1. Breastfeeding Nutrition 526 Ginna Wall, RN, MN, IBCLC gwall@u.washington.edu University of Washington Medical Center Lactation Services

3. University of Washington Medical Center Lactation Services Nancy Estill, Louise Peterson, Ginna Wall, Christy Shaw, Barb Lautman RNs, International Board Certified Lactation Consultants

4. Objectives Describe the function of placental hormones, oxytocin, and prolactin in the breastfeeding process Describe the let down reflex and list factors that may interfere or enhance this reflex Recognize major contraindications to breastfeeding Recognize factors that contribute to successful initiation and maintenance of breastfeeding Describe correct positioning and latch on for successful early breastfeeding

5. 1.Prepared mammary epithelium 2.Progesterone withdrawal 3.Maintained plasma prolactin 4.Removal of milk within an undefined interval after birth The Most Important Factors For Good Milk Supply:

7. Levels rise in pregnancy Prolactin

8. Prolactin Hormone Helps women respond to stress of perinatal period Suckling is the most effective stimulus for prolactin release Direct stimulation of the nipple is necessary for prolactin release Prolactin levels rise as long as stimulation continues

11. Prolactin = for milk production Prolactin

12. Oxytocin

13. Electron micrograph of alveoli

14. Each alveolus opens into a ductule that leads to one main lactiferous duct

16. Let Down or Milk Ejection Reflex Effective milk removal depends on the ejection reflex Duct diameter increases 50%

17. Milk duct before letdown

18. Milk duct after letdown

19. §Baby crawls to breast §Opens and closes hands §Massages the breast §Hand movements cause as high an oxytocin rise as sucking Early Post-birth Events

20. Keep baby in skin contact with mother

21. Skin-to-skin contact encourages oxytocin release Oxytocin: –Promotes milk –Promotes mothering behaviors –Alleviates pain

22. Released with nipple stimulation Released in surges, lasting about 1-2 minutes Contracts muscle cells –Causes uterine contractions, causing involution –Causes contractions of the muscle cells surrounding alveoli and ducts in the breast, causing milk “let down” or “milk ejection reflex” Oxytocin in the bloodstream

23. Oxytocin Effects: Opposite of “Fight or Flight” Response Lowers heart rate Lowers blood pressure Lowers blood cortisol Stimulates endorphins Affects metabolic actions –Contracts pyloric sphincter –Releases insulin and cholecystokinin

24. Oxytocin In The Brain Affects Social Behavior Women who have high levels of oxytocin –Produce more milk –Breastfeed longer –Are more tolerant of repetitious, boring tasks –Demonstrate more “social” behavior – better listeners –Women become more social and retain those traits if they continue breastfeeding

25. The Let Down Reflex List factors that interfere with this reflex List factors that enhance this reflex

26. Cholecystokinin stimulates oxytocin Food for mother

27. Is it ever NOT a good idea to breastfeed? Contraindications to Breastfeeding: Maternal: HIV, HTLV-1, Herpes lesion on the nipple, Some drugs (cocaine, methamphetamine, radioactive drugs) Infant: Galactosemia, PKU (partial breastfeeding may be possible)

28. Factors that contribute to successful initiation and maintenance of breastfeeding 1991 WHO/UNICEF: Baby Friendly Hospital Initiative, “Ten steps to successful breastfeeding” Certified 14,500 hospitals in 125 countries 40+ US hospitals In WA State: –Evergreen –St Mary’s –Okanogan –Tacoma General –And in 2008: UWMC! –And Group Health!

29. Baby Friendly Hospital: What are the “Ten Steps?” þ Have a written breastfeeding policy that is routinely communicated to all health care staff. þ Train all health care staff in skills necessary to implement this policy. þ Inform all pregnant women about the benefits and management of breastfeeding. þ Help mothers initiate breastfeeding within an hour of birth. þ Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.

30. “Ten Steps,” continued… þ Give newborn infants no food or drink other than breastmilk, unless medically indicated. þ Practice "rooming in" by allowing mothers and infants to remain together 24 hours a day. þ Encourage breastfeeding on demand. þ Give no artificial teats, pacifiers, dummies, or soothers to breastfeeding infants. þ Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birthing center.

31. Does “Baby Friendly” Make a Difference? Promotion of Breastfeeding Intervention Trial 30 hospitals, randomized to receive Baby- Friendly training, or continue routine practices 17,000 mother-baby pairs Followed for 1 year

32. “PROBIT” Results Kramer, JAMA, Jan 2001

33. Baby-Friendly Hospital Initiative: Reduction in GI Infections and Allergies Kramer, JAMA, Jan 2001

34. “Maternity Care Practices: Implications for Breastfeeding” Surveyed 1085 women who intended to breastfeed for more than 2 months Assessed 5 Baby-Friendly practices: 1. Breastfeeding initiation 2. Supplements 3. Rooming-in 4. Breastfeeding on demand 5. Pacifiers DiGirolamo, Grummer-Strawn, and Fein, BIRTH 28:2, 94, June 2001

35. DiGirolamo, BIRTH, June 200135 Percentage of women who stopped breastfeeding before 6 weeks, by specific hospital practices

36. Percentage of women who stopped breastfeeding before 6 weeks, by number of Baby-Friendly Hospital Initiative practices they experienced DiGirolamo, BIRTH, June 2001 % STOPPED BF% STOPPED BF Number of Baby-Friendly Practices Reported

37. Philipp, PEDIATRICS, Sep 200137 “BFHI Improves Breastfeeding Initiation Rates in a US Hospital Setting” Boston Medical Center inner-city teaching hospital 1800 births per year 15-bed Level III NICU primarily poor, minority, immigrant families Implemented Baby-Friendly policies over a 3-year period Reviewed 200 randomly selected medical records from each of the 3 years

38. Philipp, PEDIATRICS, Sep 200138 BFHI IMPLEMENTATION: EFFECTS ON BREASTFEEDING TRENDS

40. ABCs of Helping Mothers to Breastfeed A is for Attachment of baby’s mouth to mother’s breast (“latch”) B is for Breastmilk (transfer of milk from breast to baby, and how to establish a good supply) C is for Confidence (tell her what a good mother she is!)

41. A Good Latch Nipple completely disappears Lips are flanged out Angle of baby ’ s lips is about 120 degrees

43. Latch Scoring Practice with video: Jane Morton MD: “ 15 minutes of breastfeeding help ”

45. How parents can tell that baby is getting enough Stooling and urination patterns –Meconium first day (one or more)

46. Stooling and urination patterns Transitional stool day 2-4 (usually one or more each day)

47. Stools when milk is "in” By day 4: 4 stools each day (not just a stain in the diaper) Frequent bowel movements for the first 4-6 weeks

48. Common Problems Sore nipples Engorgement Low milk supply Preterm and “late preterm” infants Questions about drugs Working outside the home Infant sleep, crying, temperament issues Relationships, social isolation

49. Test Weighing Use “ integrating ” digital scale Reweigh promptly in exactly the same way 1 gram = 1 ml milk

50. Double-Pumping Single- Handedly

52. Breastfeeding Support Services in King County

53. Finding Breastfeeding Support Services in the US breastfeeding.com ilca.org iblce.org