1 The Sunshine Coast Private Hospital at Buderim is a health care facility where the practitioners who provide care for women and/or children adopt practices that protect, promote and support exclusive from birth.

Women who choose not to breastfeed are also supported in their choice of feeding and given accurate and individual instruction on artificial feeding. CONTENTs:

INTRODUCTION 4

SECTION 1: WHY BREASTFEED? 4

SECTION 2: MISCELLANEOUS TOPICS: Diet, Drugs, Role of Partner 7

SECTION 3: Commencing breastfeeding and maintaining lactation 10

SECTION 4: Dealing with difficulties 15

SECTION 5: Breastfeeding and going home 23

3 INTRODUCTION:

This comprehensive workbook is designed for use by all , is divided into 5 main sections and is for you to keep. Pack it with your hospital bag.

section 1: Why Breastfeed?

section 2: Miscellaneous topics Diet, Drugs, Role of Partner

section 3: Commencing breastfeeding and maintaining lactation

section 4: Dealing with difficulties

section 5: Breastfeeding and going home

Midwives will be able to assist you at the antenatal classes, the antenatal preadmission clinic or during your hospital stay.

Whilst there are no guarantees about who may or may not have difficulties as they learn to breastfeed, recommendations in this booklet are research based and are known to provide an excellent basis for breastfeeding.

A summary of the breastfeeding policy is on the website and a copy of the full policy is available upon request.

SECTION 1: WHY BREASTFEED?

Breastfeeding is the 100% normal way for mothers to feed their . Mothers provide the optimal growing conditions for babies from the Belly to the .

At The Sunshine Coast Private Hospital breastfeeding mums are encouraged and supported throughout their breastfeeding experience - but ultimately, the choice is YOURS. The goal of this lesson is to help you make an informed decision about how you will feed your newborn.

The World Health Organisation recommends that babies be exclusively breastfed to six months of age, before additional fluids and solids need to be introduced.

It is further recommended that mothers then continue breastfeeding until 12 months of age and beyond if both and wish. Family foods are introduced from 6 months and become a significant part of the diet at around 12 months of age. The longer that a baby breastfeeds, the greater the long term health benefits.

Breast is perfectly suited to nourish infants and protect them from illness.

For the Baby

Bonding: Many psychologists believe the breastfeeding baby enjoys a sense of security from the warmth and presence of the mother, especially when there’s skin- to-skin contact during feeding, ie. during feeding, a nursing mother cuddles her baby closely many times during the day.

4 Breastfeeding becomes more than just a way to feed a baby; it’s a source of warmth and comfort.

Protection from infection and illness: Breastfed babies have fewer illnesses because human milk transfers to the infant a mother’s antibodies to disease. Mothers produce antibodies to whatever is present in their environment, making their milk custom- designed to fight the diseases their babies are exposed to as well.

Studies have shown that breastfeeding babies:

• Higher IQ.

• Less chance of diabetes, childhood lymphomas, Hodgkin’s disease.

• Protection from allergy.

• Nutritional: Human milk contains just the right amount of fatty acids, lactose, water, and amino acids for human digestion, brain development, and growth.

• Breastmilk changes as babies’ needs and growth changes.The taste of breastmilk changes with mum’s diet. Babies that are breastfed are not as likely to be “picky eaters” when they are toddlers.

Digests Easily: No constipation, less colic, and less spitting up as compared with infant formulas!

Colostrum: the Perfect First Food : • Thick, typically clear or yellow fluid. • High in protein that is needed for baby’s brain growth. • Easily digested by the newborn. • Has a laxative effect. It helps baby get rid of meconium, the first black, tarry stools. • Contains many antibodies that provide protection from infection and illness.

Colostrum and its properties are NOT duplicated in infant formulas!

For the Mother

1) Emotional factors: • Ensures close physical contact with baby. • Mothering hormones are released. • Comforting a sick or tired baby is easier.

2) Physical factors: • Reduction in osteoporosis. • Some protection against premenopausal breast cancer, ovarian cancer. • Aids in natural weight loss (providing that breastfeeding continues for more than seven months).

5 • Decreases blood loss after the birth.

• Promotes rest, as there are no bottles to sterilize and no formula to buy, measure and mix. The mother is able to sit down, put her feet up, and relax every few hours.

• Acts as nature’s contraceptive: provided that the mother has not had a period, has not given any other food or fluids to baby, has not been using a dummy and the baby is less than 6 months old.

3) Economical:

• Even though a breastfeeding mother works up a big appetite and consumes extra calories, the extra food for her is less expensive than buying formula for the baby. Breastfeeding saves money while providing the optimal nourishment.

• Fewer doctors bills likely.

• Less waste for the community.

6 SECTION 2: MISCELLANEOUS TOPICS:

Detrimental effects of dummy use

Early use of bottles and dummies (pacifiers) can interfere with the natural processes of breastfeeding, reducing the infant’s sucking capacity and the stimulation of the mother’s .

The most important risks associated with use of a pacifier are:

• Shorter duration of breastfeeding • Tooth decay • Recurrent middle ear infection • Oral ulcers • Dental deformities • Latex allergy

The Sunshine Coast Private Hospital will not provide a dummy and strongly discourages use in a baby who is healthy and full term. Should wish to use a dummy, then this should be delayed until breastfeeding is established and the baby is gaining weight.

Any , water or juice etc in the early days:

• Puts the infant at risk of allergy to cow’s milk or soy milk protein. Interferes with the protection against infection that colostrum/ breastmilk provides.

• Delays initiating maximum lactation as infant formula is more slowly digested than breastmilk so reduces the number of breastfeeds in the day.

The Sunshine Coast Private Hospital will not routinely provide formula and strongly discourages use in a baby who is healthy and full term.

Diet, Alcohol, Drugs.

• Diet: ‘All things in moderation’ is the saying.

• There should be balance - lots of different colours on the plate will ensure variety.Sandwiches, yoghurt, cheese and biscuits and cereal are preferable at this time to salad only snacks. Sardines or tuna on toast is an ideal snack as it combines protein and carbohydrate.

• Calcium is required in higher amounts than for women who are not breastfeeding and is obtained from dairy products, nuts, apricots, sesame seeds, and broccoli.

• Vitamin C: citrus fruits, berries, tomatoes, capsicums and potatoes.

• Vitamin A: dark green and yellow vegetables such as spinach, broccoli, carrots and pumpkin.

• Folate: leafy green vegetables such as spinach and broccoli.

• Drinking more water will make your bladder work overtime but does not necessarily increase milk supply. A good, balanced, varied diet and rest will keep you healthy and feeling well. If you are thirsty then you should have been drinking more.

7 • If you are hungry, then eat.

A referral to a dietician may be sought for the following situations:

• Severe dietary restrictions for religious reasons.

• Exclusion diets for allergies.

• Poor nourishment before and during pregnancy.

• Vegetarian/vegan mothers who need to be sure of their vitamin B12 and calcium intakes.

• Breastfeeding multiples.

• Weight management advice.

• Pre-existing medical conditions which affect nutrition i.e. renal, liver, Crohns, coeliac disease and Type I diabetes.

Alcohol: No safe level of alcohol consumption has been determined: 30 minutes after ingesting one glass of beer there may be a 23% reduction in breastmilk, with a drowsy baby, poorer sucking, decreased oxytocin and decreased let down. There is a decline in motor senses in babies whose mothers consume more than one standard drink per day. (More recent findings show alcohol to be present in breastmilk in much higher concentrations than in blood, even within a few minutes of drinking - Mothersafe -Royal Hospital for Women, NSW, 2001)

Alcohol is rapidly absorbed into the bloodstream and therefore into breastmilk, with a peak in concentration at half to one hour after drinking. If taken with food then the peak is from 1 to 1 ½ hours. If a mother was to have a glass of wine with dinner, then she should wait at least 2 hours before feeding the baby.

Caffeine: Caffeine can be found in a baby’s system 60 minutes after ingestion and may remain in the baby for 80 or more hours. Caffeine may make the baby jittery, colicky, constipated and unsettled and cause the mother to have a poor milk supply and recurrent . Her milk will contain 1/3 less iron if she drinks three cups of coffee a day.

Nicotine: Babies who are smoked over are more likely to suffer: respiratory and gastro intestinal illnesses, apnoea, squint, hearing impairment, vomiting, poor growth and unexplained death. The immune system is depressed so that mothers and their babies are more prone to infections and allergies. Nicotine reduces milk production, alters the taste of the milk and acts as an appetite suppressant so those babies actually refuse the milk. A woman who smokes 15 cigarettes a day may cause nicotine poisoning in the baby. Smoking is associated with diminished milk volume and milk fats.

Marijuana: THC, the fat soluble active substance in marijuana, is readily absorbed into the brain and fatty tissue. It causes decreased milk production and reality distortion in the mothers. In the babies there will be sedation, weakness and poor feeding with possible lasting brain cell, RNA and DNA changes.

8 Partner’s Role: is an adjustment and sometimes the partner feels at a loss. The best thing that the partner can do is actively support the mother in breastfeeding their baby and know that this is providing the baby with the optimal start for growth and development.

In reality, there is only one thing that a partner is not able to do. It is only functioning breasts that are missing so with that in mind: bathing, nappy changing, settling, reading stories, bringing in the washing, cooking dinner or at least getting snacks for the breastfeeding mother are all very essential tasks that keep the relationship running smoothly and keep a partner actively involved in baby care.

9 SECTION 3: COMMENCING BREASTFEEDING AND MAINTAINING LACTATION

1. Importance of undisturbed skin-to-skin contact and the first feed

There is evidence that starting to breastfeed within the first hour or so of birth is good for both mother and baby and for continued breastfeeding. A successful first breastfeed has a number of positive effects: • It builds the mother’s confidence in her ability to breastfeed. • The infant starts to receive the immunological benefits of colostrum. • The infant’s digestion and bowel function are stimulated. • Correct sucking at the breast at this stage may avert later sucking difficulties. • The bonding and attachment between mother and infant are enhanced.

Ideally, uninterrupted skin-to-skin contact should be maintained, following birth, for at least an hour. Common practices such as early weighing, bathing the baby, or passing him or her around should be delayed until later. When the infant indicates an interest in sucking, the midwife can guide the mother into a comfortable position that will enable the infant to on correctly.

Unless there is a medical reason (such as prematurity) mother and baby should remain together, so that breastfeeding begins and proceeds according to the baby’s needs.

2. Biological Nurturing: Laid Back Breastfeeding.

For the purpose of this article, the mother is referred to as ‘she’ and the baby as ‘he’.

This involves you and your baby simply relating to each other- learning about each other and mothers getting to know how their baby works. You don’t have to remember all the steps about how to place baby; all you need is to be able to see when baby is telling you he is hungry i.e. the little feeding signs or cues which you learn.

Relax, lean back, using cushions and pillows to support your body, especially the lower back, shoulders and neck, with baby over the top of you, facing you. When you lean back there is more space to support baby and even sleepy babies can attach when given the right set of circumstances.

Baby might choose to go sideways, straight up against your body or a bit diagonally. Many babies may take up a similar position to how they were on the inside so it feels familiar to them. Mum just helps baby to get comfortable in a ‘tilted up’ position.

Baby is facing mum with its entire little body fully supported against mums’ body. This means that he feels safe and secure which enables the normal baby feeding reflexes to take over. Mum just guides baby in to the place where he is trying to get to so that they are both comfortable.With the baby lying on his belly, he is able to toss his head back so that his chin tucks in to the breast and keeps the nose free. This is a helpful feeding reflex that cannot occur in other feeding positions.

10 Mum waits to see what happens once she has baby somewhere near the breast, so that it is available for baby. Mum might just need to help baby with positioning or flicking out the lips but mostly it is gravity from above baby keeps baby facing and touching the mother. This means that mums do not have to do such a lot of work with supporting baby through the back and when baby takes control, the are treated more gently.

Tired mothers find it much more relaxing when feeding, to lean back rather than sitting upright, where you have to concentrate to hold baby firmly. The term “laid back” means “chilled out”, “low key” as well as the fact that the mother is leaning back.

Starting off with this position does not mean that you have to always feed this way but it is certainly useful in the early, learning days and many mothers successfully breastfeed babies in a sitting up position. Whatever is comfortable for mum and baby is what mothers choose to do.

This system is called Biological Nurturing: Laid Back Breastfeeding and is documented by Dr Suzanne Colson. You can read about it on the website : www.biologicalnurturing.com

3. Why rooming-in is important

Rooming-in 24 hours a day is the usual practice in most hospitals. This means the infant is with the mother, in her room, from birth and it is really important for the following reasons:

• Promotes mother–infant bonding and unrestricted breastfeeding.

• Helps prevent cross-infection.

• Allows both mother and infant contact with the partner and other family members.

• Parents learn about the baby’s behaviour and feeding, and so learn how to care for the baby. After birth the baby remains with the parents and the cot stays by the mother’s bed. Initially, rooming-in after a Caesarean section calls for extra help, so fathers usually stay in to be available to care for the baby.

Rooming In is strongly encouraged at The Sunshine Coast Private Hospital.

4. How will you know if your baby is getting enough milk

A healthy baby is alert and responsive when awake and has bright eyes and firm skin with good elasticity. The adequacy of breastfeeding (with no breastmilk substitutes) can be assessed by observing the infant’s behaviour, feeding patterns, urine output, bowel actions and by checking the baby’s weight.

Baby behaviour

Babies are generally content after feeds, although most have one period of 2 or 3 hours each day, when they want to feed frequently and will not settle.

11 Feeding patterns

After the first day, babies usually breastfeed 8 to 12 times, during a 24-hour period. Some mothers expect their infant to feed on a regular four-hourly pattern, but this is not a common pattern of feeding. The length of each feed is very variable, and during the early neonatal period feeds can take about an hour. Most babies have a stretch of time in the afternoons/evenings where they seem to want to be permanently at the breast. This is normal – it is known as “cluster feeding.” It is the way that babies make sure that mum will provide enough of the creamy milk for the evening to get the through the night and so that the meal order is in early for tomorrow. If mum starts giving formula or using dummies then – there may be a downward spiral in the milk production. Keep feeding and the baby and breasts will sort themselves out.

Urine output

Until the mother’s milk comes in an infant will not pass urine often. As the milk volume increases, the infant’s urine output will increase, and a cloth nappy will be soaked with pale or colourless urine six or more times every 24 hours. Disposable nappies tend to mask wetness so care needs to be taken to determine whether the infant has urinated.

If the urine becomes scanty and strongly yellow in colour - suggesting the development of dehydration - feeding frequency and milk transfer should be evaluated.

Bowel actions

An infant’s first bowel actions consist of meconium, which is greenish-black. After 24 to 48 hours the meconium changes - first to brownish ‘transitional’ stools and then, by the third or fourth day, to typical breastfed infants’ stools, which are loose and mustard- yellow (sometimes with milk curds), although occasionally they are orange.

Typically there should be:

• One wet and one soiled nappy Day 1 • Two wet and two soiled nappies per day Day 2 • And so on until Day 6

Then 8 wet and at least 3 or 4 soiled nappies for the next 4 to 6 weeks.

Thereafter the volume will increase but the nappy count will decrease.

Between 6 weeks and 3 months of age there may be intervals of several days or more between stools. The number of bowel motions of breastfed infants tends to decrease but the volume increases when the baby is receiving breastmilk only. This is normal and, there is no cause for concern.

12 Baby weight

An initial weight loss of 5–7 % of the occurs in the first few days. Then 20 to 30 gms weight gain, per day, is usual.

Babies are usually back to birth weight by 10 to 14 days of age. If the baby appears contented and healthy there should be no immediate cause for concern about minor fluctuations in weight. Static weight or suspected weight loss over several days should, however, be carefully examined.

In general, weight gain should be assessed on a four-week average, but the following is a rough guide:

Birth to age 3 months — a gain of 150 - 200 grams a week

Age 3 to 6 months — a gain of 100 - 150 grams a week

Age 6 to 12 months — a gain of 70 - 90 grams a week.

5. Feeding cues other than crying

Babies should be fed when they indicate hunger. Crying is a late indicator of hunger - breastfeeding is much easier for both mum and baby if mum is able to pick up on baby’s earlier hunger cues. These are especially obvious in the first 8 weeks.

Common infant hunger cues include:

Early cues

• Smacking or licking lips

• Opening and closing mouth

• Sucking on lips, tongue, hands, fingers, toes, toys, or clothing

Active cues

• Rooting around on the chest of whoever is carrying him

• Trying to position for nursing, either by lying back or pulling on your clothes

• Fidgeting or squirming around a lot

• Hitting you on the arm or chest repeatedly

• Fussing or breathing fast

Late cues

• Moving head frantically from side to side

• Crying, the last hunger sign.

13 6. Why you should breastfeed your baby on ‘demand’, known as ‘baby-led feeding’

Your baby has a job to do: Baby has to tell your breasts how much milk to make. To do this, your baby needs unlimited access to your breasts. Baby will tell you whether both breasts, just one - and even both breasts twice are needed!

Mum’s role is to watch the baby: Offer the breast in response to any feeding cue, and switch breasts when requested by your baby. Your breasts are designed to respond to a properly positioned baby with just the right amount of milk.

Here are some guidelines to help you: • Follow your baby’s signals - an exception to this would be the overly sleepy newborn that may need to be undressed and stimulated to encourage feeding. generally babies should feed 8 to 12 times each day until about 3 months of age. • Allow baby to stay on the first breast until baby is no longer swallowing. Baby may wriggle in frustration when the breast is empty or s/he may just appear to sleep at breast but be unwilling to let go. In either event, this is your signal to offer the second breast. • A full baby pulls away from the breast and will not take more. Newborn babies are not simply “sucky” by nature. A baby who wants to latch again at breast is still hungry. • Leave use of dummies until past the 4 to 6 week mark as it is easy in the early weeks to underfeed your baby in the mistaken belief that the baby is fussy and ‘sucky’ when hunger is the real problem. • Watch the baby’s chin - short, choppy movements mean that baby is sucking but not swallowing. When feeding effectively, the chin pushes into the breast to milk the breast so this is a good visual sign for mothers. A swallow is a large, slow movement of the chin followed by a soft “kuh,” or an audible gulp. Switch breasts if your baby is not swallowing most of the time. Suck-suck-suck-suck-swallow-pause means the breast is empty. • If you have a lot of milk, your baby may gulp for 10 minutes and pull off, satisfied. Your second breast may still be uncomfortably full. It is OK for you to express enough milk from this breast to relieve any discomfort. Your baby will empty this breast at the next feed. • Some mothers have so much extra milk that they may need to feed the baby on the same breast for two feeds (expressing the second breast until comfortable) before the breast feels soft and the baby’s swallowing slows down. • If both breasts are uncomfortably full of milk ensure that baby stays on one breast as long as s/he is swallowing steadily. Offer the second side when the first feels softer and more comfortable. • Sometimes your baby will need the second breast, sometimes not. Some babies take only one breast at each feed for weeks but then become hungrier and start taking both at some or all feeds. Some babies take one breast in the morning but need both breasts in the evening. Be alert to your baby’s changing needs.

14 SECTION 4: DEALING WITH DIFFICULTIES OR THE UNEXPECTED

Breastfeeding should be comfortable; baby should gain weight and have at least one settled period per day. Occasionally things go astray and if the mother is aware of the potential for these then she is able to deal with them initially. Whenever there is doubt, call the Australian Breastfeeding Association or a lactation consultant and /or your doctor, for further advice. Baby growth spurts commonly occur at about 4 to 6 weeks of age so mum will need to take measures to increase her supply over about 2 days. Milk volume will increase and then baby should settle again.

1. Pain and Damage

‘Nipple stretch’ pain is common when breastfeeding in the first few days after birth. If a baby is well positioned at the breast, this sensation should ease off in a few seconds; this should also have disappeared by the end of the first week after birth. Nipple pain continuing during a breastfeed is not normal. The most common cause of nipple pain is incorrect positioning and attachment.

Predisposing Causes • Incorrect attaching and positioning • Engorgement • Nipple variations - flatness, retraction, inversion or other abnormalities • Incorrect suckling action • Abnormal skin conditions of the nipple - thrush, eczema, dermatitis.

Prevention Some measures, which may help, protect the nipples:

• Ensure correct baby attachment. • Avoid over use of soaps and other drying agents during washing and showering. • Air drying the nipples after a breastfeed. • Express and rub in small amounts of hindmilk after a breastfeed. • Avoid using plastic-backed nursing pads which may keep the nipples wet creating an environment conducive to an overgrowth of Candida Albicans (thrush) and bacteria.

Management

• If the problem is due to poor positioning or attachment, then improve attachment. If poor attachment continues it may lead to trauma of the nipples, poor milk drainage of the breast thus predisposing to engorgement, blocked ducts and mastitis with early weaning a common result, which could have been avoided.

• Allow the nipples to dry after feeding.

15 • The mother might find leaving her bra undone helpful.

• Smear hindmilk over the nipples after feeds.

• If desperate, then use purified lanolin from the chemist.

2. Milk Supply

Correct attachment and unrestricted breastfeeding time are imperative.

Over supply

A new mother might think that she has too much milk, but full breasts are often the result of a baby who is not actually draining the breasts well.

Possible management techniques include: • Temporary feeding on one breast only ie if the baby needs feeding in less than two hours, offer the same breast. This will enable the infant to obtain some of the higher energy fat content found in hind milk. • Symptomatic relief - cold flannel, ice packs, analgesia, breast support. • Reassurance that this is a temporary problem which will resolve in time. • If it is difficult to attach the baby to the full breast, it may be necessary to express the breast just enough to soften around the . The breast may also need to be expressed (for comfort only) after feeding. The expressed milk can be refrigerated or frozen for future use.

Under supply: Apparent or actual insufficiency of breastmilk might result from the following: • Poor attachment or a sleepy baby may delay the onset of good milk production. • The use of breastmilk substitutes and/or pacifiers that reduce time at the breast. • Breast Reduction surgery. Treatment would always entail more frequent and thorough emptying of breasts with baby feeding or with expressing breasts. There may be medical reasons for poor supply and if all efforts to increase lactation are unsuccessful see your doctor.

3. Engorgement

When discussing engorgement it is important to note the two major types: a. Vascular engorgement: There is an increase in blood flow and other fluids to the breasts as the breasts are being readied for full milk production. Usually occurs around days 3 to 5 after the birth. b. Milk engorgement: Vascular engorgement and milk production can overlap.

16 Predisposing causes

Most engorgement is caused by restriction of the baby’s access to the breast and poor attachment. Management includes: • Unrestricted suckling with no limitations on frequency and length of feeding and no pacifiers or bottles. The baby suckling at the breast brings relief, provided that baby is well attached. • Correct positioning and attaching - express a little milk first to soften the breast, for easier attachment. • Symptomatic relief – pain tablets; cold packs before and between feeds; breast support - the bra should not be too tight; crop tops are comfortable. • Massage and gentle hand expression may be necessary. • Offer the same breast twice ie if the baby requires a feed more than once in a two hour period the same breast is offered instead of the alternate breast. After two hours rotate feed to the opposite breast. This practice can be tried for 24 - 48 hours but usually involves discussion with a lactation consultant.

Midwives will teach the technique of Reverse Pressure Softening which helps to reduce the swelling in the nipple area so that baby is able to latch on more easily. It also triggers the letdown reflex so that milk is more quickly available for baby.

RPS drawings by Kyle Cotterman, grandson of K.Jean Cotterman who initiated this process. Permission to use.

If engorgement persists for more than a day or two despite the above measures then a complete ‘emptying out’ of the breasts can be done to obtain relief. This may be repeated once or twice only to bring relief from pressure within the breasts. Check with midwives before undertaking this.

Use cold packs on breasts for about 20 minutes before the anticipated feeds (Use of heat has no basis during the vascular engorgement phase i.e. in the early stage, it may cause throbbing and further engorgement). Some mothers find comfort with using cold packs 20 minutes on then 20 minutes off – as you would do, for example, with the swelling of a sprained ankle.

4. Blocked Milk Duct

A blocked milk duct presents as a reddened area or segment of the breast which is very tender or painful and feels hard. It is important to clear the blockage, or mastitis may follow:

17 Predisposing causes • Poor drainage of the breast if baby attaches poorly or sucks inefficiently. • Sudden engorgement due to a missed feed. • A tight or ill-fitting bra or clothing, causing pressure on one particular segment of breast. • Constantly lying on one side during sleep causing pressure. • Pressure on one spot if the mother holds the breast too tightly, particularly close to the nipple.

Treatment • The baby feeding well on the affected breast may clear the blocked duct. • Offer the affected breast first. • A change of feeding position may help. • Application of heat and gentle massage of the affected segment during the feed may also assist. Warmth may be used once the swollen phase has passed. • The breast must be well drained while treating a blocked milk duct or breast inflammation. Unrestricted breastfeeding, with no use of pacifiers, should continue. It may be necessary to express to keep the breast well drained. • If the above measures don’t resolve the problem, seek medical advice.

5. Mastitis

Mastitis is an inflammation of the breast tissue and may be inflammatory or infective.

Signs and symptoms The breast is usually red and swollen, hot and painful. The woman feels very ill, has flu-like symptoms and has a high temperature.

Treatment • Breastfeeding must continue. The breast should be kept as well drained as possible by feeding frequently and expressing if the baby does not drain the breast sufficiently. It may be appropriate to feed from the affected breast first (but not all the time as the other breast may become engorged). • Adequate analgesia such as paracetamol. • Use heat before feeds and cold afterwards. • Rest and adequate fluids. • Varying the feeding position. • Antibiotics may need to be prescribed by your doctor . • Consult your doctor if there is no improvement within 12 to 24 hrs.

18 6. How to express and store breastmilk

Mothers may need to express their breastmilk for a variety of reasons: • The baby is sick or premature. • Mother and baby are separated. • The mother is returning to paid work. • The milk supply needs to be increased. • The mother’s breasts are uncomfortably full.

The following general hints apply: • Express in a comfortable, private place. • Disable the telephone. • Have a glass of water nearby. • Relax! Music may help. • Have all expressing equipment ready.

Hand expressing Every mother should be shown how to hand express her milk. This method has many advantages: no equipment is required; it is convenient; and the skin-to-skin contact stimulates milk production. Different massage techniques may help to facilitate the milk ejection reflex to work are as follows: • Massage: Use your knuckles to gently massage the breast from the outside of the breast towards the areola –nipple. Include the underside of the breast. This is particularly useful if you have a duct which has become blocked or if your breasts are slightly engorged. • Stroke: Gently stroke your breast from the outside towards the nipple either with the tips of your fingers or a very fine comb covered in tissue paper. • Shake: Complete this rhythm by standing up and shaking your breasts.

Here are the steps: • Wash hands with soap and warm water. • Do this several times to ensure that the whole breast is massaged. Massage, Stroke, Shake. Massage, Stroke, Shake. • Hold a clean plastic dish under the breast to collect the milk, or a wide bowl can be held between the legs or placed on a low table, leaving both hands free; a towel may be needed to catch any spills.

• Place thumb and first fingers directly opposite each other about 2.5cm to 3.5 cm behind the nipple at the 12 o’clock and 6 o’clock positions.

• Your hand does not cup the breast nor do the fingers lie in a 12 o’clock and 4 o’clock position. • Gently press straight back into the chest then roll fingers inward, towards the centre of the breast, squeezing the finger and thumb together. Do not spread the fingers apart. The movement is as though you were making thumb and finger prints at the same time.

19 • Repeat with a rhythmic rolling movement. Position fingers, Push back, Roll fingers inwards. Position, Push, Roll. Position, Push, Roll. • Once the milk flow has stopped, move the fingers around the nipple and press again. This helps express more milk and empties all sectors of the breast. The fingers move to the 11 o’clock and 5 o’clock then 2 and 8 o’clock then 3 and 9 o’clock positions. • Repeat the process on the other breast. • If more milk is required, the mother can change from breast to breast until she has the amount of milk needed or she can wait and try again later.

Do not squeeze, pull or slide as these will cause damage.

The entire process will take about 20 to 30 minutes:

• Massage, stroke, shake • Express for 5 to 7 minutes • Massage, stroke, shake • Express for 5 to 7 minutes • Massage, stroke, shake • Express for 5 to 7 minutes

Express each breast until the milk slows or ceases then switch to the other side. The more milk which is removed the greater the chance to refill. The more the breasts have to work, the greater the supply will be. Using hand pumps and electric pumps will be discussed and information will be provided once you are in the hospital.

Expressing and storing breastmilk • The requirements for storing breastmilk are stringent for sick or premature babies in hospital. Use the patient information brochure from the ward if regular expressing becomes necessary. • Mothers and health workers should wash their hands thoroughly with soap and water. • Breastmilk is best used when fresh. A mother should try to provide fresh breastmilk daily for her baby; if this is not possible, the milk can be stored in a refrigerator or freezer in sterilised plastic containers. • Freshly expressed milk should be chilled in the refrigerator before being added to frozen milk. • Warmed milk should be given straight away and any amount left over should be discarded. • Never refreeze or reheat breastmilk. • Label the container with surname, date, and time of expression.

20 • Do not thaw or warm breastmilk in the microwave. • Thaw breastmilk by placing it in either cool or warm water. Shake the milk gently before using, if it has separated. • Thawed milk should be used within 24 hours.

Storing expressed breastmilk (EBM) at home

Very little special handling of a mother’s milk is necessary. Breastmilk is already sterile when it comes from the breast, and expressed breastmilk is much safer to use than prepared infant formula. It can be stored in glass or hard plastic containers. Freshly expressed milk can be chilled in the refrigerator and added to frozen milk in the freezer.

A simple guide for mothers storing expressed breastmilk at home: • Wash hands thoroughly with soap and water. • Refrigerate or freeze milk after expressing. • Use fresh milk whenever possible. • Freeze milk that will not be used within two days. • Use the oldest milk first; date the container at the time of collection.

Transporting breastmilk • Transport breastmilk in an insulated container—an Esky with a freezer brick. • If some milk has thawed it should be used within 24 hours. Do not refreeze it. • Place the milk in the refrigerator (or in the freezer if it is still frozen) immediately upon arrival.

Cleaning the expressing and feeding equipment:

After use, all equipment should be rinsed in cold water, washed in detergent and hot water, using a bottle brush to thoroughly clean bottles and teats and expressing equipment. It should then be rinsed again in clean hot water before air drying.

Current Guidelines For home use, and with a healthy fullterm baby, mothers who are expressing actually need not worry about sterilising all of the pumping and feeding equipment. Breastmilk is so good that sterilizing is not necessary where the water supply is clean. Items need to be rinsed in cold water then washed in very hot soapy water then rinsed again or they are washed in the dishwasher.

Use of formula is very different and all feeding equipment definitely needs to be sterilized.

21 Breastmilk status Room Refrigerator Freezer temperature (4°C or lower) (26°C or lower)

Freshly expressed 6–8 hours 3–5 days 2 weeks in freezer into container If refrigeration is Store at back compartment available store milk where it is coldest inside refrigerator there 3 months in freezer section of refrigerator with separate door

6–12 months in deep freeze (–18°C or lower)

Previously 4 hours or less 24 hours Do not refreeze frozen, thawed in - that is the next refrigerator but not feeding warmed

Thawed outside For completion of 4 hours or until Do not refreeze refrigerator in feeding next feeding warm water

22 Section 5: BREASTFEEDING AND GOING HOME Lactation takes 4 to 6 weeks to become established - for the supply to build up, for the let-down to be working efficiently and for the baby to be coordinated enough to deal with feeding comfortably. At about 2 weeks the breasts will feel softer: the tightness and soreness will be virtually resolved and may only be felt in the mornings or if a feed has been missed. The milk changes from a creamy colour to a blue tinged appearance. It seems much thinner and this is the normal adaptation for a growing baby.

Babies are often unsettled at the end of the day and may require more frequent top ups partly for reassurance and partly because mum’s supply may be a little lower then but this is normal – it is nature’s design. It is called Cluster Feeding.

More frequent feeds may be required during growth spurts which commonly occur at about 6 and 12 weeks. If you feed frequently during these times the milk supply will increase over the next couple of days. This is also a normal adaptation for a growing baby and is not a time to give supplementary feeds of water or formula.

Breast milk is a complete food for the first 6 months and the World Health Organisation recommends that breastfeeding continue exclusively for 6 months. After that time, family foods are started and children should continue to breastfeed while receiving appropriate and adequate complementary foods for up to 2 years of age or as long as the mother and child wish to do so.

Help after discharge:

The hospital provides a Postnatal Clinic checkup for mothers and babies in the fortnight after discharge.

A Lactation Clinic with a fee for service is designed for mothers and babies identified at Postnatal Clinic as needing extra assistance, or for mothers who request this as an extra service.

Australian Breastfeeding Association are the experts in the area but all midwives have experience and some have a particular interest.

Child Health nurses are the nursing experts in child health generally and run special parenting courses which are a particularly useful way of learning about your new baby.

Your Obstetrician or Paediatrician is available as appropriate.

Your Family Doctor should be contacted if you are worried about any health issues and the 24-hour Medical Centres should be contacted in “out of hours” times.

A list of Lactation Consultants is available upon discharge from hospital.

23 IS BABY GETTING ENOUGH?

If: • Mother feels fullness in her breasts prior to feeds then softer afterwards • Milk is leaking from one or both breasts • There is a sensation of the ‘let down’ or tingling • Baby is able to take him/herself off the breast at the end of most feeds • You are able to detect baby’s swallowing and note the change from rapid suckling to a slower more sustained rhythm • Baby has 6 to 8 wet nappies a day of pale urine (with no other foods or fluids being added to the daily intake) • Baby is gaining weight • Baby has a least one settled period each day • The bowel motions remain soft, with up to 4 per day for the first month

-> then, baby is probably getting enough.

Follow-on recommendations:

See your nearest Community Health Clinic for baby checkups and join the parenting group. Contact Australian Breastfeeding Association to learn more and meet other mothers with experience.

Remember the Post Natal Clinic appointment at the hospital [usually 2nd week].

Call your doctor or the 13 Health phone number or take baby to a doctor if baby: • Is not waking for feeds. • Has worsening yellow skin [jaundice]. • Has urine which is not clear or the mouth seems very dry. • Does not produce as many wet or soiled nappies as expected. • The soft spot on the top of baby’s head, seems to be sunken. • 13 Health: 13 43 25 84 24 hrs 7 days a week • Australian Breastfeeding Association: 1800 686 2 686 1800 mum 2 mum: 24 hrs 7 days a week • Parentline: 1300 301 300 8am - 10pm 7 days a week

24 References:

Principle texts used as follows: • NHMRC Dietary Guidelines for Children and Adolescents in Australia incorporating the Infant Feeding Guidelines for Health Workers 2003 { soon to be updated) • The Royal Womens Hospital. Breastfeeding Best Practice Guidelines 2004 • ILCA. Clinical Guidelines for the establishment of Exclusive Breastfeeding June 2005 • Core Curriculum For Lactation Consultant Practice: Ed Marsha Walker 2002 • Integrated Management Of Pregnancy and . Managing Newborn Problems. A Guide For Doctors, Nurses, Midwives. WHO 2003 • Academy of Breastfeeding Medecine Protocol #4 Mastitis Protocol • Chele Marmet 1998 Manual Expression. The Marmet Technique.

Really worthwhile websites that parents may wish to check:

• Australian Breastfeeding Association https://www.breastfeeding.asn.au

• QLD Health Breastfeeding http://www.health.qld.gov.au/breastfeeding/documents/faq.pdf http://www.health.qld.gov.au/breastfeeding/facts_links.asp

• Kellymom.com http://kellymom.com/category/bf Brilliant for so many aspects of breastfeeding.

• Dr Jack Newman http://www.breastfeedingonline.com/newman.shtml www.breastfeedinginc.ca/content.php?pagename=videos He is a breastfeeding guru and paediatrician—numerous authentic and accurate breastfeeding video clips.

• suzanne Colson Biological nurturing http://www.biologicalnurturing.com This will give you much information and photos about why laid back breastfeeding is so good and how it works.

25 Well done!

You should now have a much greater understanding of this amazing process.

While it is natural, it is learned and most mothers and babies manage well once they have an understanding of the process and if they are receiving good support.

Like the steps of a dance - you and your baby partner practice until it becomes smooth.

26 27