breast feeding counseling-kabera rene md

8/4/2019 Breast Feeding Counseling-KABERA Rene MD

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National University of Rwanda

Family and Community Medicine

Breastfeeding Counseling

KABERA Ren, MD

PGY IV Resident

Family and Community Medicine

National University of Rwanda


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Plan

Anatomy

Physiology BF advantages and disadvantages

Principles and techniques of BF

BF and Birth control Unhealthy environment

BF challenges

Weaning References


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Anatomy


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Anatomy

1. Breast Size

Depends on amount of fat in breast

Not related to making milk

One breast often different than the other

2. During Pregnancy

Breasts get larger

Veins show more Area around the nipple darkens


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Anatomy

Areola

Darker skin around nipple

Visual target for baby

Size & color differ for every woman

Larger & darker during pregnancy


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Anatomy

Montgomery Glands

Small bumps on areola

Protects nipple from dryness

Scent helps baby find breast


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Anatomy

Milk Ducts

Carry milk from the alveoli through the nipple

Alveoli

Grape-like clusters where milk is made


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Anatomy

Nipples

Muscles & nerves 4-18 openings

Change during pregnancy & after childbirth

Size/shape

No need to prepare nipples


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Types of nipples

Everted: Sticks out at rest, and more when touched


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Types of nipples

Flat nipple : Flat at rest and when touched


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Types of nipples

Inverted Nipple: Drawn inward dimpled at rest and

when touched


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Types of nipples

Wide or non-stretchable

May not reach back of babys mouth

Hard for a newborn to latch-on

May need a breast pump to express milk


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Physiology

The mammary glands :Their role is to provide

nourishment for the newborn and to transferantibodies from mother to infant.

At the end of gestation, each breast will have

gained approximately 400 g.


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Milk production

Three important breastfeeding hormones are:

Progesterone Prolactin

Oxytocin


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Physiology Estrogen is responsible for the growth of ductular tissue and

alveolar budding. Progesterone is required for optimal maturation of the

alveolar glands.

Glandular stem cells undergo differentiation into secretoryand myoepithelial cells under the influence of prolactin,

growth hormone, insulin, cortisol, and an epithelial growth

factor.


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Physiology Prolactin is an necessary hormone for milk production, but

lactogenesis also requires a low estrogen environment. Prolactin levels continue to rise as pregnancy advances,

placental sex steroids block prolactin-induced secretory

activity of the glandular epithelium.

Sex steroids and prolactin are synergistic in mammogenesis

but antagonistic in galactopoiesis.

Lactation is not initiated until plasma estrogens, progesterone,

and human placental lactogen (hPL) fall after delivery. Oxytocin Makes milk flow out of breast (Milk Ejection Reflex)


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Physiology1. An intact hypothalamic-pituitary axis is essential to the

initiation and maintenance of lactation.2. Lactation can be divided into 3 stages:

mammogenesis, or mammary growth and development

lactogenesis, or initiation of milk secretion galactopoiesis, or maintenance of established milk secretion


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Physiology Size of a womans breasts does not affect overall milk

production

Colostrum is a Thick, yellow milk produced in Last 3 months of

pregnancy & after deliver First Immunization

Colostrum changes to mature milk 2nd to 5th day after birth

Transitional milk (takes about 1-2 weeks)

Mature milk at beginning : Bluish and watery High in milksugar (lactose) Low in fat Sometimes called foremilk


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PhysiologyTowards the end of the feeding, breastmilk is:

Thicker, like cream Higher in fat, lower in milk sugar

Higher in calories (energy)

Sometimes called hindmilk

Needed for growth

Foremilk and hindmilk


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BF Advantages

For the Mother

Breastfeeding is convenient, economical, and emotionally satisfyingto most women.

It helps to contract the uterus and accelerates the process of uterineinvolution in the postpartum period, including decreased maternalblood loss.

It promotes mother-infant bonding and self-confidence andimproves maternal tolerance to stress through an oxytocin-associated antifight/fight response.

Maternal gastrointestinal motility and absorption are enhanced.Ovulatory cycles are delayed with nonsupplemented breastfeeding.

According to epidemiologic studies, breastfeeding may help toprotect against premenopausal cancer and ovarian cancer.


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BF disadvantages Regular nursing restricts activities and may be perceived by

some mothers as an inconvenience. Twins can be nursed successfully, but few women are

prepared for the first weeks of almost continual feeding.

Difficulties such as nipple tenderness and mastitis may

develop.

Compared with nonlactating women, breastfeeding women

have a significant decrease (mean, 6.5%) in bone mineral

content at 6 months postpartum, but there is "catch-up"remineralization after weaning.


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BF advantagesFor the Infant

1. Breast milk is digestible, of ideal composition, available at theright temperature and the right time, and free of bacterial

contamination.

2. decreased incidence : diarrhea, lower respiratory tract

infection, otitis media, pneumonia, urinary tract infections,

necrotizing enterocolitis, invasive bacterial infection, and

sudden infant death.


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BF advantages Breastfed infants may also have a decreased risk of

developing insulin-dependent diabetes, Crohn's disease,ulcerative colitis, lymphoma, and allergic diseases later in life.

Breastfed infants are also less likely to become obese as

neonates and adolescents.

Suckling promotes infant-mother bonding.

Cognitive development and intelligence may be improved.


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BF Disadvantages and CIAbsolute contraindications to breastfeeding

street drugs or excess alcohol human T-cell leukemia virus type 1

breast cancer

active herpes simplex infection of the breast

active pulmonary tuberculosis in the mother

galactosemia in the infant

maternal intake of cancer chemotherapeutic agents or certainother drugs.


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BF disadvantages and CI

Breastfeeding is not usually possible for weak, ill, or very

premature infants or for infants with cleft palate, choanalatresia, or phenylketonuria

Human immunodeficiency virus (HIV) infection in the is not a

contraindication in Rwanda to breastfeeding.

Breastfeeding is a mode of HIV transmission. 15%


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Principles & Techniques Of BF

Infants and mothers who are able to initiate breastfeeding

within 1-2 hours of delivery are more successful than thosewhose initial interactions are delayed for several hours

The initial feeding should last 5 minutes at each breast in

order to condition the let-down reflex.

At first, the frequency of feedings may be very irregular (8-

10 times a day), but

after 1-2 weeks a fairly regular 4- to 6-hour pattern will

emerge


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Ct The baby should nurse at both breasts at each feeding,

because overfilling of the breasts is the main deterrent to themaintenance of milk secretion increase discomfort due to

engorgement

Mother to be taught to empty the breasts after each feeding

The use of supplementary formula or other food during the

first 6-8 weeks of breastfeeding can interfere with lactation

and should be avoided except when absolutely necessary.


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Ct The introduction of an artificial nipple, which requires

a different sucking mechanism, will weaken thesucking reflex required for breastfeeding.

Other fluids may be given by spoon or dropper

rather than by bottle.


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CtIn preparing to nurse, the mother should

wash her hands with soap and water, clean her nipples and breasts with water, and

assume a comfortable position, preferably in a rocking or

upright chair with the infant and mother chest-to-chestWith time, mom and baby will find the position that is best for

them


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Position

Cross-Cradle Hold

Side-lying hold

In early weeks When babys

neck needs more support When mother needs to support

her breast

Can move to cradle hold after

baby has latched on


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Position

Clutch Hold(football)

After c-section

Premature infants

Mothers with large breasts

Mothers can see babys mouth

open wide & help with latch


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Position

Cradle Hold

Good position for older

babies after

breastfeeding is goingwell.


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PositionSide-lying hold

When mother needs rest

Avoid in waterbeds or fluffyblankets/comforters

Can start in cradle hold &slowly lower to side-lyingposition


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BF procedure Allow the normal newborn to nurse at each breast on demand

or approximately every 3-4 hours, for 5 minutes per breastper feeding the first day.

Over the next few days, gradually increase feeding time to

initiate the let-down reflex, but do not exceed 10-15 minutes

per breast.

Suckling for longer than 15 minutes may cause maceration

and cracking of the nipples and thus lead to mastitis.


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BF procedure Stimulating the cheek or lateral angle of the baby's mouth

should precipitate a reflex turn to the nipple and opening ofthe mouth.

The infant is brought firmly to the breast and the nipple and

areola are placed into the mouth as far as the nipple-areola

line.

Slight negative pressure holds the teat in place and milk is

obtained with a peristaltic motion of the tongue.

Compressing the periareolar area and expressing a smallamount of colostrum or milk for the baby to taste may

stimulate the baby to nurse.


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BF procedure Try to keep the baby awake by moving or patting, but do not

snap its feet, work its jaw, push its head, or press its cheeks. Before removing the infant from the breast, gently open its

mouth by lifting the outer border of the upper lip to break the

suction.

After nursing, gently wipe the nipples with water and dry

them.


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BF procedureNipple Feeding versus Breastfeeding

Lack of constant pain

Chin touching breast

Cheeks rounded

Nipple may come out longer, not pinched or discolored Lips curled outward

Nostrils barely touch breast (if at all)

Babys swallows can be heard Breasts are softer & feel lighter after feeding


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Signs Breastfeeding

is Going Well

Weight gain

Babies lose at first - regain by 10-14 days

Gain 1.3 - 3 lbs over birth wt by 1 month Gain 6-12 ozs per week during second month, and more

slowly after that

Babies usually double their birth weight by 6 months &

triple by 1 year


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CtGrowth Spurts

Increase in the number of times to breastfeedAdequate output


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BF and Birth control

Non hormonal methods: Barrier Methods

Spermicides

IUDs (intrauterine device)

Sterilization LAM (Lactational Amenorrhea Method)


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BF and birth control

Hormonal methods

Progestin Started before baby is six weeks old

Dose is too high

Mother does not have a good milk supply

(The Mini-pill ,Depo-Provera ,Progestin IUDs ,The Morning After

Pill)


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BF and birth controlEstrogen

DO NOT use until baby is at least 6 months old Estrogen often reduces milk supply

(The Pill ,The Patch, Vaginal Contraceptive Ring)


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Unhealthy environments

Alcohol :Equal amounts in breastmilk as in mothers blood

No more than 1 drink per day: 148 cc of wine, 355 cc of beer, 44 cc ounces of

liquor


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Unhealthy environmentSmoking

Colds

Ear infections

Asthma

Higher risk of Sudden Infant Death Syndrome (SIDS)

If not stopped

Smoke after breastfeeding and outside ,Change/Remove clothes after smoking


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Unhealthy environmentIllegal drugs :

Cocaine


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BF challenges Twins

Premature baby Premature twins

Sick baby

Baby with other medical problems Mother with diabetes

Mother who is sick


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Methods of expressing milk Hand expression

Manual pumps Battery operated pumps

Semi-automatic pumps

Personal use electric pumps

Hospital grade electric pumps


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Weaning The process of substituting other liquids or food for the mother's

milk When fully weaned, a child no longer receives any breastmilk

Begins when baby is fed anything other than breastmilk

Most think of weaning as stopping breastfeeding

Once mothers start giving formula They breastfeed less &

stop sooner


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Weaning Around world mothers breastfeed up to 3 yrs.

In Rwanda most mothers wean by 6 months, often begins athome

Some babies wean themselves

If mother decides to wean before 1st birthday should give

formula


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References Current Obstetric & Gynecologic Diagnosis & Treatment - 9th

Ed. (2003).The Normal Puerperium - Kim Lipscomb, MD, &Miles J. Novy, MD

California WIC breastfeeding peer counseling program.

Ten steps to successful breastfeeding,WHO/UNICEF joint

statement 1989

Breastfeeding as a Public Health Issue: Planning Promotional

Campaigns.Ted Greiner La Leche League


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The end

Thank you

breast feeding counseling-kabera rene md

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