Breastfeeding Success Kirsten E. Crowley, MD Edited May, 2005

The big push American Academy of Pediatrics American Academy of Pediatrics “Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth.” “Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth.” WHO and UNICEF WHO and UNICEF Infants should be breastfed for at least the first four months of life, and if possible 6 months Infants should be breastfed for at least the first four months of life, and if possible 6 months Healthy People 2010 Objective Healthy People 2010 Objective Increase the number of mothers breastfeeding postpartum to 75%, at 6 months to 50%, and at 1 year to 25% Increase the number of mothers breastfeeding postpartum to 75%, at 6 months to 50%, and at 1 year to 25%

Benefits to the Baby Protects against Protects against Infection Infection Illness Illness allergies allergies Provides species-specific nutrition and hormones Provides species-specific nutrition and hormones May enhance development and intelligence May enhance development and intelligence Confers long term benefits Confers long term benefits

Protection against infection The studies The studies In first year of life, incidence of diarrheal illness among breastfed infants was half that of formula-fed infants In first year of life, incidence of diarrheal illness among breastfed infants was half that of formula-fed infants Infants who were exclusively formula-fed had a 70% increase in their risk of developing an ear infection Infants who were exclusively formula-fed had a 70% increase in their risk of developing an ear infection Formula-fed infants were 17 times more likely to be admitted for pneumonia Formula-fed infants were 17 times more likely to be admitted for pneumonia

More infection studies Associated with a lower incidence of RSV infection during the first year of life Associated with a lower incidence of RSV infection during the first year of life Relative risk of developing a UTI of 0.38 compared to formula-fed infants Relative risk of developing a UTI of 0.38 compared to formula-fed infants In the NICU In the NICU Among babies born at more than 30 weeks, confirmed NEC was 20 times more common in formula-fed babies Among babies born at more than 30 weeks, confirmed NEC was 20 times more common in formula-fed babies The incidence of sepsis/meningitis are significantly reduced in human milk fed VLBW infants The incidence of sepsis/meningitis are significantly reduced in human milk fed VLBW infants

Other illness There is an inverse relationship between breastfeeding and morbidity There is an inverse relationship between breastfeeding and morbidity Breastfed infants have gastroesophageal reflux episodes of significantly shorter duration Breastfed infants have gastroesophageal reflux episodes of significantly shorter duration Breastfeeding is protective against SIDS Breastfeeding is protective against SIDS Toddlers who were breastfed appear to be healthier Toddlers who were breastfed appear to be healthier

Protection against allergies In allergic families, formula introduction in the first week of life and weaning at less than 4 months were associated with increased allergies later in life In allergic families, formula introduction in the first week of life and weaning at less than 4 months were associated with increased allergies later in life Eczema was less common and milder Eczema was less common and milder Breastmilk = 22% Breastmilk = 22% Soymilk formula = 63% Soymilk formula = 63% cow’s milk formula = 70% cow’s milk formula = 70%

Enhances development and intelligence Controversial of course Controversial of course Some studies have shown higher IQ and improved cognitive development in breastfed children Some studies have shown higher IQ and improved cognitive development in breastfed children Psychomotor and social development may be improved as well Psychomotor and social development may be improved as well

Long term benefits Lower incidence of Lower incidence of diabetes diabetes childhood cancer and breast cancer childhood cancer and breast cancer May influence LDL concentration and mortality from ischemic heart disease May influence LDL concentration and mortality from ischemic heart disease Decreased cavities Decreased cavities Better response to vaccines Better response to vaccines

Benefits to mom Delays fertility due to lactational amenorrhea Delays fertility due to lactational amenorrhea Reduces risk of breast, uterine, ovarian, and endometrial cancer Reduces risk of breast, uterine, ovarian, and endometrial cancer Enhances emotional health Enhances emotional health Decreases insulin requirements Decreases insulin requirements Decreases osteoporosis Decreases osteoporosis Promotes postpartum weight loss Promotes postpartum weight loss

Societal benefits Encourages optimum child spacing Encourages optimum child spacing Improves vaccine effectiveness Improves vaccine effectiveness Decreased expense of food (formula for one year is between $1160 and $3915) Decreased expense of food (formula for one year is between $1160 and $3915) Decreased medical expenses Decreased medical expenses 1000 bottle-fed infants had 2033 excess office visits, 212 excess days in the hospital, and 609 more prescriptions = $459-$808 per family per year 1000 bottle-fed infants had 2033 excess office visits, 212 excess days in the hospital, and 609 more prescriptions = $459-$808 per family per year Reduced absenteeism due to child illness Reduced absenteeism due to child illness Protects the environment (bottles, packages, etc.) Protects the environment (bottles, packages, etc.)

So, how are we doing? In 1998 In % of women initiated breastfeeding 64% of women initiated breastfeeding 29% were still breastfeeding at 6 months 29% were still breastfeeding at 6 months 16% were breastfeeding at one year 16% were breastfeeding at one year highest rates in several generations highest rates in several generations Rates still fall short of the Healthy People goals of 75% initiation, 50% at 6 months, and 25% at one year Rates still fall short of the Healthy People goals of 75% initiation, 50% at 6 months, and 25% at one year U.S. breastfeeding rates are the second lowest of all industrialized nations U.S. breastfeeding rates are the second lowest of all industrialized nations

Who tends to breastfeed? Most common among women who are Most common among women who are college educated college educated white white married married older than 30 years older than 30 years middle or higher income levels middle or higher income levels More prevalent in the western regions of the country More prevalent in the western regions of the country

What affects success? Maternity hospital routines Maternity hospital routines accuracy and timeliness of breastfeeding assistance are the most important accuracy and timeliness of breastfeeding assistance are the most important Birth weight and health of the newborn Birth weight and health of the newborn Peer attitudes Peer attitudes Length of maternity leave Length of maternity leave Employer’s willingness to make accommodations Employer’s willingness to make accommodations Opinion of the child’s father Opinion of the child’s father Aggressive marketing of formula Aggressive marketing of formula

Promoting success Women who are better informed regarding the benefits of breastfeeding and the breastfeeding process are more likely to initiate (and probably maintain) breastfeeding Women who are better informed regarding the benefits of breastfeeding and the breastfeeding process are more likely to initiate (and probably maintain) breastfeeding

An interesting study Kistin et al. Kistin et al. First controlled trial of prenatal maternal counseling by MDs First controlled trial of prenatal maternal counseling by MDs Counseling increased the rate of initiation and duration of breastfeeding in a predominantly low-income, urban, African American population Counseling increased the rate of initiation and duration of breastfeeding in a predominantly low-income, urban, African American population

National Assessment of Physicians’ Breast-feeding Knowledge, Attitudes, Training, and Experience Freed, et al. JAMA ; 273(6): Residents and practitioners in peds, FP, and OB/gyn were lacking in Residents and practitioners in peds, FP, and OB/gyn were lacking in Breastfeeding knowledge base Breastfeeding knowledge base Ability to give appropriate advice Ability to give appropriate advice

The role of the pediatrician Promote and support Promote and support Become knowledgeable and skilled in physiology and clinical management Become knowledgeable and skilled in physiology and clinical management Provide education Provide education Parents, Colleagues, Nurses, Residents Parents, Colleagues, Nurses, Residents Become familiar with local resources Become familiar with local resources Develop and promote policy Develop and promote policy Encourage insurance coverage Encourage insurance coverage Promote breastfeeding friendly workplaces Promote breastfeeding friendly workplaces

Assessing for success The input (milk transfer) The input (milk transfer) The output (urine & stool) The output (urine & stool) The ultimate (weight) The ultimate (weight)

The intake Goal is 8-12 feedings per day Goal is 8-12 feedings per day Feedings should last minutes when the baby is a newborn Feedings should last minutes when the baby is a newborn Understand the cues Understand the cues Sleep arousal Sleep arousal Increased alertness Increased alertness Hand to mouth Hand to mouth Tongue or mouth movements Tongue or mouth movements Crying (late stage of hunger) Crying (late stage of hunger)

The output Urine Urine Before the milk is in: one void for each day of age Before the milk is in: one void for each day of age After the milk arrives: 6-8 times per day After the milk arrives: 6-8 times per day Stool Stool Days 1-4: meconium Days 1-4: meconium Day 4-4 weeks: 4 yellow, seedy BM per day Day 4-4 weeks: 4 yellow, seedy BM per day 1-4 months: varies from one per feed to once a week 1-4 months: varies from one per feed to once a week

The ultimate judge: The Weight Initial loss Initial loss 8-10% of birthweight 8-10% of birthweight Return to birthweight Return to birthweight days days Aggressive intervention if not by 2 weeks Aggressive intervention if not by 2 weeks Rate of gain for full term babies Rate of gain for full term babies First 2 months = 30 grams per day First 2 months = 30 grams per day > 2 months = grams per day > 2 months = grams per day

Assess the Latch! Incorrect latch is one of the most common etiologies for poor weight gain Incorrect latch is one of the most common etiologies for poor weight gain Observation of the mother - infant dyad is extremely important! Observation of the mother - infant dyad is extremely important!

Correct latch Mother Mother Mom holds breast back from areola and nipple with C-hold Mom holds breast back from areola and nipple with C-hold Use manual stimulation to erect the nipple Use manual stimulation to erect the nipple Tickle the baby’s lips gently Tickle the baby’s lips gently Wait for baby to open mouth like a yawn Wait for baby to open mouth like a yawn Center nipple quickly while pulling baby in close to the breast Center nipple quickly while pulling baby in close to the breast Initial latch may be painful, but abates as nursing progresses Initial latch may be painful, but abates as nursing progresses

Correct latch Baby Baby Tip of nose and chin touching breast Tip of nose and chin touching breast Tummy to tummy Tummy to tummy Lips flanged over areola - fish lips Lips flanged over areola - fish lips Gums bypass nipple and are over areola (where the milk sinuses are) Gums bypass nipple and are over areola (where the milk sinuses are) Movement of facial and jaw muscles, ear wiggling Movement of facial and jaw muscles, ear wiggling Look for suck-swallow patterns Look for suck-swallow patterns

Assessment of suck Tongue comes over the gumline Tongue comes over the gumline Cupping of tongue at the lip Cupping of tongue at the lip Feel up and down motion of the posterior tongue Feel up and down motion of the posterior tongue Strength of suck Strength of suck

Nursing positions Cradle hold Cradle hold Mom upright in comfortable chair with pillows in the lap and feet supported Mom upright in comfortable chair with pillows in the lap and feet supported Tummy to tummy Tummy to tummy Head in straight line Head in straight line Ear, shoulder, and hips in straight line Ear, shoulder, and hips in straight line Baby’s body at breast level (boppy pillow) Baby’s body at breast level (boppy pillow) Baby’s head in crook of elbow Baby’s head in crook of elbow Baby’s back supported with forearm Baby’s back supported with forearm Cup breast with free hand Cup breast with free hand

Cradle hold

Boppy pillow

Nursing positions Football hold Football hold Mom in same position Mom in same position Baby’s body and legs under mom’s arm Baby’s body and legs under mom’s arm Head snugly in mom’s hand with neck grasped by thumb and pinky and head on palm and other fingers Head snugly in mom’s hand with neck grasped by thumb and pinky and head on palm and other fingers Pillows under the baby (boppy) Pillows under the baby (boppy) Avoid flexing baby’s head too much Avoid flexing baby’s head too much

Football hold

Nursing positions: Lying Down Helpful after a cesarean section Helpful after a cesarean section Good for tired moms Good for tired moms Eases nighttime feedings early on if the dyad is co- sleeping Eases nighttime feedings early on if the dyad is co- sleeping

Common problems (and how to fix them)

Sore nipples Discomfort at the beginning is OK Discomfort at the beginning is OK Improper position is the main cause Improper position is the main cause Can also be caused by infection or inappropriate nipple care Can also be caused by infection or inappropriate nipple care Treatment Treatment Position correctly Position correctly Begin feeding on least sore nipple Begin feeding on least sore nipple Frequent shorter feeds Frequent shorter feeds Rub expressed milk onto nipple/areola Rub expressed milk onto nipple/areola Air dry nipples Air dry nipples Pump if nipples are too painful Pump if nipples are too painful

Engorgement Occurs on the second to fourth days Occurs on the second to fourth days Results from hormone changes that suddenly increase milk production Results from hormone changes that suddenly increase milk production Temporary!!!: The supply becomes balanced within a few days Temporary!!!: The supply becomes balanced within a few days Treatment Treatment Nurse frequently, around the clock Nurse frequently, around the clock Heat and massage before feeding Heat and massage before feeding Express some milk if baby can’t latch Express some milk if baby can’t latch May be harmful to supply if not relieved May be harmful to supply if not relieved

Mastitis Bacterial breast infection Bacterial breast infection caused by inadequate emptying of milk caused by inadequate emptying of milk Symptoms Symptoms achy, flu-like achy, flu-like breast pain, redness, tenderness breast pain, redness, tenderness fever/chills fever/chills Treatment Treatment Dicloxicillin 250 mg QID x 10 days Dicloxicillin 250 mg QID x 10 days Keflex 500 mg QID x 10 days Keflex 500 mg QID x 10 days Rest, fluids, pain meds, nurse often or pump after feeds, moist heat Rest, fluids, pain meds, nurse often or pump after feeds, moist heat

Candidiasis Rapid development of extremely sore nipples, burning or itching, shooting pain Rapid development of extremely sore nipples, burning or itching, shooting pain Look for deep pink areas on mom and thrush or diaper candidiasis in baby Look for deep pink areas on mom and thrush or diaper candidiasis in baby Treat both mom and baby Treat both mom and baby Topical antifungal for both, oral nystatin Topical antifungal for both, oral nystatin Wash anything in contact with baby’s mouth or breast Wash anything in contact with baby’s mouth or breast

Breastfeeding jaundice Exaggerated physiologic jaundice due to lack of food in GI tract and increased enterohepatic circulation Exaggerated physiologic jaundice due to lack of food in GI tract and increased enterohepatic circulation Usually occurs in second to third day Usually occurs in second to third day Treatment Treatment Increase feeding frequency Increase feeding frequency Mom should pump if baby is sleepy or poor feeder Mom should pump if baby is sleepy or poor feeder Feed baby EMM or formula only Feed baby EMM or formula only Use alternate feeding systems if necessary Use alternate feeding systems if necessary Watch baby’s weight Watch baby’s weight