Getting Off to a Great Start in Conflict of Interest Challenging • Founder and President of The Mob Situations • I have no financial interest in any of the devices or resources in this presentation.

Anne Eglash MD, IBCLC, FABM Clinical Professor Dept of Family and Community Medicine University of Wisconsin School of Medicine and Public Health

Objectives Reviewing • Explain 3 interventions that promote Basics immediately postpartum. • List 2 reasons for a delay in during the first week postpartum. • Describe 3 strategies to help who develop sore in the hospital. • Recite 2 reasons for newborn jaundice. • Describe 4 reasons for screening for hypoglycemia postpartum.

BABY-FRIENDLY HOSPITAL INITIATIVE (1991) Early Skin-to-Skin TEN STEPS TO SUCCESSFUL Contact BREASTFEEDING AAP 2016 Every facility providing maternity services and care for newborn infants should: • Cardioresp stabilization 1. Have a written breastfeeding policy that is routinely communicated to all • Decreased pain in newborn health care staff. 2. Train all health care staff in skills necessary to implement this policy. • Improved growth 3. Inform all pregnant women about the benefits and management of • Improved autonomic, GI, and breastfeeding. neurobehavioral adaptation 4. Help mothers initiate breastfeeding within the first hour of birth. • Improved thermoregulation 5. Show mothers how to breastfeed, and how to maintain lactation even if they • Prevents hypoglycemia should be separated from their infants. 6. Give newborn infants no food or drink other than breastmilk unless • Decreased crying medically indicated. • Increased maternal affectionate 7. Practice rooming in - allow mothers and infants to remain together - 24 hours love/touch a day. • Decreased pp hemorrhage 8. Encourage breastfeeding on demand. • Decreased maternal cortisol and 9. Give no artificial teats or (also called dummies or soothers) to depression breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers • More organized breastfeeding to them on discharge from the hospital or clinic. • Increased breastfeeding exclusivity

AAP 138(3) Sept 2016 Source: The United States Breastfeeding Committee

1 COMPONENTS OF SAFE POSITIONING FOR SUPC – Sudden Unexpected THE NEWBORN WHILE SKIN-TO-SKIN

Postnatal Collapse  Infant’s face can be seen  Infant’s head is in “sniffing” position  Infant’s nose and mouth are not covered • Occurs in 38/100,000 live births (Pejovic & Herlenius,2013) • 1/3 in first TWO hours  Infant’s head is turned to one side  Infant’s neck is straight, not bent • 1/3 in first TWO Days  Infant’s shoulders and chest face • 1/3 in 2-7 days  Infant’s legs are flexed  Infant’s back is covered with blankets • About 90% can be prevented by  Mother-infant dyad is monitored continuously by staff in the delivery environ educating moms, families and staff and regularly on the postpartum unit  When mother wants to sleep, infant is placed in bassinet or with another support person who is awake and alert

AAP Pediatrics 138(3) Sept 2016

Importance of Timing of First Feeding for Term infants • 5-10ml/side/feed • Ideally within first hour after birth • Babies nurse q1- • Delay bath, weight, eye oint 3hr • Early initiation of nursing assoc • Weight loss is nl with: • 5-10% – Greater breastfeeding duration • Freq feeding leads – Higher volumes by day 5 – Early onset of lactogenesis II to higher volumes • If no nursing by 72 hours, supply faster is at risk

ABM 2013, Parker 2015

Lactogenesis After Birth

Gradual increase in fluid, flow, oxygen, Colostrum glucose, become fuller High in WBCs, Placenta betacarotene, protein, delivered, vits, Ig (pus) hormones fall

2 Getting Started Feedback First Few Days of Breastfeeding Inhibitor of Lactation • Infants feed 10-12x/day – All suckling needs at the • Teach mom to focus on Engorgement baby, not visitors! Decreased demand – Feeding cues Poor infant feeding • No pacifiers or supplements unless MILK SUPPLY medically indicated • Cracked, bleeding Frequent feeding nipples not normal Complete emptying • Avoid shields

Removal is important!

Sensory Stimulation Nipple Stim Fullness

Increased Increased Increased ) :

Serotonin ( :

Milk Increased Milk Decreased Letdown Production Milk

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Medications Given in the Hospital That Impact Milk Supply Maternal-Infant Separation

– Decongestants, ie Pseudoephedrine • Initiate manual expression within (sudafed) 1 hour after birth – Progesterone – Pumping within 1-2 hours after birth – Estrogen – Hands-on pumping regularly – Epinephrine • Skin-to-skin as often as possible – Antihistamines (Benadryl) • Lactation consultation for optimal – Aripiprazole (Abilify) pump instruction, milk storage – High dose steroids • Allow mothers to reside where – Placenta capsules infant is

17 18

3 Mothers with a History of Low Obesity, PCOS, Insufficient Supply DM, HBP, development Infertility

Milk never PP bleed, morbid came in obesity, retained postpartum placenta Lack of nipple stimulation Milk came in but mom lost her milk Lack of breast MOST COMMON emptying CAUSE Engage Lactation Services As Soon As Possible to be Proactive Maternal illness, medication

19 20

Little-No Breast Changes Insufficient Glandular Tissue in • Little tissue to develop • Not related to size of breast Little Breast • Possible causes: Change – Trauma to the breast bud • chest surgery, chest burn – Breast Surgery • Reduction, lumpectomy Insufficient Hormonal Glandular • Breast/chest radiation Interruption Tissue

Acquired PCOS, Congenital (ie surgery, Obesity, High radiation) Androgens 22

Dx of Delayed % Weight Loss and Supplementation Lactation

• Milk is not ‘in’ by day 2-3 for multip, 2-5 for primip • No breast fullness

• Excessive infant weight Source: United States Breastfeeding Committee loss • 7-10%- look at the whole picture • Obesity, Pre-, – If milk is coming in and baby feeding well, follow Gest DM, PCOS, closely metabolic syndrome, & – If no milk on the horizon, follow VERY closely stress at higher risk • 12%- advise supplementation unless feeding has

23 improved greatly

4 Consider Manual Expression Management of Delay in Lactation During Labor

• Nurse first for each feeding • Hands on pumping after nursing • Supplement the baby after nursing – Best at the breast – Mother’s own milk, donor milk, formula • Anything else better to do?

• Follow-up within 24 hours Source: United States Breastfeeding Committee • Express colostrum for supplementation prn post discharge • May aid labor process • Consider galactogogues after 5-7 days • Lots of time to practice 26

Recommended Methods of Supplementation ABM Protocol Revised 2017 • Bottles, cup, syringe, dropper, spoon, finger, tube at breast All Mammals Make More • No supplemental method is considered unsafe Milk the Next Time • When hygiene is suboptimal, cup feeding is preferred • Avoiding bottles might help the infant return to bfeeding • No clear optimal supplementation method – Consider cost, ease of use, availability, speed, stress, duration of use, family preference

The Newborn Who Won’t Milk Never ‘Comes In’ Almost no drops of milk in the first 7-10 days

• Medical evaluation – Cortisol, TFTs, PRL, Testosterone, HCG • DDx – Pituitary insult – Retained placenta – Theca lutein cyst • Mothers desire dx/etiology

5 Bottle If Infant Does not preference Nurse Early PP

Non- • Manual expression of colostrum Sleepy Low milk and/or – Expression within first hour has greatest predictor of latching supply premature sufficient milk Baby – Manual expression regularly the first 24 hours if infant is not nursing • Supplement expressed colostrum via spoon, or at the breast – Skin to skin as often as possible Anatomic – Avoid a nipple shield or motor issues Morton J et al 5-steps to Improve Bedside Breastfeeding Care: Proposal for a Shared, Sustainable, Proactive Model, 2013 AWHONN Nursing for Women’s Health 17(6) p.31 478

Skin to Skin for the Non- Latching Baby Why Not a Nipple Shield? Chest to Chest An easy fix Risks of decreased Bobs and Milk supply Pecks Milk transfer Need to pump after Moves Down To Breast nursing Does not teach nursing Roots and Latches

No Latch by Discharge Sore Nipples

• Hands on pumping q2-3 hours • Skin-skin – Infant-led latch • Quiet alert state • Infant feeding – Finger feeding – Cup feeding • Lactation referral

6 Myths re Sore Nipple Pain Nipples Starts Early

• Having to – 11-96% of have ‘toughen up’ nipple pain at • The baby some point having a strong – 43% with sore suck nipples at hospital D/C • Nursing the – 73-76% with sore baby too much nipples at 3 days or too long pp, with 19-26% having cracks

Source: United States Breastfeeding Committee

Position

Pregnancy Latch

Sore Nipples Dermatitis Trauma

Vasospasm Infections

Keys to Comfortable and A-traumatic Latch • Keep baby close • Baby is aligned properly – nose, bellybutton, knees – Facing Mom • Mouth is wide open • Mom’s body is well supported – Pillow in mom’s lap.

7 Engorgement

• Days 3-5 pp • Increased blood flow • • Difficult to latch • Freq feeding is preventive

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Edema Occurs in the Surrounding Tissues Outside of the Glands Treatment for Engorgement

• Sandwich the breast for a deep latch • Reverse pressure softening • Heat to improve flow before feeding • Lie on back and use cold compresses between feedings • Breast massage • Manually express milk to soften • Avoid switching to pumping • Teach re symptoms and management for every mother before discharge

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8 Ito 2014

Cracked Nipple Treatment

• Moist Wound healing – Don’t let nipple stick!! • Antibacterial ointment/coconut oil • Nonstick pad/parchment paper • Silver dressings • Decrease trauma – Most important- improve latch – Check for pump trauma – Teach how to break seal – Avoid prolonged nonnutritive sucking • Start with less sore nipple first • Hands on pumping if needed

2 Types of Jaundice Related to Breastfeeding Management for Jaundice of Breastfeeding the Term Healthy Infant – Lack-of-adequate breastfeeding jaundice – Rarely need to interrupt breastfeeding • 10-18% of fully bfed newborn lose >10% bw – Lack-of-adequate breastfeeding jaundice • Increased reabsorption of unconjugated bili simply requires more breastmilk from the gut – Breastmilk jaundice – Breastmilk jaundice • Often has a high early jaundice, needing • Adequate intake of calories lights • Prolonged jaundice • Will resolve on its own over time • Polymorphism of UGT1A1 • Introducing formula will hasten its resolution but this is not necessary

9 Screen Newborns Hypoglycemia with Risk Factors AAP, WHO, NIH • Symptoms of • Microphallus or midline hypoglycemia defect • For Healthy Term Infants: • SGA < 10% for wt • Suspected infection • LGA >90% for wt • Respiratory Distress • Routine BG checks are not necessary • Discordant twins, wt 10% • Known or suspected • Routine BG checks have negative

Infants < 36 mg/dl w/o Clinical Sx Buccal Dextrose Gel

• Continue breastfeeding (~ every 1–2 hours) OR feed 1–5 mL/kg of expressed breastmilk or substitute nutrition. • 40% gel applied to buccal mucosa (200mg/kg) • Recheck blood glucose concentration before subsequent • For asymptomatic infants with low blood sugar feedings until the value is acceptable and stable. • If the glucose level remains low despite feedings, begin • Less maternal-infant separation for treatment of intravenous glucose therapy. hypoglycemia • Breastfeeding may continue during intravenous glucose • Higher exclusive bfeeding rates at discharge therapy. • No noted adverse outcomes at 2 years corrected • NO evidence that treatment of asymptomatic hypoglycemic age infants is beneficial for neurocognitive outcomes

Cochrane Database 2016 May 4;(5) 58 ABM protocol 2014 bfmed.org; Mat Health, Neonatol, Perinatol 2:3 2016 57

For Symptomatic Hypoglycemia or < 25mg/dl Conclusions

• Initiate intravenous 10% glucose solution with a minibolus. • Screen mothers for red flags indicating risk of insufficient breast development • Do not rely on oral or intragastric feeding to correct extreme or clinically significant hypoglycemia. • Close attention to latch and positioning prevents • The glucose concentration in infants who have had clinical nipple trauma. signs should be maintained at > 45 mg/dL(> 2.5 mmol/L). • Delay in lactation is a common problem. If • Adjust intravenous rate by blood glucose concentration. supported, these mothers often do well with lactation. • Encourage frequent breastfeeding. • Families with a non-latching baby would benefit • Monitor glucose concentrations before feedings while from lactation specialty care. The prognosis is off the intravenous treatment until values stabilize good! off intravenous fluids. • Proper management of jaundice and low blood • Carefully document response to treatment. sugar can minimize harm to breastfeeding.

ABM protocol 2014 bfmed.org 59

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