BASICS OF BREASTFEEDING

St. Mary’s HospitalFamily Care Suites

Orientation

Anatomy

Anatomy

Glands or lobes 15-25 lobes alveoli maternal blood supply myoepithelial cells milk ejection reflex

Anatomy

Transport

Lacitferous ducts or sinuses coming from the alveoli toward nipple expand to larger ducts (like tree

branches) transport milk

Nipple

Many shapes and sizes 5-10 openings

Areola

Darkens in pregnancy Montgomery glands

provide lubricationsecrete fluid with odor of amniotic

fluid

Fat Cells

Fat determines the size of the breast

All breasts have the about the same number of milk glands or lobes

Size does not determine ability to make milk

Blood Supply

Internal Mammary Artery (60%) Lateral Thoracic Artery (30%)

Nerve Supply

4th, 5th, & 6th intercostal nerves

Breast Assymetry

Areolar tissue

Compressible or Fibrous

Size and Shape of Nipples

Surgical or Injury Scars

Reduction or Augmentation

Burns or Trauma to chest

Hormones for Lactation

Prolactin : anterior pituitary hormone pregnancy effects inhibits ovulation stimulates milk synthesis Oxytocin signs of “let down” uterine cramps increase bleeding thirst feeling sleepy leaking changed sucking “pins and needles” ok if nothing felt

Pathway & Effects of Oxytocin & Prolactin

Other hormones

Necessary for milk production: Insulin Cortisol Thyroid Parathyroid Human growth hormone Feedback inhibitor hormone

Milk Production

Lactogenesis I during pregnancy progesterone and estrogen secretory cells colostrum

Milk Production

Lactogenesis II (2-8 days) starts after delivery of placenta drop in progesterone & estrogen prolactin level increases switch from endocrine control to

autocrine

Milk Production

Lactogenesis III Establishment and Maintenance (8-10

days) Mature Milk

Composition

Colostrum first food High in Protein, vitamins & minerals Antibodies Less fat & lactose than mature milk Laxative About 3 ounces in 24 hours

Colostrum

Composition

Mature Milk Transitional Milk (approx. 2 weeks) Increases in fat & lactose, water

soluble vitamins Decreases in protein 750 kcal/liter

Foremilk / Hindmilk

Foremilk thinner watery milk at beginning of

feeding

Hind Milk higher in fat and calories

Let baby finish one breastDo not limit length of time at breast

Fore Milk & Hind Milk

Milk Composition

Variations to milk are normal

Depend upon: time of day beginning or end of feeding maternal diet maternal hormone fluctuations

Immunologic and Bioactive Properties of Milk

Secretory Immunoglobin A provides passive immunity Inhibited bacterial growth in gut

Macrophages are abundant in human milk

destroy & digest bacteria

Reduction in Food Allergies

Benefits of Breastfeeding

Benefits of Breastfeeding

Benefits to Baby: Species specific Good Health Reduce risk of Disease Promotes Physical Development Provides Emotional Benefits

Benefits of Breastfeeding

Benefits of Breastfeeding

Benefits for mother reduce postpartum hemorrhage improve bone density weight loss reduce risk of cancers convenient and always available save time and money delays fertility travel easy & comfort for baby

Benefits to Family & Environment

Family saves money Fewer healthcare costs No energy use for production No packaging materials No production animals, feed, machinery,

waste disposal No transportation No contamination or disease transmission

Other benefits

• comfort• easing of pain and discomfort• protection during illness• building of bonding and attachment with parents• social development• inducing sleep• building of trust in parents• visual development• development of communication skills• building brain organization toward positive stress

handling throughout life• reduced heart disease risk factors• lowered risk of SIDS (Sudden Infant Death

Syndrome)

Skin to Skin contact

Infant naked or only in diaper Mom with breasts, chest and belly bare May have blanket over them both Mom can be sitting or reclining with

infant vertical between her breasts or on one breast

Benefits of Skin to Skin

Improves suckling Increases duration & exclusive

breastfeeding Higher skin temperatures Raises blood glucose Normalizes base excess Less crying Release of oxytocin-less uterine bleeding Release of prolactin- increase in

production Bonding, less anxiety for mom

Benefits of Skin to Skin

Indications

Possible dose response, separation of mom and baby for 20 minutes during 1st hour detrimental

As little as 15-20 minutes beneficial Baby awake after delivery, start skin to

skin as soon as possible, suckling may not occur for up to 2 hours after delivery

Recommend at least 30 minutes long or longer for a more difficult birth

Skin to Skin

Feeding cues

Mouthing movements Suckling movements Clenching of fingers or tight fist over

chest Hands to mouth Crying is a “Late feeding cue”

Feeding

Content Baby

Positioning

Positioning

Mother well supported with pillows, drink nearby, empty bladder, foot rest as needed

Positioning

Cradle Hold Infant’s body level with breast Towards mother: tummy to tummy Infant’s ear, shoulder and hip aligned

Breast Support

“C” hold- supports breast and hands out of the way for baby to latch well

Breast support

Cradle hold

Advantages/ Disadvantages

+ Most frequently illustrated/ familiar

+ Most often used by mothers

- Difficult to master- control of baby’s head

- Baby may wobble on mom’s arm

Side lying hold

Advantages/disadvantages

+ Allows mother more rest + more comfortable after a c-section

with support of tummy

- mother’s fear of smothering their baby

Football or Clutch hold

Advantages/disadvantages

+maximize control of baby’s head +more comfortable choice of c-sections +more easily accomplished for

SGA/preemie

-Not often pictured in media - some mother’s not comfortable with

position - more difficult to use with larger babies

Cross Cradle

Cross Cradle hold

LATCHING

Nose to nipple Manual expression Tickle lip Wide open (rooting) Tongue down, nipple to roof Bring infant in toward mother Latch with entire nipple & about 1 inch of

areola Lower jaw covers more than upper

Goal of Latching

Chin touching breast Nose lightly touching breast or not at all Lips both turned outward

As Baby Nurses

Cheeks puffed out Rocking of entire jaw Temple movement Intermittent swallows NO clicking or smacking Breast tissue

Mom as Baby Nurses

Feels no pinching Feels strong tugs at breast

Initial latch may be tender as nipple elongates

Tender if nipple trauma, needs to heal Mother to detach & start over if painful Mother may feel uterine cramping

No Biting!!

Nipple Assessment

Nipple round and erect at detachment No creasing or blanched looking Not misshapen- like lipstick end

Frequency & Duration

First 24 hours lots of skin to skin offer breast on cue at least every 2-3 hours encourage to ask for help

May not nurse the first 24 hours but at least try

Document attempts even if not successful

Nursing

Let baby nurse as long as he wants Do not watch the clock, watch the infant Generally, 10-30 minutes, longer or

shorter ok

Nursing

Active nursing from first breast Stimulate infant if sleepy When done, burp, check diaper and offer

2 nd He may or may not take 2nd

Alternate the starting breast each feeding

How much is enough?

Breastfeeding Log 8-12 feedings in 24 hours voiding and stooling weight loss less than 10 % content after nursing swallowing breasts feel softer after nursing stools transitioning black, brown,

green, yellow by one week of age

Our Breastfeeding Log

Stomach capacity

Marble sized at one day old

Large marble at 2-3 days old

Golf ball at a week old

Feeding Plan

Reasons we supplement

How do we supplement

What do we supplement

Pacifier use

Nipple Sheilds

Latch with shield

Sore Nipples

Causes: Poor positioning & latch Incorrect sucking patterns Baby with tight frenulum Tight jaw, clenching Improper placement of flanges Suction of pump too high Wrong size of flanges

Sore cracked nipples

Strategies for Sore Nipples

Care plan

Engorgement

Occurs 2-5 days after delivery Lasts 24-48 hours Swelling of the breast by increase blood

& lymph fluid as milk “comes in”

Prevention of Engorgement

Nurse frequently Correct latch Skin to skin contact No supplements Pump only for comfort Engorgement care plan

Jaundice

Physiology Bilirubin Direct & Indirect

Causes Physiologic jaundice Pathological jaundice

Treatment of Jaundice

Increase frequency of feedings May need to double pump to supplement Supplement with mom’s milk or formula Phototherapy Monitor hydration Educate parents

Plugged ducts

Inadequate emptying, pressure in breast

Tender spot Warmth & message Nurse on tender breast first Proper latching & optimal positioning Rest, report fever to MD Plug may come out & look like

spaghetti

Mastitis

Bacterial infection of breast tissue Symptoms:

hard, reddened tender areared streaking, fever, flu like symptoms

Causes: damage to nipple open to bacteriamilk stasis, inadequate emptying, plug

Care Plan

Mastitis

Thrush

Yeast overgrowth

Predisposing factors: nipple damage, antibiotic use, yeast vaginitis

Signs & Symptoms: white, pimple like dots, superficial cracking at base of nipple, constant pain, burning, itching

Infant may or may not have symptoms White patches in mouth, diaper rash

Thrush

Nutrition & Medications

Well balance diet Extra 300-500 calories per day Infant may be sensitive to mom’s diet Caffeine sparingly Alcohol passes into milk Prenatal Vitamin Q day Nicotine Educate parents Dr. Hale- “Medications & Mother’s Milk”

Breast Pumps

Manual- occasional pumping, relieve fullness, 5 minutes alternating sides for 15 mins. total

Single Electric- occasional pumping, small motor, one at a time 5mins alternate to 15 mins.

Double Electric-larger, stronger, more durable, regular pumping, more efficient, rent or buy, best for NICU moms, quicker

Breast Pumps

Reasons to Pump in Hospital

Supplement baby- SGA, Weight loss Milk to NICU baby or separation due to

illness Baby not nursing at 24 hours of age

Challenges

Universal strategies Sleepy Baby Not opening mouth wide Tongue sucking/ Thrusting Mucousy Baby Biting Baby Fussy Baby Flat/ Inverted nipples Creased Nipple

Resources

“Best Baby on the Block”- Dr. Harvey Karp

Breastfeeding Videos Lactation Counselor Certification CEU offerings Breastfeeding Books & Atlases in LC

office Your friendly Lactation Consultants

Lactation Consultants

Laura Rosenau, RN, IBCLC Rosie Sergenian, LPN, IBCLC Holly Guenther, RN, IBCLC Ruth Harding- Weaver, RN, IBCLC Melanie Betchey, RN, IBCLC Jennifer Ulmer, RN, IBCLC Crystal Huene, RN, IBCLC

Questions Comments Concerns

Case Studies

Read and discuss together the following 3 cases:

1) 26 hour old male, 40 2/7 weeks gestation, 8#1 oz, nursed after delivery & 5 times since then well, he has had 1 meconium stool and 2 voids, now he hasn’t nursed for the last 5 hours and mother states he is sleepy. She is holding him skin to skin. He is asleep. What do you do?

Case Study

2) 22 hour old female, 36 1/7 weeks gestation, 6 # 8 oz., no latch after delivery, to the breast 5 times with only licking and nuzzling. She is sleepy with latching attempts. 1 void and 1 meconium stool is recorded. Last attempt made three hours ago. She is asleep in her crib. What would you do now?

Case Study

3) 24 hour old female, 37 1/7 week gestation, 6 # 2 ounces & is SGA. She nursed well after delivery and has nursed 4 times since for 15-20 minutes per feeding. She has had 3 voids and 3 meconium stools. She is putting her fingers in her mouth and her eyes are open. What do you do now?

Case Studies on your own

1-2 nurses per case study Studies number 4 through 8 Discuss among your group & present to

others

Thank you!

References: Lawrence, R. & Lawrence, R. (2005). Breastfeeding: a guide for the medical profession, 6th edition, Philadelphia PA, Mosby Inc.

Wilson-Clay, B. & Hoover, K. (2007). The Breastfeeding Atlas, 4th edition, Manchaca, TX, LactNews Press.