Breastfeeding Support and Promotion Joan Younger Meek, MD, FAAP AAP Section on Breastfeeding
Dec 18, 2015
Breastfeeding Supportand Promotion
Joan Younger Meek, MD, FAAPAAP Section on Breastfeeding
Management of Breastfeeding
• Breastfeeding initiation• Recommended breastfeeding
practices• Weight pattern• Hypoglycemia• Jaundice• Employment
Breastfeeding Promotion in Physicians’ Office Practices Curriculum
3 Key Educational Tools for Physicians to
Teach New Mothers
• Nutritional parameters• Hand expression• Latch and positioning
AAP Policy Statement
• Initiate in the first hour.• Keep newborn and
mother together in recovery and after.
• Avoid unnecessary oral suctioning.
• Avoid traumatic procedures.
AAP Pediatrics 2012;129:e827-841.
Recommended Breastfeeding Practices
• Skin-to-skin contact– Promotes physiologic
stability– Provides warmth– Enhances feeding
opportunities– Infant crawls to breast
and self-attaches
• Delay weights and measurements, vitamin K and eye prophylaxis until after first feeding
• Knowledgeable breastfeeding advocate in labor & delivery
Breastfeeding Initiation
Photo © Joan Younger Meek, MD, FAAP
AAP Policy Statement
•Avoid the routine use of supplements unless there is a true medical indication and the physician has ordered the supplement
•Avoid the use of pacifiers in healthy, term infants, until breastfeeding is well established (approximately 3-4 weeks of age)
Recommended Breastfeeding Practices:
Medical Indications for Supplementation
• Very low birth weight or some premature infants• Hypoglycemia that does not respond to
breastfeeding• Severe maternal illness• Inborn errors of metabolism• Acute dehydration not responsive to routine
breastfeeding or excessive weight loss• Maternal medication use incompatible with
breastfeeding
Academy of Breastfeeding Medicine Clinical Protocol #3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate.(www.bfmed.org)
AAP Policy Statement
• Encourage at least 8–12 feedings per day. • Alternate the breast that is offered first.• Allow infant to nurse on at least one side until
infant falls asleep or comes off the breast to increase fat and calorie consumption.
Feeding Pattern
Infant Assessment
• Weight Loss– Average loss of about 6% over the first 3–4 days.– Loss greater than 8-10% mandates careful
evaluation of breastfeeding.
• Weight Gain– Begins with increase in mother’s milk production by
at least day 4–5.– Expect gain of 15–30 g/day (1/2 to 1 oz per day)
through the first 2–3 months of life.
Infant Weight
Infant Assessment
• Problem– Inadequate milk supply or milk transfer.
• Solution– Weigh infant, feed infant, weigh again.– Evaluate infant at the breast.– Correct latch and positioning.– Improve milk production and transfer.– Increase frequency and duration of
feeding.
Poor Weight Gain
Infant Assessment
• Expect – 4-6 pale or colorless voids/day by day 4 – 3-4 loose, yellow, curd-like stools after most
feedings by day 4, continuing through the first month
• Constipation is unusual in the first month—may indicate insufficient milk intake. EVALUATE
• Infrequent stools are common after the first month in the healthy breastfed infant.
Elimination Pattern
Infant Assessment
• Proper positioning at the breast• Proper latch and lip closure• Sufficient areola in infant’s mouth• Tongue extends over lower gums• Adequate jaw excursion with suckling • Effective swallowing motion• Coordination of suck-swallow-breathe
Breastfeeding evaluation
AAP Policy Statement
• Formal evaluation of breastfeeding during the first 24–48 hours and again at 3–5 days of age
• Assess– Infant weight– General health– Breastfeeding – Jaundice– Hydration– Elimination pattern
Recommended Breastfeeding Practices
AAP Policy Statement
• Do not give water, juice, or solids in the first 6 months.
• Initiate iron supplements only if indicated clinically in the first 6 months.
• Include iron-rich foods or supplements after 6 months of age.
• Supplement with 400 IU vitamin D daily.• Provide fluoride after 6 months if
household water supply is deficient (< 0.3 ppm).
• Avoid cow’s milk before 12 months.
Recommended Breastfeeding Practices
Maternal Trouble Signs
• Nipple pain • Nipple trauma
Photo © Joan Meek, MD, FAAP
Neonatal Hypoglycemia
• No need to monitor asymptomatic low risk infants for hypoglycemia
• Routine monitoring of healthy term infants may harm the mother-infant breastfeeding relationship
• Early, exclusive breastfeeding meets the nutritional needs of healthy term infants and will maintain adequate glucose levels
AAP; World Health OrganizationAcademy of Breastfeeding Medicine
Neonatal Hypoglycemia
• Routine supplementation of healthy, term infants with water, glucose water or formula is unnecessary and may interfere with establishing normal breastfeeding and normal metabolic compensatory mechanisms.
• Healthy term infants should initiate breastfeeding with 30-60 minutes of life and continue feeding on demand.
AAP; World Health Organization; Academy of Breastfeeding Medicine
Maternal Trouble Signs
• Engorgement
Photo © Joan Younger Meek, MD, FAAP
Jaundice and Breastfeeding
• Infants <38 weeks gestational age and breastfed are at higher risk
• Systematic assessment of all infants before discharge for the risk of severe hyperbilirubinemia is warranted
• Provide parents with written and verbal information about newborn jaundice
• Provide appropriate follow-up based on the time of discharge and the risk assessment
AAP Subcommittee on Hyperbilirubinemia Clinical Practice Guideline: Pediatrics 2004; 114: 297-316.
Management of Hyperbilirubinemia
• Promote and support successful breastfeeding
• Perform a systematic assessment before discharge for the risk of severe hyperbilirubinemia
• Provide early and focused follow-up based on the risk assessment
AAP Subcommittee on Hyperbilirubinemia Clinical Practice Guideline: Pediatrics 2004; 114: 297-316.
Primary Prevention of Jaundice
• Recommendation 1.0– Clinicians should advise mothers to nurse their
infants at least 8 to 12 times per day for the first several days.
• Recommendation 1.1– The AAP recommends against routine
supplementation of nondehydrated breastfed infants with water or dextrose water.• “Supplementation with water or glucose
water will not prevent hyperbilirubinemia or decrease total serum bilirubin levels.”
AAP Subcommittee on Hyperbilirubinemia Clinical Practice Guideline: Pediatrics 2004; 114: 297-316.
Risk Assessment for Jaundice before Discharge
• Recommendation 5.1 – Before discharge assess risk for severe
hyperbilirubinemia• Every nursery should have formal protocol• Essential for infants discharged before 72
hrs• Best method: measure serum or
transcutaneous bilirubin in every infant before discharge
• Plot on Bhutani curve (perform at same time as metabolic blood sampling)
AAP Subcommittee on Hyperbilirubinemia Clinical Practice Guideline: Pediatrics 2004; 114: 297-316.
AAP Clinical Practice Guideline• Management of Hyperbilirubinemia in the
Newborn Infant 35 or More Weeks of Gestation
Nomogram for designation of risk in 2840 well newborns at 36 or more weeks’ gestational age with birth weight of 2000 g or more or 35 or more weeks’ gestational age and birth weight of 2500 g or more based on the hour-specific serum bilirubin values.
AAP Subcommittee on Hyperbilirubinemia. Pediatrics. 2004;114:297–316
Management of Breastfeeding Jaundice
Increase caloric intakeIncrease breastfeeding
frequency to 10–12 feedings/day
Increase duration of breastfeeding
Improve latch and positioning
Provide supplements only when medically indicated
Enhances milk production and transfer
Decreased enterohepatic reabsorption
Increased stool output
Lower serum bilirubin
Breast Milk Jaundice
• Definition – Begins after day of life 5–7– Increased bilirubin reabsorption from
intestine– Lasts several weeks to months
Breast Milk Jaundice
• Management – Avoid interruption of breastfeeding in
healthy term babies.– No routine indication for water or
formula supplementation.– If bilirubin >20 mg/dL, consider
phototherapy.– Rule out other causes of prolonged
jaundice.
Nursing Supplementation
Illustration by Tony LeTourneau
Milk Expression
• Wash hands before manual or hand expression.
• Use a good-quality electric pump for regular expression.
• Milk storage– Chill as soon as possible. – Refrigerate milk for up to 4 days. – Freeze for longer storage.
Milk Expression
Photo © Kay Hoover, MEd, IBCLC
Photo © Jane Morton, MD, FAAP
Return to the Workplace or School
• Continued breastfeeding is feasible and desirable for mother and infant.
• Prepare ahead by discussing with the employer or school personnel.
• Delay introduction of bottles until milk supply well established at 3–4 weeks.
Employed Mother
• Breaks for feeding/expressing
• Private, clean place to pump
• Refrigerator or cooler with ice packs to store and transport
milkIllustration by Tony LeTourneau
Workplace support
Adolescents and Breastfeeding
• Highly recommended for adolescent mothers• Prenatal education and postpartum support
are essential• Arrange with school personnel to express
milk at school or use on-site child care program, if available
• Maintain healthy diet with adequate calories, 1,300 mg calcium per day, 15 mg iron, and a daily multivitamin
Summary
• Breastfeeding is the preferred feeding for almost all infants.
• Skin-to-skin contact should be initiated immediately after delivery.
• Supplementation is rarely indicated and interferes with successful lactation.
• Good breastfeeding technique can help to minimize problems.
• Close follow-up in the early days and weeks is essential for breastfeeding success.