transitioning from… transitioning baby...transitioning baby to the breast ©2015 nancy mohrbacher,...

Transitioning Baby to the Breast

©2015 Nancy Mohrbacher, IBCLC,

FILCA 1


Nancy Mohrbacher,

IBCLC, FILCA

~

Transitioning from…

• Bottle

• Sipping or lapping methods– Cup

– Bowl

– Spoon

– Syringe

• Tube feeding Preterm/ill baby

• Nipple shield

Does It Really Matter

How Baby Gets the Milk?

Rasmussen & Geraghty. Am J

Public Health 2011; 101(8):1356-59

Long-term pumping can be a hardship

• Stressful: “Triple duty” compared to breastfeeding

• Hormonal levels differ from less body contact

Affects breastfeeding duration

• 4 months after preterm birth:

– 72% still breastfeeding

– 10% still pumping Smith, et al. Pediatrics 2003; 111(6 Pt 1):1337-42

• Earlier formula use increases risk of

negative health outcomes Ip, et al. Evid Rep Technol Assess 2007; (153):1-186

Affects milk quality

• After expression, vitamin, antioxidant, immunological levels decrease

• Freezing kills live cells

• Contamination risk

• Leaching from container & effect on components



FILCA 2

Affects baby’s oral development • Breastfeeding

promotes normal oral development

• Bottle-feeding increases risk of oral malformations

– Cross-bite

– Maxillary atresiaCarrascoza, et al. J Pediatria 2006; 82:395-97 . Kobayashi, et al. Am J Orthod Dentofacial Orthop 2010; 137:54-58

Galán-Gónzalez, et al. Breastfeed Med 2014; 9(1):24-28

Affects feeding volumes, weight gain & obesity risk

• Consistent flow = more milk faster

• Overrides appetite control mechanism

Li, et al. Arch Pediatr Adolesc Med 2012; 166(5):431-36

Affects stress levels in preemies

• Fast milk flow of bottle disrupts organization of suck-swallow-breathing

• Greater incidence of oxygen desaturation, apnea, bradycardia

Photo: The Breastfeeding Atlas

Meier. Nurs Res 1988; 37(1):36-41 Meier & Anderson. MCN Am J Matern Child Nurs 1987; 12(2):97-105

At what age should we lose hope that baby will breastfeed?

Breast-seeking behaviors seen 8 mo to school age

Despite age & other feeding methods, older babies & toddlers do transition to breast

Gribble. Journal of Prenatal & Perinatal Psychology & Health 2005; 19(3):217-35

Babies are hardwired to breastfeed Priorities

1. Feed the baby

2. Protect mother’s milk production

3. Support baby’s transition to breast



FILCA 3

Our Primary Job: Ooze Confidence

in Breastfeeding

With Any

Transition

Start with

the Basics

• Share positive time together there– Talk

– Smile

– Play

• Don’t let it become a battleground

Keep the Breast a Pleasant Place

Keep the Breast a Pleasant Place

Mother leans back & baby rests hands free,

tummy down on her body

Let Gravity Help

• Videotaped 40 mothers/baby pairs

• 20 primitive neonatal reflexes (PNRs)

• PNRs work for or against breastfeeding, depending on positioning

Colson, et al. Early Hum Dev 2008; 84(7):441-9 Photo: Melanie Ham

Identified 20 Primitive Neonatal Reflexes Colson, et al. Early Hum Dev 2008; 84(7):441-49

• Tongue licking• Arm & leg cycling• Head lifting• Head bobbing• Stepping, crawling

Include:• Rooting• Suck• Swallow• Hand to mouth• Mouth gaping

Found more PNRs led to breastfeeding when

mothers lean back with baby on top (p=<0.0005)



FILCA 4

Sitting up, PNRs

made latching more difficult

Pull of gravity caused gaps, head-butting, arching away

Photo: Melanie Ham

A newborn’s curved spine

makes her flail like a turtle on its back

Turn baby over & she has much more body control

Start with Positions Easier for Baby Adjust Body, Baby, Breast

www.YouTube.com/NancyMohrbacher



FILCA 5

Adjust Your Baby

Think Clock

Baby Heads Up

Adjust Your Breast,Think Sandwich

• Compress breast into an oval

• Fingers parallel to baby’s lips

• Like hamburger, not taco

Wiessinger. J Hum Lact 1998; 14(1):51-56

“Breast sandwich”Photo: The Breastfeeding Atlas

“Nipple-Tilting”Photo: Rebecca Glover, RM, IBCLC

Breast Shaping

Keep baby at breast level, less to juggle

Use Sleep

Lowers baby’s resistance to the breast

• Breastfeed while baby sleeps

• Hold baby at breast during sleep

Smillie in Genna, Supporting Sucking Skills in Breastfeeding

Infants, 2013 Photo: Melanie Ham

Cuddle drowsy, sleeping baby in natural feeding positions

• Triggers inborn reflexes

• Blunts reflex response & frustration

Colson. MIDIRS Midwifery Digest 2003; 13(1):92-97



FILCA 6

Basics Checklist

� If mother lifts her arms, does baby stay in place?

� Is mother fully relaxed & partly reclined,

not upright or completely flat?

� Is baby tummy down (frog legs) & heads up

(head higher than bottom)?

� Tried varying baby’s lie (clock)?

� Baby’s feet touching mother or something else?

� Tried breast shaping (hamburger not taco)?

� Is baby upset, need to be calmed (arousal state)?

Skin-to-Skin and Body Contact

Without pressure to take breast

If baby becomes unhappy, move away

Chiu, et al. Breastfeed Med 2008; 3(4):231-37

With Severe Latch Problems

• Half were skin-to-skin during breastfeeding tries, half weren’t

• Same % overcame problems

• In STS group, happened twice as fast

Svensson, et al. Int Breastfeed J 2013; 8:1; 103 babies 1-16 wk old

If awake, feed a little so baby’s not ravenously hungry

Will be more open to trying something new

Photo: Kirsten Hedberg Nyqvist, RN, PhD

Feed a Little First

IF BABY STILL BALKS AT THE

BREAST, CONSIDER THE 4 Fs

• FEEL• FLOW• FAMILIARITY• FITNESS to

breastfeed

Target Strategies to the Cause

Glover & Wiessinger. In Supporting Sucking Skills in Breastfeeding

Infants, 2nd ed. by C.W. Genna, 2013, p. 105-48



FILCA 7

FEEL?• Expectations

altered by artificial nipples?

• Positioned to trigger feeding behaviors?

• Latched deeply enough to trigger active sucking?

FEEL Issues

• Use positioning, body contact, & sleep to release feeding reflexes

• Adjust for a deeper latch

Use tools to evert or firm mother’s nipple (FEEL):

• Inverted syringe

• Nipple everter

• Apply cold

• Breast pump

• Nipple shield

Kesaree, et al. J Hum Lact 1993; 9(1):27-29

FLOW?• Baby used to instant, consistent flow?

• Mother’s milk production low?

To increase flow

• Boost low milk production

• Deliver instant flow at breast

−Spoon

−Eyedropper

−Syringe

−At-breast supplementer

• Negative oral experiences?

• Hair-trigger temperament?

• Used to another feeding method?

FAMILIARITY?



FILCA 8

FAMILIARITY Issues

When transitioning from another

feeding method, take baby steps

Sipping/Lapping Methods

Muscles used more similar to breastfeeding than bottlefeedingFranca, et al. BMC Pregnancy Childbirth 2014; 14:154

May lead to easier transition to the breastYilmaz, et al. J Hum Lact

2014; 30(2):174-79


Baby Steps from the Bottle

Make bottle-feeding more like breastfeeding

Kassing. J Hum Lact

2002; 18(1):56-60

Photos: Karl B. Walker

Bottle-feed at breast

• Rest baby’s cheek against exposed breast

• Wrap bottle in cloth so baby can’t touch it


’Bait & Switch’

Start bottle-feeding against exposed breast

As baby sucks and swallows, quickly remove bottle and insert breast




FILCA 9

FITNESS to breastfeed

Is baby in pain?

Is there a physical or health issue

affecting breastfeeding?


Fitness Issues Genna, Supporting Sucking Skills, 2013

Baby• Unusual oral

anatomy?

• Pain or birth injuries?

• Respiratory issues?

• Preterm?

• Health issues?

• Neurological or tone issues?

Mother• Large

breasts?

• Taut breast tissue?

• Unusual nipple placement?

• Unusual nipple anatomy?

Do What

Works.

Don’t Do

What

Doesn’t

Work.

One Mother’s Story

0

100

200

300

400

500

600

700

800

900

0 1 2 3 4 5 6 7 8 9 10

ml

weeks

Daily average of supplement given to baby

ave MyS

ave F

Transitioning Preterm Babies to the Breast



FILCA 10

When to Start Breastfeeding

Rather than “readiness,”

think of breastfeeding as a normal

behavior like walking & talking

71 healthy babies born at 26-35 wk– Breastfeeding

began when babies breathe without ventilator or CPAP

– Earliest breastfeeding: 28 wk gestation

Nyqvist, et al. Early Hum Dev 1999; 55(3):247-64


Keep environmental stimulation

• Lights

• Sound

• Touch

to a minimum

Nyqvist, et al. Early Hum Dev 1999; 55(3):247-64

If baby has breathing or heartbeat irregularities

– At first, HCP monitors baby during feedings

– If baby stays stable, mother can monitor breathing & color

Nyqvist, et al. Early Hum

Dev 1999; 55(3):247-64

Baby Signs Nyqvist, in Supporting Sucking Skills in Breastfeeding Infants 2013

Keep Breastfeeding Stop Breastfeeding

Baby Signs Nyqvist, in Supporting Sucking Skills in Breastfeeding Infants 2013



FILCA 11

Preterm Breastfeeding StagesNyqvist, In Supporting Sucking Skills in Breastfeeding Infants 2013

1. Tube-feeding, skin-to-skin contact, and frequent

milk expression

2. Breastfeeding begins—Rooting, licking, mouthing

3. Single sucks, short bursts, long pauses, some

milk intake

4. Longer suckling bursts, stays fixed longer, more

milk more often, supplements gradually reduced

5. Milk intake increases, occasional larger volumes

6. Milk intake varies, immature suckling pattern,

can fully breastfeed with semi-demand feeding

7. Vigorous, mature suckling, long bursts,

breastfeeds on demand

Photos: Kirsten Hedberg Nyqvist, RN, PhD

Older or healthier babies may start at a later stage

Semi-Demand Feeding

Stage 6 of 7

When most Swedish preemies are discharged

Effective with late preterm babies


Semi-Demand Feeding

Don’t rely on baby’s cues alone

Initiate feedings every 1-2 hr during

waking hours

Used until about term corrected age

Photos: Kirsten Hedberg Nyqvist, RN, PhD

Feeding every 1-2 hr during the

day eases transition to full breastfeeding

Closer to typical breastfeeding

rhythm

Photo: Kerstin Hedberg Nyqvist, RN, PhD

To Qualify for NICU Semi-Demand Feeding

Baby 32-36 wk, gaining well

Mother producing ≥200 mL/day, wants to BF &

is available ≥6 hr stretches

Davanzo, et al. J Hum Lact 2014; 30(4):405-09

Semi-Demand Feeding Protocol

• Morning wt & daily milk volume set

• Test wt at feedings

• Feed on cue

• Wake after 3 hr

• Gavage supplement

• Fully semi-demand, no supplements

Davanzo, et al. J Hum Lact 2014; 30(4):405-09



FILCA 12

Feeding More Often Improves Feeding Tolerance

VLBW fed 2 hr reach full feedings 2.7 days sooner than fed 3 hr

VLBW fed 3 hr more likely to:

– ≥28 days of parenteral nutrition

– Have feeds held for ≥7 days

DeMauro, et al. J Perinatol 2011; 31:481-86; N=354

Odor of Mother’s Milk Speeds Transition to Oral Feedings

Preemies who smelled mother’s milk

while gavage fed

transitioned to oral feedings 3 days earlier than controls

Yildiz, et al. J Nurs Scholarsh 2011; 43(3):265-73

Cue-Based & Paced Bottle Feeding

Feed when baby cues

Use paced bottle feeding

See handout For the

Caregiver of a Breastfed Baby

Video: Paced Bottle-Feeding by Wilson-Clay, IBCLC, FILCA & Hoover, MEd, IBCLC, FILCA; Available from ww.breastfeedingmaterials.com

Feeding practice better predictor of effectiveness than gestational age

Cunha, et al. Early Hum Dev 2009; 85(2):125-30 Pickler, et al. J Perinatol 2006; 26:693-99

Practice Makes PerfectOn average babies began

taking milk at breast: 30 6/7 wk

With regular practice, by 36 wk 57 of 67 (85%)

exclusively breastfeeding, some at 32 wk

Median age of exclusive breastfeeding: 35 wk

Nyqvist, et al. Acta Paediatr 2008; 97(6): 776-81Nyqvist, et al. Early Hum Dev 1999; 55(3): 247-64



FILCA 13

Emotional Barriers

Mother’s gain? (↑time, ↓work)

Value of breastfeeding (not just the milk)

Start in the hospital (>nutrition)Pineda. J Perinatol 2011; 31:540-45

0 of 785 Swedish mothers pump/bottle-feed at d/cAkerstrom, et al. Acta Paediatr2007; 96:1450-54

Signs of milk intake

– Swallowing sounds

– See milk around mouth

Wt check

Test wt– Reliable for measuring milk intake at breast

Meier, et al. J Hum Lact 1994; 10:163-68

– Even reliable with leads Haase, et al. Breastfeed Med 2009; 4:151-56

Nipple Shields?

Useful tool if preemie:– Slips off nipple at pauses

– Falls asleep quickly

Preemies on shield took mean 14.4 mL more milk

No association between length of shield use & breastfeeding duration

Meier, et al. J Hum Lact 2000; 16:106-14

Nipple Shields

Nipple shields once considered verboten by many, but pendulum has swung back J Hum Lact 1996;12(4)

95% of LCs & 80% of other HCPs use nipple shields in their practiceEglash, et al. Breastfeed Med

2010; 5(4):147-51

Reasons Nipple Shields Used

Mother-related: 63%

– Flat or inverted nipples

– Nipple pain

– Nipple trauma

– Engorgement

Baby-related: 39%

– Poor or weak latch

– Ineffective suck

Chertok. J Clin Nurs 2009;18:2949-55; N=54



FILCA 14

Reasons Nipple Shields Used

Ekström, et al. Breastfeed Med 2014; 9(9):458-66; N=540, 81 shields

Reasons at 3 days

• Latch problems (62%)

• Nipple trauma (29%)

• Pain (7%)

Nipple shield use

• 3 days: 18%

• 3 mo: 10%

• 9 mo: 1%

Women who used shields at 3 days had higher BMIs at

start of pregnancy than those who didn’t use shields

Nipple Shield Application

Deep latch key to milk transfer

Shield tip should not be visible during

breastfeeding

Photos: Catherine Watson Genna, BS, IBCLC

• Signs of milk transfer:– Milk seen in the

shield after feedings

– Swallowing sounds

– Breast feels less full, heavy

• Weight checks

• Test-weighing


Thick, rubber shields reduced milk intake by 22%

– Do mothers need to pump to maintain milk production?

– Study babies had breastfed well & were using shield for 1st time

Woolridge. Early Hum Dev 1980;4(4):357-64

No difference in weight gain in babies using

thin, silicone nipple shield vs

not using shield Chertok. J Clin Nurs 2009;

18:2949-55

Lower weight gain in shield group that

got less supportEkström, et al. Breastfeed Med

2014; 9(9):458-66



FILCA 15

Weaning from a Nipple Shield

• Start with shield on

• When swallowing, slip off shield, slip in breast

• If not, try again at a relaxed time

• Not every day

Cutting the shield no longer

recommended

Was safe with latex shields

With silicone shields, creates

sharp edges

• 67% eventually weaned from shield

• 33% used it throughout

– 11% could have nursed without it

– Continued using it for greater comfort

Powers, et al. J Hum Lact 2004;20(3):327-34; N=202

Priorities

1. Feed the baby

2. Protect mother’s milk production

3. Support baby’s transition to breast

• Is it a fitness issue?

• Use feel, flow & familiarity to help baby take the breast

When the basics don’t work, think “Four Fs”

Target tools & strategies to the problem’s cause



FILCA 16

Babies are hardwired to breastfeed

Choose strategies that make

the most of baby’s hardwiring

[email protected]

www.NancyMohrbacher.com Facebook.com/NancyMohrbacherIBCLC

Pinterest.com/nancymohrbacher@BFReporter

www.YouTube.com/NancyMohrbacher

~

transitioning from… transitioning baby...transitioning baby to the breast ©2015 nancy mohrbacher,...

Documents