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Crucial ConversationsCrucial ConversationsPQCNC NCCCPQCNC NCCC
Human Milk Initiative Focus 2Human Milk Initiative Focus 2
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Encouraging Mother to ProvideEncouraging Mother to Provide
Milk for her InfantMilk for her Infant Despite well documented benefits of human milkDespite well documented benefits of human milkobstetricians, pediatricians, and nurses may beobstetricians, pediatricians, and nurses may bereluctant to encourage mothers to express milkreluctant to encourage mothers to express milk
Common concerns:Common concerns: Does it really make a clinically significant difference?Does it really make a clinically significant difference? Increase maternal anxietyIncrease maternal anxiety Influence on maternal decisionInfluence on maternal decision CoerciveCoercive
Mothers health/living situationMothers health/living situation Personal choicePersonal choice Time consuming/expensiveTime consuming/expensive UnethicalUnethical
Meier PP. Clinics in Perinatology. 2010;37:217-245
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Lactation Counseling for Mothers of VeryLactation Counseling for Mothers of VeryLow Birth Weight Infants: Effect on MaternalLow Birth Weight Infants: Effect on Maternal
Anxiety and Infant Intake of Human Milk.Anxiety and Infant Intake of Human Milk.
Enrolled 196 mothers of VLBWEnrolled 196 mothers of VLBW
infantsinfants 81 planned to formula feed81 planned to formula feed
115 planned to breast feed115 planned to breast feed
Anxiety inventory administeredAnxiety inventory administeredbefore and after counselingbefore and after counselingand every 2 weeks until infantand every 2 weeks until infantdischargedischarge
Sisk et al. Pediatrics. 2006;117:e67Sisk et al. Pediatrics. 2006;117:e67
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Counseling ScriptCounseling Script
Benefits of human milk for VLBWBenefits of human milk for VLBWinfantinfant Focused on short term benefitsFocused on short term benefits
Protection from infection/NECProtection from infection/NEC Better feeding toleranceBetter feeding tolerance Better stooling patternBetter stooling pattern
Common myths:Common myths: MedicationsMedications SmokingSmoking Transporting milk to the hospitalTransporting milk to the hospital NutritionNutrition PainPain Combination feedingCombination feeding
Procedure for collection andProcedure for collection andstorage of milkstorage of milk
Preterm alternative if decide not toPreterm alternative if decide not topumppump
www.medela.com
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ResultsResults
State Anxiety scoresState Anxiety scoressignificantly lower for bothsignificantly lower for bothgroups after counseling thangroups after counseling thanbeforebefore
No difference in anxietyNo difference in anxietybetween groupsbetween groups
Similar decrease in anxietySimilar decrease in anxietyover timeover time
Mothers stated that theyMothers stated that they
appreciated the information,appreciated the information,assistance, andassistance, andencouragement they receivedencouragement they receivedabout providing breast milkabout providing breast milk
10
20
30
40
50
60
Before State After State 2 Wks State 4 Wks State
Breast
Formula
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Breast Milk Expression Before andBreast Milk Expression Before and
After CounselingAfter Counseling
0%
10%20%
30%
40%
50%
60%70%
80%
90%
100%
Be e C nse ing A e C nse ing
a (I G)
B eas (IBG)
Sisk, et al Pediatrics 2006;117:67Sisk, et al Pediatrics 2006;117:67
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Co ri ht 2006 American Academ of Pediatrics
Sisk, PM et al. Pediatrics 2006;117:e67-e75
FIGURE 1 Proportion of enteral feeding that was breast milk during the first 4 weeks and
during the total hospitalization
* Significantly different: P< .05.
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ConclusionsConclusions
Maternal anxiety notMaternal anxiety notheightenedheightened
Mothers were willing to initiateMothers were willing to initiatepumpingpumping
Infants received clinicallyInfants received clinicallyimportant volumes of humanimportant volumes of humanmilkmilk
lower incidence of NEClower incidence of NEC
shorter time to full enteralshorter time to full enteralfeedingsfeedings
Counseling was worth the effortCounseling was worth the effort
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Influence on Maternal Decision?Influence on Maternal Decision?
ProviderE
ncouragementProviderE
ncouragement Several studiesSeveral studies
Mothers of full termsMothers of full termsinfantsinfants
More likely to initiateMore likely to initiatelactation when alactation when aphysician or nursephysician or nursehas introduced thehas introduced the
topic and providedtopic and providedindividualizedindividualizedinformation andinformation andanswers to questionsanswers to questions
Lu MC, et al. Obstet Gynecol.2001;97:290-297Britton C et al. Cochrane Database Syst Rev. 2007;ICD001141.
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Effect of prenatal consultation with neonatologistEffect of prenatal consultation with neonatologiston human milk feeding in VLBW infantson human milk feeding in VLBW infants
Objective:Objective: effect of prenatal consultation (PC) with aeffect of prenatal consultation (PC) with aneonatologist on the incidence and duration of humanneonatologist on the incidence and duration of humanmilk feeding in preterm infants.milk feeding in preterm infants.
Methods:Methods: Retrospective matched caseRetrospective matched case--control studycontrol study Performed at a perinatal centrePerformed at a perinatal centre PC infants gestational agesPC infants gestational ages -- 2323--35 wk whose35 wk whose
mothers received counseling regarding importance ofmothers received counseling regarding importance ofhuman milkhuman milk Control infants were matched by birth weight,Control infants were matched by birth weight,
gestational age and multiplicitygestational age and multiplicity
Friedman S, et al Acta Paediatr. 2004;93:775-8
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Effect of prenatal consultation with neonatologistEffect of prenatal consultation with neonatologiston human milk feeding in VLBW infantson human milk feeding in VLBW infants
Results: PC infants received human milkResults: PC infants received human milksignificantly longersignificantly longer Hospital: PC 37 +/Hospital: PC 37 +/-- 34 d vs. control 15 +/34 d vs. control 15 +/-- 19 d, p =19 d, p =
0.0010.001 Discharge: PC 60 +/Discharge: PC 60 +/-- 57 d vs. control 21 +/57 d vs. control 21 +/-- 32 d; p =32 d; p =
0.0001)0.0001) No significant difference in neonatal morbidityNo significant difference in neonatal morbidity
between the groupsbetween the groups
Conclusions: PC is associated with significantlyConclusions: PC is associated with significantlylonger human milk feeding in preterm infants,longer human milk feeding in preterm infants,both in hospital and after dischargeboth in hospital and after discharge
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Mothers decisions to change from formulaMothers decisions to change from formulato mothers milk for VLBW infantsto mothers milk for VLBW infants
Qualitative study, semiQualitative study, semi--structured interviews, attitudesstructured interviews, attitudesassessedassessed
21 mothers (76% African American, 62% low income)21 mothers (76% African American, 62% low income)
Planned formula feeding, decided to provide breast milkPlanned formula feeding, decided to provide breast milkafter provider encouragementafter provider encouragement
All provided breast milkAll provided breast milk >>30 d, 19 breast fed30 d, 19 breast fed
Reasons originally cited for planning to formula feed:Reasons originally cited for planning to formula feed: Didnt know anyone who had ever breastfedDidnt know anyone who had ever breastfed
Felt lactation would involve discomfort and lifestyle changesFelt lactation would involve discomfort and lifestyle changes Identified rewards for themselves and infantsIdentified rewards for themselves and infants
Denied feeling pressured or coercedDenied feeling pressured or coerced
Miracle et al. J Obstet Gynecol Neonatal Nurs. 2004;33:392-703
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Economic ImplicationsEconomic Implications
Reduction in NEC may have a profound effectReduction in NEC may have a profound effecton cost of health careon cost of health care
One case of medically treated NEC increasesOne case of medically treated NEC increases
the cost of hospitalization by $73,700the cost of hospitalization by $73,700 4% incidence of NEC w/ human milk4% incidence of NEC w/ human milk vs.vs. 10% w/10% w/
formulaformula
22402240 vs.vs. 5600 infants/year might be affected in5600 infants/year might be affected in
the United States with a cost savings of of $2.5the United States with a cost savings of of $2.5millionmillion
Data from 1992Data from 1992--19941994
Bisquera JA, Cooper TR, Berseth CL. Pediatrics 2002;109:423Bisquera JA, Cooper TR, Berseth CL. Pediatrics 2002;109:423428428
Arias E, et al. Pediatrics 2003;112:1215Arias E, et al. Pediatrics 2003;112:121512301230Caicedo RA, SchanlerRJ, Neu J. PediatrRes 2005;58:625Caicedo RA, SchanlerRJ, Neu J. PediatrRes 2005;58:625
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Ethical?Ethical?
Human milk confers unique health benefits to both infantHuman milk confers unique health benefits to both infantand mother:and mother: VLBW infantVLBW infant covered previouslycovered previously MotherMother many have pregnancy related illnessesmany have pregnancy related illnesses
Benefits for mothersBenefits for mothers lower risk of cancer (breast and ovarian) and gestational diabetes,lower risk of cancer (breast and ovarian) and gestational diabetes,sooner return to presooner return to pre--pregnancy weight, mood improvement andpregnancy weight, mood improvement andpossible lower risk of postpartum depression, no known harmpossible lower risk of postpartum depression, no known harm
Health care providers have an ethical obligation toHealth care providers have an ethical obligation todiscuss human milk feedingdiscuss human milk feeding
Mother is not able to exercise her right to autonomy andMother is not able to exercise her right to autonomy andselfself--determination if she does not have relevantdetermination if she does not have relevantinformationinformation
Informed consent is a shared decisionInformed consent is a shared decision--making processmaking process
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Mothers Need forEvidence BasedMothers Need forEvidence Based
InformationInformation Most mothers who plan to formula feed knowMost mothers who plan to formula feed know
breast milk is better but also believe formula isbreast milk is better but also believe formula isadequateadequate
May not think breastfeeding is compatible withMay not think breastfeeding is compatible withtheir lifestyle and obligationstheir lifestyle and obligations
Need specific information regarding benefits forNeed specific information regarding benefits fortheir infanttheir infant
milk as medicinemilk as medicine special nutritional and immunological needs of infant,special nutritional and immunological needs of infant,
i.e. difficulty digesting fat and immature immunei.e. difficulty digesting fat and immature immunesystemsystem
Miracle et al. J Obstet Gynecol Neonatal Nurs. 2004:33:692-703
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Content of Informed ConsentContent of Informed Consent
DiscussionDiscussion PresentPresent
Potential benefits and potential harms ofPotential benefits and potential harms ofinfant feeding methodsinfant feeding methods
Preventive health strategyPreventive health strategy
Distinguish providing breast milk fromDistinguish providing breast milk frombreastfeedingbreastfeeding
Translate evidence into message that isTranslate evidence into message that iseasily and consistently deliveredeasily and consistently delivered
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Content of Informed ConsentContent of Informed Consent
DiscussionDiscussion Emphasize there is noEmphasize there is no
right way to provide milkright way to provide milk
Reassure women theyReassure women theycan discontinue milkcan discontinue milkexpression at any timeexpression at any time
Avoid focusing onAvoid focusing onbonding or closenessbonding or closeness
Avoid value ladenAvoid value ladenconversationconversation
www.Medela.com
Rodriguez N, et al. JOGNN. 2004;34:109-119
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How Should Providing Milk beHow Should Providing Milk be
Introduced?Introduced? Educate about perceived discomfort and lifestyleEducate about perceived discomfort and lifestyle
changeschanges
Breast and nipple painBreast and nipple pain
Dietary restrictionsDietary restrictions
Prescription medicationsPrescription medications
Maternal employmentMaternal employment
Living a distance from the hospitalLiving a distance from the hospital
Concern about returning to work or schoolConcern about returning to work or school
Reassure that decisions about this are weeks awayReassure that decisions about this are weeks awayand there are many optionsand there are many options
Rodriguez N, et al. JOGNN. 2004;34:109-119
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Helping Mothers Get StartedHelping Mothers Get Started
If they discontinue prior to infant dischargeIf they discontinue prior to infant dischargereassure mothersreassure mothers ReassureReassure -- they provided breast milk duringthey provided breast milk during
their infants most important phases of growththeir infants most important phases of growthand developmentand development
Put into perspectivePut into perspective only a minority of termonly a minority of terminfants receive exclusive mother milk for 30infants receive exclusive mother milk for 30--
60 days in the US60 days in the US PraisePraise -- especially since providing milk wasespecially since providing milk was
not her initial intentnot her initial intent
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ConclusionConclusion
Does human milk really make a clinically significantDoes human milk really make a clinically significantdifference? Yesdifference? Yes
Increase maternal anxietyIncrease maternal anxiety -- NoNo Do health care providers have an influence onDo health care providers have an influence on
maternal feeding decisionsmaternal feeding decisions -- YesYes Is encouragement perceived as coerciveIs encouragement perceived as coercive -- NoNo Is the mothers health or living situation conduciveIs the mothers health or living situation conducive
For her to decide after information providedFor her to decide after information provided Her personal choiceHer personal choice --Yes, for her to decideYes, for her to decide Counseling is time consuming/expensiveCounseling is time consuming/expensive Yes andYes and
NoNo UnethicalUnethical -- NoNo