LEC 6 Breastfeeding and infant feeding essentials

LEC 6 Breastfeeding and infant feeding essentials IBCLC · International Board Certified Lactation Consultant · A health care professional who is specialized in the clinical management of lactation · Certified by the International Board of Lactation Consultant Examiners · Some private insurance plans cover IBCLC consultation services · IBCLCs have: o Over 90 hours of accredited lactation education o Minimum 1000 hours of lactation support experience before writing the IBLCE exam o Have passed the IBLCE exam in order to obtain the IBCLC credential o Recertify every 5 years with minimum 75 hours accredited continuing education principles of family centred care · Mothers and babies are mutually interdependent units (dyads) · BF is the unequalled method of infant feeding · Respect parents informed choices o Remember: culture, personal experiences, knowledge, marketing, and attitudes all affect decision-making Goal: Support each dyad and their family to feed their baby the best possible way within their unique lived context WHO recommendations · Exclusive breastfeeding (BF) for the first 6 months of life for healthy, term infants with the introduction of nutrient rich complementary food at 6 months, and continued partial BF up to 2 years or beyond. · Daily Vitamin D supplement (until 1 year) à 400 IU/day "D-drops" · If weaned before 1 year- recommend iron-fortified Step 1 commercial infant formula (until 1 year) · Focus on introducing Iron rich foods at 6 months 6 months? · By 6 months, babies reach several growth and developmental milestones indicating that they are ready to begin eating complementary foods: o Gut closure - maturation of the gut o Ability to sit up on their own o Tongue protrusion reflex has subsided ways to feed an infant · Exclusive Breastfeeding (optimal - recommended) · Breast Milk/Expressed Breast Milk (EBM) o Pumping (EBM) o Donor milk o Cup feeding, spoon feeding, supplemental nursing systems (SNS) o Bottles o NG tube o Informal milk sharing · Mixed Feeding (partial breastfeeding) · Formula Feeding · Cross Nursing and Wet Nursing language is important · Careful using the word natural · Remember: o Breastfeeding is a learned skill between 2 people (one of whom hasn't read the books, websites, blogs, pamphlets, and the other may have specific expectations) o What is normal for one dyad may be very different from what is normal for another. o What is best for one dyad may not be the best for another. breastmilk · Human milk is so much more than nutrition! o Commercial Infant Formula o Breast milk / Human milk properties of breastmilk · Composition of milk changes over time to meet the nutritional and immunological needs of the infant · Enhances the maturation of the GI tract/gut microbiome · Contains anti-infective and nutritional components, growth factors, enzymes that aid in digestion and absorption of nutrients, and fatty acids for brain development · Contains immunologically active components - provide some protection against a broad spectrum of bacterial, viral, and protozoan infections. · Major immunoglobulin (Ig) in human milk is secretory IgA (sIgA). Human milk also contains IgG, IgM, IgD, and IgE · Also contains T and B lymphocytes, epidermal growth factor, cytokines, interleukins, bifidus factor complement (C3 and C4), and lactoferrin- all help prevent bacterial and viral infections human milk for human babies · Human milk is the biological norm for human babies. · Every mammal has milk adapted to its infant's needs. · Our closest mammal cousins, chimpanzees and gorillas are "carry" mammals. Their infants are constantly carried and feed very often. The macronutrient composition of their milk is reflective of this. · Mature human milk: o 87-88% water o 7% carbs o 1% protein o 3.8% fat o Some variation with factors, such as gestational age of infant, timing of feedings, maternal health, etc. · Advantages of breastfeeding vs. risks of not breastfeeding. Why does this matter? advantages of breastfeeding for baby · Reduced infant morbidity and mortality · Decreases the risk of SIDS · Decreases risk of gastroenteritis, celiac disease, Chron disease, necrotizing enterocolitis in preterm infants, and obesity in childhood, adolescence and adulthood. · Meets the nutritional requirements for every stage of development · Enhances cognitive development for term and preterm infants · Decreases risk of type 1 and 2 diabetes & certain childhood cancers, such as leukemia and lymphoma · Protests against otitis media, respiratory infections and illnesses, such as pneumonia, UTI, bacteremia and bacterial meningitis · Promotes healthy tooth and jaw development · Baby controls how much they drink at each feeding, no adult trying to make them finish the bottle even after they are full. · No risk of contaminated formula and optimal food available even in disasters. advantages of breastfeeding for mom · Helps control bleeding after delivery and uterine involution. · Helps body return to pre-pregnancy state (more rapid pp weight loss) · Reduces risk of certain types of breast cancer and ovarian cancer, rheumatoid arthritis, hypertension, hypercholesterolemia, cardiovascular disease, and type 2 diabetes. · Decreases risk of osteoporosis. · Mothers who breastfeed report feeling more rested than mothers who formula feed. · Decreased risk of PMD when BF difficulties are appropriately addressed · Easy on the budget and the environment. Less single use plastic waste. · Less likely to miss work for child getting sick. (Also reduced healthcare cost) · Is convenient and portable. No additional equipment needed. · Baby will always have food in case of disaster. · Less time consuming than formula feeding in the long run. contraindications of breastfeeding · HIV (maternal) - high income countries only o *In high income countries with reliable safe water source and consistent access to commercial infant formula, recommendation is to formula feed if there is confirmed maternal positive HIV status. · Active TB (maternal) - not in treatment · Herpes lesion(s) on breast (maternal) · Cancer therapy (maternal) · Diagnostic and therapeutic radioactive isotopes (maternal) (check half life of individual isotope for length of pump and dump option or need to wean) · Human T-cell leukemia virus type 1 (maternal) · Galactosemia-classic- (infant can't process galactose) *newborn screening* · Maternal substance use? (Guidelines for each substance, also consider unique situation) not contraindications of breastfeeding · Cytomegalovirus (CMV)- maternal **but is a contraindication for informal/unpasteurized breast milk sharing and for premature and sick infants · Hepatitis A or C (maternal) · Hepatitis B (maternal) · Fever (maternal) · HIV (maternal) in low income countries or where there is no safe water source and/or limited access or no access or ability to safely prepare commercial infant formula. Exclusive BF more safe than partial BF. common reasons for early BF cessation · Perceived insufficient milk supply (maternal) · Lack of breastfeeding support and social support o Care from ambivalent or unsupportive healthcare professionals · Lack of practical knowledge, including: o process of BF, newborn cues and normal behaviours, and how to deal with common issues of early BF · Inconsistent information · BF challenges, including: o sore nipples, difficulty with latching, thrush, mastitis, etc. · Low maternal self-efficacy related to BF breast anatomy · Fatty tissue: fills the space around the ducts and lobules · Alveoli: produce milk · Lobules: contain many alveoli · Ducts: carry breast milk to the nipple. There are 15-25 lactiferous ducts · Areola: dark circle of skin surrounding the nipple · Nipple: multiple outlets of milk ducts · Montgomery glands: small raised bumps on the areola that lubricate nearby tissue Rapid mamogenesis · (1st half of pregnancy): o Rapid growth of ducts & lobules, increase in epithelial cells (Progesterone and Estrogen) lactogenesis 1 · Secretory differentiation (2nd half of pregnancy to ~48-36 hrs PP): o 1st stage of milk production, epithelial cells change into milk producing cells (lactocytes), production of colostrum begins around 16 weeks gestation, & increased density of the mammary glands (Prolactin- inhibited by Progesterone & Estrogen and Prolactin-inhibiting factor (PIF - also known as dopamine)) o By birth, colostrum is produced in small but suitable quantities (2-20ml/feed) for newborn's needs. Newborn stomach capacity is approx. 5ml. lactogenesis 2 · secretory activation (48-72hhrs PP to 8 days): o Triggered by drop in Progesterone & Estrogen levels after delivery of placenta. Prolactin levels rise (no longer inhibited by PIF, Progesterone & Estrogen) o Increased Prolactin stimulates the alveoli to produce and secrete milk. o Junctions between alveolar cells close, & increased development of the alveoli and ducts o Rapid increase in milk volume that then levels off § Referred to as "milk coming in" o Can be ++ engorged and feel flu-ish lactogenesis 3 · Galactopoesis (~9 days PP to weaning/involution): o Maintenance stage o Shift from endocrine to autocrine control o Supply driven by demand o Milk production regulated by: § FIL (Feedback Inhibitor of Lactation): builds up when alveoli full - prevents uptake of Prolactin à when milk removed, concentration of FIL decreases, Prolactin uptake resumes, and production begins again § Prolactin receptors change shape/stretch as alveoli fill up with milk, disabling prolactin attaching to receptor, once milk is removed, the wall of the alveoli return to neutral and prolacin receptor is able to bind prolactin hormone to trigger milk production milk production · Frequent milk removal is essential for lactation maintenance and adequate milk supply to meet infant's needs. · Prolactin peak at night (dependant on progesterone & estrogen, insulin, oxytocin, thyroid, and parathyroid hormones) day 9 and onwards · First 2 weeks after birth is a time of rapid increase in milk volume, from drops of colostrum to appox. 750ml/24 hours. · Can take up to 6 weeks to establish and stabilize milk supply · 8-12 feeds/24 hours (until start of complementary solids at 6 months) · On average every 2-4 hrs (huge variation in what's normal) + cluster feeding · Output, weight gain, and infant development best indicators of feeds · Multiple, predictable growth spurts o Periods of cluster feeding o 2nd night, ~day 6, 2-3 weeks, 6 weeks, 3 months, and 6 months o Normal for BF patterns to change as baby develops stage 4 involution · Gradual apoptosis of milk-producing cells in the mammary gland occurs when weaning begins. Cell death begins within 2 days. The mammary gland returns to a pre-pregnancy state. The breast returns to being influenced by hormonal changes of the menstrual cycle · Usually a gradual process led by needs of mother and child beginning with the introduction of solid foods around 6 months · Involution occurs approx. 40 days after last breastfeed o Cessation of milk secretion. breast milk progression · Colostrum · Transitional milk · Mature milk colostrum · Thick, small amount · Can be yellowish, clear, white, brown ("rusty pipe") · Higher concentration of immune cells than mature milk · Rich in proteins due to a large number of immunoglobulins, fat soluble vitamins, and some minerals · Less fat and lactose than mature breast milk · Helps build immune system and establish a healthy microbiome · 2-20 ml/ feed (1st three days postpartum) · Newborns stomachs small (approx. 5 ml capacity) and kidneys immature · Natural laxative, helps clear meconium which has a high concentration of bile (reduces risk of jaundice) · Small volumes help to coordinate infant's suck-swallow- breathe pattern in the first few days. · Contains essential nutrients: including cholesterol for nerve myelination, and enzymes that aid with digestion, and also contains antibodies and antioxidants transitional milk · Milk volume gradually increases · Concentration of fat, lactose and the amount of calories gradually increases · Concentration of immunoglobulins gradually decreases · Gradually transitions to mature milk mature milk · Always changing to meet infant/child's needs · Foremilk: Higher concentration of protein, lactose, and water · Hindmilk: Higher concentration of fats- happens gradually throughout the feed- fat tends to increase as breast fullness decreases · Immunological benefits continue (lower concentration of immune cells than earlier milk - changes with maternal immune responses) · Teaching implication: o For baby to receive foremilk and hindmilk, encourage mothers to let baby drain first breast before offering the second breast. Start the following feeding on the breast on which the baby ended the last feeding in order to equally drain and stimulate both breasts. Baby will likely be more vogorous and drain the first breast more thoroughly than the second. This will ensure baby gets foremilk and hindmilk. prolactin · Hormone that stimulates milk production · Stimulates mammary glands to produce milk · Released from the anterior pituitary gland · Inhibited during pregnancy by Progesterone, Estrogen and Prolactin-inhibiting factor (dopamine) (PIF) · Levels rise with delivery of the placenta (P&E and PIF levels drop- Prolactin levels rise) · After ~ day 4 PP, Prolactin levels increase by baby's sucking, frequent removal of milk, and effective draining of breast oxytocin · Hormone for milk ejection reflex · Sends messages to the alveoli to release milk into ducts (milk ejection reflex {MER}) via contraction of myoepithelium around alveoli · Causes multiple MER during a feed (2-3X/ 45secs-3.5min long) · Released from posterior pituitary during labour, BF, skin to skin, orgasm, when thinking about baby, etc. · Sends messages to uterus to contract (decreases haemorrhaging and increases uterine involution) · Decreases cortisol levels = feelings of calm, well-being, and reduced stress in mother and infant 'Love or Parenting hormone' · Inhibited by stress review of early milk production · First days milk production is hormone driven (endocrine) · Within first 9 days, it becomes a demand and supply driven system (autocrine) · Prolactin and Oxytocin are the primary hormones responsible for production and release of breast milk respectively · Early, frequent, and effective milk removal is the #1 factor influencing establishment and maintenance of milk supply (i.e. BF on demand) prenatal BF support · Assess: o Breastfeeding goals o Breastfeeding history o Access to breastfeeding support o Breast examination (observation, palpation, pinch test for inverted/flat nipple, hx of breast surgery) o Medications and health history · Inform the mother and the family of the importance of early and frequent skin-to-skin contact after birth. · Provide education with evidence-based information on realistic expectations of what to expect in early weeks of BF. Support informed decision-making related to infant feeding. after birth BF support · Encourage the mother to position her baby skin-to-skin as soon as possible after birth and uninterrupted until after the first feeding unless medically contraindicated · Assist with recognition of early feeding cues, latching, and positioning, as needed · Lots of positive reinforcement for mom · Reinforce the need for frequent feedings of breast milk, at least 8-12 times per day (without medically unnecessary supplementation) · Encourage rooming-in · Always ask permission to handle breasts and baby first few hours BF support · Skin to skin (immediate and uninterrupted) - supports BF initiation · Allow mother and baby to get to know each other o Facilitate skin to skin ASAP after the birth. Encourage breastfeeding parent to continue to do skin-to-skin frequently with baby. · Help mother recognise her babies early hunger cues and attempts to reach her breast- gentle respectful teaching · Remember BF is a learned skill between two people o New moms need lots of encouragement and positive reinforcement of what is going well optimal habitat for baby · Immediate skin-to-skin after birth · Benefits of skin-to-skin: o Helps stabilize baby's temperature, breathing, heart rate, oxygen saturation and blood sugar. o Helps to calm baby and mom o Promotes bonding o Babies cry less when they are held skin to skin o Promotes release of hormones of lactation and stress-relieving hormones o Promotes healthy immune system for baby (skin microbiome, protective and especially important for babies in the NICU) 9 stages of readiness to feed · Birth Cry: Intense cry just after birth, transition to breathing · Relaxation: Rest. No activity of mouth, head, arms, legs or body · Awakening: BB begins to be active, small head thrusts up and down, side to side, small movements of limbs. · Active: BB moves head and limbs, rooting activity, pushing with limbs without shifting body. · Resting*: Rest. Some mouthing activity, such as sucking on hand. · Crawling: BB pushes, slides, leaps, throws themselves gradually towards the areola/nipple. · Familiarization: BB has reached the areola/nipple, sniffs, brushes, licks areola/nipple. · Suckling: BB has taken nipple in their mouth and begins suckling · Sleeping: BB closes eyes and falls asleep. separated BF support · If mother and baby are separated, encourage mother to begin hand expression or pumping and save EBM · Teach basics of hand expression, pumping and early breast care (including what to expect when milk comes in, managing edema, and engorgement) · Discuss importance of colostrum and that small amounts are normal - baby stomach capacity at birth is approx. 5ml or 1tsp. Drops are enough. · Provide emotional support to mother. Active listening. hand expression · Press. Compress. Relax. · No cost and no tools/infrastructure required · Very empowering/confidence building for mothers · Great for softening breast tissue to make easier latch or more comfortable mother (if breast edematous, engorged, help clear blocked ducts, mastitis, etc.) · Great to help stimulate MER for a sleepy baby infant cues BF support · Teach parents to recognize and follow her infant's cues · Principle of feeding often o 8-12 feeds/24 hours (approx. Q2-3h). Count from start of one feed to start of next. · Cue-Based, Responsive, on-demand BF o Offer breast when baby displays early hunger cues o Allow baby to finish the first breast before switching sides o Allow baby to feed until shows satiation cues · Teach signs of effective BF/Infant Feeding postpartum BF support · Assess mother's goals, expectations, and intentions and support her to meet these · Teach mother basics of breast care, self care, and hand expression · Lots of positive reinforcement/cheerleading · Provide health teaching on normal newborn behavior, normal output for age, and normal patterns of growth spurts and cluster feeds o Discuss the second night! (Keenan-Lindsay et al, 2022, p. 649) · Discuss community resources/supports for when family discharged newborn hunger cues · Early Hunger Cues: o Quiet alert state o Hand-to-mouth or hand-to-hand movements o Sucking motions/ smacking mouth motions o Rooting reflex o Mouthing o Flexed arms and legs with clenched fists held over chest and tummy (Arm flexion) · Late Hunger Cues: o Crying o Irritable, frustrated, fall asleep infant satiation cues · Slowed/ decreased sucking (even with breast compressions) · Release nipple, turn head away, arch away · Fall asleep o (Baby may wake after 15-20 min. and need "top-up" before falling asleep for longer period, due to effect of cholecystokinin (CCK), makes baby sleepy, relaxed and feeling of satiety after breastfeeding) · Relaxed body (extended limbs etc.) · Remember early feeds can be long - good if baby is feeding effectively · Teach mothers to watch their baby- not the clock (also great for maternal confidence) positioning · Ideally mother and baby are safe and comfortable · General guidelines: o Tummy to tummy (infant lying prone, mother semi-reclining) o Baby coming to breast, not breast to baby o Support baby's neck and head o Mother is comfortable and well supported o Eye contact is possible between mother and baby · Sandwich hold o C or U hold depending on BF position laid back breastfeeding o Lay back and get comfy. o Hold baby skin to skin, tummy to tummy with you, with their head between your breasts. o Support baby's back and bottom. o Allow baby to move towards the breast. o Support the breast with one hand as needed, fingers away from the areola. o Baby may touch the breast with their hand before trying to latch on. o Baby will dig in their chin and reach up and over to latch onto the breast. positions · Cradle · Cross-cradle · Football · Side-lying mother led latching o Get comfy. o Tune into your baby's cues and instinctive behaviours. o Hold baby tummy to tummy, nose to nipple o Use a sandwich hold and tickle baby's upper lip with your nipple o Wait until baby opens their mouth wide o Bring baby towards the breast (not the breast towards baby) o Continue to hold your breast in the sandwich hold until you feel baby suckling rhythmically. signs of a good deep latch · Breastfeeding is not painful. · Most of the areola is in baby's mouth, not just the nipple. · Baby's mouth is open wide (140 degrees) and lips are flanged outward (like a little duck) · Baby's chin touches the breast and nose is free or just touching the breast lightly. · More of the areola is visible near the baby's nose than under the chin. · Cheeks stay rounded, not sunken in. · No clicking or popping sounds with suckling. · Nipple is round when released from baby's mouth, not pinched. break suction · Break the suction of the latch by inserting a finger into the corner of baby's mouth at the breast before taking baby off the breast. · Essential teaching! effective breast milk transfer · Watch the baby & teach mom to watch the baby o Baby goes from quick, shallow sucks to slower deeper suckling pattern o Baby is swallowing when drop in chin and pause o Cawing sound (audible swallows) o May see milk around mouth o Baby relaxes into feed o Responds to breast compressions latch assessment · L (characteristics of latch-on) · A (degree of audible swallowing) · T (type of nipple) · C (maternal comfort) · H (holding skills) · Assessment with mother. Focus on strengths and practical interventions that assist with areas where the mother needs some extra help. signs of effective BF · Urine Output o Day 1-4: # wet diapers/day = days old (ex. day 3 = 3 wet diapers) o Day 5 onwards: 6 heavy, wet diapers/day (no uric acid crystals present, clear urine) · Bowel Movements (BM) o Day 1-2: 1-2 BM/meconium o Day 3-4: 3-4 BM/transitional greenish soft stool o Day 5 onwards: 3+ large, yellowish, seedy, soft BM normal newborn weight loss and weight gain · First 3 days: up to 7% weight loss is well within normal limits · Discuss supplementation after 10% weight loss (careful- birth weight not always accurate- 24 hr weight is a better baseline) · Day 4 onwards: gain of 20-35gr (~1oz)/day o What usually happens around day 3-5? · Regain birth weight by 10-14 days supplementation · Ideally only when medically indicated · EBM is usually the first choice · Medical Indications include: o 10% or more weight loss o Inadequate weight gain o Hypoglycemia o Still passing meconium at day 3-4 (or no stooling in 24hrs+ during first week) o Signs of dehydration or inadequate urine output o Maternal contraindications to BF · In case of supplementation, always implement action to protect the mother's milk supply, i.e. hand expression and pumping (10 min post BF) to ensure effective milk removal and adequate breast stimulation throughout duration of supplementation. consequences of unnecessary supplementation · Undermine mother's self-confidence · Shortened duration of breastfeeding · Exposure to potential allergens · Nipple confusion and breast refusal · Engorgement (short term) · Reduced breast milk supply (long term) · Sore nipples · Incorrect sucking patterns and ineffective sucking · Amount fed is larger than physiologic amount · Obesity (long term) factors with negative impacts on BF · Induction of labour · Labour interventions o epidural o Instrumental delivery (forceps and vacuum) o Birth injury, such as bruised clavicle, cephalohematoma, o C-section o IV fluids (1225 ml during labour associated with increased edema and BF difficulties, 7% wt loss (Sheehan et al., 2009)) · Separation of dyad (ex. separation after c-section, BB in NICU, not rooming-in) · Preterm or late preterm infant · Poor early BF support · Low maternal self-efficacy · Maternal medical history ex. insulin-dependent diabetes, PCOS, BMI 30, breast surgery. increasing or maintaining milk supply · Best way to increase and maintain milk supply is frequent on demand BF with a good latch, effective milk removal, and a baby who drains the breast. · Hand expression and pumping are useful tools to increase and maintain supply. rooming in · Higher exclusive BF rate with rooming-in, 81% vs 43% with partial rooming-in (Zuppa, 2009) · Infants in "well-baby nursery" more likely to be unnecessarily supplemented (Bystova, 2007; Flores-Huerta, 1997; Ward-Platt, 2002; Yamauchi, 1990) · Mothers sleep better and report feeling more rested with rooming-in (Montgomery-Dows, 2010; Quillen, 2004) promote rest · Teach side-lying BF position · Teach parents how to soothe their infants · Teach parents about normal infant behaviour patterns, normal for baby to wake frequently to feed. · Organize nursing activities to minimize intrusions · Provide resources for community support after discharge swaddling in LD and postpartum · Effects of swaddling babies in L&D: o Delayed feeding behaviours o Babies suckled less at first feeding o Established effective breastfeeding later (Moore & Anderson, 2007) o Swaddling and separation resulted in more infant weight loss (Bystrova, 2003) · Effects of swaddling on babies in the nursery: o Lowest temperature o Consume less milk o Lost more weight despite consuming more formula (Bystrova et al., 2007) routine tight swaddling at home · Greater risk of respiratory illness (Yurdakok, 1990) · Greater risk of hip dysplasia (Sahin, 2004; Van Sleuwen, 2007) · Greater risk of overheating (Van Gestel, 2002) pumping · Useful for increasing and maintaining milk supply · Essential to provide EBM for infants who cannot BF (ex. preemies, severe tongue tie, separation from mother, etc.) and to maintain mothers milk supply · Some mothers choose to exclusively pump · Pumping minimum 6X/day (or Q4hrs) ~ 15-20 minutes (until MER stops)- Hands-on pumping is best · Essential to pump at night (at least once at night) if aiming for full milk supply and to decrease risk of complications from milk stasis. · Can be frustrating and stressful at first- takes some practice · Need well-fitting flanges · Pump rentals/purchase can be expensive- get free short term loaner pumps from Ottawa Public Health Parenting in Ottawa (PIO) clinics/ & Home visits + LC support · Hospital-grade pump recommended during the 1st 6 weeks to establish milk supply if routinely replacing breastfeeding with pumping. o Hospital-grade dual electric pump o Symphony Dual Electric Pump o Hand pumps expressed breast milk · Average amounts/age (average ~750ml/day by 2 wks) o Birth to 24 hrs (drops colostrum or 10-15ml formula) o Gradual increase over 1 week: 30-60ml (8-12 feeds/day) o 1 to 2 weeks: 60-90ml o 2wks to 2 months: 60-150ml o 2 to 4 months: 120-180ml o 4 to 12 months: 150-240ml · Storage o Room temperature: ideally 3-4 hrs, 4-8 hrs still considered safe o Fridge: 3-8 days (healthy term baby) o Freezer: 3-6 months · Feeding o Alternative feeding methods: cup, spoon, SNS, finger feeding o Bottle § Paced bottle feeding § Supplemental Nursing System care of the BF mother · Mothers need: o To eat (BF uses ~500 calories/day) o To sleep (encourage mom to sleep when the baby sleeps) o To feel supported o Positive reinforcement of what is going well (strength-based approach) o Realistic information and appropriate interventions (listen to the patient) o To be supported to make informed decisions based on her unique situation- without judgement before discharge BF support · Review signs of successful breastfeeding (especially frequency, normal output, & signs of dehydration) · Provide information about community resources for breastfeeding support · Encourage frequent breastfeeding, especially for preterm and low-birth-weight infants · Reinforce the recommendation for exclusive breastfeeding for the first 6 months, with the introduction of complementary foods at 6 months and continued breastfeeding up to 2 years and beyond teaching points before discharge for baby · When all else fails, do skin to skin! · Encourage following baby's feeding cues. o Babies usually need to feed 8-12 times/24 hours. o It is normal for babies to feed at night. Night feeds are very important for establishing adequate milk supply. Prolactin levels are higher at night. · Output is a great way to assess BF at home (watch the wet diapers, 6+/day is good) · Review normal newborn behaviours in first days and cluster feeding during growth spurts. · Ask questions and get support (call 311 or look at for resources/help, La Leche League, IBCLC) key teaching points before discharge for mom · Moms need care too: healthy mom à healthy baby · Support families with whatever choices are best for them (all situations, families, moms, and babies are unique) · Feed the baby · Anticipatory guidance is essential common problems in early BF · Engorgement · Blocked Ducts · Nipple Pain · Mastitis · Thrush · Slow Weight Gain (infant) · Tongue Tie (infant) · Jaundice · Flat/Inverted Nipples engorgement · ~day 3-5 · Hard, full, hot, erythema, and shiny · Usually lasts ~24hrs · Management: o Effective and frequent draining of breast(s) (ideally BF, hand expression and pumping also effective) o Warm compresses, warm shower with breast massage to soften breasts before breastfeeding o Hand expression to soften breast to make latch easier o Cool compresses for comfort between feeds (15-20min on, 45 min off) o Tylenol or Advil prn for discomfort o If not BF- then hand express to comfort to keep breast healthy during involution. nipple pain · Usually due to poor positioning, latch issues, infection, and/or improper suck · Mild discomfort at beginning of feed common and normal · Severe pain, abraded, cracked, and/or bleeding is not normal · Can also be thrush, vasospasm or Reynaud's syndrome · Management: o Mild discomfort: express some milk onto nipple before feed o For all else: identify the cause and correct the issue (assess mom and infant) o #1 intervention is to correct the latch o Feed on least sore nipple first o If it hurts: reposition (break suction with finger) o Post feed EBM on nipple, lanolin or baby-safe nipple cream, hydrogel dressing o Assess infant for tongue-tie, assess for thrush. o **Nipple shields are NOT meant as "treatment" for painful nipples. Not recommended to use in first 24 hours and recommended to consult with IBCLC if considering use. plugged/blocked milk duct · Swollen, tender lump · Mother afebrile (if fever present, assess for Mastitis) · Usually the result of inadequate emptying of breast (tight and ill-fitting bras or tight seat belt can be an issue too) · Management: o Warm compress before BF and massage site during BF to encourage draining o Frequent feeding o Changing BF position. Point baby's chin to affected area. Creative positioning. mastitis · Inflammatory mastits or infective mastitis (infection in the breast) · Localized breast pain and tenderness, area red and hot · Infective: Sudden onset of flu-like symptoms (fever, chills, body aches, headache) · Management: o Rest, maternal self-care (ensure adequate food and fluids) o Effective draining of breasts, no extra draining (no extra pumping, this would worsen the issue) o Cool compress after and in between feedings. No warm compress, since this worsens inflammation (warm compress for mastitis is no longer recommended). o Antibiotics (if infective mastitis, no improvement after 24 hours or high fever is one of symptoms) BF duration · The immediate postpartum period, maternity staff (nurses) have the most influence on breastfeeding behaviours. · Neutral attitude towards BF from hospital staff is associated with not breastfeeding beyond 6 weeks. (DiGirolamo, 2003) · In the following weeks/months postpartum at home, support from the partner has the most influence on continued breastfeeding. partners role · Create and protect a supportive breastfeeding environment · Bonding time with baby · What can partners do? o Be at the birth o Help make mom comfortable. Make sure she has snacks and water when breastfeeding. o Assist with positioning, latch, hand expression. o Encourage mom she is doing a great job breastfeeding. Be her cheerleader! o Start a bath ritual with baby now. This can last for may years to come. o Take baby out for a walk. Give mom time to rest, nap, take a shower. o Do skin to skin with baby. Wear baby in a sling/baby carrier. o Bring baby to mom at night and change diapers. o Watch other kids o Keep intruders away o Do something nice for mom (change the sheets, make sure there is food in the fridge ready to eat) bonding time with baby · Take over bath time · Sing songs · Play with the baby · Babywear or do skin to skin · Attend any doctor visits · Give baby a massage · Read to the baby and tell stories · Bring baby to mom at night · Slow dance with baby · Make baby laugh · Learn baby's body language · Be a breastfeeding advocate infant formula safety · 3 types of formula o Ready-to-feed o Concentrated liquid o Powder · Basic cow's milk based formula is adequate for most formula-fed infants. o Soy-based not recommended unless followed by health care provider. · Stage 1 formula recommended for infants 0-12 months. No need for "follow-on" formulas or stage 2 and these are not recommended unless individually advised by a healthcare provider. professional help · Low milk supply or milk never "came in" (after 5 days) · Mother in need of intensive support when discharged home from hospital · Oversupply · Unrelieved engorgement · Nipple pain - bruised, cracked, bleeding, blistered nipples · Nipple tenderness beyond one week - Tenderness, redness, pain in one are of the breast · Regular supplementation with commercial preparation for infants · Poor weight gain or significant initial weight loss requiring supplementation · Nipple confusion - Breast refusal · Tongue-tie noted by care provider legal right to breastfeed in public · Parents have the protected legal right to breastfeed anywhere in public. · In Canada, it is illegal to ask a breastfeeding parent to vacate a premises because they are breastfeeding their baby or to ask them to feed her baby in the bathroom. · Parents can choose whether or not to use a covering. · Many locations have a breastfeeding room/space if parents would prefer breastfeeding in private. Ex. breastfeeding pods in airports, breastfeeding room at botanical gardens commercial infant formula safety · Important to follow recommended safe formula preparation method · Even if term infant with no elevated risk of infection, still best practice to sterilize equipment and water and add powder to water when it is still at least 70 degrees Celsius to kill as many contaminants as possible. · Important to follow manufacturer dilution instructions. · Teach parents to have at least 72 hours worth of ready to feed formula in case of loss of safe water source or loss of power. Ex. Ice storm. misinformation and marketing tactics · Beware of misinformation and propaganda funded by corporations with special interest in undermining parents' breastfeeding goals. These corporations spend billions of dollars annually on emotional, exploitative, aggressive marketing tactics. There are too many WHO Code violations to count because Canada has not integrate the WHO Code into law. · The WHO Code and BFI are protective for all infants, no matter how they are fed. o BFI ensures that nurses are trained not only to support breastfeeding, but also to teach parents who choose to feed formula how to do so safely. o The WHO Code protects parents from undue influence and false advertising from corporations that manufacture formula. · Social media influences, marketing baby boxes have replaced formula representatives and free formula samples being given out at the hospital upon discharge. These are incredibly misleading and detrimental to parents' breastfeeding self-confidence and self-efficacy. The phenomenon of the "just in case" formula sample. summary · Nurses make it happen! · Your actions have ripple effects. Make a commitment today to gain confidence in your skill-set because you have the opportunity in your role as a nurse to help the dyad, the mother, the family, to get breastfeeding off to a good start, to help them gain the information and the confidence they need in order to reach their breastfeeding goals when they go home. · It is our professional responsibility to give evidence-based information about infant feeding and facilitate informed-decision making. · Encourage parents to follow baby's feeding cues. Respond to the baby, not the clock. · If all else fails... remember skin-to-skin.