    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
    • increased heat of both breasts
    • difficulty latching baby effectively and achieving milk removal
    • mild pyrexia (fever)

    Cause

    • Milk stasis in the breast
      • poorly latched infant, or ineffective suckling
      • reduced breastfeeding8
      • 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 9,10
    • Low serum albumin11

    Prevention

    Engorgement can be prevented by implementing good breastfeeding practices.
    • early initiation of breastfeeding - more breastfeeding in the first 48 hrs is associated with less engorgement 12,13
    • baby well latched to the breast
    • frequent feeds day and night
    • fully draining of one breast before offering other side14
    • if baby not feeding, express every few hours from time of birth

    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 preventable in most cases.

    Did you know?

    Allowing breasts to become engorged is the physiological way to suppress lactation.

    That's NOT what you want to happen with your new mothers.

    Workbook Activity 8.1

    Complete Activity 8.1 in your workbook.

    Clinical Management

    This painful condition can be resolved with diligent attention to:
    • Frequent, effective removal of milk
      • Encourage the mother to breastfeed her baby often.
        • Ensure baby is latched on to breast well.
        • Allow the baby to feed as long as he will on one side before offering the other side, optimizing drainage.

      • Firm, but gentle massage of lumpy areas while baby feeds helps milk flow. Allow the other breast to drip freely.

      • Hand express breastmilk, if necessary.
        • Before feeding: to help baby latch to a very full, firm breast.
          A few minutes of expressing milk from around the nipple/areola can make a big difference. Also, after baby has suckled for a minute unlatch him from the breast and relatch - frequently achieving an even deeper, more effective and more comfortable latch.
        • After feeding: If breasts still uncomfortably tight, express enough to achieve comfort.
          This should be done after and between feeds as often as necessary.
          If baby does not breastfeed on the second side, hand express milk from that side until comfortable to prevent engorgement getting worse.

      • When breasts are particularly full stimulate a milk ejection by gentle massage or a warm compress. 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 is experiencing a lot of pain.

    Will expressing increase milk production?

    Ideally, milk production will increase daily until peak milk volume is reached around 2-3 weeks postpartum.

    Until engorgement is resolved:
    • breastfeed to meet the infant's needs (effectively and frequently)
    • if breast/s still uncomfortably full, hand express until comfortable (not empty!)
    • between feeds when breasts uncomfortably full, hand express until comfortable (not empty!)
    Milk removal additional to the immediate needs of the baby should only be enough to achieve breast comfort.
    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 that this management will assist 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 15 found:
        • 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 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 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. 15
    Therapeutic ultrasound was found to be of no benefit in a randomized, controlled, double-blind trial. 16

    Heat or cold?

    Heat increases blood flow to the breast and movement of fluid into the tissues to further exacerbate the engorgement. 17 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 breast via lymphatic system).
    Mothers usually prefer the feeling of cold on their hot breasts, but it is important to individualise your management and be responsive if a mother finds this to be unpleasant.

    Workbook Activity 8.2

    Complete Activity 8.2 in your workbook.

    Unit Activity

    Revise your unit's policy on the management of engorgement. Develop a teaching plan for a 15-minute educational session you could lead on the prevention and management of engorgement for your colleagues.

    Advanced care

    Generally speaking engorgement can be prevented in most mothers by implementing the breastfeeding standards described. If engorgement should develop, prompt intervention will manage the signs and symptoms and normal breastfeeding will be able to continue.

    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. 11,9

    [link: http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening]

    Read this practical article[link: http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening]

    Click on the link to be taken to a description of Reverse Pressure Softening for the treatment of areolar edema. Print the paper for filing in your Workbook.

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

    Additional strategies include

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

    Overactive milk production

    Mothers with overproduction are usually very uncomfortable with large, swollen breasts, leaking milk and an abundant 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.
    Full drainage and block feeding may be the solution.18
    [link: http://www.internationalbreastfeedingjournal.com/content/2/1/11]

    Read this article[link: http://www.internationalbreastfeedingjournal.com/content/2/1/11]

    Click on the title of this box to open the article: "Overabundant milk supply: an alternative way to intervene by full drainage and block feeding".
    Print the article, read it and file it in your workbook for future reference.

    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.

    Self-test quiz

    Notes

    1. # Cox DB et al. (1999) Breast growth and the urinary excretion of lactose during human pregnancy and early lactation: endocrine relationships
    2. # Hurst NM (2007) Recognizing and treating delayed or failed lactogenesis II.
    3. # Henderson JJ et al. (2008) Effect of preterm birth and antenatal corticosteroid treatment on lactogenesis II in women.
    4. # Perez-Escamilla R et al. (2001) Validity and public health implications of maternal perception of the onset of lactation: an international analytical overview
    5. # Pang WW et al. (2007) Initiation of human lactation: secretory differentiation and secretory activation.
    6. # Neville MC et al. (1991) Studies in human lactation: Milk volume and nutrient composition during weaning and lactogenesis
    7. # Lawrence R (2010) A Breastfeeding guide for the Medical Profession
    8. # Renfrew MJ et al. (2000) Feeding schedules in hospitals for newborn infants.
    9. # Miller V et al. (2004) Treating Postpartum Breast Edema With Areolar Compression
    10. # Hunter D (2004) Oedema and its impact on breastfeeding outcome: Assessment and management of the mother and her breastfeeding baby during the postpartum period.
    11. # Cotterman J (2004) Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement
    12. # Moon J et al. (1989) Engorgement: contributing variables and variables amenable to nursing intervention
    13. # Academy of Breastfeeding Medicine (2009) Clinical Protocol #20: Engorgement
    14. # Evans K et al. (1995) Effect of the method of breastfeeding on breast engorgement, masitits and infantile colic
    15. # Mangesi L et al. (2010) Treatments for breast engorgement during lactation.
    16. # McLachlan Z et al. (1993) Ultrasound treatment for breast engorgement: A randomised, double-blind trial
    17. # Robson BA (1990) Breast engorgement in breastfeeding women
    18. # van Veldhuizen-Staas CG (2007) Overabundant milk supply: an alternative way to intervene by full drainage and block feeding.

    8.2 Nipple Pain

    Nipple pain is a common early postpartum concern. 1

    It causes mothers

    • to wean early 2 3 4 5 6 (is a reason given by one third of mothers who wean prior to 6 weeks postpartum)
    • emotional distress 7 8
      (women with nipple pain experience high levels of emotional distress, which resolves once the pain resolves)

    Nipple pain can be caused by several factors:

    • Technical issues:
      • poorly latched baby
      • baby with incorrect sucking technique
      • incorrect use of lactation aids eg. a breast pump, nipple shields, breast shells, etc.
    • Maternal anatomy issues
      • non-protractile nipples (not always resulting in nipple pain)
      • firm, dense breast tissue
    • Dermatological conditions of the nipple
      • dermatitis (atopic and contact)
      • psoriasis, and other skin conditions
    • Infections
      • fungal overgrowth, eg. candidiasis
      • bacterial infections, eg. staph aureus
      • viral infections, eg. herpes simplex
    • Neurovascular conditions
      • vasospasm of the nipple
      • Raynaud's phenomenon
      • nerve response to damaged nipples
    • Infant anatomy issues
      • high arched palate or a bubble palate
      • short lingual frenulum
      • receding/small mandible
      • teething

    Transient nipple pain is common during the first week postpartum, peaking at day 3 and decreasing by day 7. 9 There is no damage evident and the pain disappears within a short time of commencing the feed (ie, about 30 seconds).

    Management basics

    There is nothing to be achieved by treating sore or damaged nipples if you don't simultaneously treat the cause.
    1. Identify the cause of the pain or damage.
    2. Treat or manage the cause.
    3. Initiate supportive management strategies to aid healing.

    Supportive strategies

    When the cause of the damage is treated the nipple will heal quickly even while the mother continues to breastfeed from the affected breast. After identifying the cause and initiating the appropriate action plan, the mother will also benefit from other supportive measures.

    Topical applications

    Many topical applications have been tried and studied (or not studied!) with often conflicting outcomes. What this essentially means is that no single evidence-based intervention can be recommended for all mothers. In the absence of an evidence-based practices that will provide pain relief, speed healing and prevent premature weaning the goal is to 'first, do no harm' .

    The most common topical applications include:

    • Expressed breastmilk (EBM). Breastmilk contains:
      • anti-infective agents that reduce the risk of a superimposed infection,
      • epidermal growth factor that aids healing,
      • as well as the hindmilk being high in fat to soothe the nipple.
        Applied after and between breastfeeds to keep the wound moist, it is a simple, no-risk, no-cost and very successful intervention.

    • Warm water compresses. A meta-analysis 10recommended the application of warm water compresses to relieve pain, and breastmilk to hasten healing of cracked nipples. Again, simple, no-risk, no-cost and often effective.

    • Pharmaceutical grade lanolin. Mothers often report an immediately soothing effect from this treatment. Some studies found faster healing of nipple trauma and nipple pain reduction when compared to EBM 11 while others 12 find no difference between the two.
      Contamination of the lanolin within the container risks causing or prolonging the nipple problem.

    • Hydrogel dressings. There have been no reviews of the effectiveness or safety of this intervention for nipple wound treatment in recent years. Older studies 13 14 noted an increased incidence of infections in the groups using this wound dressing, with one study discontinued early because of this outcome. Recommend with caution, stressing the importance of hygiene.
      Generally considered unsuitable for use in the presence of nipple infection.

    Wound management

    The damage on a nipple is a wound. However, unlike a wound on other parts of the body, a nipple wound has unique characteristics:
    • a large volume of a bodily secretion (ie breastmilk) must be allowed to flow past it frequently
    • an infant must latch over the top of it frequently

    Moist wound healing management that involves occluding the wound for days at a time while the wound exudates perform healing and antiinfective functions, can not be applied.
    However, scab formation or a covering that sticks to the wound causing damage on removal is to be avoided.

    What about resting the nipple?

    Severely damaged nipples may need to be rested for 24 hours or longer due to the severe pain caused to the mother. During this time regular expressing of breastmilk will be required.

    We live in a time of technology and gadgets. A breast pump (electric or manual) is often the only option considered for milk removal. Just as infants who exert a stronger baseline peak and pause vacuum will cause more pain for their mothers compared to infants with vacuum within normal range15 so too the vacuum of breast pumps has been associated with increased nipple pain and damage.16 If a pump is to be used careful instruction to mothers about the correct use will prevent a bad situation becoming worse.

    Hand expressing breastmilk is frequently the better option for many mothers.

    Group Activity

    Review the management of nipple pain and damage in your unit's Breastfeeding Policy. Is it up-to-date and focussed on 1. identifying the cause, 2. treating the cause and 3. supportive management?

    If not, you may like to form a small committee to review the contemporary literature and draft a new section for consideration by the relevant parties.

    Identification and Management of Specific Causes

    Technique factors

    Historically, an intervention to try to prevent nipple damage was to limit the number of feeds and length of time on the breast. A Cochrane Review 17 concluded that this practice was associated with an increased incidence of sore nipples, engorgement and the need to give additional (formula) feeds, and is therefore not recommended.

    One study noted that 94% of women with breastfeeding problems had babies who had a "superficial, nipple-sucking" technique. 18

    Many authors implicate a poorly latched baby as being the major culprit of nipple damage. 19 20 21

    It has also been noted that there is a correlation between the early use of bottles and/or pacifiers and a disorganized suck and nipple damage. 18 22

    From this body of work it is clear that the most common cause of nipple pain and nipple damage is preventable by:

    • achieving correct positioning and latching techniques, and
    • avoiding artificial nipples (teats/pacifiers/dummies) during the learning period.

    Back to basics

    Poor latch (whether from maternal technique or infant ability) may exist in the presence of other risk factors for nipple pain/damage.
    In assisting the mother, go back to basic principles of position and latch FIRST to obtain a clearer picture of the other factors.

    The most important factor in decreasing the incidence of nipple pain is the provision of education in relation to proper breastfeeding technique and latch-on ...23

    Quality assurance activity

    Would you and a small group of colleagues be able to organize an audit of all cases of nipple damage at discharge from your maternity unit over a one-month period?
    It may be as simple as just an incident report, though trying to determine a cause for each would be useful. You may like to discuss with your colleagues the significance of this data once collected. Together you could work on ways to reduce the incidence before surveying again.

    General tips:

    • Skin-to-skin contact and the biological nurturing position are your first line of assistance whenever latching difficulties are evident.
    • Gentle touch or massage, or a cold cloth over the nipple will stimulate the nipple erectile tissue.
    • Compress the breast to hold the shape - the compression points on the breast coincide with where the baby's bottom and top jaws will be. Maintain this hold for a minute or two until sucking well established.
    • The best time for the baby to learn to breastfeed from his mother's breasts is prior to secretory activation (lactogenesis II) while her breasts are still soft. Avoid artificial teats (bottle nipples or nipple shields) until baby has this opportunity.

    Workbook Activity 8.3

    Complete Activity 8.3 in your workbook.

    Inverted or non-protractile nipples

    Non-protractile or inverted nipples are difficult to draw out. Attempt to shape the breast well and hold that shape until infant is well established on the breast.

    Some devices may assist:
    Syringe on right modified for mother to gently draw out non-protractile or inverted nipple.

    Syringe on right modified for mother to gently draw out non-protractile or inverted nipple.
    Photograph © Health e-Learning

    Devices to evert the nipple immediately prior to latching can be successful. For example

    • a modified syringe, 24 25 or commercial nipple everting devices
    • using a hand pump immediately before latching.

    These techniques are not always necessary though as many babies latch well to the breast regardless of nipple protractility.

    Remember it is breastfeeding, not nipple feeding.


    Infant well-latched to nipple shield.

    Infant well-latched to nipple shield.
    © B. Wilson-Clay IBCLC

    Sometimes a nipple shield may be helpful. 26

    However, thin silicone nipple shields are associated with 27 a decrease in milk transfer, loss of maternal self-confidence, 28 and premature weaning 29 30

    Milk transfer via a shield before secretory activation will be negligible and therefore shields should not be started until mother has established a good milk supply. Introduction during the first postpartum week gives mothers a false sense of breastfeeding success and is more likely to lead to poor milk transfer, sore nipples and loss of milk supply. 27

    Note: Once a nipple shield has been introduced, observe for a good deep latch and nutritive sucking pattern. Follow-up assessment of infant condition and maternal milk supply is very important with the aim to weaning off the shield when the initial problem has resolved.


    Ankyloglossia (tongue tie)

    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.
    © Dr E. Jain

    A short or tight lingual frenulum (the membranous attachment between the inferior aspect of the tongue and the floor of the mouth) may prevent the baby from extending the tongue over the bottom gum line or elevating the tongue (both essential actions for breastfeeding).

    This can result in:

    • breastfeeding difficulties
    • nipple pain and trauma
    • ineffective feeding
    • poor infant weight gain
    • down-regulation of milk supply


    Treatment

    Mild or even moderate tongue-tie may have minimal effect on breastfeeding. However, when tongue-tie is noted it must always be considered when a breastfeeding problem develops.

    Frenotomy
    - is a simple surgical procedure to release the restriction and provide greater movement.

    The following outcomes of frenotomy have been achieved:
    • Where poor latch was their major complaint, 100% of women found latch was improved. 31
    • Of those presenting with nipple pain, mean pain score reduced from 6.9 to 1.2 immediately after the procedure. 31
    • A significant decrease in nipple pain score reported after frenotomy compared to after sham procedure. 32
    • Ultrasound post-frenotomy demonstrated less nipple compression by the tongue and was associated with "better attachment, increased milk transfer and less maternal pain". 33
    • Normal milk volume transfer possible by direct breastfeeding.34

    When tongue-tie is noted ...

    and in the presence of breastfeeding difficulties
    • refer the mother and her infant to a health professional who has experience assessing tongue ties and performing frenotomy.
    Unfortunately, despite obvious breastfeeding difficulties affecting both mother and baby, some health professionals refuse to treat ankyloglossia.

    Fungal overgrowth (candidiasis, thrush, yeast)

    Amongst women who report breastfeeding-associated pain, Candida albicans is the most commonly cultured organism. 35 36

    C. albicans is a fungus (a form of yeast), which exists normally on the mucous membranes of the gut and vagina and usually presents no problems to a healthy individual. Factors that cause an imbalance of the normal flora of the body often result in candidiasis - the condition caused by an overgrowth and change in form of the fungus as it infects the host tissue.

    Factors often associated with nipple candidiasis are:

    • presence of vaginal candidiasis - up to 25% of women are affected by end of pregnancy 37
    • use of antibiotics 7
    • break in skin integrity of nipple36
    • infant who has oral candidiasis (acquired during birthing or being introduced on fingers, etc)
    • infant use of pacifiers/dummies 38 39 - may also contribute to persistence of infant oral infection
    • use of bottles - 23% of lactating women who used bottles tested positive for Candida and 20% had nipple candidiasis. A risk factor for colonization of the mother was bottle use in the first 2 weeks postpartum. Of these women 57% had weaned by 9 weeks postpartum, compared to 31% who were negative for Candida. 40

    Presentation and Diagnosis

    Notice the shiny red areas around the nipple.

    Notice the shiny red areas around the nipple.
    © Goldfarb Breastfeeding Clinic

    Nipple candidiasis commonly presents with the following signs and symptoms

    • acute breast/nipple pain after a period of pain-free feeding
    • deep shooting, burning, or stabbing pain in the breast
    • burning nipple pain, during and for some time after a breastfeed
    • nipple and/or areola may be red, shiny or flakey; though may show no changes
    • Candida may be obvious in the baby's mouth
    • history that includes a risk factor, eg. recent antibiotics, bottle use, etc.
    • observation of a breastfeed to eliminate other causes

    Workbook Activity 8.4

    Complete Activity 8.4 in your workbook.

    Management

    Candida branches and multiplies rapidly and exists in many different stages at the same time. Management is aimed at eradicating the pathogen and preventing re-infection. The mother's doctor will confirm the diagnosis and may prescribe a pharmaceutical antifungal agent.

    Antifungal agents that have been found to be effective in treating Candida albicans include:

    • Effective home remedies:
      • Gentian violet aqueous 0.5% - painted on the nipples. This purple dye kills Candida on contact.41 42 (not readily available in some countries)
      • honey in a >80% concentration 43
      • Pure coconut oil - rubbed into nipples and ingested for candida in other sites. 100% effective against candida albicans in vitro 44
    • Miconazole - cream applied sparingly to nipples; also oral gel for infant. Effective in 99% of cases.45
    • Fluconazole - systemic agent, usually administered orally. 46
    • Nystatin. Not usually the drug of first choice. Resistance has developed to this drug, only being effective in 54% of cases. 45

    Educate the mother about the following supportive strategies that will enhance the antifungal treatment and prevent re-infection.

    • Meticulous attention to hygiene.
      • wash hands in warm, running soapy water before and after breastfeeding and any time when potentially infected areas have been touched, drying hands on a paper towel.
      • discard reusable gel breast pads if they were being used and don't recommence until infection is cured, and preferably not at all.
      • wash bras and cloth nursing pads daily and dry in direct sunlight if possible.
      • boil pacifiers or artificial teats/nipples daily and replaced frequently.
      • wash and thoroughly dry all toys, etc the baby puts in his mouth.
    • Rinse the nipples in a bicarbonate of soda solution to create an alkaline skin environment. Nipples may respond differently to traditional vaginal thrush soothing treatments.
    • Consider and treat all possible sources of recurring infection
      • trim the baby's finger nails to prevent Candida being harbored under the nail and transferred to the mouth.
      • the moist fold under the breasts of large breasted women
      • other children, maternal vaginal infection, sexual partner, a pet
    • Some women have reported faster resolution of symptoms when they eliminate simple sugars and yeasts from their diet and consume pure coconut oil, acidophillus and/or bacillo bifidus either in yoghurt form or in a commercially prepared capsule.
    Treatment of the infant
    The infant may be a source of a re-infection cycle. Simultaneous treatment of infant with an appropriate infant preparation such as miconazole gel is standard care.

    Workbook Activity 8.5

    Complete Activity 8.5 in your workbook.

    Bacterial infections

    Whenever nipple skin integrity is broken the risk of colonization with bacterial and fungal pathogens is significantly increased.
    Staphylococcus aureus is the most common causative organism of bacterial infections on the nipple, 36 though streptococcus may also be implicated. Mastitis is often associated with S. aureus-infected nipple damage

    Diagnosis is usually made following careful history taking:

    • pain described as stinging,
    • observation of nipple damage,
    • presence of an exudate that could be yellow to red and crusting,
    • a delay in wound healing


    © Goldfarb Breastfeeding Clinic

    Management:
    • Treat the original cause of the break in nipple skin integrity.
    • Gently clean the nipple wound in a saline solution.
    • Apply antibiotic ointment as ordered by the doctor. A compound many find useful is a combination of a mild topical steroid, an antibiotic and an antifungal agent. 47

    What should I remember?

    • Nipple pain threatens breastfeeding continuation and is therefore a SERIOUS PROBLEM requiring prompt and effective management.
    • The many causes of nipple pain, but especially the MOST COMMON cause.
    • Supportive management strategies for damaged nipples.
    • How to assist mothers with non-protractile nipples.
    • Identification of ankyloglossia and impact on breastfeeding dyad.
    • How to recognise nipple infections such as candidiasis and Staph aureus.
    • Treatment choices for nipple candidiasis and Staph aureus.

    Self-test quiz

    Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column

    Notes

    1. # Buck ML et al. (2014) Nipple pain, damage, and vasospasm in the first 8 weeks postpartum.
    2. # Schwartz K et al. (2002) Factors associated with weaning in the first 3 months postpartum.
    3. # Lewallen LP et al. (2006) Breastfeeding support and early cessation.
    4. # Amir LH et al. (2005) Why do women stop breastfeeding? A closer look at not enough milk among Israeli women in the Negev Region.
    5. # Indraccolo U et al. (2012) Pain and breastfeeding: a prospective observational study.
    6. # McClellan HL et al. (2012) Nipple pain during breastfeeding with or without visible trauma.
    7. # Amir LH et al. (1996) Candida albicans: is it associated with nipple pain in lactating women?
    8. # Annagur A et al. (2013) Is maternal depressive symptomatology effective on success of exclusive breastfeeding during postpartum 6 weeks?
    9. # Morland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review.
    10. # Johanna Briggs Institute et al. (2009) The management of nipple pain and/or trauma associated with breastfeeding.
    11. # Abou-Dakn M et al. (2011) Positive effect of HPA lanolin versus expressed breastmilk on painful and damaged nipples during lactation.
    12. # Vieira F et al. (2013) A systematic review of the interventions for nipple trauma in breastfeeding mothers.
    13. # Ziemer MM et al. (1995) Evaluation of a dressing to reduce nipple pain and improve nipple skin condition in breast-feeding women.
    14. # Brent N et al. (1998) Sore nipples in breast-feeding women: a clinical trial of wound dressings vs conventional care.
    15. # McClellan H et al. (2008) Infants of mothers with persistent nipple pain exert strong sucking vacuums
    16. # Clemons SN et al. (2010) Breastfeeding womens experience of expressing: a descriptive study.
    17. # Renfrew MJ et al. (2000) Feeding schedules in hospitals for newborn infants.
    18. # Righard L (1998) Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles?
    19. # Gunther M (1945) Sore Nipples: Causes and Prevention
    20. # Prachniak GK (2002) Common breastfeeding problems
    21. # Wight NE (2001) Management of common breastfeeding issues
    22. # Centuori S et al. (1999) Nipple care, sore nipples, and breastfeeding: a randomized trial
    23. # Moreland-Schultz K et al. (2005) Prevention of and therapies for nipple pain: a systematic review
    24. # Kesaree N et al. (1993) Treatment of inverted nipples using a disposable syringe
    25. # Patel Y (2008) Inverted nipples: correction using a simple disposable syringe.
    26. # Hanna S et al. (2013) A description of breast-feeding outcomes among U.S. mothers using nipple shields.
    27. # McKechnie AC et al. (2010) Nipple shields: a review of the literature.
    28. # Keemer F (2013) Breastfeeding self-efficacy of women using second-line strategies for healthy term infants in the first week postpartum: an Australian observational study.
    29. # Rius JM et al. (2014) [Factors associated with early weaning in a Spanish region].
    30. # Pincombe J et al. (2008) Baby Friendly Hospital Initiative practices and breast feeding duration in a cohort of first-time mothers in Adelaide, Australia.
    31. # Ballard JL et al. (2002) Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad
    32. # Griffiths DM (2004) Do Tongue Ties Affect Breastfeeding?
    33. # Geddes DT et al. (2008) Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound.
    34. # Garbin CP et al. (2013) Evidence of improved milk intake after frenotomy: a case report.
    35. # Andrews JI et al. (2007) The yeast connection: is Candida linked to breastfeeding associated pain?
    36. # Amir LH et al. (2013) Does Candida and/or Staphylococcus play a role in nipple and breast pain in lactation? A cohort study in Melbourne, Australia.
    37. # Cotch MF et al. (1998) Epidemiology and outcomes associated with moderate to heavy Candida colonization during pregnancy
    38. # Comina E et al. (2006) Pacifiers: a microbial reservoir
    39. # da Silveira LC et al. (2009) Biofilm formation by Candida species on silicone surfaces and latex pacifier nipples: an in vitro study.
    40. # Morrill JF et al. (2005) Risk factors for mammary candidosis among lactating women
    41. # Wright SC et al. (2009) Treatment of oral thrush in HIV/AIDS patients with lemon juice and lemon grass (Cymbopogon citratus) and gentian violet.
    42. # Gomes-de-Elvas AR, (2012) In vitro assessment of gentian violet anti- candida activity.
    43. # Banaeian-Borujeni S, (2013) Comparison of the effect of honey and miconazole against Candida albicans in vitro.
    44. # Ogbolu DO et al. (2007) In vitro antimicrobial properties of coconut oil on Candida species in Ibadan, Nigeria.
    45. # Hoppe JE et al. (1996) Randomized comparison of two nystatin oral gels with miconazole oral gel for treatment of oral thrush in infants. Antimycotics Study Group
    46. # Moorhead AM et al. (2011) A prospective study of fluconazole treatment for breast and nipple thrush.
    47. # Newman J et al. (2005) Dr Jack Newman's Guide to Breastfeeding (The Ultimate Breastfeeding Book of Answers)

    8.3 Breast Problems

    Many of you will only be caring for mothers during the early postpartum recovery period. You will probably rarely see mastitis at this time. However, a significant percentage of mastitis infections occur soon after hospital discharge and can be traced back to hospital-acquired bacteria.
    Teaching mothers about ideal breastfeeding practices and how to avoid nipple damage will ensure their breasts remain healthy and less prone to this infection.

    Blocked (Plugged) Duct

    Blocked ducts are a common occurrence for breastfeeding mothers at any stage of lactation. Milk ducts become blocked and distended and are palpable as a tender, small lump in the breast. The skin over the lump may be reddened and warm to touch.

    Blockage may occur as a result of

    • occlusion of a duct from pressure applied by an ill-fitting bra, clothing or compressing the breast throughout the feed
    • excessive movement of the breasts such as running or aerobics
    • poorly drained breast - poor positioning, latch, not 'finishing the first breast first'.

    It has been noted that some mothers who experience repeated duct blockages have thicker milk, or the blockage may contain more fatty material than usual. 1 2 ( Note: this should not be your first assumption - always investigate other causes first )

    Management involves

    • identification of the cause
    • meticulous attention to position and latch
    • warm compresses to the affected area or a soak in warm water prior to gentle, but firm massage
    • massage the lump towards the nipple as the baby suckles, or when hand or pump expressing
    • feed more frequently until lump clears
    • massage and hand expressing under a warm shower

    If a blocked duct fails to be cleared it may progress to mastitis; infective mastitis may follow.

    Mastitis

    Lactational mastitis occurs most commonly during the first four postnatal weeks, either as a result of mis-management of lactation initiation, or the infective organism having been hospital-acquired. 3 4 2
    However it may occur at any stage of lactation.

    Causes

    Mastitis means inflammation of breast tissue. The inflammatory process in lactational masitis is caused by either milk stasis or infection.

    " Without effective removal of milk, non-infectious mastitis was likely to progress to infectious mastitis... " 5

    • Milk stasis is non-infective, but may progress to an infective state if good clinical management is not implemented. Milk stasis is most commonly associated with:

      • engorgement
      • infrequent feeds, or scheduling the frequency and/or duration of feeds
      • poor latching leading to inefficient removal of milk
      • missing feeds, eg. overnight or because baby has received a bottle feed
      • pressure on the breast (eg. tight bra, car seatbelt)
      • a blocked nipple pore or duct
      • rapid weaning
    • Associated factors which increase incidence of mastitis

      • nipple damage - especially if colonised with Staphylococcus aureus
      • illness in mother or baby
      • oversupply of milk
      • maternal stress or fatigue
      • anaemia or malnutrition
    • Infection

      • usually by a penicillinase-resistant Staphylococcus aureus
      • less commonly the organism is a streptococcus or Escherichia coli

    (Sources: WHO 6 ABM protocols 7 )

    Milk stasis and mastitis causes movement of sodium and chloride into the milk space 8 and milk supply will fall as synthesis temporarily slows in the affected area. The infant may fuss during breastfeeds as a result of these factors.


    Preventing Mastitis

    Educate mothers about the importance of good breastfeeding management, caring for themselves and their breasts.

    • A well-latched baby who breastfeeds according to his needs will help to regulate the mother's milk supply and avoid nipple damage.
    • Teach mothers to hand express to prevent engorgement.
    • Encourage rest and a healthy diet to support her immune system.
    • Encourage an awareness of breast lumps or areas of milk stasis and discuss treatment with massage, extra feeding, expressing and heat packs.

    An ounce of prevention ...

    While you need to be very familiar with appropriate diagnosis and treatment of mastitis, prevention is a better approach.

    During pregnancy, and as you educate mothers about effective breastfeeding focus ongood positioning and latch, and effective breast drainage as the basis for all markers of good breastfeeding. Mothers will understand that problems such as mastitis can be avoided - if the mother enters her breastfeeding relationship feeling confident and is well-educated about breastfeeding she is less likely to encounter problems.

    Workbook Activity 8.6

    Complete Activity 8.6 in your workbook.

    Diagnosis

    Diagnosis is usually made by clinical presentation.

    • inflamed area of the breast
    • a painful wedge-shaped lump
    • associated with fever of 38.5ºC (101.3ºF) or greater, and
    • chills, flu-like aching and systemic illness.

    One researcher9 desribes her criteria for mastitis as "at least 2 breast symptoms (pain, redness or lump) AND at least one of fever or flu-like symptoms."

    Laboratory cultures of the breastmilk are rarely performed unless it does not respond to classical management strategies, or the mother has repeated episodes.


    © Goldfarb Breastfeeding Clinic


    Management

    Knowing that milk stasis is the most common predisposing factor to mastitis, it stands to reason that the first management strategy will be to ensure frequent and effective milk drainage from the affected breast.

    Effective milk removal

    • breastfeed baby frequently, beginning on the affected breast to enhance drainage
    • ensure baby latching and suckling well. Observe the baby breastfeeding!
    • warm breast soak or applying warm compresses prior to breastfeeding may help milk ejection
    • massage the breast gently during the breastfeed
    • review the frequency of breastfeeding; most babies will feed 6 to 18 times in 24 hours, and feeding should not be regulated by the mother 10
    • hand expressing, or pumping after a breastfeed may be necessary

    Supportive measures

    • bed rest
    • adequate fluids and nutrition
    • practical help at home
    • vitamin E-rich sunflower oil, echinacea and vitamin C supplements have been suggested to assist immune and inflammatory responses. 11

    Pain relief

    Researchers and clinicians have yet to conclude whether heat or cold is preferred, most suggesting both with heat being used prior to breastfeeding or expressing and cold afterwards.

    • Use of moist heat...

      • soak a cloth in warm water and apply to affected breast
      • immerse the breast in a container of warm water. Some mothers have obtained relief from putting magnesium sulphate (Epsom Salts) into the water.
      • limit use of heat if significant inflammation is present
    • Application of cold - either a chilled moist cloth or a covered ice pack.

    Paracetamol (acetaminophen) and ibuprofen are both safe analgesics to use during lactation; paracetamol (acetaminophen) having better antipyretic properties, while ibuprofen has better anti-inflammatory properties.

    Antibiotics

    If symptoms of mastitis are mild and have been present for less than 24 hours:
    conservative management (effective milk removal and supportive measures) may resolve the problem without need for antibiotic therapy. 12

    • If symptoms are not improving after 12-24 hours of conservative management (or if the woman is acutely ill): antibiotics should be started. 13
      Preferred antibiotics are usually penicillinase-resistant penicillins (dicloxacillin or flucloxacillin).
      Cephalexin is indicated in suspected penicillin allergy.
      Clindamycin when penicillin hypersensitivity is severe.
    • Infections caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) are being increasingly observed. 14,15

    The mother wants to wean ...

    This is not the time to wean! The pain and disruption to family life may make the mother feel that weaning is a solution. Use all your communication and empathic skills to support the mother through this difficult time.

    Weaning now (as tempting as it may seem) is achieved by stopping breastfeeding and causing milk stasis. Milk stasis increases the inflammatory response, further increasing risk of worsening mastitis and possible development of a breast abscess.

    It is important to clear the milk and allow the time for the breast to recover and heal before the mother considers weaning.

    Workbook Activity 8.7

    Complete Activity 8.7 in your workbook.

    Educational material

    Develop an information sheet to be discussed with mothers who have a blocked duct or mastitis, outlining the supportive measures they can take to facilitate a speedy recovery. This should be suitable for them to take home.

    Complications

    • pain, feeling very ill, loss of productivity
    • reduced milk supply
    • early weaning
    • candida overgrowth
    • breast abscess and drainage

    What should I remember?

    • The management of blocked ducts
    • The predisposing factors for mastitis.
    • Prevention of mastitis.
    • The clinical and supportive management strategies for mastitis.
    • At what stage antibiotics are indicated and which categories of antibiotics will be effective.

    Self-test quiz

    Click and drag the missing words below into their correct place

    The missing words are: Staph antibiotic before blocked breastfeeds cold damaged drainage ducts express fever flu-like frequency infection inflammation inflammation lactational latch less lump massage position pressure rest stasis towards warm

    Mastitis is __________ of the breast. When it occurs during breastfeeding it is called __________ mastitis. This condition may have its origin from milk __________ or __________.

    Initially, __________ __________ may be the result of the milk stasis. The recommended management of this situation would include:
    • __________ compresses before the breastfeed
    • gentle __________ of the lumps __________ the nipple during breastfeeding
    • increase breastfeeding __________ until the blockages have cleared.

    Milk stasis may be the result of externally applied __________ from tight bra or clothing. However, the main reason for milk stasis is ineffective __________ of the breast. This can be achieved by meticulous attention to __________ and __________ of the infant to the breast. If unresolved, milk forced into the tissues causes __________ and resultant further milk stasis.

    Infection with organisms such as __________ aureus is the most common cause of infective mastitis. A strong risk factor for infective mastitis is __________ nipples. The mother will display breast symptoms such as a red, inflamed area over the site of a hard __________ and the mother may also have a __________ and __________ symptoms.

    You can assist the mother to recover by suggesting supportive management such as __________, good fluid and nutritional intake.
    During this time, the most important management is frequent drainage of the breast - this can be achieved by:
    • increasing the number of __________
    • warmth applied to the breast __________ a feed and application of __________ after the feed
    • __________ regularly if the baby is not breastfeeding
    If the symptoms are mild or have been present for __________ than 24hrs, the mother can continue with these strategies. However, if symptoms are not improving within 12-24 hrs or the mother becomes acutely ill, __________ therapy should be started.

    Notes

    1. # Eglash A (1998) Delayed milk ejection reflex and plugged duct. Lecithin therapy
    2. # Fetherston C (1998) Risk factors for lactation mastitis
    3. # Amir LH et al. (2007) A descriptive study of mastitis in Australian breastfeeding women: incidence and determinants
    4. # Kinlay JR et al. (1998) Incidence of mastitis in breastfeeding women during the six months after delivery: a prospective cohort study
    5. # Thomsen AC et al. (1984) Course and treatment of milk stasis, noninfectious inflammation of the breast, and infectious mastitis in nursing women
    6. # World Health Organisation (2000) Mastitis: causes and management
    7. # Academy of Breastfeeding Medicine (2008) Clinical Protocol 4
    8. # Nguyen DA et al. (1998) Tight junction regulation in the mammary gland.
    9. # Amir LH et al. (2007) A descriptive study of mastitis in Australian breastfeeding women: incidence and determinants.
    10. # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
    11. # Riordan J (2005) Breastfeeding and Human Lactation
    12. # Jahanfar S et al. (2013) Antibiotics for mastitis in breastfeeding women.
    13. # World Health Organisation (WHO) (2001) The optimal duration of exclusive breastfeeding. Results of a WHO systematic review.
    14. # Saiman L et al. (2003) Hospital transmission of community-acquired methicillin-resistant Staphylococcus aureus among postpartum women
    15. # Reddy P et al. (2007) Postpartum mastitis and community-acquired methicillin-resistant Staphylococcus aureus

    8.4 Insufficient breastmilk

    Before you can understand and problem-solve breastmilk insufficiency you must first be confident in your knowledge of normal initiation and maintenance of lactation.

    How is breastmilk production regulated?

    A quick reminder of how lactation commences ....

    Secretory differentiation (Lactogenesis I)

    • commences during pregnancy
    • causes growth of functional breast tissue and begins colostrum production
    • is an endocrine function dependent on hormonal control

    Secretory activation (Lactogenesis II)

    • commences soon after birthing
    • is seen clinically as a copious production of breastmilk
    • is an endocrine function

    Factors that interfere with normal hormonal status of the mother can impact early lactogenesis:

    • sub-optimal glucose metabolism, 1 retained placenta, 2 3 obesity, 4 5 diabetes, 6 7 severe hemorrhage, 8 stress, 9 10 hypothyroidism 11
    • breast hypoplasia

    Forewarned is forearmed

    If you can be alerted early to the possibility of low supply you can implement measures immediately to prevent an inevitable poor outcome.

    Lactogenesis III (Maintenance)

    Lactogenesis III is the maintenance of milk synthesis.

    This is an autocrine function, meaning milk production is under local control at the breast. Simply explained, milk must be removed from the breast for more milk to be made. Each breast is independent of the other in regards to milk production.

    Researchers have described the following mechanisms, which both work together.

    1. Feedback Inhibitor of Lactation (FIL)

      FIL is a small whey protein that is found in breastmilk. It works on an inhibitory basis. The more milk present in the breast, the more FIL is present to be absorbed, slowing milk production. Conversely, as the breastmilk volume in the breast drops there is less FIL and production of breastmilk is more rapid. 12 13

    2. Prolactin receptors:

      The hormone prolactin is necessary to form the substrate of breastmilk. Prolactin must pass from the bloodstream through the alveolus and into the milk.
      Prolactin receptors on the alveolus control how much prolactin can move into the milk. (Imagine the prolactin receptors to be like keyholes, and prolactin is the key. The keyhole must be the perfect shape to allow the key to fit into it.) As the the breast is filling the alveoli become increasingly distended and the receptors become distorted preventing prolactin moving in, which slows milk production. 14 As the alveolus empties of milk, the receptors regain their shape allowing prolactin to bind and pass through them and into the milk increasing the rate of milk production again. 15 16

    What was that again?

    Simply put:

    1. Full breast = lots of milk in alveoli = lots of FIL = slow breastmilk production

    2. Full breast = distorted receptors = slow passage of prolactin = slow breastmilk production

    Two very good reasons to ensure frequent, effective milk removal for adequate milk production.

    Workbook Activity 8.8

    Complete Activity 8.8 in your workbook.

    Breast storage capacity and rate of breastmilk production

    Breastmilk storage capacity is unique to each mother, and each breast.

    • A mother who has a small storage capacity will find that her baby must feed frequently, removing most milk at each breastfeed. This mother's rate of breastmilk production will be high most of the time. If she is told not to feed baby as frequently her breasts will remain full for longer, breastmilk production will slow and she will not be able to produce enough milk for her baby.

    • A mother with a large storage capacity will have higher degree of breast fullness for longer. Her infant may need only one side per feed or may feed less frequently. Breastmilk production during this time will be slow, increasing as the available milk is removed.

    Over a 24-hour period both babies may take very similar amounts of milk, but one baby may have to breastfeed many more times per day to achieve it.
    Every mother and baby is unique.

    Warning: It takes sophisticated technology to determine breastmilk storage capacity, ie large breasts don't necessarily mean large storage.

    Perceived breastmilk insufficiency

    Along with nipple pain, this is the most common breastfeeding problem which women experience and a reason mothers give for introducing artificial infant formula and weaning prematurely. "Not enough milk" is reported by women, but often their perception does not match reality.17,18

    To help prevent this misunderstanding and unfortunate outome always include education about:

    • normal infant behavior (all crying or unsettled behavior isn't from hunger),
    • normal infant breastfeeding frequency, (which is different for every mother and baby),
    • normal infant output (which shows the mother how much her baby is consuming).

    Output is the most obvious and reassuring way for a mother to know her baby is being well fed. Remind the mother: If it's coming out, it must have gone in!

    Confirmed breastmilk insufficiency

    • delayed onset: absence of noticeable fullness/heaviness of the breasts within 72 hours. 19
    • persistent insufficiency: lactation never reaches levels sufficient to meet infant's needs, or gradually declines to be inadequate over time.

    Diagnosis of insufficient breastmilk supply is generally made by observing the condition of the baby. As mentioned in Topic 7.5 , it may not be low supply that has caused failure to thrive, which is why a pediatric review is always indicated.

    Management

    As always: determine and treat the cause! If it is a medical issue refer the mother for assessment, diagnosis and treatment by the appropriate health practitioner. A team approach may be required depending on the cause. Insufficient milk may be temporary or permanent.

    Your role will be to guide the mother on how to increase her production, assisting her to effectively and regularly remove breastmilk, improving breastmilk production.

    1. The breastfeed - assess a breastfeed as discussed in Topic 5.3
      • Observe for good positioning, deep latch, effective suckling, swallowing. Believe it or not this very first step is one often neglected, particularly by health professionals whose specialty is not breastfeeding.
        • Correcting a poor latch may be all that's required to solve the mother's lactation insufficiency.
      • Breast compression during breastfeeding increases milk transfer. Breast compression involves holding the breast in the hand and gently squeezing it. Hold the compression until the baby's sucking pattern changes then release. Repeat.
      • Switch feeding can also be effective. When the infant stops nutritive sucking on the first breast, swap to the other breast. Repeat this on each breast to encourage infant's interest and promote milk synthesis.
    2. Breastfeeding frequency
      • There are many misconceptions about breastfeeding frequency. Remember that the frequency of breastfeeding depends on:
        • how much milk is available in the breast (breastmilk storage capacity)
        • how hungry the baby is (is he given water or supplements between/after feeds)
        • BREASTFEEDING FREQUENCY WILL BE UNIQUE FOR EVERY MOTHER AND BABY
      • Infrequent or 'spaced out' breastfeeding causes milk production to slow and therefore decrease.
      • Teach mothers about milk synthesis and breast storage capacity giving them confidence to breastfeed as their breasts and baby require.
    3. Additional stimulation - milk removal between breastfeeds
      • Fact: The more frequently milk is removed from the breast the more rapidly the breast will produce breastmilk.
        The fuller the breast, the slower the breast will make breastmilk.
      • Additional milk removal after or between breastfeeds will increase total breastmilk produced in that period. Use this milk as a supplement later.
      • Use a tube-feeding device at the breast when supplements are necessary. If possible commence the breastfeed without the supplement flowing to encourage good drainage of the breast first. When nutritive sucking stops allow the supplemental milk to flow. Review Topic 7.5.1
    4. Galactagogues - discuss the pros/cons and types available
      • A galactagogue is a substance that increases the volume of breastmilk produced.
      • Effective galactagogues include domperidone and metoclopramide, as well as the herbals fenugreek, blessed thistle and goat rue. Discuss with mother's doctor.
      • Galactogogues will only be successful if combined with clinical measures that ensure frequent, effective milk removal.
    5. Counselling the mother - sensitivity and caring will be needed to assist this mother.
      • Reassure her that your recommendations won't be detrimental to the baby (and make sure they aren't - baby must receive adequate nutrition, preferably all breastmilk, but may include artificial infant formula) .
      • Carefully assess her understanding of the feeding and lactation plan.
      • Be sensitive to her feelings; some people have probably criticised her decision to breastfeed, and she may see this problem as justification of their criticism.
      • Be careful that she doesn't perceive you to be unapproachable if she does decide to artificially feed. She's still going to need lots of support to help her through possible emotional and guilt reactions.

    When is the best time to pump breastmilk?

    Assume a mother has an insufficient milk supply. Her baby latches effectively and drains both breasts well each breastfeed but it is not enough for him. When will you tell her to pump?

    Immediately after breastfeeding?? This is what is frequently advised. Mother breastfeeds, then pumps and gets only a few mls, or maybe nothing. That's understandable: the baby had just breastfed effectively.
    Mother feels disheartened - it proves her inability to provide for her baby.
    Breastmilk production will not be increased because the breast was already as empty as possible.

    However, if she waits for an hour then pumps, breastmilk production would have been at maximum rate for the majority of that time, beginning to slow now as more milk accumulates in the breast.
    Pumping may produce 30ml (1 ounce) from each breast (depends on individual rate of milk production). The breast will be emptied again, milk production will be back to maximum rate once again increasing overall volume produced, and the mother will feel positive about her ability to produce breastmilk.

    This is an example of applying your knowledge of physiology to a problem.
    Warning: if the baby is unable to remove all breastmilk at each breastfeed, pump immediately afterwards (and again in another hour - it needn't take long!)

    Workbook Activity 8.9

    Complete Activity 8.9 in your workbook.

    Did you know?

    Women are able to relactate having prematurely weaned their baby, and also induce lactation, if they did not previously go through pregnancy. Always offer this as an option for mothers who weaned prematurely or are adopting a baby.

    What should I remember?

    • That lactogenesis III is the maintenance of milk synthesis and is an autocrine function.
    • Breastmilk production is increased when breastmilk is removed more frequently and effectively.
    • Be able to describe the 2 mechanisms of autocrine control of milk synthesis at the breast level.
    • Understand why breastfeeding frequency is unique for every mother and baby.
    • The FIVE important steps in the management of low supply.

    Self-test quiz

    Notes

    1. # Nommsen-Rivers LA et al. (2012) Timing of stage II lactogenesis is predicted by antenatal metabolic health in a cohort of primiparas.
    2. # Pieh-Holder KL et al. (2012) Lactogenesis failure following successful delivery of advanced abdominal pregnancy.
    3. # Anderson AM (2001) Disruption of lactogenesis by retained placental fragments
    4. # McGuire E (2013) Breastfeeding and high maternal body mass index.
    5. # Amir LH et al. (2007) A systematic review of maternal obesity and breastfeeding intention, initiation and duration
    6. # Finkelstein SA et al. (2013) Breastfeeding in women with diabetes: lower rates despite greater rewards. A population-based study.
    7. # Matias SL et al. (2014) Maternal prepregnancy obesity and insulin treatment during pregnancy are independently associated with delayed lactogenesis in women with recent gestational diabetes mellitus.
    8. # Ramiandrasoa C et al. (2013) Delayed diagnosis of Sheehan\'s syndrome in a developed country: a retrospective cohort study.
    9. # Lau C (2002) The effect of stress on lactation--its significance for the preterm infant.
    10. # Dewey KG (2001) Maternal and fetal stress are associated with impaired lactogenesis in humans
    11. # Speller E et al. (2012) Breastfeeding and thyroid disease: a literature review.
    12. # Wilde CJ et al. (1998) Autocrine regulation of milk secretion.
    13. # Knight CH et al. (1998) Local control of mammary development and function.
    14. # Cregan MD et al. (2002, March) Milk prolactin, feed volume and duration between feeds in women breastfeeding their full-term infants over a 24 h period
    15. # DeCarvalho MD (1983) Effect of frequent breastfeeding on early milk production and infant weight gain
    16. # Zappa AA (1988) Relationship between maternal parity, basal prolactin levels and neonatal breast milk intake
    17. # Amir LH (2006) Breastfeeding--managing supply difficulties.
    18. # Lamontagne C et al. (2008) The breastfeeding experience of women with major difficulties who use the services of a breastfeeding clinic: a descriptive study.
    19. # Nommsen-Rivers LA et al. (2010) Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding.

    8.5 Medical, Surgical Issues

    Diabetes mellitus

    Breastfeeding and diabetes have a close relationship - breastfeeding has an impact on pre-existing and potential diabetes and diabetes has an impact on breastfeeding. Lactation may be delayed or impaired for reasons both of diabetes and obesity, so women in the diabetic spectrum need special consideration and attention to breastfeeding and lactation assistance. 1

    Gestational diabetes mellitus (GD)

    • mothers who had GD and suppress lactation
      • have higher serum glucose than had they breastfed 2
      • experience an immediate detrimental effect on their glucose tolerance 3
      • cause lasting effects on their metabolic profiles 3
      • significantly increase their risk of developing Type 2 diabetes 3 4
    Type 2 diabetes mellitus
    • Children who were artificially fed in infancy
      • are put at increased risk of developing Type 2 diabetes. 5
    • Mothers who suppress lactation
      • do not receive the protection that normally delays or prevents Type 2 diabetes mellitus
      • obesity and lactation suppression combined significantly increases the risk of developing Type 2 diabetes mellitus. 4
    Type 1 diabetes mellitus (insulin-dependent)
    • For the child who was artificially fed in infancy
      • Being artificially fed significantly increases their risk of developing Type 1 diabetes mellitus. 6 7 8
    • For the mother who has Type 1 diabetes
      • onset of secretory activation (lactogenesis II) may be delayed. 1 9
      • lactating mothers can reduce their insulin by 25% or more of pre-pregnancy dose, while increasing their carbohydrate intake. Insulin requirements of mothers who suppress lactation is significantly greater. 10 11 12

    Impact on lactation

    • women who are diabetic are more likely to birth preterm, have a caesarean section or assisted birth and experience other obstetric complications, all of which increase the risk of lactation difficulty
    • mothers who are diabetics are more likely to NOT breastfeed or have a shorter breastfeeding duration 13 14
    • separation of mother and baby is more likely due to preterm birth, Caesarean section and blood glucose testing
    • maternal diabetes delays the onset of lactogenesis II 1 15
    • in some units the baby is at greater risk of being given artificial infant formula, increasing breastfeeding difficulties

    Recommendations

    It is unfortunate that mothers with diabetes are at increased risk of breastfeeding difficulties which not only impacts on their own health but also on the health of their child who then becomes at risk of developing the same diabetic condition.

    For the present and future health of the mother with diabetes and her baby:

    • provide education about the effects of artificially feeding on herself and her baby
    • suggest prenatal expressing of breastmilk;16 give infant the milk prophylactically during first day
    • encourage skin-to-skin contact after birth, early initiation and frequent breastfeeding
    • support measures to establish milk supply if mother and infant separated or infant not able to latch

    In light of the increased risk to the health of this woman and her child practices which interfere with breastfeeding, such as separation and giving artificial infant formula should be reviewed.

    Do mothers know this?

    Do the mothers with diabetes in your Unit get told of the effect of premature weaning on themselves and their babies?

    Maternal overweight and obesity

    Artificial feeding and onset of obesity

    • Mothers who artifically feed compared to those who breastfeed (>6 months) have

      • a 2 kg greater weight gain by 1 year postpartum
      • larger waist girth
      • greater weight gain 10-15 years later
    • being artificially-fed correlates to obesity in childhood and adulthood 17 18 19

    Obesity and breastfeeding

    • overweight and obesity increases obstetric complications and is associated with a greater risk of operative delivery, making lactation initiation more difficult
    • lactogenesis II may be delayed 20
    • positioning the baby to facilitate good latching is more difficult
    • the greater the BMI the greater the risk of early cessation of breastfeeding compared to women with normal BMI
    • overweight and obese women are less likely to plan to breastfeed, initiate breastfeeding and wean earlier 21

    Recommendations

    Give additional education and support to breastfeed to overweight and obese mothers -

    • encourage skin-to-skin contact after birth, early initiation and frequent breastfeeding
    • support measures to establish milk supply if mother and infant separated or infant not able to latch
    • assistance with positioning infant could include using the underarm hold, raising their breast on a pillow or using a rolled up cloth or towel under the breast, and using a mirror to allow them to view their infant latching correctly to their breast.

    Social measures that increase breastfeeding will result in less overweight and obese adults. Pre-conception education should provide help for women to achieve a normal BMI before pregnancy.

    Urgently needed are qualitative studies from women's perspective to help us understand women in this situation and their infant feeding decisions and behaviour.

    Thyroid disease

    Autoimmune thyroid dysfunctions are a common cause of both hyper- and hypo-thyroidism. 22

    Graves' disease (hyperthyroid) and postpartum thyroiditis are two major causes of thyrotoxicosis in the postpartum period. Antithyroid drugs, propylthiouracil or methimazole, are the mainstay of the treatment of postpartum thyrotoxicosis and both are safe to take while breastfeeding. Radioiodine treatment is contraindicated during lactation. 23

    There is a relatively high prevalence of hypothyroidism, especially subclinical hypothyroidism. Hypothyroidism is associated with insufficient breastmilk supply and may be one of the symptoms which alerts you to this condition. Thyroxine replacement therapy is safe for the breastfeeding baby 24 and milk levels will improve once the mother becomes euthyroid.

    Thyroid status varies considerably postpartum. Medication dosage may need adjusting during the postpartum months. Be mindful of symptoms such as fatigue, palpitations, weight loss, loss of concentration and depression. Facilitate medical review of the mother.

    Recommendations

    All women with diagnosed thyroid disease should have their therapy re-evaluated frequently during pregnancy and lactation and medication dosage adjusted as necessary. This is particularly necessary for women who are being treated for hypothyroidism because of the impact on breastmilk sufficiency.

    Evaluate all mothers who have breastmilk insufficiency for hypothyroidism.

    Hepatitis

    Hepatitis B (HBV)
    With appropriate immunoprophylaxis, including hepatitis B immune globulin and hepatitis B vaccine, breastfeeding does not contribute to mother-to-child transfer of HBV. 25 26,27
    Prior to vaccination, concern of transmission of HBV via cracked nipples was speculated but not recorded.

    Hepatitis C (HCV)
    There is no evidence of mother-to-infant transmission of hepatitis C from breastfeeding. 28

    Recommendations

    Women who are hepatitis B or C positive should be encouraged to breastfeed their babies.

    Workbook Activity 8.10

    Complete Activity 8.10 in your workbook.

    HIV

    Untreated, about 5-15% (1 in 20, to 1 in 7) of babies born to women who are HIV infected will become HIV-positive through breastfeeding.
    Exclusive breastfeeding reduces this risk of transfer by about half for HIV +ve mothers.
    Exclusive breastfeeding with the addition of(highly active anti-retroviral therapy)HAART regime reduces the mother's viral load to virtually undetectable, with a 0% - 3% risk of her infant acquiring HIV - the higher failure rate being associated with non-compliance to the ARV (anti-retroviral) regime. 29 30

    When mixed feeding is practiced the artificial formula damages the gut permitting transfer of virus from breastmilk.
    Note: Before giving a supplement to ANY breastfed baby consider the risk you are submitting the baby to should the mother unknowingly be HIV positive.

    International Recommendations for infant feeding

    World Health Organization

    When the mother's HIV status is unknown
    • exclusive breastfeeding for the first 6 months, then
    • introduce complementary foods while continuing to breastfeed for 24 months and beyond.
    When the mother is HIV positive31
    • commence anti-retroviral therapy (ARV) as soon as she is diagnosed and continue for the rest of her life
    • infants to receive ARV therapy
    Breastfeeding guidelines
    The World Health Organization encourages each country to review their infant feeding recommendations, taking into consideration circumstances related to their unique situation.
    • At this time most high-income countries recommend HIV positive mothers exclusively feed their infant on a safe alternative, such as infant formula.
    • Mothers living in middle to low income countries are advised to
      • exclusively breastfeed for 6 months, before
      • continuing to breastfeed until 12 months with the addition of appropriate complementary foods.
      • Strictly adhere to HAART regime as adopted in each country.
    A high success rate in prevention of HIV transmission has been achieved with this regime in these countries.

    Well-informed and motivated mothers in high-income countries may be assisted to breastfeed after receiving expert advice and support on how to do so safely with minimal risk of mother-to-child transfer. 32

    When infant formula is being considered ...

    Mothers known to be HIV-infected should only give commercial infant formula milk as a replacement feed to their infants, when specific conditions are met:

    1. safe water and sanitation are assured at the household level and in the community, and,
    2. the mother, or other caregiver can reliably provide sufficient infant formula milk to support normal growth and development of the infant; and,
    3. the mother or caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhoea and malnutrition; and
    4. the mother or caregiver can, in the first six months, exclusively give infant formula milk; and
    5. the family is supportive of this practice; and
    6. the mother or caregiver can access health care that offers comprehensive child health services.

    Guidelines on HIV and Infant Feeding. (2010) WHO

    Workbook Activity 8.11

    Complete Activity 8.11 in your workbook.

    Breast surgery

    Reduction mammoplasty is frequently associated with insufficient milk supply due to

    • severing large numbers of lactiferous ducts, (some ducts may re-anastomose)
    • removal of large amounts of glandular tissue, or
    • severing the 4th intercostal nerve innervating the nipple/areola (4th intercostal nerve is the stimulus for the milk ejection reflex

    Breast augmentation usually has minimal impact on breastfeeding. However it has the potential to negatively affect breastfeeding if a peri-areola incision was used, or from compression of glandular tissue with sub-glandular placement of implant.
    Breast hypoplasia (inadequate glandular tissue) may have been the indication for the augmentation surgery. Assessment for this should be performed prior to surgery.33

    Referral is needed

    This is an ongoing issue which will require support throughout breastfeeding.

    Breastfeeding, milk transfer and the baby's condition should be closely monitored to ensure the baby continues to thrive. An antenatal consultation with a Lactation Consultant followed by close supervision of initial and ongoing breastfeeding management and early interventions to increase supply is important.

    Breastfeeding and medication usage

    Some women need to take medications while breastfeeding. It is important to ensure the baby will not be harmed via breastmilk transfer of the medication. It is equally as important not to forfeit breastfeeding when there are safe, effective medications. In most cases, it is far preferable to continue breastfeeding with small amounts of drug present in milk rather than risk many more hazardous effects of infant formula feeding.

    All medications transfer into breastmilk to some degree but very, very few medications are contraindicated during breastfeeding. As a general rule of thumb less than 1% of the maternal dose passes via the breastmilk to the baby. Up to 10% of maternal dose is usually considered to be safe. 34

    Several factors influence the ultimate medication dose which the infant will receive via breastmilk:

    • the transfer of the drug into the breastmilk - influenced by specific drug properties such as maternal drug level reached, molecular weight, protein binding capacity.
    • the uptake of the drug by the infant from the breastmilk - daily intake of infant, stomach acidity, gut absorption.

    Everyone who prescribes medications for breastfeeding women should have access to a recent text that specifically reviews medications for mothers. This is the link to an excellent online resource. Externalhttp://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT[link: http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT] . Bookmark this resource for future reference.

    The known detrimental effect of artificial infant formula feeding for both mother and baby needs to be seriously considered prior to ceasing breastfeeding due to maternal medication use. An alternative drug should be sought if the one usually prescribed is contraindicated.

    What should I remember?

    • The important cause/effect cycle of each type of diabetes and breastfeeding.
    • The important cause/effect cycle of obesity and breastfeeding.
    • How thyroid conditions may impact on breastfeeding.
    • That HBV and HCV infection is not a contraindication for breastfeeding.
    • Exclusive breastfeeding for 6 months reduces risk of HIV mother-to-child transfer. ARV therapy and breastfeeding reduces transfer to negligible.
    • Your national guidelines for HIV and infant feeding and the criteria for safe formula feeding.
    • How breast surgery impacts breastfeeding and why.
    • The usual percentage transfer of a medication to infant via breastmilk. The generally safe percentage transfer. Safe and effective alternatives are usually available for the breastfeeding mother if necessary.

    Self-test quiz

    Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column

    Assessment Quiz

    When you are happy that you've understood all the information in this topic you will be ready to complete the Module 8 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 8.

    Notes

    1. # Nommsen-Rivers LA et al. (2012) Timing of stage II lactogenesis is predicted by antenatal metabolic health in a cohort of primiparas.
    2. # Mielke RT et al. (2013) Interconception care for women with prior gestational diabetes mellitus.
    3. # Kjos SL et al. (1993) The effect of lactation on glucose and lipid metabolism in women with recent gestational diabetes
    4. # Gunderson EP (2007) Breastfeeding after gestational diabetes pregnancy: subsequent obesity and type 2 diabetes in women and their offspring
    5. # Das UN (2007) Breastfeeding prevents type 2 diabetes mellitus: but, how and why?
    6. # Rosenbauer J et al. (2007) Early nutrition and risk of Type 1 diabetes mellitus - a nationwide case-control study in preschool children.
    7. # Malcova H et al. (2006) Absence of breast-feeding is associated with the risk of type 1 diabetes: a case-control study in a population with rapidly increasing incidence
    8. # Tenconi MT et al. (2007) Major childhood infectious diseases and other determinants associated with type 1 diabetes: a case-control study
    9. # Hartmann P et al. (2001) Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity
    10. # Illingworth P et al. (1989) Insulin requirements during breast feeding
    11. # Davies HA et al. (1989) Insulin requirements of diabetic women who breast feed
    12. # Riviello C et al. (2009) Breastfeeding and the basal insulin requirement in type 1 diabetic women.
    13. # Finkelstein SA et al. (2013) Breastfeeding in women with diabetes: lower rates despite greater rewards. A population-based study.
    14. # Hummel S et al. (2008) [Breastfeeding in women with gestational diabetes]
    15. # Hartmann P et al. (2001) Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity
    16. # Cox SG (2006) Expressing and storing colostrum antenatally for use in the newborn period
    17. # von Kries R et al. (1999) Breast feeding and obesity: cross sectional study.
    18. # Kalies H et al. (2005) The effect of breastfeeding on weight gain in infants: results of a birth cohort study
    19. # Harder T et al. (2005) Duration of breastfeeding and risk of overweight: a meta-analysis
    20. # Rasmussen KM et al. (2004) Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum.
    21. # Amir LH et al. (2007) A systematic review of maternal obesity and breastfeeding intention, initiation and duration
    22. # Speller E et al. (2012) Breastfeeding and thyroid disease: a literature review.
    23. # Azizi F (2003) Thyroid function in breast-fed infants is not affected by methimazole-induced maternal hypothyroidism: results of a retrospective study
    24. # Lao TT (2005) Thyroid disorders in pregnancy
    25. # Hill JB et al. (2002) Risk of hepatitis B transmission in breast-fed infants of chronic hepatitis B carriers
    26. # Zhongjie Shi (2011) Breastfeeding of newborns by mothers carrying Hepatitis B virus
    27. # Geeta MG et al. (2013) Prevention of mother to child transmission of hepatitis B infection.
    28. # Cottrell EB et al. (2013) Reducing risk for mother-to-infant transmission of hepatitis C virus: a systematic review for the U.S. Preventive Services Task Force.
    29. # Shapiro RL et al. (2010) Antiretroviral regimens in pregnancy and breast-feeding in Botswana.
    30. # Ngoma M et al. (2011) Interim results of HIV Transmission Rates Using a Lopinavir/Ritonavir based regimen and the new WHO Breast Feeding Guidelines for PMTCT of HIV
    31. # World Health Organisation and UNICEF (2010) HIV and infant feeding
    32. # UK Chief Medical Officers Expert Advisory Group on AIDS et al. (2004) Guidance from the UK Chief Medical Officers Expert Advisory Group on AIDS.
    33. # Cruz NI et al. (2010) Breastfeeding after augmentation mammaplasty with saline implants.
    34. # Hale T (2010) Medications and Mothers Milk

    9.0 Promotion, Protection and Support

    You may wonder how this module is relevant for your practice. An understanding of the history of artificial infant formula promotion and the impact it has had on breastfeeding will help you to understand how your values, the values of the mothers you assist and the community in which you live have been formed.

    Artificial infant formula manufacturers are businesses, large businesses with shareholders whose concern is profit. Even though a LOT of evidence exists that artificial infant formula causes serious acute and chronic diseases and developmental and neurological damage to babies and children, and that in developing countries it is deadly, it is still marketed unethically to those who don't need it with the aim being to limit breastfeeding and increase profits, at the expense of our children. The World's first international code of practice ever developed to regulate the practices of trans-national corporations had to be developed specifically to curb the marketing practices of artificial formula manufacturers - a sad indictment.

    The formula industry puts corporate profits before child health by subtle and less subtle marketing to parents, wooing of health professionals and disregard for national and international conventions. Artificial infant formula does have a role to play in infant feeding, but a professional will acquire the knowledge needed from unbiased published research, not from salesmen or saleswomen. Mothers who need to use infant formula can receive accurate, unbiased information from their health professional.

    When you are aware of their practices you will realise that free lunches, pens, diaries or other give-aways are only given to you for one purpose - so that you will promote their product - and it works! A similar problem exists with pharmaceutical companies and the medical profession. Evidence is very clear that accepting their give-aways does influence the medical and nursing professional even when they don't think it does.1,2,3

    Notes

    1. # Erlen JA (2008) Conflict of interest: nurses at risk!
    2. # Civaner M (2008) [A proposal for the prevention of ethical problems related to drug promotion: a national network for drug information].
    3. # Sarikaya O et al. (2009) Exposure of medical students to pharmaceutical marketing in primary care settings: frequent and influential.

    9.1 The International Code of Marketing of Breastmilk Substitutes

    In 1981, the World Health Assembly adopted the International Code of Marketing of Breastmilk Substitutes (the WHO Code). This document was prepared jointly by the World Health Organisation and UNICEF. The original document has continued to be developed as more resolutions have been passed by the World Health Assembly to see the WHO Code refined into the working document which we know today.

    Aim of the WHO Code

    The safe and adequate nutrition of all infants.

    The WHO Code aims to contribute to the provision of safe and adequate nutrition for infants by the protection and promotion of breastfeeding and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.
    To achieve this aim
    • Protect, promote and support breastfeeding.
    • Ensure that breastmilk substitutes are used properly when they are necessary.
    • Provide adequate information about infant feeding
    • Prohibit the advertising or any other form of promotion of breastmilk substitutes.

    The WHO Code is clear that the manufacture and availability of safe and appropriate products is not prohibited, but promoting them as you would harmless consumer products is unacceptable.

    The WHO Code also protects artificially fed infants by ensuring that the choice of products available is impartial, scientific and protects the child's health. The WHO Code ensures that labels carry warnings and the correct instructions for safe preparation for when they are to be used.

    Workbook Activity 9.1

    Complete Activity 9.1 in your workbook.

    What's covered by the WHO Code?

    Breastmilk substitutes

    ...... any food being marketed or otherwise presented as a partial or total replacement for breastmilk, whether or not suitable for that purpose.

    The WHO Code applies to:
    • breastmilk substitutes, including bona fide artificial 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 breastmilk before 6 months
    • anything that replaces the milk part of the child's diet after 6 months, which would ideally be fulfilled by breastmilk, is a breastmilk substitute, for example 'follow-on' milks or cereals promoted to be offered by bottle
    • feeding bottles and teats/artificial nipples
    • the quality of these, the availability and information concerning their use

    The scope of the WHO Code does not include any food, solid or semi-solid intended to be given to infants after 6 months. Such foods are complementary or weaning foods and can not be considered breastmilk substitutes.

    Workbook Activity 9.2

    Complete Activity 9.2 in your workbook.

    Promotion and product information

    • Product labels must clearly state their inferiority to breastfeeding, the need for the advice of a health care worker, and a warning about health hazards. They may not show pictures of babies, or other pictures or text idealising the use of infant formula.
    • Advertising of breastmilk substitutes to the public is not permitted.
    • Companies can provide necessary information to health workers on the ingredients and use of their products. This information must be scientific and factual, not marketing materials. This product information should not be given to mothers.
    • No financial or material inducements (pens, lunches) which promote products within the WHO Code should be provided for health workers or accepted by health workers.

    Free samples

    • No free or low-cost breastmilk substitutes can be supplied in any part of the health care system.
    • The small amount of infant formula needed for any babies who are not breastfeeding should be bought through regular purchasing channels.
    • Free samples should not be given to mothers, their families or health care workers. Small samples of artificial formula may not be given to mothers either from hospital or in the community, as these are samples to encourage mothers to use those products.
    • Supplies of breastmilk substitutes to be given by the institution for free or at a reduced price to mothers or caregivers for social welfare purposes must continue to be provided for each baby for as long as the baby needs them. (ie, the responsibility of continued cost)

    What can you do?

    • Remove posters that advertise formula, teas, juices or baby cereal, as well as any that advertise bottles and teats and refuse any new posters.
    • Refuse to accept free gifts from companies.
    • Refuse to allow free samples, gifts, or leaflets to be given to mothers.
    • Give individual private teaching of artificial infant formula use postnatally when a baby has a need for it. Do not allow group teaching of artificial formula preparation to pregnant women.
    • Encourage all mothers to breastfeed their infants for a minimum of 2 years, only introducing complementary foods after 6 months of age (and that the use of follow-on milks is unnecessary and expensive).
    • Accept only product information from companies that is scientific and factual, not marketing materials.
    • Report breaches of the Code to the appropriate authorities.

    As a health care worker who cares about the health of mothers and babies it is up to each individual to uphold the WHO Code, regardless of your country's commitment to it. If your hospital intends to seek Baby Friendly accreditation it must comply with the WHO Code in its entirety, including the WHA Resolutions.

    Workbook Activity 9.3

    Complete Activity 9.3 in your workbook.

    [link: http://ibfan.org/code-monitoring]

    Monitoring the Code[link: http://ibfan.org/code-monitoring]

    Click on the link above to be taken to the IBFAN website. Here you'll find a lot of useful and interesting information about an organization that is working hard to protect children. As Health Professionals it is our joint responsibility to ensure the Code is adhered to.
    This is also where you will be able to report violations of the Code at this link: ExternalMonitoring the Code.[link: http://ibfan.org/code-watch-form]

    The WHO Code

    The WHO Code

    [link: http://www.who.int/nutrition/publications/code_english.pdf]

    A copy of the WHO Code[link: http://www.who.int/nutrition/publications/code_english.pdf]

    Click on the title of this box, above, to be taken to a site where you can download and print a copy of the International Code of Marketing of Breastmilk Substitutes (it's a .pdf document which will open your Acrobat Reader) . If that website is 'down' it's also available at the ExternalIBFAN[link: http://ibfan.org/the-full-code] website, which has all the WHA Resolutions listed for you to read and print also.

    Your workplace should have a copy (or several copies) of this document. It can be purchased inexpensively. ExternalCLICK HERE[link: http://www.who.int/bookorders/anglais/detart1.jsp?amp;sesslan=1&codlan=1&codcol=15&codcch=94] to open the Order Form.

    What should I remember?

    • What is the WHO Code
    • The purpose of the WHO code
    • What company products and marketing tactics are included in the scope of the Code
    • How to identify and report breaches of the WHO Code
    • My responsibilities as a health care worker

    Self-test quiz

    9.2 The Baby Friendly Initiative

    Innocenti Declaration

    Some 10 years after the WHO Code was first signed a group of high-level policy-makers convened; the outcome was the release of the Innocenti Declaration. The Innocenti Declaration was endorsed by the World Health Assembly in 1991, giving it world-wide status and acceptance. It is the most concise international statement on breastfeeding and covers all three facets of protection, promotion and support.

    The Innocenti Declaration set 4 targets for all governments:

    1. To appoint a national breastfeeding coordinator and a multi-sectoral national breastfeeding promotion committee. This target put accountability directly in the hands of each nations' government.
    2. That governments would have taken action to implement the International Code of Marketing of Breastmilk Substitutes.
    3. That maternity facilities should practice the recently published Ten Steps to Successful Breastfeeding. This came at just the right time historically. The launching of the Baby Friendly Hospital Initiative has been the most important and powerful step ever taken on behalf of breastfeeding. It has put breastfeeding on the health policy map in almost every country in the world.
    4. To enact imaginative legislation to protect the breastfeeding rights of working women.

    Reaching the targets

    In 2005, 15 years after setting the original goals, a celebration was held to evaluate progress and re-affirm commitment to the targets.
    The targets were ambitious and although they were not fully achieved by the projected date, great progress was made:
    • 80 countries formed national breastfeeding authorities
    • 19,000 hospitals became designated Baby-Friendly
    • 80 countries had laws implementing the WHO Code on Marketing of Breastmilk Substitutes
    • declining breastfeeding rates were reversed and exclusive breastfeeding rates increase 15% worldwide.

    The Baby Friendly Initiative

    You may be working in an accredited Baby Friendly facility already or your hospital/institution may be working towards that now.

    Baby Friendly hospitals

    The Baby Friendly Hospital Initiative (BFHI) was launched by WHO and UNICEF in June 1991 at a meeting of the International Pediatric Association. The goal is to promote the adoption of the Ten Steps to Successful Breastfeeding in hospitals worldwide by the designation of a Baby-Friendly Hospital Initiative award. It is designed to remove hospital barriers to breastfeeding by creating a supportive environment with trained and knowledgeable health workers.
    A proud hospital!

    A proud hospital!


    Ten Steps to Successful Breastfeeding

    Every facility providing maternity services and care for newborn infants should:

    1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
    2. Train all health care staff in skills necessary to implement this policy.
    3. Inform all pregnant women about the benefits and management of breastfeeding.
    4. (Help mothers initiate breastfeeding within a half-hour of birth.) Place babies in skin-to-skin contact with their mothers immediately following birth for at last an hour and encourage mothers to recognize when their babies are ready to breastfeeding, offering help if needed.
    5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
    6. Give newborn infants no food or drink other than breastmilk unless medically indicated.
    7. Practise rooming-in - allow mothers and infants to remain together - 24 hours a day.
    8. Encourage breastfeeding on demand.
    9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
    10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
    Source: 1989 WHO/UNICEF

    Baby Friendly communities

    To continue the best practices initiated in the hospital situation, and to provide supportive care to the mother, UNICEF/BFI United Kingdom developed best practice standards for the community. The Seven-point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Services follows the same principles as the Ten Steps to Successful Breastfeeding. The emphasis is to ensure consistency of advice for mothers and continuity of care when care is passed from maternity to community services.
    Community facilities who acquire the Seven-Point Plan Award are often referred to a "mother-child friendly" or "breastfeeding-friendly".

    Seven-Point Plan

    The 7 points in summary are:

    1. Have a written breastfeeding policy that is routinely communicated to all health-care staff.
    2. Train all staff involved in the care of mothers and babies in the skills necessary to implement the policy.
    3. Inform all pregnant women about the benefits and management of breastfeeding.
    4. Support mothers to initiate and maintain breastfeeding.
    5. Encourage exclusive and continued breastfeeding, with appropriately-timed introduction of complementary foods.
    6. Provide a welcoming atmosphere for breastfeeding families.
    7. Promote cooperation between health-care staff, breastfeeding support groups and the local community.

    Source: 2001 UNICEF/BFI UK

    Does Baby Friendly Work?

    • UNICEF, in 1999, reported widespread increases in rates of breastfeeding in urban areas, reductions in respiratory infections and diarrhea in infants, and savings in terms of both costs and staff time when BFHI is implemented.
    • USA - Baby-Friendly designated hospitals have elevated rates of breastfeeding initiation and exclusivity. Elevated rates persist regardless of demographic factors that are traditionally linked with low breastfeeding rates. 1
    • China - after 2 years of implementation of the Ten Steps, exclusive breastfeeding rates doubled in rural areas and improved from 10% to 47% in urban areas.
    • Cuba - exclusive breastfeeding rates increased from 25% in 1990 to 72% in 1996. 2
    • Scotland - babies born in a Baby-Friendly accredited hospital were 28% more likely to be exclusively breastfed at 7 days of postnatal age than those born in other maternity units. 3
    • UK - in a 2 year period of mandatory BFI training of health visitors and nursery nurses resulted in a 1.57 times increased likelihood of an infant being breastfed at 8 weeks. 4
    • New Zealand - Exclusive breastfeeding rates at discharge from hospital increased from 55.6% (2001) to 84.4% (2011). 96.1% of New Zealand hospitals now hold BFHI accreditation.5

    Becoming accredited

    To receive the Baby Friendly designation a hospital or community health unit will have fully embraced all of the Steps or Points, as well as adhere to the International Code on the Marketing of Breastmilk Substitutes. Achievement of the criteria will be assessed by a team of trained assessors who will make observations, view charts and feeding records and speak with mothers and the unit's staff.

    Workbook Activity 9.4

    Complete Activity 9.4 in your workbook.

    Poster Promotion

    Gather a small working group to collect appropriate photos (or obtain permission from mothers to photograph them and their babies) which could be made into a poster for each of the Ten Steps or each of the Seven Points.

    Display the posters in strategic areas in your workplace.

    What should I remember?

    • The significance of the landmark Innocenti Declaration on the protection, promotion and support of breastfeeding.
    • An understanding of the purpose of the Baby-Friendly Initiative.
    • The application of each of the Ten Steps or Seven Points to my work practice.

    Self-test quiz

    Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column

    Notes

    1. # Merewood A et al. (2005) Breastfeeding Rates in US Baby-Friendly Hospitals: Results of a National Survey
    2. # Philipp BL et al. (2004) The Baby-Friendly way: the best breastfeeding start.
    3. # Broadfoot M (2005) The Baby Friendly Hospital Initiative and breast feeding rates in Scotland
    4. # Ingram J et al. (2011) The effects of baby-friendly iniatiative training on breastfeeding rates and the breastfeeding attitudes, knowledge and self-efficacy of community health care staff.
    5. # Martis R et al. (2013) The New Zealand/aotearoa baby-friendly hospital initiative implementation journey: piki ake te tihi--strive for excellence.

    9.3 Young Child Feeding

    The Global Strategy for Infant and Young Child Feeding was endorsed by the World Health Assembly in 2002. The aim of this strategy is to improve, through optimal feeding, the nutritional status, growth and development, health, and thus the survival of infants and young children.

    "Malnutrition has been responsible, directly or indirectly, for 60% of the 10.9 million deaths, which are often associated with inappropriate feeding practices, occurring during the first year of life.....malnourished children who survive are more frequently sick and suffer the life-long consequences of impaired development."1,2

    The strategy's specific objectives are:

    • to raise awareness of the main problems affecting infant and young child feeding, identify approaches to their solution, and provide a framework of essential interventions;
    • to increase the commitment of governments, international organisations and other concerned parties for optimal feeding practices for infants and young children;
    • to create an environment that will enable mothers, families and other caregivers in all circumstances to make, and implement, informed choices about optimal feeding practices for infants and young children.
    The document acknowledges these important background principles:
    • Inappropriate feeding practices and their consequences are major obstacles to sustainable socioeconomic development and poverty reduction.
    • Mothers and babies form an inseparable biological and social unit; the health and nutrition of one group cannot be divorced from the health and nutrition of the other.
    • Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; infants should be exclusively breastfed for the first 6 months to achieve optimal growth, development and health.
    • Infants are vulnerable during the transition period when complementary feeding begins. Nutritional status needs to be maintained by complementary foods which are timely, safe, adequate and properly-fed.
    • Infants and children are among the most vulnerable victims in natural and human-induced emergencies. Interrupted breastfeeding and inappropriate complementary feeding heighten the risk of malnutrition.
    Note also that this document also states the hierarchy of feeding options as you have learned in Topic 7.3 and 7.5.

    Source: Global Strategy for Infant and Young Child Feeding, WHO 2003

    Workbook Activity 9.5

    [link: http://www.who.int/bookorders/anglais/detart1.jsp?sesslan=1&codlan=1&codcol=15&codcch=510]

    Does your Unit have a copy of this document?[link: http://www.who.int/bookorders/anglais/detart1.jsp?sesslan=1&codlan=1&codcol=15&codcch=510]

    If your Unit does not have a copy of this document it can be obtained, for a small cost, from the World Health Organisation website. Click on the icon to be taken to the order form. While at the website order Implementing the Global Strategy for Infant and Young Child Feeding at the same time - it is a free publication.

    Alternatively, you could download the Strategy for no cost from PDFthe World Health Organisation website.[link: http://www.who.int/nutrition/publications/gs_infant_feeding_text_eng.pdf]

    Global Strategy for Infant and Young Child Feeding

    Global Strategy for Infant and Young Child Feeding

    What should I remember?

    • To ensure my workplace has a copy of the Global Strategy for Infant and Young child feeding.
    • The aim of the Global Strategy for Infant and Young Child Feeding
    • The 3 specific objectives outlined that will achieve the aim
    • Consider your role in the implementation of this strategy in your place of work

    Notes

    1. # World Health Organisation (2003) Global Strategy for Infant and Young Child Feeding
    2. # Gupta A. (2006) Infant and young child feeding: an optimal approach.

    9.4 Local initiatives

    Breastfeeding in public

    Baby Friendly Point 6

    Point 6 of the Seven-point Plan for Sustaining Breastfeeding in the Community states:
    Provide a welcoming atmosphere for breastfeeding families

    The health care facility should welcome breastfeeding in all public areas and this should be indicated by appropriately worded signs. Suitable facilities should be available for mothers who prefer to feed in privacy.

    Reception staff should be aware that mothers are welcome to breastfeed in all public areas and be able to describe how they would advise a mother who wished to feed in privacy.

    The normal act of breastfeeding seen in public

    Many States, Provinces and Countries have now passed legislation which makes it illegal for anyone to discriminate against breastfeeding mothers. Mothers are free to meet their infant's needs by breastfeeding at any place where it is appropriate to have a child.

    Does your community health unit make it explicitly clear that breastfeeding is welcomed in all public areas? Do you have an area set aside should a mother prefer to breastfeed in privacy?

    Encouraging mothers

    Encouraging mothers

    Support

    Support

    Take a walk

    Go for a walk around your hospital or community health centre. Are there obvious signs in all the public areas making it clear that mothers may breastfeed in any them, AND referring her to a private area should she prefer it?

    If not design your own signs and display them until the organisation develops 'official' signs.

    Supporting mothers in the community

    Baby Friendly Step 10 and Point 7

    Step 10 of the Ten Steps to Successful Breastfeeding, and Point 7 of the Seven-point Plan for Sustaining Breastfeeding in the Community state:
    Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
    Point 7: Promote co-operation between health care staff, breastfeeding support groups and the local community.

    Attendance at mother-to-mother support groups or follow-up by peer counsellors has demonstrated significant increases in maintaining exclusive breastfeeding. 1,2 The peer counsellor role is unique from a health professional role in that it brings a mother together with another mother - the experienced can share with the new, the new can be supported and learn from the experienced. 3

    A report on the effects of implementation of the Baby Friendly Hospital Initiative (BFHI) and community postnatal support on breastfeeding rates indicated an increase in breastfeeding at one month of age in the BFHI group compared to the control. 4 However, once breastfeeding support groups activity increased, breastfeeding at 6 months and 12 months was significantly increased.

    Unit Activity

    Gather a small group together to list all of the breastfeeding support organizations in your community, both mother-to-mother and professional organizations.
    Ring each group and update your list with the name and phone number of the appropriate contact person. Request some of their brochures that can be distributed to the mothers on discharge from hospital.
    • All breastfeeding mothers should know which professional(s) to contact for breastfeeding support and how to access this help.
    • All breastfeeding mothers should know how to contact a breastfeeding counsellor or support group for help with breastfeeding.
    • All breastfeeding mothers should know how to access help with breastfeeding outside surgery/office hours.
    • Relevant staff should be able to describe a procedure which ensures that information on the progress of breastfeeding is passed on during the handover of care between hospital and community.
    • Mothers should demonstrate an awareness that such a procedure exists.

    What procedures does your unit have in place to meet this standard?

    How is the availability of professional support and peer support communicated to mothers? Do you have a method of recording that mothers have received this information? How does your Unit encourage mothers to attend peer support organisations? If you are unsure of this could you form a group to look at what is done now, improve the procedure if necessary, and ensure the procedure is communicated to all staff at your Unit?

    If applicable, what handover procedures are in place between the birthing service and the community service?

    Peer support in unusual circumstances

    As a sign of the changing times Internet breastfeeding support groups can provide mother-to-mother support to those breastfeeding in unusual circumstances. 5,6

    Consider forming a small group to research online support groups with the goal being to produce reference material for staff when counselling a mother whose situation may be unique (eg. adoptive breastfeeding, breastfeeding after reduction mammaplasty, etc). Contacting the facilitator of the group to determine their goals and the way the group functions would help to determine if their goals are consistent with those of your organisation.

    You can't do it alone!

    Peer support offers mothers a different type of support to that given by health professionals. Both are needed by mothers and, working together, both will help her to give her baby the healthiest start in life.

    Engage the peer breastfeeding support organisations in your community.

    Engaging the Community

    Each year the World Alliance for Breastfeeding Action (WABA) promotes World Breastfeeding Week. World Breastfeeding Week (WBW) is the greatest outreach vehicle for the breastfeeding movement, being celebrated in over 120 countries. Officially it is celebrated from 1-7 August. However, groups may choose other dates to make it a more successful event in their countries.

    Each year a theme is chosen and WABA produces resource materials to assist groups and individuals to celebrate this event, raising community and media awareness of breastfeeding. This is an ideal opportunity for your Unit to celebrate breastfeeding and use the occasion to educate your community about breastfeeding.

    You will be able to get ideas and download resources from their website when they become available: ExternalWABA World Breastfeeding Week[link: http://worldbreastfeedingweek.org/].


    Logo for WBW 2007

    Logo for WBW 2007

    Logo for WBW 2010

    Logo for WBW 2010


    Have fun this year!

    Start now! Get a group together to plan activities and promotions (of breastfeeding and your wonderful unit!) during Breastfeeding Awareness Week.

    There are lots of resources available on the Internet and you could think up many others. This is an ideal opportunity to work with your local peer breastfeeding supporters too. Don't forget to involve the media in your celebrations.

    What should I remember?

    • Breastfeeding is the normal way to feed an infant, and a mother breastfeeding should be treated normally.
    • The importance of specifically welcoming breastfeeding mothers in public areas.
    • How breastfeeding support groups play a vital role in continued support for breastfeeding mothers.
    • That there are opportunities to become involved in breastfeeding promotion on a personal and professional level.

    Self-test quiz

    Notes

    1. # Hoddinott P et al. (2006) Effectiveness of a breastfeeding peer coaching intervention in rural Scotland
    2. # Chapman DJ et al. (2010) Breastfeeding peer counseling: from efficacy through scale-up.
    3. # Lewin SA et al. (2005) Lay health workers in primary and community health care.
    4. # Bosnjak AP et al. (2004) The effect of baby friendly hospital initiative and postnatal support on breastfeeding rates - Croatian experience
    5. # Gribble KD (2001) Mother-to-mother support for women breastfeeding in unusual circumstances: a new method for an old model.
    6. # Cowie GA et al. (2011) Using an online service for breastfeeding support: what mothers want to discuss.

    9.5 Infant feeding in emergencies

    The problem

    In a nutshell the problem is to provide ongoing food security for everyone involved.

    Some emergency nutrition situations can be anticipated, eg famine and war; however, the majority can not. Earthquakes, floods, tsunami, fire, cyclones, hurricanes and tornadoes happen quickly and with little warning or time to prepare. During or following such an event there may be:
    • no clean drinking water
    • no clean area for food preparation
    • no supplies to clean or sterilize feeding utensils
    • no refrigeration

    Donations of baby foods and breastmilk substitutes in situations such as this is dangerous and can do more harm to the infants than good.

    The solution for the breastfed infant

    Providing food to the mothers of infants less than a year old, and giving them support to breastfeed their infant is the best way to protect the infant from malnutrition and diseases, and ease the trauma they have experienced.

    Some frequently asked questions

    Question: Does a mother lose her milk supply when she is in a stressful situation?
    Answer: Stress will not stop the mother producing milk; however it may delay her milk ejection. If a quiet area can be set aside for mothers to breastfeed, with reassurance and support offered, the suckling of the infant will elicit the milk ejection.
    Question: Won't stress or trauma cause the mother's milk to be unsuitable?
    Answer: The composition of a mother's milk will always be perfect - it is not possible to make 'weak' or 'spoiled' breastmilk.
    Question: Could a mother's milk become contaminated?
    Answer: If the infant is suckling directly from the breast there will be no contamination from infectious organisms in the environment. Even if the mother has diarrhea or other infections acquired as a result of the emergency situation these will not be passed via breastfeeding to her infant.

    Learning from experience

    Following the 2010 Haiti earthquake it was expected that disruption of breastfeeding would lead to increased infant morbidity, malnutrition and mortality.

    Baby Tents were set up in affected areas where pregnant women and all mothers, whether breastfeeding or artificially feeding, were provided with support and a safe place for mothers to breastfeed or receive ready-to-feed infant formula. Over 180,000 mother-infant pairs were cared for.

    Support for breastfeeding was strong and many women who were 'mixed' feeding converted to full breastfeeding. With this support only 13.5% of infants were not breastfed, breastfeeding practices were not disrupted and the fears for infant health were nearly abolished. 1

    Helping a mother to breastfeed in a Baby Tent

    Helping a mother to breastfeed in a Baby Tent

    The solution for the artificially fed infant

    Artificial feeding in these situations is difficult and increases the risk of malnutrition, disease and infant death. The resources required to provide safe nutrition to artificially fed infants may be scarce. They include:
    • an ongoing source of a safe infant formula, and safe storage for it
    • utensils for the preparation of the infant formula, and bottles and teats for feeding
    • an ongoing source of clean drinking water
    • fuel to heat the water to a safe temperature for formula preparation
    • the ability to thoroughly clean all the preparation and feeding utensils

    In crisis affected areas where an imminent end is not in sight, assisting mothers to relactate could be the only solution.

    What can you do to help?

    • Protect, promote and support breastfeeding for all infants for at least the first two years of life, with the addition of suitable complementary foods from six months of age. Breastfed infants are in a much more secure situation should an emergency strike.

    • Discourage the public from donating infant formula at these times as it is likely to cause more morbidity than it prevents.

    • If you are in a position to, volunteer your services to provide support, encouragement and information to the breastfeeding mothers caught in the emergency; and education to the other relief workers.

    • Know how to assist a mother to relactate should it become necessary.

    • Discuss with ALL parents emergency preparedness for themselves and their children. Encourage them to have an emergency plan and kit always ready.
    [link: http://www.internationalbreastfeedingjournal.com/content/6/1/16]

    Emergency preparations parents can make[link: http://www.internationalbreastfeedingjournal.com/content/6/1/16]

    Click on the icon, save and print the paper, "Emergency preparedness for those who care for infants in developed country contexts".
    Read the paper, provide copies of it for your colleagues at your place of work, and discuss how you can ensure that this very important message is given to all parents who access your care.

    What should I remember?

    • emergency situations are usually unexpected, with little or no time for preparation
    • breastfeeding provides the best food security for infants
    • artificially fed infants require a lot of care and resources to ensure their safety
    • parents are unlikely to be prepared for an emergency if there is not a procedure in place to educate them

    Assessment Quiz

    When you are happy that you've understood all the information in this module you will be ready to complete the Module 9 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 9.

    Notes

    1. # Ayoya MA et al. (2013) Protecting and improving breastfeeding practices during a major emergency: lessons learnt from the baby tents in Haiti.

    10.0 Closing session

    Thank you for participating in Breastfeeding Essentials. We hope you have found it thought provoking and interesting, and that it has revitalised your desire to provide the best care for mothers and babies.

    The key points of the course are

    • Breastfeeding is important for the health and well-being of mothers and babies.
    • Most mothers and babies can breastfeed.
    • Hospital and community health practices have a significant impact onthe 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 mothers and babies.

    Have you completed everything?

    Skills competencies

    Four competencies

    There are four Skills Competencies for you to complete. You'll find each of them linked to the relevant course content at the topics listed below, as well as linked here (click on title of box).

    Module 3.0: Communicating with pregnant women about breastfeeding.
    Module 5.3: Observing, assessing and assisting breastfeeding.
    Module 6.1: Hand expressing and safe milk storage.
    Module 7.5.4: Teaching formula preparation and feeding.

    Nine assessment quizzes

    Your certificate.

    Have you passed all 9 of the Assessment Quizzes yet? If you have “Congratulations!” You can now collect your Certificate and display it at your place of work.