9/21/2018 OVERCOMING BREASTFEEDING Presented by: CONCERNS- PART 2 Kary Johnson, IBCLC OVERVIEW • Pacifiers • Pumping • Low Milk Supply • Feeding Multiples • Supplementation • Discharge Guidelines PICTURE FROM HTTPS://WWW.ETSY.COM/LISTING/464346270/BREAST-ENCOURAGEMENT-CARD-BREASTFEEDING 1 9/21/2018 PACIFIERS Step 9: Counsel mothers on the use and risks of feeding bottles, teats and pacifiers. What does the AAP say? •NG/Gavage •“Mothers of healthy term infants should be instructed to use pacifiers at •Hypoglycemia infant nap or sleep time after breastfeeding is well established, at Infant approximately 3 go 4 weeks of age.” •Lab draws • “Pacifier use should be limited to specific medical situations. These include Pain •Circumcision uses for pain relief, as a calming agent, or as part of a structured program •Illness for enhancing oral motor function.” •Medications Maternal •PMAD • NICU: to organize suck, swallow, breathe pattern of premature infant (in addition to reasons above) (AAP, 2012) PACIFIERS Ask yourself…what is the reason for use? Management: • All effort should be made to prevent separation of mom & baby (i.e. newborn nursery) • Avoid overuse • Be careful to not incorrectly pacify infant hunger • Non-nutritive sucking on mother’s breast is a great alternative Overuse or misuse results in: • Decreased breastfeeding duration • Reduced milk supply • Dental issues, difficulty weaning, and use well into childhood 2 9/21/2018 BREAST PUMPING Reasons a mother may need to pump: • Nipple trauma • Low milk supply • Late preterm infants • Maternal infant separation • Back to work/school • NICU admission • Exclusively bottle feeding • Infant conditions • Jaundice, Cleft lip/palate, Trisomy 21 (BOIES ET AL., 2016; LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013; USBC, 2018) BREAST PUMPING GUIDELINES • Pump for 15-20 minutes • Ensure proper flange size • Ensure appropriate suction • Utilize a quality double electric pump to maximize prolactin levels • Use “hands on pumping” • Follow each pumping session with 3-5 minutes of hand expression • Clean appropriately after each use • Refer to CDC guidelines (LAUWERS & SWISHER, 2016) 3 9/21/2018 LOW MILK SUPPLY Perceived: • Frequent feedings or cluster feeding • Growth spurts result in temporary increase in feedings • Misinterpret crying as a symptom of low supply • Breasts not feeling full • Pumping lower milk volume (than another mother) (LAUWERS & SWISHER, 2016; USBC 2018) LOW MILK SUPPLY Milk removal triggers milk production! Encourage mothers on: • Frequent, on demand feedings 8-12x daily • Actual breastfeeding rates and capacities differ for each mother baby dyad • Importance of latch and positioning • Breast compression and massage during feedings • Performing hand expression after feedings to ensure breast emptiness • Utilize IBCLC resources and community support groups (LAUWERS & SWISHER, 2016) 4 9/21/2018 INFANT STOMACH CAPACITY 3 Factors influence breastfeeding frequency: 1. Breast storage capacity 2. Infant stomach capacity 3. Infant’s gastric emptying time (LAUWERS & SWISHER, 2016) INFANT STOMACH CAPACITY •Physiologic stomach capacity is different from anatomic capacity • Physiologic capacity = infant is satisfied • Anatomic capacity = infant is stuffed •Anatomical capacity at day 1 of life is approximately 30ml • Helps to explain the difference in intake amount for exclusively breastfed infants vs. breastfed infants being supplemented 5 9/21/2018 ACTUAL LOW MILK SUPPLY Management: • Frequent removal of milk and emptying Red Flags: of the breast • Previous history of low milk supply • Ensure adequate milk transfer • Multiples • Pump after feedings for extra • Inadequate breast tissue growth in stimulation puberty/pregnancy • Galactagogues • Support! • History of breast surgery • Radiation to chest Referral Suggestions: • Endocrine disorders (hypothyroid, • OBGYN for metabolic lab work • Pediatrician to monitor adequate PCOS) growth and development • Obesity • IBCLC for additional resources, such as • Diabetes a SNS (supplemental nursing system) • Medications (LAUWERS & SWISHER, 2016) BREAST PUMPING If pumping to increase supply: • Pump after all daytime feedings • Decrease pumping frequency once an increase in supply is attained (LAUWERS & SWISHER, 2016; USBC, 2018) 6 9/21/2018 PUMP EARLY, PUMP OFTEN Preterm, Late Preterm and Exclusively Bottle Feeding Considerations: Pump Early: • NEW! - Ideally within the first hour of delivery and after the first feeding • Regardless of delivery mode Pump Often: • Recommend 8 pumping sessions in a 24 hour period • Not to exceed 4 hours without pumping Breast, Bottle, Pump (MORTON ET AL., 2012; STEUER & SMITH, 2018) BACK TO WORK & SCHOOL Mothers need: • Pumping recommendations to prepare for returning to work/school • Once or twice a day right after a feeding is sufficient • Pumping in the morning will provide higher volumes • Pumping recommendations after returning to work/school • Goal: approx. 3, 15-20min session in 8 hr. work day • Education on possible milk supply issues • It is easier to prevent an issue than fix it! • SUPPORT • Policies/laws for breastfeeding & milk expression outside the home. (EVANS ET AL., 2014) 7 9/21/2018 FEEDING MULTIPLES Common Concerns: • Prematurity of the infants • Maternal-Infant/Infant-Infant Separation • Feeding success • Feeding 3 or more babies • Maternal Exhaustion, Lack of Time • Bonding (LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013; USBC, 2018) FEEDING MULTIPLES MANAGEMENT Infant prematurity and/or separation: • Supply and demand – early and often milk removal • Hands on pumping every 3 hours, day and night • Hand expression and skin to skin Feeding Success: • Feed individually until at least 1 baby is assessed for consistent & effective feedings. • Feeding schedule options: • Both babies may eat when the first gets hungry – do not wait for the second to cue! • Both babies may be allowed to follow their own patterns and feed them individually • Use a combination of both methods • Rotate breasts/babies with every feeding or every day (LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013) 8 9/21/2018 FEEDING MULTIPLES MANAGEMENT Feeding 3 or more babies: • Breastfeed 2 at a time and the other(s) on both breasts afterward • Alternate babies so each take turns breastfeeding first • Breastfeed 2 at a time while another person feeds the other baby(ies) • Alternate babies so a different one is fed with alternate means each feeding Maternal exhaustion/lack of time: • Set the expectation that, in the beginning, mom should plan to do nothing else besides feed the babies and sleep • Utilize a flexible feeding schedule • Enlist support (household chores, meals, doctor appointments, etc.) Bonding: • Breastfeed separately at least one time each day • Remember each baby is an individual & has separate needs (LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013) SUPPLEMENTATION Step 6: Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated. What does the AAP say? • “Give no supplements (water, glucose water, commercial infant formula, or other fluids) to breastfeeding newborn infants unless medically indicated using standard evidence-based guidelines for the management of hyperbilirubinemia or hypoglycemia.” (AAP, 2012) 9 9/21/2018 SUPPLEMENTATION Supplementation can inhibit Medical reasons for or delay the establishment supplementation include: of a mother’s milk supply, • weight loss >10% • signs of dehydration decrease rates of • lethargy breastfeeding initiation and • hyperbilirubinemia duration, interfere with • hypoglycemia maternal infant bonding, • actual low milk supply alter infant gut flora, and • multiples sensitize the infant to • NICU admission allergens. (HOLMES ET AL., 2013) SUPPLEMENTATION What supplement should be used? How much should be given? 1. Mother’s expressed milk • Follow the pediatrician recommendation/guidelines as this 2. Donor breast milk is variable for each baby. 3. Formula • In general: • Start with 15ml per feeding, if infant is still going to breast. • Supplement by cue and to infant satiety. • Remember infant stomach size • NICU: per MD order (BOIES ET AL., 2016; LAUWERS & SWISHER, 2016) 10 9/21/2018 SUPPLEMENTATION Methods: • Spoon • Cup • Syringe https://www.youtube.com/watch?v=OGPm5SpLxXY • Supplemental Nursing System (SNS) • Bottle https://www.youtube.com/watch?v=jIkFP2MtYcg •When supplementing, it is important to perform paced feeding to: •Help infant coordinate suck/swallow/breathe •Facilitate smooth transition back to breast after supplementing FORMULA FEEDING Mothers who choose to formula feed need support and education too! • Feeding options to make an informed decision • Opportunity to talk about her desires and reasons for feeding choice • Support for her decision • How to safely prepare, store, handle and feed formula (WOOD, 2018) 11 9/21/2018 DISCHARGE GUIDELINES Initial follow up appointment should be scheduled prior to discharge • Term Infants: • Within 48–72 hours after discharge • Infants discharged before 48 hours of age should be seen within 24–48 hours after discharge • Late Preterm & Early Term: • Within 24-28 hours after discharge • NICU: • Within 72 hours after discharge • F/U “with a trained, skilled lactation professional within 2-3 days after discharge” (BOIES ET AL., 2016; EVANS ET AL., 2014; NOBLE ET AL., 2018) QUESTIONS? 12 9/21/2018 REFERENCES American Academy of Pediatrics (2012). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 129(3), 827-841. Doi 10.1542/peds.2011- 3552 Academy of Breastfeeding