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2.4 Poor Attachment

Key Points - Case Study B

Joanne asks you what she can do before the baby is born to help her successfully breastfeed.

The Ten Steps to Successful Breastfeeding, designed by the ExternalWHO and ExternalUNICEF summarise the maternity practices needed to support and encourage breastfeeding.
Topic 2.1: Preparation Before Birth
Inform all pregnant women about the benefits and management of breastfeeding
Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?
Topic 2.2: Birthing Factors that Affect Breastfeeding
Labour analgesia and near-term birth
Topic 2.3: Management After Birth
Place Rosie in skin-to-skin contact; Encourage breastfeeding on demand; Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day; Give Rosie no food or drink other than breastmilk, unless medically indicated; Give Rosie no artificial teats or dummies; Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie.
Rosie is now 24 hours old. Although she seems interested in the breast, she is not attaching well and tends to slip off the breast easily. What is the most appropriate management to suggest at this time?
Topic 2.4: Poor Attachment
Investigate whether there an underlying reason; Maximize breastfeeding opportunities; Protect the milk supply; Feed the baby; Nipple shields may be useful.
Rosie is now 24 hours old. Although she seems interested in the breast, she is not attaching well and tends to slip off the breast easily. What is the most appropriate management to suggest at this time?
Investigate whether there is an underlying reason
Investigate whether there is an underlying reason why Rosie is having difficulty staying attached to the breast, including factors associated with the labor, birth and analgesia.1 Infants born to primiparous women, particularly if they have received analgesia during labour, are less likely to breastfeed effectively up to day 3 compared with other infants, although this difference is not significant by day 7.2 Other causes of ineffective breastfeeding may have more long lasting effects and need to be addressed as soon as possible.
For example flat or inverted nipples (See Case Study 1 and Case Study 4) or conditions that affect the infant's ability to create and maintain intraoral negative pressure such as ankyloglossia (See Case Study 4), a cleft palate, respiratory dysfunction or neurological or muscular problems require individual and specific treatment to ensure breastfeeding progresses well.
Maximize breastfeeding opportunities
Encourage skin-to-skin contact to capitalize on any innate reflex behaviours. Using a semi-reclined position for the mother, with the infant prone on her chest, optimizes normal feeding reflexes.3 Teach Joanne how to watch for early feeding cues and encourage her to initiate breastfeeding Rosie whenever she displays these cues.
Protect the milk supply
Encourage Joanne to express colostrum at least eight times a day if Rosie is not effectively feeding. Hand expression is often easiest when small amounts of colostrum are being collected, but an electric breast pump may be more effective as milk supply increases.4,5
Feed the baby.
Give Rosie expressed colostrum/milk with cup, spoon, dropper or syringe. Only small quantities are required in the first couple of days.6 but by day three infants consume on average 408ml/24 hours 6(approximately 50ml per feed for 8 feeds a day). If Rosie is still not feeding at the breast by that time and Joanne is unable to express enough to satisfy Rosie she may need to be supplemented with an alternative milk such as banked human milk or infant formula.7
Nipple shields
By providing a firmer surface to attach to nipple shields may be helpful for non-latching infants, especially if the nipples are flat or inverted.8 However, it is preferable to wait until at least day 3 by which time the milk supply has increased before suggesting their use.

Most infants are interested in attempting to breastfeed by 24 hours postpartum. Therefore, infants who are not interested require further evaluation to exclude other conditions such as sepsis, respiratory distress, hypoglycaemia, hypothermia or continued effects from maternal drug administration. However, the premise of feeding the baby and protecting the milk supply remain.

Notes

  1. # Smith LJ (2013) Why Johnny can\'t suck; impact of birth practices on infant suck. IN: Genna CW. Supporting sucking skills in breastfeeding infants.
  2. # Dewey KG et al. (2003) Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss
  3. # Colson S et al. (2008) Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding.
  4. # Flaherman VJ et al. (2012) Randomised trial comparing hand expression with breast pumping for mothers of term newborns feeding poorly.
  5. # Ohyama M et al. (2010) Manual expression and electric breast pumping in the first 48 h after delivery.
  6. # Saint L et al. (1984) The yield and nutrient content of colostrum and milk of women from giving birth to 1 month post-partum
  7. # Academy of Breastfeeding Medicine Protocol Committee (2009) ABM clinical protocol #3: hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009.
  8. # Wilson-Clay B (1996) Clinical use of silicone nipple shields