Breastfeeding Support and Promotion Joan Younger Meek MD

Breastfeeding Support and Promotion Joan Younger Meek, MD, FAAP Section on Breastfeeding

Management of Breastfeeding • • • Breastfeeding initiation Recommended breastfeeding practices Weight pattern Hypoglycemia Jaundice Employment

Breastfeeding Promotion in Physicians’ Office Practices Curriculum 3 Key Educational Tools for Physicians to Teach New Mothers • Nutritional parameters • Hand expression • Latch and positioning

AAP Policy Statement Recommended Breastfeeding Practices • Initiate in the first hour. • Keep newborn and mother together in recovery and after. • Avoid unnecessary oral suctioning. • Avoid traumatic procedures. AAP Pediatrics 2012; 129: e 827 -841.

Breastfeeding Initiation • Skin-to-skin contact – Promotes physiologic stability – Provides warmth – Enhances feeding opportunities – Infant crawls to breast and self-attaches Photo © Joan Younger Meek, MD, FAAP • Delay weights and measurements, vitamin K and eye prophylaxis until after first feeding • Knowledgeable breastfeeding advocate in labor & delivery

AAP Policy Statement Recommended Breastfeeding Practices: • Avoid the routine use of supplements unless there is a true medical indication and the physician has ordered the supplement • Avoid the use of pacifiers in healthy, term infants, until breastfeeding is well established (approximately 3 -4 weeks of age)

Medical Indications for Supplementation • • • Very low birth weight or some premature infants Hypoglycemia that does not respond to breastfeeding Severe maternal illness Inborn errors of metabolism Acute dehydration not responsive to routine breastfeeding or excessive weight loss • Maternal medication use incompatible with breastfeeding Academy of Breastfeeding Medicine Clinical Protocol #3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate. (www. bfmed. org)

AAP Policy Statement Feeding Pattern • Encourage at least 8– 12 feedings per day. • Alternate the breast that is offered first. • Allow infant to nurse on at least one side until infant falls asleep or comes off the breast to increase fat and calorie consumption.

Infant Assessment Infant Weight • Weight Loss – Average loss of about 6% over the first 3– 4 days. – Loss greater than 8 -10% mandates careful evaluation of breastfeeding. • Weight Gain – Begins with increase in mother’s milk production by at least day 4– 5. – Expect gain of 15– 30 g/day (1/2 to 1 oz per day) through the first 2– 3 months of life.

Infant Assessment Poor Weight Gain • Problem – Inadequate milk supply or milk transfer. • Solution – Weigh infant, feed infant, weigh again. – Evaluate infant at the breast. – Correct latch and positioning. – Improve milk production and transfer. – Increase frequency and duration of feeding.

Infant Assessment Elimination Pattern • Expect – 4 -6 pale or colorless voids/day by day 4 – 3 -4 loose, yellow, curd-like stools after most feedings by day 4, continuing through the first month • Constipation is unusual in the first month—may indicate insufficient milk intake. EVALUATE • Infrequent stools are common after the first month in the healthy breastfed infant.

Infant Assessment Breastfeeding evaluation • • Proper positioning at the breast Proper latch and lip closure Sufficient areola in infant’s mouth Tongue extends over lower gums Adequate jaw excursion with suckling Effective swallowing motion Coordination of suck-swallow-breathe

AAP Policy Statement Recommended Breastfeeding Practices • Formal evaluation of breastfeeding during the first 24– 48 hours and again at 3– 5 days of age • Assess – Infant weight – General health – Breastfeeding – Jaundice – Hydration – Elimination pattern

AAP Policy Statement Recommended Breastfeeding Practices • Do not give water, juice, or solids in the first 6 months. • Initiate iron supplements only if indicated clinically in the first 6 months. • Include iron-rich foods or supplements after 6 months of age. • Supplement with 400 IU vitamin D daily. • Provide fluoride after 6 months if household water supply is deficient (< 0. 3 ppm). • Avoid cow’s milk before 12 months.

Maternal Trouble Signs • Nipple pain • Nipple trauma Photo © Joan Meek, MD, FAAP

Neonatal Hypoglycemia • No need to monitor asymptomatic low risk infants for hypoglycemia • Routine monitoring of healthy term infants may harm the mother-infant breastfeeding relationship • Early, exclusive breastfeeding meets the nutritional needs of healthy term infants and will maintain adequate glucose levels AAP; World Health Organization Academy of Breastfeeding Medicine

Neonatal Hypoglycemia • Routine supplementation of healthy, term infants with water, glucose water or formula is unnecessary and may interfere with establishing normal breastfeeding and normal metabolic compensatory mechanisms. • Healthy term infants should initiate breastfeeding with 30 -60 minutes of life and continue feeding on demand. AAP; World Health Organization; Academy of Breastfeeding Medicine

Maternal Trouble Signs • Engorgement Photo © Joan Younger Meek, MD, FAAP

Jaundice and Breastfeeding • Infants <38 weeks gestational age and breastfed are at higher risk • Systematic assessment of all infants before discharge for the risk of severe hyperbilirubinemia is warranted • Provide parents with written and verbal information about newborn jaundice • Provide appropriate follow-up based on the time of discharge and the risk assessment AAP Subcommittee on Hyperbilirubinemia Clinical Practice Guideline: Pediatrics 2004; 114: 297 -316.

Management of Hyperbilirubinemia • Promote and support successful breastfeeding • Perform a systematic assessment before discharge for the risk of severe hyperbilirubinemia • Provide early and focused follow-up based on the risk assessment AAP Subcommittee on Hyperbilirubinemia Clinical Practice Guideline: Pediatrics 2004; 114: 297 -316.

Primary Prevention of Jaundice • Recommendation 1. 0 – Clinicians should advise mothers to nurse their infants at least 8 to 12 times per day for the first several days. • Recommendation 1. 1 – The AAP recommends against routine supplementation of nondehydrated breastfed infants with water or dextrose water. • “Supplementation with water or glucose water will not prevent hyperbilirubinemia or decrease total serum bilirubin levels. ” AAP Subcommittee on Hyperbilirubinemia Clinical Practice Guideline: Pediatrics 2004; 114: 297 -316.

Risk Assessment for Jaundice before Discharge • Recommendation 5. 1 – Before discharge assess risk for severe hyperbilirubinemia • Every nursery should have formal protocol • Essential for infants discharged before 72 hrs • Best method: measure serum or transcutaneous bilirubin in every infant before discharge • Plot on Bhutani curve (perform at same time as metabolic blood sampling) AAP Subcommittee on Hyperbilirubinemia Clinical Practice Guideline: Pediatrics 2004; 114: 297 -316.

AAP Clinical Practice Guideline • Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation Nomogram for designation of risk in 2840 well newborns at 36 or more weeks’ gestational age with birth weight of 2000 g or more or 35 or more weeks’ gestational age and birth weight of 2500 g or more based on the hour-specific serum bilirubin values. AAP Subcommittee on Hyperbilirubinemia. Pediatrics. 2004; 114: 297– 316

Management of Breastfeeding Jaundice Increase caloric intake Increase breastfeeding frequency to 10– 12 feedings/day Increase duration of breastfeeding Improve latch and positioning Provide supplements only when medically indicated Enhances milk production and transfer Decreased enterohepatic reabsorption Increased stool output Lower serum bilirubin

Breast Milk Jaundice • Definition – Begins after day of life 5– 7 – Increased bilirubin reabsorption from intestine – Lasts several weeks to months

Breast Milk Jaundice • Management – Avoid interruption of breastfeeding in healthy term babies. – No routine indication for water or formula supplementation. – If bilirubin >20 mg/d. L, consider phototherapy. – Rule out other causes of prolonged jaundice.

Nursing Supplementation Illustration by Tony Le. Tourneau

Milk Expression • Wash hands before manual or hand expression. • Use a good-quality electric pump for regular expression. • Milk storage – Chill as soon as possible. – Refrigerate milk for up to 4 days. – Freeze for longer storage.

Milk Expression Photo © Jane Morton, MD, FAAP Photo © Kay Hoover, MEd, IBCLC

Return to the Workplace or School • Continued breastfeeding is feasible and desirable for mother and infant. • Prepare ahead by discussing with the employer or school personnel. • Delay introduction of bottles until milk supply well established at 3– 4 weeks.

Employed Mother Workplace support • Breaks for feeding/ expressing • Private, clean place to pump • Refrigerator or cooler with ice packs to store and transport milk Illustration by Tony Le. Tourneau

Adolescents and Breastfeeding • Highly recommended for adolescent mothers • Prenatal education and postpartum support are essential • Arrange with school personnel to express milk at school or use on-site child care program, if available • Maintain healthy diet with adequate calories, 1, 300 mg calcium per day, 15 mg iron, and a daily multivitamin

Summary • Breastfeeding is the preferred feeding for almost all infants. • Skin-to-skin contact should be initiated immediately after delivery. • Supplementation is rarely indicated and interferes with successful lactation. • Good breastfeeding technique can help to minimize problems. • Close follow-up in the early days and weeks is essential for breastfeeding success.