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Dr Carol's Advice
  Newborn baby
Breastfeeding Support: A National Campaign
By: Carol Chamblin, DNP, APN, RN, IBCLC
 
 
Breastfeeding Rates
Improving the health of mothers and infants by breastfeeding is a national campaign. Recommendations for increasing rates for exclusive breastfeeding and duration rates have been addressed by the Surgeon General’s Call to Action to Support Breastfeeding, 2011. The United States Breastfeeding Committee, The Centers for Disease Control and Prevention (CDC), and the Academy of Breastfeeding Medicine are a few of the key stakeholders for this campaign.
According to the latest CDC Breastfeeding Report Card – United States, 2012, 76.9% of new mothers initiate breastfeeding, 36% are exclusively breastfeeding at 3 months, 47.2% are breastfeeding at six months with 16.3% exclusively breastfeeding, and 25.5% breastfeeding at 12 months.

Although initiation rates are high, current rates of duration and exclusivity remain low. Healthy People 2020 objectives are to increase the proportion of infants who are breastfed. Targets consist of 81.9% initiation rates, with duration rates of 60.6% and 34.1% at three months and six months respectively. Targets of exclusivity are 46.2% and 25.5% at three and six months respectively. In the state of Illinois, the initiation rate is 76.8% with continuation rates of 49.8% at six months and 25.3% at 12 months. Rates of exclusivity are 35.7% and 13.6% at three months and six months respectively. Many mothers discontinue breastfeeding before six months of age and lack the ability to exclusively breastfeed their infants.
 
Health Benefits of Breastfeeding
According to The Surgeon General’s Call to Action, breastfeeding for a year provides many health benefits for infants including but not limited to protection from diarrhea, ear infections,; pneumonia, asthma, childhood obesity, and sudden infant death syndrome (SIDS). Economic benefits feature savings on infant formula for the first year of life estimated to be about $1,200-$1,500, and savings from reduced medical costs by breastfeeding for six months as estimated to be between three and 13 billion dollars for the United States (U.S).
 
Implementing The Joint Commission Perinatal Care Core Measure on Exclusive Breast Milk Feeding
One major document by the United States Breastfeeding Committee is “Implementing The Joint Commission Perinatal Care Core Measure on Exclusive Breast Milk Feeding." Its purpose is to enhance evidence-based clinical practice for the promotion of breastfeeding. The term breast milk feeding rather than breastfeeding is preferable based on findings that health benefits are similar. While breastfeeding is the goal for optimal health, it is recognized that human milk provided indirectly is still superior to alternatives. Exclusive breast milk feeding is defined as: a newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines. Breast milk feeding includes either expressed mother’s milk or donor human milk. Both are fed to the infant by means other than suckling at breast.
 
Reasons for Supplementation

Supplementation with expressed breast milk, donor milk, or formula may be considered for medical reasons. Despite the fact that top-performing hospitals in the U.S. have less than ten per cent of breastfed infants being supplemented, the goals of infant feeding care is to diminish the numbers of infants who become dehydrated from insufficient milk transfer. Amounts for supplementation should reflect stomach capacity of the infant:

  • Approx. 5-7 ml on day 1
  • 7-12 ml on day 2
  • 18-25 ml on day 3
  • 28-42 ml on day 4
  • 34-48 ml on day 5
 
Infant Reasons for Supplementation:
  • Hypoglycemia
  • Excessive weight loss
  • Failure to latch
  • Delayed lactogenesis
  • Jaundice related to decreased intake
  • Large for Gestational Age (LGA) and Intrauterine Growth Retardation (IUGR) requiring caloric supplementation
  • Mother/baby separation
  • Maternal wishes (Many mothers feel their concerns about lack of adequate infant intake are being ignored).
Avoiding artificial nipples helps avoid nipple preference, which can interfere with the establishment of breastfeeding. If the infant needs supplementation for medical reasons, then the mother should also hand express and feed any colostrum she obtains to her infant. If feeding and hand expression is unsuccessful, the mother should initiate pumping with an effective electric breast pump. Electric breast pumps that are typically available on a rental basis post-discharge from the hospital setting are preferable to pumps that are made for purchase when breastfeeding is not going well. Though hand expression is encouraged, many new mothers are not as comfortable with hand expression as they are in using a breast pump.
 
Maternal Reasons for Not Exclusively Feeding Breast Milk:
  • HIV
  • Human t-lymphotrophic virus type I or II
  • Substance and/or alcohol abuse
  • Active, untreated tuberculosis (TB)
  • Taking certain medications–
    Prescribed cancer chemotherapy
    Radioactive isotopes
    Antimetabolites
    Antiretroviral meds
    Undergoing radiation therapy
  • Active, untreated varicella
  • Active herpes simplex virus with breast lesions (although breastfeeding can occur on the non-affected breast)
 
WHO/UNICEF - Ten Steps to Successful Breastfeeding
To optimize breastfeeding outcomes, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) identified Ten Steps to Successful Breastfeeding. A national study of U.S. women giving birth in facilities using the Ten Steps were shown to be six times more likely to achieve exclusive breastfeeding.

The Ten Steps are:

  • Have a written breastfeeding policy that is routinely communicated to all health care staff.
  • Train all health care staff in skills necessary to implement this policy.
  • Inform all pregnant women about the benefits and management of breastfeeding.
  • Help mothers initiate breastfeeding within one hour of birth.
  • Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
  • Give newborn infants no food or drink other than breast milk, unless medically indicated.
  • Practice rooming in allow mothers and infants to remain together 24 hours a day.
  • Encourage breastfeeding on demand.
  • Give no pacifiers or artificial nipples to breastfeeding infants.
  • Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
 
Labor and Delivery Care
Recommendation for evidence-based best practice begins with the labor and delivery care. Initial skin-to-skin contact is emphasized immediately after birth to facilitate imprinting of proper breastfeeding technique by the infant. Infants are quickly dried and placed naked on their mother’s bare chest. Both mother and infant are covered, except for infant’s head, with warm blankets. A cap may be placed on the infant’s head but his face should remain visible. Ensuring that the infant is dried between his skin folds and that wet towels and clothing are not in contact with the infant promotes adequate thermoregulation.

Next steps for labor and delivery care involves the umbilical cord care. The umbilical cord is not clamped until the infant is dried and on his mother’s chest. The cord may be clamped with the infant turned slightly on his side. Delayed cord clamping may also prevent anemia in the infant. Skin-to-skin contact is also emphasized as soon after birth as possible in cases of cesarean delivery. For non-emergent cesarean births, immediate skin-to-skin contact while incisions are being closed may help to prevent maternal and neonatal hypothermia and provide a pleasurable distraction for the mother. Infants who remain near their mothers adjust to extra-uterine life more readily due to the warmth of mother’s body, and by being exposed to familiar sounds of her heartbeat and voice. Studies show that mother’s body responds to her infant’s body temperature, aiding in thermoregulation of the infant.
 
Initial Breastfeeding Opportunity

Promoting breastfeeding is inclusive of emphasizing breastfeeding opportunities in the first hour of life. Infants immediately placed skin-to-skin with their mother after birth without interruption tend to find the breast and spontaneously initiate breastfeeding within the first hour. It is usually not necessary to bring the infant to the breast. Ventral positioning may facilitate this process: with mother semi-reclining, infant placed prone on mother’s chest, with infant’s head between her breasts and abdomen resting on hers. During this time, the infant should not be removed for bathing, weighing, examinations, or medications according to the WHO guidelines. It is noted, though, that it may take some infants longer than one hour to spontaneously initiate breastfeeding, particularly if the mother was given sedating medications during labor.

The importance of possible attaching to the breast within one hour from birth is based on evidence that has shown that postponing the first feed is a strong predictor of breastfeeding failure. Infants appear to have a heightened sense of olfactory learning in the first hour after birth, naturally seeking mother’s breast by smell, particularly if any amniotic fluid is present. Immediate skin-to-skin after birth results in the infant having enhanced recognition of his own mother’s milk, and is associated with longer breastfeeding duration rates. Performing Apgar scoring and other painful procedures such as heel-sticks should be conducted while mother and infant are skin-to-skin. This practice may diminish newborn stress, hypothermia, and hypoglycemia. Skin-to-skin contact and breastfeeding are also known to have an analgesic effect on the newborn.

Continuous physical, emotional, and informational support from skilled health care providers, such as doulas, nurses, physicians, and midwives promote successful breastfeeding experiences. During labor, continuous care from birth doulas has been shown to decrease the need for pain medications and more invasive birth practices. This labor support can lead to higher breastfeeding intent and initiation. It may help to lower rates of cesarean deliveries by as much as half.

 
Breastfeeding Advice and Counseling
Several aspects of breastfeeding need to be highlighted for new mothers to initiate breastfeeding correctly so that national and state breastfeeding rates continue to improve. It is normal for exclusively breastfed infants under six months to feed 8-11 times in 24 hours. Infant hunger cues include eye opening, rooting, yawning, and stretching. Though infants rapidly pursue crying as a hunger cue, it is considered to be a late sign. Infants may cluster feed, asking for several closely-spaced feeds followed by longer sleep period (this doesn’t mean 24 hrs.). During the hospital stay, the newborn not waking to feed at least 8 times needs to be assessed for hydration status, sepsis, or hypoglycemia. If the infant appears healthy, monitoring needs to be continued until feeding effectively and spontaneously waking for feeds. Frequent feedings help to increase milk supply. The sleepy infant does not frequently feed and may contribute to decreased milk supply, undue engorgement, and risk of early weaning.
 
Observation of Breastfeeding
Staff should allow the mother to position the infant and achieve latch, with guidance if necessary, rather than positioning and latching the infant for the mother. This method for latching technique helps to optimize mother’s chances of success after returning home. Mothers are better able to learn how to become independent with latch and positioning, and they improve self-efficacy. Mothers at risk for a delay in milk production include: cesarean delivery, especially unscheduled, large infants (> 3600 g), primiparas, prolonged labor, obesity, infants of diabetic mothers, and possibly those using selective serotonin-reuptake inhibitors. Close observation prevents complications associated with insufficient milk transfer.
 
Pacifier Use

Clear and limited indications for pacifier use are during circumcisions for analgesia, and if parents supply their own. Pacifiers have been shown to interfere with establishment of breastfeeding if “such interference results in excessive weight loss or dehydration.” American Academy of Pediatrics (AAP) states pacifiers are not to be used in breastfeeding newborns for the first month, until breastfeeding is well established. Energetic supporters of breastfeeding may go beyond their scope of practice by denying a mother’s informed choice to use a pacifier. When infant excessive weight loss or dehydration doesn’t exist, there is no reason to alarm the mother. Expansion of breastfeeding-related knowledge enhanced by internet resources, or successful prior breastfeeding experiences, may lead towards breastfeeding being well established sooner than one month, allowing new mothers to use a pacifier to calm their infants when unable to self-soothe on their own accord.

 
Contact Between Mother and Infant
Mother and infant care should be as a unit called “pair care” or “couplet care." Encouragement of rooming-in for new mothers has been shown to promote exclusive breastfeeding and duration. Infants rooming-in are more likely to take more breast milk and gain more weight, as well as being less likely to have jaundice. Infants who stay with their mothers sleep better and cry less. It has been shown that mothers get the same amount of sleep whether their infant is in the room or the nursery. Mothers learn to recognize their infant’s cues and feed them at the earliest signs of hunger.
 
Post-Discharge Care
The AAP recommendation is to perform evaluations of all breastfeeding newborns within 3-5 days of age. This important visit consists of infant weight, physical exam, especially for jaundice and dehydration, breast problems for mothers, such as painful feeds and engorgement, infant elimination patterns, and a formal, observed evaluation of breastfeeding, including position, latch, and milk transfer. This recommendation helps prevent serious complications due to insufficient milk transfer. AAP notes weight loss in the infant >7% from birth weight as indicative of possible breastfeeding problems, requiring more intensive breastfeeding evaluation and interventions to correct the problems and improve milk production and transfer. Ongoing lactation consultation may be necessary. Access to specialists in lactation has a direct impact for increasing breastfeeding success. New mothers often need ongoing lactation support when they are discharged before mature milk comes in. These examples are just some of the reasons that so many new mothers abandon breastfeeding in the first two weeks after birth. Future direction for impacting breastfeeding rates may lead towards consistent utilization of practitioners with lactation-related expertise to be available within pediatric practice settings.
 
Consistency for Promoting Breastfeeding by Health Care Providers
While educating mothers on how to breastfeed, it is important for health providers to be consistent with lactation care so that mothers are not confused and frustrated, leading to some mothers quitting altogether. There is a trend to only pump and feed infants expressed breast milk. In this capacity of breast milk feeding, infants and mothers achieve the health benefits, but miss out on putting their infants to breast. This trend may be partially based on the upgrade in technology to offer more efficient electric breast pumps as effective tools for initiating and maintaining milk production. One of the key components for the need of consistency is in the use of breast pumps. The documents described within this self-study article feature that there are medical necessities for breast pump use. New heights for providing mothers with the tools to pursue normal breastfeeding are being fostered in this exciting new era of health care delivery. However, future direction will need to emphasize processes to support breastfeeding when maternal and infant factors impede normalcy. One aspect will be the future of comprehensive women’s preventive care by the Affordable Care Act which will provide breastfeeding support, supplies, and counseling.
 
References
Academy of Breastfeeding Medicine Protocols
The Surgeon General’s Call to Action to Support Breastfeeding, 2011
Centers for Disease Control and Prevention (CDC) Breastfeeding Report Card – United States, 2012. United States Breastfeeding Committee: Implementing The Joint Commission Perinatal Care
 
(by Carol M. Chamblin, This article was published in The Illinois Nurse, Vol. 8, No. 4, December 2012, An Official Publication of the Illinois Nurses Association.)
Refer to Medela, Inc. at www.medela.com for education and research findings on breastfeeding.
 
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