-FEEDING AND MATERNAL-CHILD HEALTH 3 CE hours

Learning objectives  Discuss issues pertinent to breast-feeding.  Review the anatomy of the breast.  Describe the physiological functioning of the breast.  Identify breast changes that occur during pregnancy.  Explain how to deal with and .  Discuss the benefits of breast-feeding for mother and child.  Identify the economic benefits of breast-feeding.  Identify the societal benefits of breast-feeding.  Discuss the barriers to breast-feeding.  Describe strategies for successful breast-feeding.  Offer suggestions for successful breast-feeding in public.

Introduction Chris is 32 years old and gave birth to her second child late last night. This morning, she tells Karen, her hospital roommate, that she is looking forward to breast-feeding her baby. Chris had a very positive experience breast-feeding her first child and she tells her roommate, in great detail, about the benefit to both mother and child of breast-feeding.

As Chris is speaking, a visitor arrives. The visitor’s name is Lisa and she and Chris have been close friends for years. Karen hesitantly tells both women that she had a very difficult time trying to breast- feed her first child. “My were so sore and I developed a terrible infection in them. I finally had to stop trying to breast-feed, so I don’t know if I should try again.”

Both Chris and Lisa express their disapproval, telling Karen that she “had” to breast-feed, and if she cared about her baby, she would not hesitate. Karen becomes tearful. At this point, a nurse arrives and gently but firmly puts an end to the confrontation.

The nurse helps Karen to her office and they have a lengthy discussion about breast-feeding and other feeding options. After the conversation, Karen asks the nurse for her help in breast-feeding the baby. “I really do want to try again, but I don’t need someone pressuring me and making me feel guilty.”

______Breast-feeding provides a multitude of benefits to both mother and baby. However, it is important to provide mothers with support, assistance and adequate education so the experience is positive for both mother and child. This includes discussing not only the benefits but also possible complications and how to deal with them. Persons involved in facilitating breast-feeding must remain objective and nonjudgmental. Although most women can successfully breast-feed, there are some exceptions. Consider the following scenario: Angela is a registered nurse who works on the obstetrics unit of a large community hospital. She loves her work, especially the patient/family education aspects of the job. Despite this, Angela sometimes

1 feels a bit wistful when she helps new mothers to breast-feed. Angela was not able to breast-feed her own child, something she desperately wanted to do.

Angela has had a life-long struggle with serious depression, and the medications she needs have the potential to harm babies during breast-feeding. After much discussion with her physician and husband, it was decided that the risk of stopping or changing her medications outweighed the need to breast-feed. Angela had not taken medications during her pregnancy, and it proved to be extremely difficult. In fact, it was so difficult that she and her husband decided not to have any more children.

Because of her own problems, Angela has developed a knack for helping women who have problems breast-feeding.

______

The preceding example shows that there are some circumstances that make it dangerous for mother and child if breast-feeding occurs. These kinds of circumstances can have devastating effects on women who want to breast-feed. Health care professionals need to provide empathy and support in such cases. Empathy and support are also needed as women make the choice to breast-feed in public places. Women may experience both support and disapproval if they choose to breast-feed in public.

Marlene is the mother of a 6-week-old baby girl. She is breast-feeding her new baby as she did with her first child, a little boy who is now 4 years old. With her first child, Marlene was not comfortable breast-feeding in public. Today, she is more confident and comfortable in her role as mother, and she often discretely breast-feeds her daughter in public.

This afternoon, Marlene is with both children at McDonalds. She begins to breast-feed her daughter. An elderly woman passes by and says, “What a lovely family you have.” A few minutes later, a woman about Marlene’s age stops and tells her, “You should be ashamed doing that in public and in a place where children can see you.”

______

The preceding scenario shows that breast-feeding in public can trigger a variety of emotions and behaviors, not all of them productive or appropriate. This education program deals with both the physiological and psychological issues pertinent to breast- feeding. It also addresses the emotions breast-feeding can trigger in family members and friends of the nursing mother and her baby, and even strangers. Anatomy and physiology of the breasts The breasts are paired mammary glands located on either side of the anterior chest wall over the greater pectoral and anterior serratus muscles. They are composed of glandular, fatty (adipose), and fibrous tissues. The breasts are supported by connective tissue. Fibrous bands called Cooper’s ligaments attach the breast to the chest wall and prevent breasts from sagging. The breasts of males and females are similar until puberty, at which time female breast tissue enlarges due to hormonal influences. Normally, the mammary glands function only in the female.2,8,13

2 The areola is the pigmented area of the center of the breast and contains elevated sebaceous glands called Montgomery glands. In the center of the areola is the , which contains erectile tissue that responds to sexual stimulation, friction, and cold.2,13 Each breast contains 15 to 25 lobes that are separated by fat and connective tissue. These lobes branch out around the nipple. The lobes are composed of clusters of acini, very small sac-like duct terminals that are responsible for the secretion of milk during lactation (secretion or production of milk by the mammary glands). 2,13 The ducts that drain the lobules come together to form the lactiferous excretory ducts and sinuses called ampullae. The ampullae store milk during lactation. The ducts drain onto the surface of the nipple through 15 to 20 pores.2,8,13 The female breast undergoes age-related changes in response to hormonal changes. At puberty, the pituitary gland, ovaries, and hypothalamus secrete hormones that stimulate the buildup and shedding of the endometrium during the menstrual cycle. These hormones are estrogen, progesterone, follicle stimulating hormone (FSH), and luteinizing hormone (LH). At puberty, the female breasts enlarge and mature in order to produce milk.2,8,13 The female breasts and reproductive structures are dependent on estrogen. As a woman ages, reduced levels of estrogen and progesterone lead to significant changes in these structures. The fatty, glandular, and supporting tissues of the breast . Cooper’s ligaments lose elasticity, causing the breasts to become pendulous. Over time, the become smaller and flat and ridges of the breasts become more obvious.2 Breast changes during pregnancy During pregnancy, the female breasts undergo changes in preparation for breast-feeding. During the first trimester of pregnancy, the amount of fatty tissue in the breasts increases as does blood flow to the breasts. These changes occur to promote growth of the mammary glands and the milk ducts. 2,9 As the breasts grow, they generally become tender and heavier. The nipples and veins of the breast become more prominent and the areola become larger and darker. Breasts may have a tingling sensation with changes in temperature. Women may find relief from some of the discomfort by wearing a less constricting bra and limiting sodium intake to reduce water retention.6, 9 Cotton bras allow the skin to “breath” and are usually more comfortable than those made from synthetic material. A maternity bra not only provides some relief from breast tenderness but includes extra rows of hooks so that size can be adjusted as breasts enlarge.6 Patient education alert! Although breast changes can cause discomfort, women should be advised not to take analgesic medications, even over-the-counter preparations, while pregnant unless specifically told to do so by their physicians. Medications have the potential to pass to the baby and adversely affect him or her. 9 During the second and third trimester, the breasts continue to enlarge but breast discomfort generally decreases. Stretch marks may appear on the breasts, and the Montgomery glands of the areola enlarge. There may be some leaking of colostrum, the precursor to breast milk, from the breasts. This leakage is normal. Disposable breast pads may be worn if leaking occurs. As the skin of the breasts stretch, it may become itchy. To reduce the itching, women may use a moisturizer after bathing and at bedtime. The breasts should be allowed to dry thoroughly after bathing and prior to applying moisturizer. Women should avoid using soap on the nipples and over the areola because soap can dry out skin and increase itching.6,9

3 Patient education alert! Females should be educated about the various changes in their breasts throughout the life cycle and during and after pregnancy. They need to know what is normal and what is abnormal. Knowledge of these issues will help women to implement proper breast self-examination. Physiology of lactation Breast milk is widely believed to be the best form of nutrition for neonates and infants.11 Lactogenesis, commonly referred to as milk production, involves all necessary steps for the production and excretion of milk from the mammary glands.11 The first stage takes place about the middle of a woman’s pregnancy. At this point, concentrations of the following substances increase in the glandular fluid:11  Lactose.  Total protein.  Immunoglobulin.

While these substances increase, concentrations of sodium and chloride decrease. The breasts are now prepared to secrete milk. By the fifth to sixth month of pregnancy, the breasts are making colostrum, which is thick and sometimes yellow in color. (Colostrum is the first breast milk that the baby receives after birth). At this point in the pregnancy, colostrum may leak from the breasts. However, high levels of progesterone and estrogen prevent most milk secretion and keep the volume of milk in check.11,16.18 The second stage of lactation takes place about the time of the baby’s delivery. It is characterized by profuse secretion of milk. Progesterone and placental removal play important roles in this stage of lactogenesis. The placenta is the source of progesterone during pregnancy. After the placenta has been expelled or removed from the body, the source of high circulating levels of progesterone is gone. This helps to facilitate milk excretion. The mother’s secretion of insulin, growth hormone (GH), cortisol, and parathyroid hormone (PTH) are also necessary for lactation.11 Lactation is dependent upon two hormones, prolactin and oxytocin. These hormones function independently and affect different cellular receptors. Prolactin “stimulates mammary glandular ductal growth and epithelial cell proliferation and induces milk protein synthesis.”11 Oxytocin is essential to the ejection of milk, also known as the letdown reflex. When the baby is placed at the breast and begins to suckle, oxytocin is released. Touch receptors located around the nipple and areola are stimulated, which in turn leads to stimulation of cells that line the breast ducts. When these ductal cells are stimulated, milk is expelled into the ducts and through nipple pores to the baby.11,18 The production of milk is related to the mother’s health and well-being. Stress, fatigue, and illness have an adverse impact on milk supply. Additional factors that affect lactation include problems such as mastitis and breast engorgement. It is important that mothers learn to recognize such problems and how to deal with them. Mastitis and breast engorgement Mastitis and breast engorgement are problems that may occur in lactating females. The prognosis for both disorders is good. However, these problems may interfere with the breast-feeding experience. It is essential that mothers be taught how to recognize mastitis and breast engorgement and what to do if they occur! Mastitis Stacey and her husband are the proud parents of a baby girl. This is their first child, and Stacey is breast-feeding her baby. The family is doing well, and both parents are bonding successfully with

4 their new addition. About two weeks after giving birth, Stacey begins to feel especially tired and develops a fever of 101 degrees F. Her right breast is swollen, feels hard, and is warm to the touch.

Stacey is alarmed, and all sorts of ideas occur to her. “Do I have some type of infection? The nurses told me about some kind of infection! Maybe it’s !” Stacey arrives at her physician’s office and is seen by the nurse practitioner, who explains that Stacey has mastitis.

Mastitis, or parenchymatous inflammation of the mammary glands, is an infection in the breast tissues. It occurs after delivery in about 1 percent of women, usually in those who have given birth to their first child.3,7 The infection is generally caused by a pathogen that travels from the nursing baby’s nose or pharynx to breast tissue via a break in the skin of the nipple. The most common infecting organism is Staphylococcus aureus. Other less common infecting organisms include S. epidermidis or beta-hemolytic streptococci. On rare occasions, mastitis may be caused by disseminated tuberculosis or even the mumps virus.3 Patient education alert! Mastitis usually affects breast-feeding women. Infections of the breast that are not associated with breast-feeding may be indicative of a rare type of breast cancer.7 Although mastitis can occur at any time during lactation, it usually begins one to two weeks after delivery. of mastitis include:3,7 • Fever of 101 degrees F (38 degrees C) or higher. • Fatigue. • Malaise. • Flu-like symptoms, such as nausea and vomiting. • Swelling of infected breast(s). • Breast lump. • . • Itching of the breasts. • Changes in nipple sensation. • Redness and warmth of the affected breast tissue. • that may contain pus. • Tender or enlarged axillary lymph nodes on the side of the affected breast.

Patient education alert! Women should be taught about the potential for mastitis as soon as possible before or immediately after delivery. They must be able to recognize the signs and symptoms of the disorder and told to seek medical attention as soon as signs and symptoms develop. Otherwise, without prompt treatment, a breast abscess may develop.3 Diagnosis is based on signs and symptoms and patient history. A culture of the drainage from the nipple may be helpful in confirming the diagnosis and identifying the causative organism. For women who are not breast-feeding, a mammography or breast biopsy may be needed.3,7 Primary treatment of mastitis is antibiotic therapy. Symptoms generally abate within two to three days. It is important that the patient be told that she must take the entire course of therapy (usually for 10 days) even if she feels better. Supportive measures include analgesics for pain and moist heat to the infected breast for 15 to 20 minutes several times a day.3,7

5 Mothers may continue to breast-feed with their physicians’ approval. It is important that patients tell their physicians if they plan to take analgesics or other medications (including herbal preparations) for mastitis. Some medications, even herbal medicines or over-the-counter preparations, may require that breast- feeding be temporarily stopped. Patient education alert! Mastitis usually resolves with appropriate antibiotic therapy. However, if treatment is delayed or the infection is severe, a breast abscess may develop. An abscess needs to be incised and drained. If an abscess does develop, the patient may need to stop breast-feeding temporarily.7 There are several factors that are associated with an increased risk for mastitis. These include:3  The presence of a fissure or abrasion on the nipples.  Blocked milk ducts (Tight bras or too-long time periods between breast-feeding can cause blocked milk ducts).  Incomplete “letdown” reflex. (This is usually due to emotional stress.)

Women should be taught ways to prevent the development of mastitis. Appropriate instructions include:3,7  Empty breasts completely. Milk that remains in the breast can lead to infection.  Alternate feeding positions to rotate the sites of nipple pressure.  Position the baby properly on the breast and ensure that the entire areola is in the baby’s mouth.  Expose sore nipples to the air as often as possible, and be sure to cleanse the nipples gently and carefully.  Wash hands frequently, including before and after breast-feeding.  Get plenty of rest.  Consume sufficient amounts of fluids and nutrients.  Wean the baby from breast-feeding slowly over a period of several weeks when the time comes. Avoid stopping breast-feeding abruptly.

Breast engorgement Helen is breast-feeding her 2-week-old infant. She is enjoying breast-feeding her baby, just as she did with her first child. Unfortunately, Helen’s mother dies unexpectedly, causing much stress and upheaval in Helen’s normal routine. She has not been able to breast-feed or pump her breasts as often as she normally would.

After a few days, Helen notices that her breasts have become swollen and painful and warm to the touch. The breasts also appear rather shiny, and the nipples appear rather flattened. This did not happen when she breast-fed her first child.

Frightened, Helen calls her physician. She is diagnosed with breast engorgement.

Breast engorgement or breast congestion occurs when the breasts retain or are filled with too much milk.12 Although painful, it is not an infectious process. All women who breast-feed experience some degree of engorgement, but severe cases require intervention.3 Patient education alert! Breast engorgement is one of the most common reasons that women stop breast- feeding.12 It is important that all new mothers be taught about breast engorgement and how to avoid it. Severe engorgement is commonly due to:3,12  Not breast-feeding often enough.  Waiting too long to begin feeding the newborn baby.  Not emptying the breasts effectively.

6  Disruption in the normal routine that interferes with the frequency of breast-feeding or pumping the breasts.  Suddenly stopping breast-feeding.

Severe engorgement can cause several adverse effects. For example:3,12  The baby may not be able to onto the breast properly.  The baby may not receive enough milk when breast-feeding.  The breasts do not completely empty, which can lead to a blockage of the milk ducts and consequent infection (mastitis).  Nipples become sore and cracked.

Breast engorgement may only be minimal, causing only a little discomfort. However, severe engorgement can trigger the following signs and symptoms:3,12  Breasts become swollen, firm, hard, and painful. They are warm and “lumpy” to the touch and may appear shiny.  Nipples may flatten and areola may become hard.  The mother may develop a fever of about 100 degrees F (37.8 degrees C).  The mother’s axillary lymph nodes may become swollen and tender.

The goals of breast engorgement treatment are to control swelling and relieve discomfort.3 Treatment interventions include:3,12  Administration of analgesics for pain relief. (The woman’s physician should be aware of any medications, even over-the-counter preparations, that she is taking while breast-feeding).  Application of ice packs to relieve swelling and discomfort.  Use of a support bra that helps to minimize edema.  Use of oxytocin nasal spray to release milk. (This is used only rarely.)  Express excess milk manually before breast-feeding to facilitate the baby’s grasp on the nipple.

Women should be taught ways to prevent breast engorgement. The goal is to keep milk moving from the breasts and avoid having them become over-full.12 This can be accomplished by:  Breast-feeding often enough. The baby should nurse when he or she shows signs of hunger.  Manually expressing milk to soften nipples before nursing if breasts feel over-full.  Monitoring the baby to make sure that he or she is latching on properly and feeding well.  Emptying the breasts with each feeding. This helps milk to move more easily and to make sure that the supply of milk meets the baby’s needs.

The benefits of breast-feeding Diana is a registered nurse who works in a busy obstetrics office practice. She especially enjoys teaching mothers-to-be about breast-feeding and Cheryl is one of her patients. Cheryl is 8 months pregnant and a busy corporate administrator. She and her husband are looking forward to the birth of their first baby and have definite ideas about how they plan to raise their child.

As Cheryl is about to leave the office following her regular check-up, Dianna invites her to attend a class on breast-feeding to be held at the office next week. Cheryl puts up a hand to stop Diana. “I don’t want to be rude, but you should know right now that I have no intention of breast-feeding. Some of my friends have breast-fed their babies and it takes so much time and interferes with their work, and I plan on going back to work. Some of them even got awful breast infections! So please don’t try to talk me into anything!”

7 Diana realizes that Cheryl has the right to make her own decision about breast-feeding. She also knows that breast-feeding has multiple benefits for both mother and child. She explains to Cheryl that she has no intention of trying to talk her into doing something that she does not want to do. Diana then asks Cheryl if anyone has ever explained the benefits of breast-feeding and how to avoid some of the complications. Diana hopes to be able to give Cheryl the information she needs to make a truly informed decision.

Benefits for the baby Breast-feeding provides an abundance of benefits to both mother and child. The first breast milk to be produced is colostrum, thick yellow milk that is made during pregnancy and immediately after birth. Colostrum is profuse in nutrients as well as antibodies that protect the baby from disease. By the third to fifth day after birth, mature breast milk is produced. This milk is thinner than colostrum and is composed of the appropriate nutrients and antibodies necessary for the infant. Breast milk is also generally easier for the baby to digest than formula, which contains proteins made from cow’s milk. The baby’s digestive system needs time to adapt to digesting such proteins.17 Patient education alert! On very rare occasions, some babies are unable to tolerate milk of any kind, even breast milk. These babies may need soy formula. In some cases, mothers may be unable to breast- feed because of their own health status. Babies of these mothers may benefit from obtaining breast milk from donor milk banks.17 In the United States, the rate of breast-feeding (although it has increased in the last few years) is less than that identified by the Healthy People 2010 objectives. The Healthy People 2020 objectives include a goal of 81 percent of infants being breast-feed. This is in accordance with universal medical recommendations that babies be “breast-feed exclusively for six months with continued breast-feeding for at least one year.” 19 Breast-feeding is not simply a way to provide the best possible nutrients to a baby. Breast-feeding can have a lifelong impact on the health of both the mother and child. Breast milk provides the baby with essential immunologic factors that protect the child from a number of illnesses and diseases.17,19 Research shows that babies who are formula-fed have a higher rate of ear infections as well as episodes of diarrhea. Formula-fed babies also have a higher risk of lower respiratory infections, asthma, obesity, and diabetes.17 The risk of sudden infant death syndrome (SIDS) is twice as great for formula-fed babies when compared to breast-fed babies.19 Studies also show that breast-feeding is a public health initiative to improve infant and child morbidity and mortality rates as well as maternal morbidity.19 There is a reduction in risk for the following diseases and health problems in babies and children who have been breast-fed compared to those who have been formula fed.19  Asthma.  Acute otitis media.  Atopic dermatitis.  Childhood leukemia.  Childhood obesity.  Gastrointestinal infections.  Type I diabetes.  Type II diabetes.

Necrotizing enterocolitis

8 Breast-feeding can also help to prevent the development of necrotizing enterocolitis (NEC), the most common gastrointestinal (GI) medical/surgical emergency that occurs in neonates.10 NEC is an acute inflammatory condition characterized by scattered or patchy intestinal necrosis along with sepsis in about 33 percent of cases.3,10 The disease usually occurs in infants who are premature or have a low birth weight. Prompt recognition and aggressive treatment are imperative. NEC is a serious condition that has a death rate of about 25 percent.3 The exact cause of NEC is unknown, but predisposing factors include:3,10  Birth asphyxia.  Post-natal hypotension.  Respiratory distress.  Hypothermia.  Perinatal hypoxia.  Patent ductus arteriosis.  Exchange transfusion.  Prenatal stress.  Breech or cesarean birth.  Umbilical vessel catheterization.

The most common sign of NEC is a distended, rigid abdomen with gastric retention. This sign generally appears one to 10 days after birth.3 Other signs and symptoms include:3,10  Feeding intolerance.  Bile-stained vomitus.  Bloody diarrhea.  Occult blood in the stool.  Decreased bowel sounds.  Apnea.  Lethargy.  Shock.  Cardiovascular collapse.

Patient education alert! A shiny or red, taut abdomen may suggest peritonitis.3 Parents should be taught about this disease and significant signs and symptoms and the need for immediate emergency medical intervention! Diagnosis is confirmed with abdominal x-rays that show nonspecific intestinal dilation and, later in the disease, gas or air in the intestinal wall. Platelet count may be less than 50,000/ul, serum sodium levels are decreased, and bilirubin levels are increased. Arterial blood gases show metabolic acidosis. There may be occult blood in stools. Blood and stool cultures are performed to identify the causative organism.3 At the first signs and symptoms of NEC, the umbilical catheter is removed and the baby is not to receive any oral nutrition for seven to 10 days so that the bowel can rest. Intravenous fluids (including total parenteral nutrition) are administered, and a nasogastric (NG) tube is inserted to facilitate decompression of the bowel. Antibiotic therapy is administered and dextran is given if coagulation studies show that a transfusion is necessary.3 Health care personnel must be alert to signs of perforation. These signs include abrupt drop in temperature, bradycardia, limpness, sudden listlessness, and abdominal tenderness and involuntary abdominal rigidity. Perforation is treated with surgery. All of the necrotic and severely inflamed bowel is removed, and a temporary colostomy or ileostomy is created.3

9 Breast-feeding is a strategy that helps prevent the development of NEC. Colostrum contains significant amounts of immunoglobulin that has a direct protective effect on the bowel for several days after delivery. Breast milk not only helps to prevent and fight infections but also has a low pH, which acts as a barrier to bacterial growth.3 Patient education alert! Nursing mothers should be told that they can refrigerate their breast milk for 48 hours but not to freeze or heat it because this destroys the protective antibodies that are a major component of this milk. Additionally, breast milk should be stored in plastic containers, not glass containers. This is because leukocytes (white blood cells) adhere to glass, thus decreasing the amount of protection the breast milk would provide.3 Benefit to the mother Breast-feeding is also important in helping mother and child to bond. During breast-feeding, babies feel their mothers’ skin. They are secure, warm, cuddled, and comforted. Mothers also sense this closeness and security.17 Patient education alert! Skin-to-skin contact also has a physiological benefit in addition to the emotional benefits described. This contact can enhance the mother’s oxytocin levels, which helps milk flow and can have a calming effect on her.17 Breast-feeding is linked to positive effects on the mother’s health as well as the baby’s. For example, research shows that for each year a woman breast-feeds, she is 4 percent to 28 percent less likely to be diagnosed with breast cancer. Breast-feeding is also believed to reduce the risk of ovarian cancer by 21 percent and the development of type 2 diabetes by 12 percent.19 Research is now underway to determine a link between breast-feeding and a reduction in the rate of postpartum depression and osteoporosis. Breast-feeding may also help women return to their pre- pregnancy weights.19 Breast-feeding can actually save the lives of breast-fed babies during emergencies. For example, in the event of a natural or man-made disaster, water supplies may be contaminated and power outages may exist. Breast-feeding does not require the use of water or electricity to sterilize bottles or heat formula. Breast milk is always the right temperature regardless of the environmental temperature, and is readily available.17 Benefits to the economy It is estimated that the cost of infant formula costs the average American family between $1,200 and $1,500 annually. The cost in terms of health care is even greater. The United States Department of Agriculture reports that a minimum of $3.6 billion in medical expenses would be saved annually if half of the children in this country were breast-fed for the first six months of their lives. If the rate of breast- feeding were to increase to 90 percent, about $13 billion would be saved, thanks to a reduction in medical expenses and the health benefits of breast-feeding.19 Benefits to society In addition to the tremendous cost savings that would be generated by breast-feeding, society would benefit from a decrease in infant deaths. A summary of the benefits of breast-feeding to society includes the following factors.17  If 90 percent of women breast-fed their babies exclusively for six months, almost 1,000 infant deaths could be prevented.  Mothers who breast-feed miss less work time to take care of sick babies. This helps to lower medical costs to employers.

10  Breast-feeding contributes to a greener environment, reducing the need to discard formula cans, containers and bottles and producing less trash and plastic waste products.

Resources that help to explain the benefits of breast-feeding include: • Breast-feeding: Offers information about the benefits of breast-feeding and as well as what to do if mothers are having difficulty breast-feeding. www.cdc.gov/breast-feeding/ • Your Guide to Breast-feeding: Simply written publication that offers information about successful breast-feeding. www.womenshealth.gov/publications/our-publications/breast- feeding-guide/ • Feeding Your Newborn: Provides information on both bottle-feeding and breast-feeding, including advantages of breast-feeding, challenges of both bottle-feeding and breast-feeding, and dealing with challenges associated with feeding newborn babies. http://kidshealth.org/parent/food/infatns/feednewborn.html. • La Leche League International: An international organization with a mission to facilitate breast- feeding by offering support, encouragement, and education. www.llli.org/

Barriers to breast-feeding The Centers for Disease Control and Prevention (CDC) estimates that almost three of every four new mothers in the United States start to breast-feed their newborns. This indicates an increase over the past few years, but is still short of the Healthy People objectives of 2010. As previously noted, the 2020 objectives include the goal of having 81 percent of infants being breast-fed. 19 To achieve this goal, it is necessary to remove the barriers that interfere with breast-feeding. Lack of knowledge about the benefits of breast-feeding is certainly one barrier. It is essential that health care professionals involved in the care of women and children before and after delivery provide accurate, easy-to-understand information about the benefits of breast-feeding to mother and baby. This education should also include an explanation of the economic benefits of breast-feeding. Research shows that more than 70 percent of mothers employed full-time have children under the age of 3. These mothers cite the following barriers to breast-feeding their babies:19  Rigid hours of work.  Lack of a proper, private location to express milk.  No place to store expressed milk.  Difficulty obtaining work breaks to express milk.  Pressure from supervisors and peers to discontinue breast-feeding.  Concern that jobs may be in jeopardy if they take time to express milk while on the job.

Patient education alert! In 2009, 25 percent of companies surveyed made accommodations for employees who were breast-feeding.19 Mothers, their families, and the health care community must work to educate employers about the benefits of breast-feeding, including those that most impact them. For example, breast-feeding women take less time from work to care for sick babies. Another barrier may be the mothers’ fears that they will not be able to successfully breast-feed. Or perhaps they have had an unsuccessful experience with breast-feeding in the past. Education and support of health care professionals, family, co-workers, and friends as well as education on the process of breast- feeding should help to alleviate many fears and concerns. Removing barriers to breast-feeding Nurses and other health care professionals need to work diligently to help remove barriers to breast- feeding. Appropriate patient, family, and community education is, arguably, the most important

11 intervention. The benefits of breast-feeding to mothers, babies, families, and society as a whole are not as well-known as they should be. Thus patient/family and community education are essential. However, education is not the only way to advocate for breast-feeding. Health care professionals should advocate and support legislation and other initiatives to eliminate barriers to breast-feeding. Here are some of the initiatives that advocates of breast-feeding need to know about:  The federal government and many states have passed laws that protect the rights of nursing women. The laws are based on the recommendations of organizations such as the American Academy of Pediatrics and the World Health Organization (WHO) that breast-feeding is the best option for the health of mother and child.14  In 1991, WHO, the United Nations Children’s Fund, and the Baby-Friendly Initiative in Community Health Services came together to introduce the Baby-Friendly Hospital Initiative (BFHI). The BFHI is considered to be the “gold standard” for evidenced-based breast-feeding care in hospitals.19  The Joint Commission now includes “exclusive breast milk feed” as part of its core measures for perinatal care.19  Section 4207 of The Patient Protection and Affordable Care mandates that women who breast-feed are allotted appropriate break times and a private location to breast-feed or to express their milk. 19  Various organizations, such as the American Nurses Association (ANA), the American Academy of Nursing, and the U.S. Breast-feeding Committee, have partnered to encourage workplace environments that support breast-feeding. In its publication, “The Imperative of Breast-feeding,” the ANA and other advocacy groups identify the following strategies to enhance the workplace environment for breast-feeding mothers:19  Establish polices that explain the benefits of breast-feeding.  Provide information to women about breast-feeding resources.  Promote a positive attitude about breast-feeding.  Provide a clean, comfortable area for women to breast-feed that includes hot water and soap.  Ensure that women who breast-feed have enough break time to breast-feed or express milk.  Provide a refrigerator so that women can store expressed milk safely and appropriately.

Patient education alert! When promoting breast-feeding, it is also important that health care professionals remain objective and supportive and respect a woman’s choices about feeding her baby. There are situations and circumstances that prohibit a woman from breast-feeding, such as serious illness and the need to take medications that could potentially harm the baby if breast-fed. It is the responsibility of health care professionals to present all available information to women and their families so that they can make the best possible informed decision for themselves and their babies. Strategies for successful breast-feeding Health assessment Interventions for successful breast-feeding should begin before pregnancy whenever possible. As with all health care interventions, the first step is to conduct a thorough physical and mental health assessment. A healthy baby needs a healthy mother. While many women plan the timing of their pregnancies, many pregnancies also are unplanned. The point is, as soon as women decide to attempt pregnancy or as soon as they become pregnant, a health assessment is a necessity. Health assessments can determine what kinds of issues may impact pregnancy and ability to breast-feed. As previously noted, some women may require a medication regimen post-delivery that prohibits breast- feeding. Serious illnesses, such as some cancers, may interfere with the ability to breast-feed. Remember that not all illnesses or medication regimens prohibit breast-feeding. Treatment options and changes in medication regimens may make it possible for breast-feeding to take place.

12 Fortunately, most women can successfully breast-feed. But it is important that they undergo a thorough physical and mental health assessment before (if possible) their pregnancy and receive good pre- and post-natal care. Patient education alert! As part of ongoing assessment and pre- and post-natal care, women must inform their health care providers of all medications they currently take, plan to take, and will need to take after delivery. This includes not only prescription drugs, but over-the-counter preparations, herbal medicines, and any nutritional supplements. Women should also report if they drink alcohol and how much they drink; if they smoke and how much they smoke; and if they use any recreational or illegal drugs. All of these factors can significantly impact the health of mother and baby. Before delivery Women and their husbands or partners should talk to health care providers about the plans to breast-feed. They should investigate birthing options in their geographic areas; some hospitals and birth centers have created environments that are particularly suited to women who breast-feed. These types of facilities are referred to as “baby-friendly hospitals and birth centers” and offer significant support for those who choose to breast-feed.16 Here are some recommendations to offer women (and their spouses or partners) about breast-feeding.16  Take a class on breast-feeding. In general, women who learn about breast-feeding before delivery have a better rate of successful breast-feeding than those who do not. Husbands and partners should attend as well!  Ask health care providers to recommend a lactation consultant. This is best done before delivery. This facilitates the development of a rapport between mother and consultant.  Join a breast-feeding support group. Talk to family members and friends who have successfully breast-fed their babies.  Tell health care providers that you would like to breast-feed the newborn baby as soon as possible after giving birth. “The sucking instinct is very strong within the first hour of life.”16

Involvement of the father It is essential that babies’ fathers are supportive of and take part in the decision to breast-feed. They should receive education and attend the same classes that mothers do. Mothers will need their support and encouragement as long as they are breast-feeding. They also need someone to talk to about breast- feeding concerns and to help them receive adequate nutrition and rest.16

Patient education alert! Don’t forget that the father of the baby needs to bond with the child just as much as the mother does. Encourage fathers to have skin-to-skin contact with the baby. It helps with bonding in much the same way that it does for mother and child.16

Strategies post-delivery The womenshealth.gov (www.womenshealth.gov) website has an extensive section on breast-feeding. It offers women these instructions for breast-feeding immediately after delivery:16  Breast-feed as soon as possible after delivery.  Select a hospital or birthing center that allows the baby to stay in your hospital room throughout the day and night to facilitate breast-feeding and bonding.  Ask that the hospital or birthing center staff not give the baby other sources of nourishment unless it is medically necessary to do so.  Make arrangements to have a lactation consultant come to the hospital after birth to assist you with breast-feeding.  Avoid giving the baby pacifiers so that he or she becomes accustomed to latching onto your breast.

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Positions for breast-feeding There are several positions to assume when breast-feeding. It takes patience and practice for mothers to identify the positions that are the most comfortable and work best for them. Here are some common positions for breast-feeding.1,16  Cradle hold: The baby’s head is cradled in the crook of the mother’s arm, with his or her head on the mother’s forearm and the whole body facing the mother’s. The baby is held in the mother’s lap or on a pillow on the lap. The baby’s lower arm should be tucked under the mother’s arm, and the mother’s forearm and hand down the baby’s back to support the neck, spine, and bottom. The cradle position generally works best for full-term babies delivered vaginally. Some women find that this position works better when the baby’s neck muscles are stronger at about the age of 1 month. Women who have delivered their babies via Cesarean section sometimes find that the cradle position puts too much pressure on their abdomens, causing discomfort.  The crossover hold (also called the cross cradle or transitional hold): This position is often best for premature babies or for those who have a weak suck because it provides additional head support and facilitates latching. The baby is held along the opposite arm from the one the baby is using. The baby’s head is held at the base of the neck with the palm of the mother’s hand. The baby’s stomach and chest are directly facing the mother. This position may also work best for small infants or for those who have difficulty latching on.  The clutch or football hold: This position allows the mother to see and control the baby’s head and body. The baby is tucked under the mother’s arm (like a football) on the same side as that of the breast from which the baby is nursing. The baby is facing the mother with his or her nose level with the nipple, and feet pointing towards the mother’s back. The mother’s arm should rest on a pillow to facilitate supporting the baby’s shoulders. The palm of the mother’s hand supports the baby’s head at its base. The baby is guided to the nipple chin-first. It is important not to push the baby toward the breast so vigorously that he or she resists and arches the back. This may be the most comfortable position if the mother has had a Cesarean section or if the baby has trouble latching on. It may also be preferred for women who have large breasts, flat or inverted nipples, or a strong letdown reflex. This position also helps babies assume a more upright position.  Side-lying or reclining position: The mother lies on her side with the baby facing her. Several pillows should be placed behind the mother’s back for support. Pillows can also be placed under the mother’s head and shoulders as well as between bent knees. The mother should position herself so that her back and hips are in a straight line. The baby faces the mother, is pulled close, and her or his head is cradled with the hand of the mother’s bottom arm. The baby should not strain to reach the mother’s nipples, and the mother should not have to bend down toward the baby. If the baby needs to be positioned higher, a small pillow or folded receiving blanket may be placed under his or her head. The mother may need to lift her breast so that the baby can latch on properly. This position is best for mothers who are recovering from a difficult delivery or who have had a Cesarean section.

Tips for facilitating breast-feeding When offering tips to facilitate breast-feeding, encourage mothers to:1,16  Assume a comfortable position when breast-feeding. Make sure that the body is adequately supported with plenty of pillows for the back and arms. Choose a chair with armrests when sitting to nurse. Avoid couches. Most do not provide adequate support when breast-feeding.  Support your breasts. Breasts become bigger and heavier when breast-feeding. When nursing, use your free hand to support your breast. Keep your fingers at least two inches behind the nipple so that the baby does not suck on them instead of the nipple.  Support the baby. Keep him or her close to you. Maintain skin-to-skin contact, which stabilizes the baby’s heart rate and respiratory rate.

14  Avoid nursing the baby when you are upset or distracted. Relax before nursing. Take some deep breaths and think pleasant, calm thoughts. While nursing, keep a glass of water, milk, or juice close by. Adequate hydration helps with milk production.  Alternate feeding positions. This helps to avoid clogged milk ducts and sore nipples because different positions put pressure on different parts of the nipples.  Avoid using pacifiers, bottles, or supplements of infant formula unless medically necessary. This reduces any possible confusion while the baby is learning to breast-feed.  Learn to recognize the baby’s hunger signs. Examples include putting their hands or fists in their mouths, making sucking motions or sounds, turning their heads to look for the breast. Crying is actually a late sign of hunger. Waiting too long to feed the baby causes him or her to become upset and makes it harder to breast-feed.  Let your baby guide you. Some babies take only one breast per feeding while others take both breasts. Help the baby to “finish” the first breast as long as he or she is still sucking and swallowing. When finished, the baby will let go of the breast. If he or she is still sucking and swallowing, offer the other breast.  Wake the baby (in the first weeks after birth) to eat if four hours have passed since the beginning of the last feeding.

It is important to help mothers learn how to help the baby to latch and to assess the effectiveness of the latch. To help the baby latch onto the breast, hold the baby against the bare breast so that skin-to-skin contact is made. The baby’s neck and shoulders should be supported and the baby’s head tilted slightly back to facilitate sucking and swallowing. Breasts should hang naturally.16 A proper latch should not cause discomfort or pinching. As the baby is latching, the mother should be able to see little or no areola, and the baby’s mouth should be filled with breast.16 How to know if the baby is getting enough milk Some women will express doubts about whether their babies are getting enough milk. Here are some suggestions from www.womenshealth.gov/breast-feeding for signs that the baby is getting an adequate amount of milk:16  The baby is producing adequate amounts of pale yellow or clear urine. The urine should not be deep yellow or orange.  The baby has enough bowel movements.  The baby alternates between short periods of sleep and periods of being awake and alert.  The baby is content after feedings.  The mother’s breasts feel softer after breast-feeding.

Patient education alert! If the baby does not seem to be receiving adequate nourishment, tell the mother to contact her health care provider. Patient education alert! In the first few days after birth, the baby will likely feed at least eight to 12 times every 24 hours. The baby will then develop his or own feeding schedule.16 Breast-feeding in public Breast-feeding in public has, in recent years, received a significant amount of publicity. Some women feel uncomfortable breast-feeding in public. Health care professionals need to help mothers understand that breast-feeding is an appropriate activity. In fact, federal and state legislation has been enacted to protect breast-feeding women.16 Breast-feeding in public can be done discreetly and comfortably. Clothes should be worn that allow the mother easy access to her breasts. Examples include loose-fitting tops that pull up from the waist or unbutton from the waist. Special nursing blouses, dresses, bras, and other clothing can be purchased. The

15 La Leche League is a good resource for purchasing such clothing. A small shawl or blanket can cover the baby and midriff.4,14 Some women find baby slings useful when breast-feeding in public. Such slings are worn over one shoulder and form a sort of pouch for the baby. The slings are available under several brand names and are made of washable cotton. The slings allow the baby to be placed in several positions.4,14 Patient education alert! It is important that women follow manufacturers’ instructions for using infant slings carefully to avoid injury to the baby!14 Encourage women to practice techniques for breast-feeding in public in the privacy of their own homes before actually breast-feeding in public areas. This will help women become accustomed to using slings, unbuttoning clothing, and so forth.14 Discreet breast-feeding in public becomes easier and more comfortable with practice. But it depends on issues in addition to clothing positioning. Women should be taught to plan ahead. For example, they should know, generally, at what intervals their babies will need to be fed and what signals babies give when they are hungry. When in public, women can look around for a comfortable place in which to breast-feed in advance of the need whenever possible. This may help them to relax without worrying about finding someplace to breast-feed.14 Examples include a booth in a restaurant, a bench in a park, and so on. In time, women become so comfortable breast-feeding in public that most people in the same location will not even realize that the mothers are breast-feeding. Most people are not offended when women breast-feed in public, but yes, some are. Persons may show their disapproval in a variety of ways. Some may simply exhibit facial expressions that suggest annoyance, disgust, or disapproval. Others may make negative comments to each other in a voice loud enough for the nursing mother to overhear. Still others may confront the breast-feeding mother directly.

Sadly, those who disapprove are not always strangers. Family members, friends, and co-workers may also be among those persons who have negative feelings about breast-feeding in public. No matter who disapproves, the nursing mother needs help dealing with the disapproving, negative comments of others. The La Leche League International offers some suggestions for dealing with criticism in the form of positive statements.5,14  Use “I” statements instead of “you” statements. Using “you” puts blame on the other person and can further escalate the confrontation. For example, “I am doing what is best for my baby” instead of “You obviously don’t know anything about breast-feeding.”  “I don’t want to offend anyone. I am being as discreet as possible.”  “I understand that you feel strongly about this. I would be glad to explain how important it is to be able to breast-feed whenever the baby is hungry.”

Having a discussion is probably not going to work when dealing with strangers. Some women choose to ignore the comments or looks of disapproval from strangers. By not engaging such people in a confrontation, it may resolve itself. If the comments continue and the mother feels threatened, she should leave the location or call for help. The situation should never be allowed to escalate into a shouting match or other types of verbal altercations. This solves nothing and may actually endanger the mother and child. Disapproval of family, friends, and co-workers may be more emotionally upsetting. These are people who new mothers should be able to count on for support. Mothers may choose to engage these people in

16 discussions. Again, they should avoid, as much as possible, becoming angry and defensive. A calm discussion of the reasons for breast-feeding and for breast-feeding in public may help increase the understanding of everyone involved. At the very least, perhaps everyone involved can agree to disagree and also agree that the negative comments will stop. Some suggestions to give mothers to avoid triggering criticism include:5  Be as discreet as possible.  Avoid becoming involved in a public argument.  As appropriate, offer an explanation of why it is important to you to breast-feed in public.  Assume a confident and comfortable posture.

Resources for additional information about breast-feeding Here are some additional helpful resources on breast-feeding.15,16  La Leche League International: An international organization with a mission to facilitate breast- feeding by offering support, encouragement, and education. www.llli.org/  Breastfeeding: Hints to Help you Get Off to a Good Start: A fact sheet prepared by the American Academy of Family Physicians. http://familydoctor.org/online/famdocen/home/women/pregnancy/birth/019.html.  Breastfeeding 101: A publication from the American College of Nurse-Midwives that outlines the basics of breast-feeding. www.mymidwife.org/Breast-feeding-101.  Breastfeeding vs. Formula Feeding: Discusses breast-feeding benefits and the strengths and weaknesses of bottle-feeding. www.kidshealth.org/parent/food/infants/breast_bottle_feeding.html.  Got Mom: This is a source of breast-feeding information and resources for mothers and families. It is a publication of the American College of Nurse Midwives. www.gotmom.org.  Weaning Your Child: This publication offers information about when and how to wean. www.kidshealth.org/parent/pregnancy_newborn/feeding/weaning.html.

References

1. Babycenter.com. (2011). Positions and tips for making breast-feeding work. Retrieved February 9, 2013 from www.babycenter.com/0_positions-and-tips-for-making-breast-feeding-work_8784.bc.

2. Comerford, K. C. (Ed.). (2013). Anatomy & physiology made incredibly easy (4th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

3. Durkin, M. T. (Ed.). (2013). Professional guide to diseases (10th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

4. La Leche League International. (2008). Can you give me some tips for discreet breast-feeding? Retrieved February 10, 2013 from www.llli.org/faq/discreet.html.

5. La Leche League International. (2008). How do I respond to and avoid criticism about breast- feeding? Retrieved February 10, 2013 from www.llli.org/faq/criticism.html.

6. March of Dimes. (2009). Your pregnant body: Breast changes. Retrieved February 9, 2013 from www.marchofdimes.com/printableArticles/yourbody_breastchanges.html.

17 7. National Institutes of Health. (2009). Breast infection. Retrieved February 9, 2013 from www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002460.

8. Nursingcrib.com. (2010). Anatomy and physiology of mammary glands. Retrieved February 13, 2013 from http://nursingcrib.com/anatomy-and-physiology/anatomy-and-physiology-of- mammary-glands-breast/

9. Parents.com. (copyright 2013). Breast changes before and after baby. Retrieved February 18, 2013 from http://www.parents.com/parents/templates/story/printableStory.jsp?storyid=/templatedata/ab/ story/data/1144700736841.xml&catref=prt1019

10. Springer, S. C. (2012). Necrotizing enterocolitis. Retrieved February 9, 2013 from http://emedicine.medscape.com/article/977956-overview.

11. Wagner, C. (2012). Human milk and lactation. Retrieved February 9, 2013 from http://emedicine.medscape.com/article/1835675-overview.

12. WebMD. (2011). Breast engorgement-Topic overview. Retrieved February 9, 2013 from www.webmd.com/parenting/baby/tc/breast-engorgement-topic-overview.

13. Weber, J. R. (2009). Nurses’ handbook of health assessment (6th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

14. Womenshealth.gov. (2010). Breast-feeding in public. Retrieved February 7, 2013 from www.womenshealth.gov/breast-feeding/breast-feeding-in-public.

15. Womenshealth.gov. (2010). Finding support and information (breast-feeding). Retrieved February 8, 2013 from www.womenshealth.gov/breast-feeding/finding-support-and- information/index.html.

16. Womenshealth.gov. (2010). Learning to breast-feed. Retrieved February 9, 2013 from www.womenshealth.gov/breast-feeding/learning-to-breast-feed/index.html.

17. Womenshealth.gov. (2010). Why breast-feeding is important. Retrieved February 6, 2013 from http://www.womenshealth.gov/breast-feeding/why-breast-feeding-is-important/index.html.

18. Pregnancy and Children. (not dated). Breast feeding. Retrieved February 18, 2013 from http://www.pregnancyandchildren.com/pregnancy/pregnancy_breast-feeding.htm

19. American Nurses Association. (2011). ANA issue Brief: The imperative of breast-feeding. Retrieved February 20, 2013 from http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and- Resolutions/Issue-Briefs/Breast-feeding.pdf

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BREAST-FEEDING AND MATERNAL-CHILD HEALTH

Final examination questions

Choose True or False for questions 1 through 10 and mark your answers online at Nursing.EliteCME.com.

1. The lobes are composed of clusters of acini, very small sac-like duct terminals that are responsible for the secretion of milk during lactation.

TRUE FALSE

2. Progesterone is essential to the ejection of milk from the breasts.

TRUE FALSE

3. Breast engorgement is generally treated with antibiotics.

TRUE FALSE

4. The risk of SIDS is the same in breast-fed and formula-fed babies.

TRUE FALSE

5. Research shows that for each year a woman breast-feeds, she is 4 percent to 28 percent less likely to be diagnosed with breast cancer.

TRUE FALSE

6. Among the reasons a woman might choose not to breast-feed are barriers to the practice in the workplace, including rigid hours and the lack of a proper or private location to express milk and store it.

TRUE FALSE

19 7. A strategy to facilitate breast-feeding is that the baby should be breast-fed as soon as possible after delivery.

TRUE FALSE

8. The cradle hold position for breast-feeding is especially good for women who have had Cesarean sections.

TRUE FALSE

9. A sign of proper latching is that the mother should be able to see almost all of the areola.

TRUE FALSE

10. The use of a baby sling is often useful when breast-feeding in public.

TRUE FALSE

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