1. Supporting Breastfeeding in the Hospital Breastfeeding Education Copyright © 2007 Georgia Chapter, American Academy of Pediatrics. All rights reserved.

2. Faculty Disclosure Information In accordance with ACCME* standards for commercial support, all faculty members are required to disclose to the program audience any real or apparent conflict(s) of interest to the content of their presentation. I would like to disclose the following: * Accreditation Council for Continuing Medical Education

3. Program Objectives Examine current hospital breastfeeding policies and promote the use of evidence based guidelines Emphasize mother/ infant bonding by avoiding separation of mother and baby Define the 10 steps to successful breastfeeding.

4. EPIC Breastfeeding Program Partners Georgia Chapter – American Academy of Pediatrics Georgia OB/GYN Society American Academy of Family Physicians Georgia Department of Public Health Centers for Disease Control (CDC)

5. Supportive Research Healthy People 2020 Baby Friendly Initiative CDC’s Guide to Breastfeeding Interventions Academy of Breastfeeding Medicine Policy Statements –American Academy of Pediatrics –OB/GYN Society –Family Practice Physicians Surgeon General’s “Call to Action” to Support Breastfeeding

6. Benefits for Mom Reduces risk of postpartum hemorrhage Reduced risk of cardiovascular disease Promotes uterine involution and weight loss Decreases incidence of breast and uterine cancer Enhances bonding Decreases postpartum depression Saves money

7. CDC’s Breastfeeding Report Card 2014 Ever breastfed Breastfed at 6 months Breastfed at 12 months Exclusively breasted at 6 months National rates 79.2%49.4%26.7%18.8% Georgia rates 70.3%40.1%20.7%14.5%

8. Childhood illness and disease risk reduction with breastfeeding

9. Obstacles to Breastfeeding Lack of knowledge among parents and staff Inconsistent messages/advice Disruptive hospital policies Lack of adequate follow-up

10. Baby Friendly 10 Steps 1. Have a written breastfeeding policy that us routinely communicated to all health care staff. 2. Train all healthcare staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within one hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.

11. 10 steps - continued 6. Give newborn infants no food or drink other than breastmilk, unless medically indicated. 7. Practice “rooming-in” – allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no pacifiers or artificial nipples to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

12. You need buy-in from staff

13. Stakeholders Physicians Labor and delivery staff Postpartum staff Administrators Lactation staff Health educators Quality assurance personnel

14. Joint Commission Exclusive breastfeeding is a “Core Measure” –document breastfeeding exclusivity –supplement ONLY if medically indicated –mother “changing her mind” is not cause to abandon exclusive breastfeeding but highlights need for breastfeeding support

15. Prenatal Breastfeeding Education Monitor breast changes and provide encouragement All providers are responsible for encouraging breast milk feedings Breastfeeding classes for mom and her support person Breastfeeding materials, free of formula advertisements

16. Staff Training Policy training for all new staff Periodic breastfeeding trainings –lunch and learns –online breastfeeding education –conferences/workshops 18 hours of training for mother/baby staff Three hour physician training

17. Breastfeeding Champions

18. Breast or formula What does the mom really want to do? –breastfeed –formula feed –both?

19. After Delivery Skin to Skin

20. Skin to Skin Educate staff / parents on benefits Baby placed between the breasts –better temperature regulation –normalizes breathing and heart rate –procedures done skin to skin –prevents hypoglycemia –assist with breastfeeding www.skintoskincontact.com

21. Delay Procedures

22. Rooming-in 24 hour rooming-in is encouraged Physicals, weight checks, hearing screenings are done in mother’s room –facilitates questions from the mother –minimal infant separation Limit visitors Some hospitals have a quiet time, no visitors for several hours in the afternoon so that mom and baby can get rest and practice breastfeeding.

23. Getting Started Assist with breastfeeding at delivery Teach mother: –positioning –latch –feeding cues –hand expression –signs of sufficient intake

24. Exclusive Breastfeeding No food or drink other than breast milk Mothers own milk is the first choice No promotion of breast milk substitutes, bottles or pacifiers given to parents. Supplement only when necessary

25. Risks of Supplementing Interferes with the establishment of maternal milk supply Increased risk of engorgement May cause nipple confusion Alters infant bowel flora Undermines maternal confidence in her ability to provide her baby with sufficient milk Shortened duration of exclusive breastfeeding

26. Teaching Effective Breastfeeding Audible swallowing Appropriate out put – urine/stools Adequate weight gain

27. Staff Documentation Observe a feeding once per 8 hours Ask mom, “How does it feel” Check wet diapers and stools Check LATCH

28. LATCH Score L - latch on A - audible swallowing T - type of nipple C - comfort level H - hold Each of these 5 things are rated from 0-2 and then totaled. (Similar to an apgar) If a mother has a score of ≤ 7 the mother will need further assistance.

29. What makes more milk???? Removing milk from the Breasts!

30. Reasons to supplement Maternal Medication –Most medications are compatible –Weigh benefit of breastfeeding vs. risks of medications Excessive weight loss Hypoglycemia Jaundice Every hospital should have a written policy on supplementing

31. Maternal Medications Hale’s Medication and Mother’s Milk Lactmed @http://toxnet.nlm.nih.gov/cgi- bin/sis/htmlgen?LACT Poison Control 1.800.222.1222 Rarely necessary to interrupt breastfeeding Short list of contraindicated medications Lithium Phenindione Radioactive Compounds Retinoids Tetracyclines (chronic use >3weeks) Amiodarone Chemotherapy agents Chloramphenicol Drugs of Abuse Ergotamine Gold salts

32. Separation of mother and baby Encourage early and frequent pumping Pumping frequency every 2-3 hours Bonding is encouraged –Skin to skin –Pumping at baby’s bedside –Pump rental information Hand expression has been proven to increase milk supply

33. Infant in NICU Encourage skin-to-skin (Kangaroo) –promotes better oxygen levels –increases mom’s milk production –baby’s temperature is regulated

34. Dad can “Kangaroo” too

35. Barriers No buy-in from administration Lack of staff support Inconsistent information Formula distribution/advertisement Formula bags Financial costs

36. Discharge “gifts” Do they have formula samples in them? Do they support breastfeeding? Ban the Bags

37. Discharge Instructions Instruct mom on signs of sufficient intake –wet diapers –changes in stool color Frequent feedings are common –8-12 feedings in 24 hours –cluster feeding Give mom realistic expectations

38. Follow-up Baby should see the pediatrician 1-2 days after discharge Provide telephone number for breastfeeding questions Provide mom with information about where and how to get a breast pump Provide a list of community lactation support –WIC –LaLeche League

39. WIC Formula feeding package

40. WIC Breastfeeding Mothers Food Package

41. What do you tell a mother who ask that her baby remain in the nursery at night so she can sleep?

42. What do you say to the mother who says she doesn’t have milk or it’s not sufficient?

43. Your patient says that she is going to breastfeed but has to go back to work and wants to get her baby used to the bottle. What is your response to her?

44. “While breastfeeding may not seem the right choice for every parent, it is the best choice for every baby.”