CLC Exam Study Guide

BF = breastfeeding
Ex BF = exclusively breastmilk
BM = breastmilk
S2S = skin to skin
NB = newborn

Breastfeeding and Public Health (1A)

• Need to improve BF is a health priority

• improving BF duration and exclusivity linked to favorable outcomes in mom and baby

Exclusive breastfeeding = the infant is receiving solely mother’s milk and it’s own food source
 can receive oral rehydration solution, vitamins/minerals, po meds
 can include devises such as syringe, cup, at breast supplementer etc

After 6 mo of exclusive bf = add solids, high in iron/zinc

Exceptions to exclusive BF
• galacstosemia
• phenylketonuria (PKU)
• premature
• all bf infants should get 400 international units of Vet D shortly after beginning at hospital dc
• medical/nutritional conditions
• mother has a contraindications medically/medication

Predominant feeding = infant receiving mother milk as well as water, water based drinks, ritual foods
(teas), oral rehydration solution, vitamins, minerals, oral meds
NOT receiving other foods/drinks, including formula/animal milk

Breastfeeding = infant receiving human milk AND other foods/fluids, formula

Complementary feeding = child between 6-23 months receiving human milk AND solid/semisolid food
(zinc, iron, protein, nutrient rich imperative at this age)
 PER WHO
o Complementary feeding start at 6 months with BM
o 2x/day between 6-8 mo
o Increase to 3x/day between 9-24 mo
o Additional snacks offered between 1-2 x/day

NOTE: Breastfeeding is natural not instinctual, skills must be developed

Reason BF is stopped:
 Concerns about milk quality/quantity
  Feeding problems during first week
 Problems with the infant latching on or sucking
 Lack of info/support

Why BF so difficult and mothers need help:

 Unrealistic expectations
 Lack of timely interventions (problems days 3-7 pose greatest risk for stopping, drop off
is in the first 10 days from discharge)

NOTE: Vit K should be given shortly after birth

NOTE: No supplementary fluoride during first 6 mo

Ten Steps to Successful Breastfeeding for Hospitals and Births Centers

 10 steps etc first published by world health organization and unicef in 1989
 Basis for baby friendly hospital initiative (bfhi)
 Inaugurated in 1991
 Revised in 2018 to separate management/policies from clinical care

BFHI = encourages hospitals and birth facilities to develop polices and implement practices that
support parents in learning appropriate, responsive infant feeding

10 Steps to Successful Breastfeeding (2018)

Clinical Management Procedures

1.
a. Comply fully with the international code of marketing of breast milk substitutes
and relevant world health assembly resolutions.
b. Have a written infant feeding policy that is routinely communicated to staff and
parents
2. Ensure that staff have sufficient knowledge, competence, and skills to support
breastfeeding

Key Clinical Practices

3. Discuss the importance and management of breastfeeding with pregnant women and
their families
4. Facilitate immediate and uninterrupted skin to skin contact and sport mothers to initiate
BF as soon as possible (within the first hr)
5. Support mothers to initiate and maintain bf and manage common difficulties
6. Do not provide bf newborns any other food or fluids other than bm, unless medically
indicated
 7. Enable mothers and their infants to remain together and to practice rooming in 24
hours a day (rooming in)
8. Support mother sit recognize and respond to their infants’ cues for feeding (responsive
feeding)
a. Four dimensions of responsive parenting are feeding, soothing, sleep, physical
activity
9. Counsel mothers in the use and risks of feeding bottles, teats, and pacifiers (don’t give
to them)
10. Coordinate discharge so that parents and their infants have timely access to going
support and care

Leverage points for BFHI

 Recognition of excellence
 Enhances the facilities status
 Supports JC perinatal core measure sets
 Supports facilities community benefits strategies
 Cost neutral
 Recognizes prevention as the key strategies to improve health of the nation

WHO and UNICEF three strategies to increase BF initiation and duration

 Promotion
 Protection
 Support

Protocol to Calculate Baby’s Approximate Daily Needs (lbs and oz)

 Any one feeding does not necessarily indicate a typical intake, observe several feedings,
different positions
 Baby’s wt in lbs and multiply by 2.5 for standard gain and 2.7 to 3.0 if the baby needs to
catch up
o Rough calculation
o Pediatrician dictates the 2.5, 2.7, 3.0
o Ex: 8lb baby gaining well
 8 x 2.5 = 20 oz/day
o Ex: 8 lb no gaining well
 8 x 2.7 = 21.6 oz/day or 8 x 3 = 24 oz/day
o Ex: baby weighs 6 lbs
 6 x 2.5 = 15 oz/day
 15 oz/10 feedings a day = 1.5 oz per feeding

Appendix G-1 Table of Daily Breastmilk Volume Requirements Estimates in Ounces

Appendix G-2 Table of Daily Breastmilk Volume Requirements Estimates in Grams &
Millimeters
Appendix H-1 Baby Weight Loss Table in Lbs and Oz
Appendix H-2 Baby Weight Loss Table in Grams
  Reviewed in online competency 1

Weight Gain Expectations and Infant Elimination Patterns

 It is expected that BF newborns be evaluated by physician/midwife/physician supervised
breastfeeding trained healthcare provider 48-72 hrs after discharge
 Key components of this visit include
o Hydration and elination
o Obs of feeding
o Wt gain/loss
 BABIES SHOULD NOT LOSE MORE THAN 7 PERCENT OF BIRTH WT
o Wt gain should be seen by day 4 or 6
o Not gained wt, explore reasons for inadequate milk supply/transfer
o Discuss maternal/infant issues
 Newborns should have 4 stools (some yellow) daily by day 4, for the first month along
with at least 6 wet diapers w/ light colored urine
o Stools most important sign of getting enough milk
o Baby should be back to birth wt by 12-14 days (two weeks) or severe eval must
happen
o Babies should gain 1 oz/day
 Babies lose wt in the first few days due to
o Labor meds
o Intrapartum fluids given
o No labor prior to cesarean section

Breastfeeding Goals for the US

 Healthy People Goals by 2030
o Review table on p. 260

The International Code of Marketing of Breastmilk Substitutes (WHO, 1981)

 Intended to protect and promote breastfeeding through the provision of adequate info
on appropriate infant feeding and the regulation of the marketing of bm substitutes,
bottles, and teats
 No promo of bm substitutes, bottles, teats (nipples) to general public, no promo of
these same items from healthcare facilities and/or health professionals to families; and
restriction of the interaction of employees of companies that make, sell, or distribute
products covered by the Code w/ general public, healthcare facilities, systems,
professionals, and childbearing families

Appendix U – The Global Strategy for Infant and Young Child Feeding (WHO 2003)
Appendix V – Innocenti Declaration on Infant and Young Child Feeding 2005 (Who and UNICEF
2005)
Breastfeeding benefits for moms
 Decrease risk of
o MI
o Metabolic syndrome
o HTN
o Diabetes
o Hyperlipidemia
o Cardiovascular disease
o Breast, endometrial, ovarian cancer

CLC = certified lactation counselor through ALPP, health professional who provide lactation
support

What contributes to low rates of exclusive BF

 Caregiver/societal beliefs
 Hospital/healthcare policies not supportive of bf
 Lack of adequate skilled support
 Aggressive promo of formula/substitutes
 Lack of paternity/maternity leave
 Lack of knowledge about dangers of not BF

Making Milk

 Messages travel from breast, through nervous system to the brain, then hormones
travel to the breast through the bloodstream
 Two separate hormone pathways (pituitary gland important to both)
 2 milk hormones: prolactin and oxytocin
 Prolactin causes milk to be made, levels rise during nursing, decrease in between
feedings
 Lactogenesis III requires frequent milk removal and nipple stimulation to succeed
 Nipple stretching w/ appropriate latch releases oxytocin

Mechanism #1
 Conditioned response = conditioned milk ejection (let down) reflex, given too much
importance over the eyars, faster for women who have already bf, condition resonse
smell, touch, hear the stimulus
Mechanism #2
 Oxytocin release
 Nipple stretching happens with proper latch
Mechanism #3
 Oxytocin release
  Baby hand massage (each hand movement releases oxytocin)

NOTE: Lactation hormones have an emotional/behavioral function as well has making and
movement milk: aggression, protection, bonding/trust

Milk Composition
 Species specific (each mammal has specific milk)
 Mammal species w/ high fat/protein and low water content milk have infrequent feeds
 Mammal species with higher water content have more frequent feeds
 All mammal milk contains lactose
 Species composition and feeding frequency related
 We are carriers, not nesters when it comes to feeding
 Human milk is ideal for brain growth, the most rapidly developing organ

Stages of Making Human Milk

 Secretory differentiation (lactogenesis I)  placental hormones  colostrum
 Secretary activation (Lactogenesis II)  complete delivery of placenta, rapid drop in
progesterone  transitional milk
 Lactation (Lactogenesis III) Galactopoesis  Prolactin from frequent nipple stim and
frequent removal of milk  mature milk

Preterm vs Term Milk

 Preterm milk different composition for the first 5-7 wks after delivery of
 Preterm milk higher in protein, fat, electolytes
 After one year of lacation, milk has more fat and energy

Foremilk = milk at the beginning of the feed

Hindmilk = milk at the end of the feed
 foremilk can sometimes be lower in fat, but not always, sometimes can have equal amount
of fat in both

Human milk continually changes

 Over course of lacation
 Within a day
 Within a feeding
 Way its taken
o Baby can regulate fat by intaking quickly , practice baby led feeding
o Some babies feed better on one breast per feeding
o Milk is more than nutrition, bioavailability of nutrients higher in human milk than
in any other foods
Exclusively BF babies protect from diarrhea
 Bf babies gut more acidic
 Low in iron
 Presence of bifidus factor that crowds out other pathogenic organisms
 Presence of hormones and growth factors that stimulate growth and development of GI
and GI motility such as
o GI hormones
o Prolactin
o Epidermal growth factor
o Prostaglandins
 Antibodies like SIgA
 White blood cells that kill microbes
 Cell wall disruptors, fatty acids, lysosomes
 B12 binding factor reduces B12
 Lactoferrin, deprives bacteria of iron
 Antimicrobial activity booster (fibronectin and gamma interferon)
 Mucosal wall protectors (mucins and oligosaccharides) so microbes cant attach to gut
wall
 Microbes, build microbiome
 Absence of contaminants (formula etc)
 Mom makes antibodies if exposed to organism, made in breast, go to baby
 Synergistic effect of all of these mechanisms

Gastrointestinal Hormones and BF

 Gastrin and cholecystokinin promote glucose induced insulin release and growth
promoting effects in gut
 Somatasin inhibits GI secretion, inhibits motility in GI tract and release most GI
hormones, inhibits secretion of HGH from pituitary and inhibits cellular
growth/proliferation in gut

What increases gastrin and decreases somatostatin in babies?

 Sucking babies have cutaneous touch receptors in mouth that respond to sucking
starting at 27 wks
 Species own milk
 Decreased stress
 Touch
 Wellness

Breastfeeding Myths
 No difference in growth of babies between malnourished moms and nourished moms
o Nourished moms give more care and stimulation to babies, breastfed longer
 Size of breast does not relate to amount of milk
 Not getting enough fluids does not decrease milk
 Exercise/hard working out does not decrease milk
  Not getting enough rest doesn’t decrease milk
 Worry/stress can affect milk supply, however exclusively BF moms stress less than
formula feeding moms
o 2 conditions affect pp-ptsd
 Depressive symptom scores
 Physical symptoms experienced since birth
 Types/amount of food doesn’t matter
o Lactation has lower energy cost for humans
o Cholecystokinin and gastrin help expand nutrients

How is it possible for humans to make milk with such a small amount of energy?
 Maternal plasma prolactin concentration increases under negative energy balances
 Changes in maternal processes spare energy
 Large fat reserve from pregnancy

How do we assure adequate milk supply?

 Understanding how BF works
 Early initiation/adequate BF (10-12x/day)
 Appropriate bf assessment
 Improved/early bf support to decrease lactastrophes
 Appropriate HCP and LCP f/u in pp
 Admitting there’s no magic m=bullet

Breastfeeding Management Issues

When to breastfeed: feeding frequency
 When feeding responsively its difficult to predict how many times a day a bf baby will be
fed
 Factors that play a part in feeding frequency
o Storage capacity in breasts differs from person to person
o Babies have a range of skill in latching/transferring milk, the more feeding the
better the skills
o Calorically deprived babies are sleepy/apathetic feeders
o Babies stomach capacity
o Breast milk is perfect for human baby, easy to digest, can be fed more frequently
o Crying babies shut down and act asleep
o NBs need to nurse 10-12x/day
o People think crying is the signal to feed, it’s the late signal

Feeding Cues
  First sign: Active sleep (REM raped eye movement), then others follow
 Rooting = turning head, searching movements w/ mouth
 Increasing alertness (REM)
 Flexing legs/arms
 Hand to mouth
 Sucking on fist/finger
 Mouthing motions of lips and tongue
 Crying = LATE SIGN

 less mature babies, go from REM to crying in short period of time, feeding cues can be
missed
 skin to skin can help with motor state maturation for this subtle cues

Expected Weight Gain in the Breastfed Baby

 After initial 7% wt loss, no further wt loss after day 5
 After day 5, ebf baby should gain 1 oz or more a day
 At 6 mo solid foods added
 Second half of year ebf babies gain slower than formula fed babies

Weight Loss in the Newborn

 Wt loss in nb should be no more than 7% from birth wt
 Wt loss stop by day 5
 If baby loses more than 7%
o prompt intense eval
o correct milk production/transfer
o if problems not identified, feeding baby is most important, use expressed breast
milk, donor milk, or any whatever pediatrician says

Insufficient Milk
 is there an actual problem or a perceived problem
 Perceived vs actual issues
o parents may think there isn’t enough colostrum
 colostrum is newborn milk, high in antibodies that will protect baby from
pathogens,
o babies need to practice feeding before there is an abundance of milk
o fussy baby does not equal calorically deprived baby, they are more sleepy and
quiet
o calorically deprived babies have weak suction, decreasing stimulation and milk
supply
o amount of milk from pumping/expressed milk does not dictate sufficient milk
supply

Assessing expression w/pump

  both side being pumped at same time?
 Missing parts, working correctly?
 Flange too tight? (nipple can’t expand)
 Flange too large? (cause friction)
 Use guided imagery
 Power pumping
 More milk with different shape flange?
 Different style pump make a difference?

Maternal Reasons for Inadequate Milk Supply

(maternal reasons for inadequate milk supply demonstrated by poor baby wt gain)
 Inadequate breast stim
o Inverted nipples
o Nipple shield use
 Infrequent breastfeeding
o Scheduled feedings
o Formula
o Pacifiers
 Inadequate milk removal resulting engorgement
 Inadequate hormone stim d/t slow feeding (longer than 20 mins)
 Suboptimal hormone balance
o Retained placental fragments
o Hypo/hyper thyroidism
o Sheehan’s syndrome (pituitary infarct)
o Insulin (delaying LactoGen II, delaying milk)
o Theca lutie/PCOS
 Smoking
 Nipple shield
 Breast injury
 Spinal injury (thoracic nerves, T1-T6)
 Congenital breast anomalies
 Breast size discrepancy
 Breast surgery
 Certain drugs
o Pseudoephedrine
o Corticosteroids
o Early admin of birth control drugs
o High doses of vitamin b6
 New pregnancy
 Maternal depression

Not Related to decreased Milk Production

  Fluid intake
 Physical labor
 Stress
 Fatigue
 Diet

Diet
 No difference in growth of babies between malnourished moms and nourished moms
o Nourished moms give more care and stimulation to babies, breastfed longer
 Vegans/bariatric surgery moms, increase B12
 East the flavors of your culture (spice is fine!)
 Babies like flavored milk
 Babies get used to flavors
 Chocolate, tea, coffee, diet sodas w/ caffeine are fine in moderation
o Caffeine
 Caffeine may accumulate in premature and very newborn infants
 Not associated with duration of BF or infant sleep
 Does not relate direction to amount of caffein in milk
 Avoid alcohol per cdc, but 1 drink/a day two hrs before bf is fine 
o Oxytoxin levels decrease, prolactin increase
o Not water soluble, passes in and out of milk as her blood alcohol increases, then
decreases. Not trapped in milk (pumping and dumping wont remove alcohol)
 Colicky bf babies could be related to whey/cows milk, stop dairy, can take up to 10 days-
2 wks before its gone
 Eczema, proctocolitis = stop cows milk, soy, eggs, wheat, fish

Altering diet to prevent allergies in baby?

The most modifiable RF for child allergy are:
 Maternal smoking
 Type of infant feeding
 Cesarean birth
 Allergic food consumption in pregnancy reduces allergy and asthma in children

Cows milk
 Can cause colic symptoms
 Allergic symptoms may not show depending on amount of cow milk exposure
 Protocolitis = rectal bleeding
o Can occur from cows milk
o Can occur in ex BF babies
o Consider hidden bottle practices
o Tx: exclusion on offending protein, cows milk, soy, corn, egg, chocolate
o Rectal bleeding usually stops in 72-96 hrs, up to a week
Supporting calcium needs
 Calcium deman is not the same as in pregnancy
 Regardless of amount of calium in diet, BF calcium is met by renal calcium conservation
and loss of bone (recovered in post lactation)
 Estrogen levels rise during weaning to adapt body

Baby Gaining too Fast/Too Much

 Pound or more a week for the first 8-12 wks
 Questions to ask
o Rapidly gaining wt baby happy or unsettled?
o Sore nipple/recurrent mastitis?
o Difficult nursing sessions with baby latching/unlatching
o Large stools a day?
o Stools shiny/green?
 Yes to two or more of these, the issue could be oversupply

Oversupply
 Not worried about wt gain, worried about how fast milk is going though baby’s GI tract
 What to do about oversupply
o Find posture where baby can freely move head away from flow (reclining, semi
sitting, Australian)
o Nursing on one breast at each feed for two or more feedings (block feeding)
o Firm bra
o Instead of decreasing, store or donate milk
 Confirm oversupply
o Use scale set to 2gram
o Weigh before and after feed
o If like 3 oz gained in 5 mins

Working and Breastfeeding

 Done for generations, difference now is that parents are separated from baby
 Work does not equal impacting breastfeeding
 Timing of returning to work linked to ending breastfeeding
 First month back to work strategies
o Express, save milk to feed to baby later
o Keep baby at work, nurse during the day
o Don’t pump
o Go to baby to to nurse
o Have baby brought to workplace to nurse
o Express and discard milk
 2010 us health care reform bill included in amendment to section 7 of the fair labor
standards act requires employees of more than 50 employees: “reasonable breaktime
 (hrly) for employee to express or feed milk 1 year after birth and a private place other
than bathroom”

Strategies for supporting BF when there is a separation due to return to work/school

 Get tuned into reality for family
 Focus on getting BF off to a good start
 Assure community support
 Save teaching tips for 2-3 weeks before work
 Become familiar with available recourses
 Returning to work can interrupt exclusively breastfeeding

Sleeping Though the Night

 Babies learning to regulate the first 4 months (crying, feeding, sleeping)
 Changes around 4 months
 Newborns feed around the clock bf or not
 No realistic that babies sleep more than 3 hrs in a row at night until they weigh 10 lbs (2
years of age)
 Babies wake up to feed at night if not adequately fed during the day
 Behavioral intervention programs to sleep train don’t work
 Pay attention to baby during day for feeds, cuddles, ands needs and will decrease baby
wanting things at night
 Prolactin levels in milk are highest in early morning and in early lactation
o Babies that feed after 2am getting more volume of milk and more prolactin
o Benefits of prolactin
 Assist with development of pituitary/adrenal glands, reproductive organs,
GI and Resp tracts and modulation of immune system

Sleeping in Close Proximity

 Close proximity = baby shares room with parents for at least 6 months
o Safest way to sleep
o Parents can hear needs and cues
o Synchronizes breathing and sleep cycles
o Protects against sids
o SIDS

Sids
 ABCs
 BF protects against sids beginning at 2 mo and increases over time]ex bf at 1 mo halve
sids risk
 Gut microbiome who died from sids offers explanation
2A
Negative Influences on Milk Production
 Long spaces between feedings
 Long slow feedings
 Excessive pressure on breast
 Breast surgery or injury
 Suboptimal breast anatomy
 Suboptimal or altered physiology
 Physical objects

Pressure can result from

 Vascular
 Lymphatic
 Third spacing forces
 Early secretary activation (lactogenesis 2)
 Too much milk left in breast
 Restrictive bras/clothing
 Breast implants
o Reduces storage capacity

Normal breast fullness signs/symptoms

 Breast soft to touch
 Body temp normal
 Mom feels well
 Breast may be hot
 Baby can grasp nipple

Engorgement symptoms
 Breast hard
 Temp normal
 Feels discomfort
 Breast hot and shiny
 Nipple difficult to grasp, baby can’t latch

Engorgement
 Symptoms occur commonly between day 3-5
 IV fluids can attribute to swelling up to day 9
 Cesarean sections peak engorgement 24-48 hrs later than those that delivery vaginally
 More time spent BF in the first 48 hrs is associated with less engorgement

Pressure and Engorgement

  Pressure in breast increases, milk production decreases
 Natures early lactation dry up mechanism
 Failure to resolve can cause negative impact on milk supply

Tx for engorgement:
 increase feedings
 gentle expression
 nsaids
 Shower
 Dipping breasts in basin (lukewarm water)

Breast Surgery or Injury

 Concerns with breast surgery
o Damage to nerves
o Damage to ducts
 Peri-areolar incision can extend all around areola, look for defined margin where the
color changes from areola to breast
 Many breast reduction surgical techniques
 Free nipple graft
 Pedicile
 Chest masculinization surgery “top”
o Different experiences
o Restarting testosterone and binding were common concerns
o Communicate and provide transgender people with care

Counseling Implications After Breast Surgery

 Likelihood of full bf unknown
 Hormonal exposure of pregnancy and lactation my mitigate some effects of surgery
 Assessment and close f/u care are keys
 Assure adequate nutrition for infant

Suboptimal Breast Anatomy

 Anatomical concerns
 Absence of breast changes, in pregnancy or early days of postpartum
 No postpartum breast fullness or signs of abundant milk production
 Hypoplastic breasts
o One implant may indicate there was discrepant breast tissue

 any abnormality, breast surgery, and/or breast injury can impact bf

Counseling Mothers w/Breast Enhancements/Surgery

  Assure privacy
 Ask about surgery “improvement” or injury
 Determine innervation/sensation
 Ask yourself when counseling:
o Are the ducts patent?
o Are the nipple pores patent?
o Signs of hormonal connections
o Concerns about baby wt gain
o Adequate pediatric supervision

Flat/Inverted Nipples
 Babies don’t need nipple to latch, they form a teat
 May evert in pregnancy
 May evert in pp
 Flat nipple may evert during suckling
 Both nipples evert sometimes (sexual stim, finger manipulation, cold)

Prolactin – nipple stroking

Oxytocin – nipple stretching

Nipple Stretching
 Nipple stretches one time to twice its length, then is stable in length
 Nipple expands in diameter into the open mouth to accommodate optimal milk flow
 Nipple compresses during swallow

Inverted Nipples Classification – function during feeding, not how inverted/flat they look at
rest
 Grade 1 = are easily pulled out with pump/nursing
 Grade 2 = can be pulled out, don’t stay out
o go back rapidly after feeding
 Grade 3 = difficult/impossible to pull out
o Before and after feeding are the same
o Women w/ grade 3 have lower prolactin levels/less milk

Counseling Implications Inverted Nipples

 Ask if and when nipple everts
 Look over shoulder after feeding for nipple inversion, compare to prefeed nipple
 If not seen, intensive f/u
 Consider expression
 Assure adequate nutrition of infant
NOTE: PP eversion techniques (shells, evertors, shields, pumps have not been studied in
experimental controlled trials, check gadgets are FDA approved and have safety and efficacy
studies

Suboptimal or Altered Physiology

 Iron deficiency/anemia
 Hemorrhage
o Sheehan’s syndrome
 Hormone imbalance
 Drugs
 Retained placental fragments
 Hormones with new pregnancy
 Tandem nursing
 Smoking

Iron deficiency due to:

 Physiologic (poor oxygenation to milk making cells)
 Exhaustion/depression
 Combination
 20% pp women have anemia

Hemorrhage
 Can result in anemia and Sheehan’s syndrome
 Sheehan’s syndrome: pituitary deprived of blood, functions are impaired (even from well
managed hemorrhage)
o SS are low bp, anemia, fatigue, profound hair loss, dry dull hair (can take 30 years to
develop)
o Low grade or transient sheehan like symptoms resolve fully or partially

Hormone Imbalance
 Thyroid imbalance (hypo or hyper)
 Obesity/over wt can first 7 days can delay lactogenesis ii
 Insulin dysregulation (prediabetes), DM, GDM
 PCOS

Drugs Alter Physiology

 Pseudoephedrine
o Single 60 mg dose decreased 24 hr milk production by 24 %, decreased prolactin
levels
 Corticosteroids
o Temperary suppression of lacation (24-48 hrs) after local injection of 24 mg
prednisone bf women 6 wks pp
o Betamethasone

Retained Placental Fragments

  Delays lactogenesis ii, because only the complete delivery of the placental will cause
lactogen 2

Hormones of Pregnancy
 Milk reverts to colostrum mid pregnancy
 Extremely tender nipples/breast
 Plan for nutrition since milk has changed back to colostrum
 Is BF safe during pregnancy?
o Does not affect pregnancies ends or birth wts
o Might be attributed to miscarriages

Tandem nursing = Nursing two babies not from the same pregnancy
 Milk volume increases faster, less engorgement
 May require specific teaching to manage faster flow
 Help parents respond to individual needs of both children
 Find time for non nursing interactions with older babies

Smoking
 Alters physiology
 Makes less milk
 Have low prolactin levels
 Pump dependent moms collects less milk
 Wean earlier
 Babies may nap less
 Quitting smoking, decreases premature birth
o Prenatally is a great time to counsel on smoking cessation
 Cannabis
o Passive smoke concern
o No safe threshold
o High fat solubility can make it hard to measure in bm

Physical Objects
 Pacifiers
o Can indicate parents need extra bf teaching
o Why is pacifier being used?
 Sore nipples
 Hunger
 Crying
 Sleep problems
o Can help with SIDS at naptime and nighttime, but to wait until breastfeeding has
been established
o Pacifiers for preemies
 May have earlier discharge
 Tube fed babies may gain wt faster and have improved physiologic and
behavioral responses
  Reduced time to full oral feeds
 Nipple shields
o Can cause concerns
 Formula
o Given due to lack of confidence
o Bf d/ced at 2 weeks associated with lack of confidence to bf on day 1 and 2

Counseling for Fears About Milk Supply

 Avoid inappropriate reassurance, give facts per scope of practice
 Do complete eval, history, feeding assessment, before any conclusions
 Adequate pp teaching to distinguish between real or perceived insufficient milk
 Eliminate the zone of professional unavailability by establishing system wide community
between days 3-7
 40% of moms worry about milk supply

2B
Conversing using relationship theories

Silence - a position of not knowing in which the person feels.

 Voiceless, powerless, and mindless
 Afraid of words
 See themselves as relatively powerless and dependent on others for survival
 Do not trust their ability to understand or remember
 Have little awareness of their intellectual capabilities
 Live at the behest of those around them
To develop a relationship with Women in Silence:
 Use few words
 Use familiar words (not areola or alveoli)
 Short, easy, comfortable
 Nothing to remember
 You may need to be an advocate

Receivers of Knowledge – believe that all authorities tell the truth

 Like to learn the right answer and repeat it to the teacher
 Cannot tolerate ambiguity
 Submit to the command of authority – not inner voice
 Sense of self is embedded in external definitions and roles
To develop a relationship with Receivers of Knowledge:
 Teacher or counselor must project authority
 Never be ambiguous
 Advantages must be concrete and appropriate for her
 Teaching should center on the right way and include return demo
Subjective Knowing Believers – knowing is personal, private, and based on intuition and/or
feeling states … rather than on thought and articulated ideas that are defended with evidence.
Subjective knowers:
 Sense of self is embedded in external definitions and roles
 Sense of authority arises primarily from the power of a group
 Trust their own intuition
 Inner voice helps guide them
 Distrust male authority figures
 “Experts don’t know what they’re talking about”
 Trust other women with similar experiences
 Find female support groups helpful
 Attracted to natural things…like breastfeeding
 Want to be helped by someone who has breastfed
 Interested in breastfeeding from her own point of view
To develop a relationship with Subjective Knowers:
 Create time for them to talk about themselves and what they think about breastfeeding
 (otherwise they can take over classes or group sessions)
 Offer help with possible misconceptions about breastfeeding
 Offer to make contacts and referrals

Procedural Knowing - the position at which techniques and procedures for acquiring,
validating,
and evaluating knowledge claims are developed and honored.
Procedural Knowers:
 Invested in learning – constantly taking in new information
 Interest in obtaining and applying knowledge
 Want to understand other people’s points of view
 May attend several classes and change health care providers easily
 May be viewed as inconsistent by others
 May want very technical information about breastfeeding
To develop a relationship with procedural knowers:
 Be prepared to back up statements with evidence
 Be knowledgeable about multiple sources of reference
 Limit personal stories
 Understand that options and change are part of the process

Constructed Knowing – the position at which truth is understood to be contextual, knowledge

is tentative; and it is understood that the knower is part of (constructs) the known.
Constructed Knowers:
 Have abandoned “either/or” thinking
 Have learned to live with conflict and have a high tolerance for internal contradiction
  and ambiguity
 Believe all knowledge is constructed and the knower is an intimate part of the known
 Want to avoid compartmentalizing thought and feeling, home and work, self and other
 Want to embrace all of the pieces of the self in some ultimate sense of the whole:
 mother-daughter-wife-thinker-artist
 Aspire to work that contributes to the empowerment and improvement in the quality of
 life of others
 Believe that ideas and values must be nurtured
 Have a unique and authentic voice
The position of constructed knowledge involves enormous “empathetic potential” … the
capacity to feel connected with another person despite potentially enormous differences.
Many women in this position nonetheless experience loneliness and discouragement largely
due to difficulty in finding companionable and supportive partners.

Hierarchy of Infant Feeding Choices for Term Baby

 Baby at mom breast
 Moms expressed milk
 Milk from HMBANA or State Licensed Milk Bank
 Cow milk formula
 Soy formula

Pumps (Cochrane review)

 w/ lack of breast mouth contact can influences milk microbiota
 should be appropriate for moms use
 used according to instructions and cleaned per cdc guidelines
 2/3 women have problems, 15% reported injury
 Care providers and consumers can report damage/injury to fda
 No one pump that’s right for every situation
 Hospital distributions decreased odds of bf around 10 weeks
 Distribution of pumps do not increase ex bf
 No one flange shape is going to be okay for all women
 Should be a reason why pumping is being used after delivery

Hand expression
 Cleanest way to collect milk
 Simple process of handwashing and clean container
 Appendix M (at bottom of SG)

Human Milk storage

 Fresh milk
o If using after 4 days, freeze for 12 mo (0F or 18C)
o If using within 4 days refrigerate (less than 40 F or 4C)
o If using in 4 hrs room temp, use cooler bag or ice or refrigerate (less than 77 F or 25
C)
  Thawed, previously frozen milk
o Plan to us after 1 day, don’t, never refreeze human milk after thawing
o Plan to use within a day, refrigerate up to 24 hrs
o Plan to use within 1-2 hrs, room temp or cooler bag or fridge
 Raw food, handles with care
 Heat little or not at all to preserve immune properties and nutrients
 Never use microwave

Banked Donor Milk is:

 Preventative, reduces long term morbidity
 Reduces mortality (can be a matter of life and death for some infants)
 Decreases NEC
 Cost effective
 Safe
o Donor screening by hx, serology, bacteriology, heat tx/pasteurization (does not
destroy benefits, retains 90%)
 Can be used + moms milk

Donor Milk does not equal informal sharing

 not condoned in US
 can be called wet nursing/cross nursing
 acceptable in some cultures
 buying or sharing pf internet or peer to pee could have bacteria and cows milk
 all donors may be criminally liable

Formula Issues
 used d/t inadequate and unpaid maternity leave, unequal pay, maternal mortality and
morbidity, lack of counseling, health care inequities
 recalled frequently
 can be contaminated
o clostridia
o cronobacter (enterbacter) sakazakii
 water is used to dilute formula
 additives added such as melamine
 bottles can pose a risk for improper cleaning and bisphenol a (BPA) and other chemicals can
be in plastic bottle
 FDA found that 77% o formula feeding mothers did not receive instruction on prep and 73%
did not receive instruction from health care providers

How to prepare formula:

 Mix PIF w/ water heated to temp of 70 degrees C or 158 degrees F
 Cooled off until body tempt before feeding
 If not using, refrigerate right away
 Do not formula stretch by watering down
Feeding Issues:
Reflux = may be associated w/ cow milk allergy in infants one year of age or less

Colic = easily identified childhood problem with no clearly defined treatment guidelines
 Colic not associated with good
 Baby’s with colic have more abundant proteobacteria
 Anaphylaxis is possible related to cows milk allergy
 Formula can cause allergy, diarrhea
 Soy can also issues/allergies and estrogenic effects
 Marketing can state formula is just as good as BM

NOTE: Avoid homemade formulas, animal or plant milks are not appropriate for human babies.
Causes electrolyte imbalances, metabolic acidosis, folate deficiency, and specific and nonspecific
antigenicity

NOTE: Scurvy is new and on the rise due to improper use of almond drinks in the first year of life

How much milk do we make

 750-1000 mls/day
 Twins moms 2355-4170 ml/24 hr

Growth in BF baby
 Growth charts and growth standard per WHO should be used for all children under 24 mo
per CDC

Difference in wt gain patterns

 Formula wt gain after 2 mo can be caused by hyperinsulinemia, production of insulin that
does not move glucose into cells, receptor sites on cells seem to be blocked by fat, excess
insulin in the blood is used to make and lay down fat, cells send out repeat signals to secrete
more insulin cause lack of glucose in cells
 Breastfeeding protects children against obesity
o Per cdc along w/ bf to prevent obesity to have a diet rich in fruits and veggies and
increased physical exercise

Contraindications to BF or Feeding of Breast Milk

 Mom has HIV (can differ in other countries)
 Mother has human T-cell lymphotropic virus type I or II (HTLV1/2)
 Mother using illicit drugs such as pcp (phencyclidine) or cocaine, methadone is an exception
 Mom has suspected or confirmed ebola virus
Temporary do not BF/feed ex BM
 Mother is infected with untreated brucellosis
 Mother taken certain meds
 Mother undergoing diagnostic imaging w/ radiopharmaceuticals
 Mother has active herpes simple infection w/ lesions present on breast
o Can feed with other non affected breast, just need to cover the affected breast

Temporarily NOT bf but can give ex BM

 Active TB
o Contact and airborne precautions with baby
o Should continue to maintain milk supply
o Can resume BF 2 wks after treatment
 Mother has active varicella (chicken pox) that has developed 5 days prior to delivery to 2
days following delivery

NOTE: NEVER go off of feelings or memory always research contraindications vis conferences,
LactMed, drug hotlines, medications and mother milk, infant risk center

3A

Influencing moms to BF
 Influenced by embodied knowledge (gained from seeing breastfeeding)
 Does not come from prenatal education

Why do moms choose not to BF

 Think formula is easier
 More comfortable with idea of formula
 How we counsel
o Don’t make BF appear hard and schoolish
o Focus on advantages to baby
o Intervention: Normalize BF instead of “less ear infections” say “less ped office visits
for ear infections”
 Ask how you can help breastfeed the baby
 May be rejecting BF
o Intervention: positive experiences with knowledgeable peers
 Confidence and empowerment thru group based peer learning
 Videos alone aren’t effective
 Wic can increase bf numbers
 La leche league is a great resource
o Men think it not natural to bf
 Worry breasts will get ugly (breast changes aren’t associated with bf)
 Fathers worry bf separates them from children and will be heard to establish
relationship
  Tell fathers bf is normal, achievable, desirable, protects from disease,
breasts made for bf
 Father can be eager to learn

Counseling
8 level breastfeeding counseling process by healthy children
 Don’t skip around
 Helps to refine choice of solutions
 Helps w/ compassion

1. Take complete hx
2. Assess mom, baby, feeding
3. Develop symptom list
4. Formulate problem list
5. Reconcile hx, assessment, symptoms, problems
6. Generate/prioritize solutions and pland for interventions
7. Reconcile prioritized solutions and planned interventions w/ problems
8. Eval solution and interventions

Counseling strategies, ask yourself do I:

 Smile
 Know/remember names
 Make eye contact
 Take knowing style into consideration
 Pay attention to pain, worries, situation
 Give praise

Bad counseling:
 One size fits all
 Talking to a friend
 Teacher talking to student
 Mechanical fixing of what wrong
 Hands on, makes mom feel like machine
 Giving advice that works for you
 One size fits all info
 Imposition of the counselors agenda on family

Good counseling
 Family concerns are hear and valued
 Baby feels heard and valued
 Counselor elicits the whole story before offering feedback/intervention
 Adults, baby, counselor fully involved in problem solving
  Safety is primary focus (even over bf)
 Technology and gadgets are used v carefully
 Avoid loaded and judging words

Horse, zebra, unicorn analogy

 Horse: plugged duct
 Zebra: galactocele
o If not moved or resolved in 48 hrs
 Unicorn: breast cancer
o Via needle aspiration etc

Lactation Counseling = emphasizes interactions with individualized parents to support their

decision making, which means that the content and style of intervention varies for different people
at different times

Motivation Interviewing
 four key principles
o partnership
o acceptance
o compassion
o evocation
 Communication should be
o Open
o Respectful
o Compassionate

Miller and Rolnick’s Three Definitions of Motivational Interviewing (2013)

1. Layperson’s definition = motivational interviewing is a collaborative conversation style for
strengthening a person’s own motivation and commitment to change
2. Practitioner’s definition = motivational interviewing is a person centered counseling style for
addressing the common problem of ambivalence about change
3. Technical definition = motivational interviewing is a a collaborative, goal oriented style of
communication w/ particular attention to the language of change. It’s designed to
strengthen personal motivation for and commitment to a specific foal by elicitation and
exploring the persons own reasons for change within atmosphere pf acceptance and
companion

OARS: Steps to Motivational Interviewing from Bershard

 Open ended questions
 Affirmation
 Reflection listening
 Summarize and teach back
Open ended questions
 Show interest in what is on the clients mind
 Ask questions that can’t be answered with a single word
 How, who, what, when, where
 “how can I help you today” don’t use “why” say “tell me about”

Affirmation
 Builds empathy and connection between client and counselor
 Listen for and call attention to examples of food actions/decision to affirm
 Strive for genuine and specific recognition, not generic response
 “how wonderful you chose to trust your knowledge in following your babys feeding cues”

Reflective listening
 Listen for deeper understanding of the situation – hearing not only the words, but open to
possible underlying meanings and beliefs
 Rephrase or paraphrase statements, reflect on the meaning of what you heard to assure
understanding
 Ex: mom expresses concerns about milk production via her family experience, say “it sounds
like you are wondering if that would happen to you also, have I understood you?”

Summarize and teach back

 Summarize strengths shared by client and action steps planned
 Ex: “you’ve identified some strategies that will help improve your milk flow. Let’s go over
your feeding plans”

Teach back
 Ask client to demonstrate skill or learning

Greater support is needed for the following:

 First time parents
 Mother of late preterm infants born at 34-37 wks
 Women w/ family or financial problems
 Women experiencing postpartum anxiety disorder (PPAD)
o 85% of women experience mood changes d/t hormones w/o support
o PPAD is not related to feeding choices
o Hx of PMS/dysphoric disorder have higher risk of PPAD
o Pospartum post traumatic stress disorder PP-PTSD
 9% of pp women met DSM IV criteria
 Two conditions significantly increased the odds of PP-PTSD
 Depression symptoms scores
 Total number of physical symptoms experiences since birth

Edinburgh Postnatal Depression Scale

 Developed to screen pp moms
  10 questions, takes 5 ins
 Rate Reponses to how they felt in past week (0, 1, 2, 3 according to increased severity of
symptom)
 Screening tool DOES NOT diagnose, high scores mom should be referred
 Woman scoring a 10 or more should be immediately referred for follow up (q10 is suicidal)

NOTE: More info isn’t better, recall is better with less topics. Communication should be centered
around mother’s concerns not biomed conversation, info is enhanced with gathering and
relationship building

Supporting the Desire to Exclusively Breastfeed:

 Optimal start
 Babies born during the nigh and early morning (10pm-9am) had double the odds of
supplementing compared to babies born during day
 At one month frequency of BF was higher w/ group that had doula
 Pitocin (intrapartum synthetic oxytocin) used
o Decreases oxytocin released from sucking
o Lower apgars, admissions to NICU lasting more than 24 hrs
o Higher risk of anxiety/depression and Rx for that in the first year

Pain meds during labor

 Mixed results
 Mother need extra bf support
 May have delayed onset of milk coming in

Research Suggests for Labor and supporting BF:

 Avoid longer duration, delay epidural
 Conserve IV fluids
 f/u BF support
 continuous labor support/doula
 reduce need for pain meds by comfort measures

Supporting EBF during Hospital Stay

 hands off technique in helping
 implement 10 steps to suc bf
o bags have bf supplies or no bag at all
o weaning risk is higher in hospital that don’t support bf
o positive relationship between mPINC score and in hospital ebf
o QA to identify and change unhelpful practices

TJC’s Perinatal care core measure set for implementation beginning of 2010:
 Decrease elective delivery
 Decrease c/s
 Increase antenatal steroids
 Decrease HCA bloodstream infections in NBs
  Increase ex bm feeding
 Quality Measure: hospitals have strict definition of supplementation and work towards
100% Ex BF

Cesarean section is a barrier to BF

 Bf can be delayed and cause more separation
 Better pain control help bf
 Baby’s gut biome is affected by antibiotic use, mode, place of birth
 S2s is important after c/s to help with bf initiation, decrease formula use, and
thermoregulation
 If mom and baby are separated, partner should do s2s
 Common labor meds can affect whether baby suckles in first hr or no, baby will need 2 hrs
before of s2s self latching

Smell is important
 Moms areola and milk odor attract and guide baby
 Calms babies during procedures
 Mothers rewarded in cerebral areas when they smell babies

Delayed bath = for 12 hrs

Step 4 of 10 StS BF = Skin to skin in the 1st hr and encourage early feeding, all babies transition
through 9 stages

1. Birth cry
2. Relaxation
3. Awakening
4. Activity
5. Rest
6. Crawling
7. Familiarization
8. Suckling
9. Sleeping

Skin to skin promotes(at least 65 mins)

 Decreased rate of primary pp hemorrhage
 Faster expulsion of placenta
 Correct suckling
 Less crying
 Warmer babies, warmer breasts

When babies are in close proximity:

 Families can observe feeding cues
 Babies can be held s2s
 Babies can smell the milk
 Babies can be fed at their best time
  Learning happens together
 Rooming in helps moms to sleep longer and higher in quality

S2S promotes BF
 Ex bf higher in moms with longer s2s
 Less depressive symptoms (need to BF in the first 2 hrs)

Risks of Delay BF in Hrs after Birth

 Mother
o Decreased prolactin receptors activated
o Decreased oxytocin/uterine contractions
o Decrease milk volume
o Decrease opportunities to practice w/ colostrum
o Decreased confidence
o Increase risk of supplementation
 Baby
o Increase risk of jaundice/sleepiness/lethargy
o Increase risk of hypoglycemia
o Decrease opportunities to practice w/colostrum
o Increase risk of supplementation
o Increase ph and opportunities microorganisms in gut

3B
LAT tool = a tool for lactation care providers to solve latch problems w/ assessment, continuity of
care, and direct individualized corrective interventions

In the first hour:

 Deep sleep (don’t attempt feed)
 Light sleep state (REM, happens every 27-30 mins during sleep)
 Quiet alert (still body, fixed eye focus) ideal time to start feeding
 Growing restlessness w/hand to mouth activities
 Open eyed w/ rooting
 Crying (change in state is needed before attempting feeding)

Sleep wake cues in first hour

 All babies have at least one hr awake time after birth
 After first hr wakefulness varies

Feeding cues: study resulted that rooting is the most common feeding cues followed by hand to
mouth

Babies show more feeding cues:

 When close to milk source
 When cues are missed or state is not optimal, infants fret or sleep at breast
 o Solution is s2s and reteach feeding cues
 When baby is in optimal state for learning and feeding, baby will have long periods of
concentration, usually during rem and quiet alert

Snuggle Poem
Tummy to mommy
Nose to nips
Flex the hips
To open the hips

Side lying more comfy then laid back

How to Correctly Latch:

 Nose to nipple
 Move baby back an inch or two
 Baby should game. Repeat as needed.
 Baby moves towards breast, the head should tilt back, don’t place hand on back of head
 Bottom lip and chin reach breast first
 Nipple should align with upper half of mouth, optimal latch there is more of lower part of
breast drawn in
 Nose and chin close to breast
 Mouth corner should be 140 degrees
 Tongue take ups half of mouth, wide angle needed for nipple to stretch in the top half of
mouth
 Both lips sealed
 Cheek line rounded
 Not broken cheek line
 No dimple chin
 Sucks in bursts of 1:1 or 2:1
 Baby should be off center, this is asymmetric latch, the lower half of breast in baby’s mouth
 Rocker motion not piston
 Baby should end feed with both hands relaxed

4A
Breastfeeding shouldn’t hurt!
 Need to assess feeding, educate, and do correct interventions to correct nipple pain
 Pain is associated with poor latch
 Assess for proper latch on, good seal, babys tongue, swallowing sounds, feeding cues
 May need to reteach
Infected nipples
 Heal best w/ antibiotics (systemic or topical)
 Lanolin can increase infection
o Creams
 Still questioning effectiveness
 Fears of indigestion by baby

Hand on baby’s back or shaping breast with hand can cause nipple trauma
Anatomical problems can cause damage
Bottom lip tucked in or tongue tie (lingual frenulum) can cause damage

Tongue ties (lingual frenulum) – isn’t typically associated with nipple pain/decrease bf, and
rarely needs frenectomy

Role of lactation care provider regarding tongue or lip tie

 Feeding assessment and suggest way to optimize latch
 Refer for dx
 Provide support
 Pacifiers and feeding bottles in hospital are associated with sore nipples so try and
decrease use

Other reasons for sore nipples

 Oversupply (baby clamps down on nipple to decrease flow)
 Yeast/thrush
 Raynauds
 Strong vacuum baby
 Clogs/plugs/cakes
 Mastitis
 Abscesses

Oversupply (hyperlactation)
 Rapid wt gain
 Unsettled baby, esp after feeding
 Recurrent ducts and mastitis
 Painful feedings
 Large stools – often green/shiny

How to counsel for oversupply

  Is there a deep latch with nipple stretching?
o Nipple not stretched, less oxytocin flows, less fat in the mix, less fat, milk
digested more quickly, not enough time to for lactase to digest lactose
 Is there a lot of milk?
o Lactase may not be able to keep up with lactose
 Decrease additional stim/milk removal
 Block feeding (nursing on one side)
 Australian posture
 Watch for mastitis
 Donate milk
 If not fixed consult with HCP

Candida albicans/yeast/thrush
 Can cause pain for mom and or baby
 May be visible or not
 Mother usually has itchy, flaky, skin and shiny skin
 Treatment
o Pharmacologic tx (possibly other family members too)
o Nystatin ointment
o Fluconazole (Diflucan) oral capsules
o Cleaning or replacing all vectors (toys, paci, pump parts)
o If tx doesn’t work may not be yeast
o Antihistamines can relieve symptoms
o Not in milk, continue to feed

Raynaud’s Phenomenon of the Nipple

 Not the same as blanching w poor feeding attachment
 Involves vasospasm of nipple
o Triple color: white to blue to raspberry
o Bi color: white to raspberry
 Pain is extreme and spasmodic (not continuous)

Tx of Raynaud’s
 Prevent cold exposure
 Avoid vasoconstrictive drugs (HTN drugs), caffeine, nicotine
 Nifedipine (Procardia) a calcium channel blockers can help

Clogs/plugs/cakes = Palpable lumps of milk within lumen or duct system, usually not visible
 If not resolved in 24-48 hrs healthcare referral
Clogs
 Find out cause (if reoccurring, bra)
 Massage, warmth, double nursing, point chin towards clog
 See hcp if systemic symptoms appear or if clog doesn’t move in 24-48 hrs

Clogs may appear at nipple tip

 This is a bleb, small white spots on nipple that look like milk filled blisters
 one duct opening is covered
 stabbing pinpoint pain
 blebs may exit when treated as clogs (see above)
 may need to be lanced by hcp

Common Mastitis
 breast inflammation, can be non infective or infective
 factors
o blocked ducts, engorgement, hurried feedings, use of nipple
o attachment difficulties
o tight bra
o use of breast shell
o nipple pain
o anemia in mom
o tongue tie (ankyloglossia) in baby
 systemic symptoms: fever, ill feeling, pain, redness, ONE INFLAMED BREAST
 if ineffective, its staph
 not in milk, in breast tissue

Tx of Mastitis
 NSAIDS
 Antibiotics can be used, but little evidence on effectiveness
 Keep milk flowing and breasts soft and comfortable to avoid abscess development
 If tx ineffective consider anemia, ductal or inflammatory breast cancer

Emergent Mastitis
 BOTH BREASTS inflamed
 Strep is the cause
 Not a problem with milk
 Medical emergency
 MRSA can look like mastitis
o Newly recognized issue
o Can cause abscesses and lesions
Abscess
 Pus not milk
 60% positive for MRSA
 Nurse on other breast, cover breast with abscess
 Ultrasound guided technique should be first choice of tx
 Any lesion on breast should be consulted by a HCP, herpes and MRSA are deadly to
babies

Always careful assessment is needed when baby slips off breast, tires easily, repeated latches
and sucks only a few times before letting go of breast

Recurrent feeding problems need eval/referral

Goldsmith’s Sign = baby won’t latch on one breast

 Rule out common problems like ear infection, teething, birth trauma
 Breast cancer can be possible (can be dx 5 years later)
o Recognition can be vital to early dx of cancer

Neonatal Hypoglycemia = low blood sugar

 Healthy term bf babies do not need glucose monitoring
 Aap guidance current evidence does not support specific concentration of glucose that
separates normal from abnormal
o However usually tx symptomatic nb with glucose of 40 mg/dl
 Symptoms
o Jitteriness
o Cyonisis
o Apenia
o Hypothermia
o Poo body tones
o Poor feeding
o Lethargy
o Seizures
 Occurs mose commonly in SGA, LGA, late preterm infants, and those with moms that
are diabetic
 Skin to skin is so important to decrease nicu visits
 Bf and glucose gel decreased nicu admits

Jaundice (hyperbilirubinemia) = yellow coloration of skin and sclera (whites of eyes)

 Yellow caused by unconjugated bilirubin (UCB)
 Advancing jaundice needs clinical eval

Why we are concerned about jaundice

  UCB is fat soluble and crosses blood brain
 If UCB is too high could cause brain, spinal cord, nerve cells damage
 Warning signs of jaundice
o Jaundice advancing from upper to lower body
o Fussiness
o Lethargy
o Feeding difficulties
o Fewer than 4 wet/dirty diapers/24 hrs
 Can lead to kernicterus = bilirubin-induced neurological damage
 Types of jaundice
o Pathologic = occurs before 24 hrs od age, due to sepsis or blood incompatibility
o Early onset (aka physiologic, starvation, lack of breastfeeding jaundice) = peaks
at 72-96 hrs, due to underfeeding
o Late onset (aka breast milk jaundice) = related to metabolic or other issues with
infant (G6PD, Gilbert Syndrome, UTI)
 Benign, prolonged unconjugated hyperbilirubinemia associated w/ bf
 Presents 2nd week and persists for 12 weeks
 Continue to bf, and use phototherapy
 Tx should not prevent moms from breastfeeding

Skin to skin influences state organization and motor system modulation of the newborn,
helps with latching and sustaining feed, not for just after birth.

Kangaroo Mother Care (KMC) = s2s holding for premature and fragile babies, decreases
mortality, sepsis, hypoglycemia, hypothermia, and hospital admission
 Adult stay in upright positions
 Can last for 24 hrs
 Premies who have KMC or skin to skin benefits
o Better long term physiologic organization and cognitive control
o Improved cerebral blood flow
o Improved wt gain
o Nostrils decolonized that have been colonized by MRS/MRSE
o Sleep patterns more mature
o Warmer, physiologically stable
o Better bf outcomes

Very low birth wt babies and s2s

 Longer bf
 Breasts get warmer for twins separately
 Warmer in moms arms
 Burned fewer calories in moms arms vs incubator

4B
Premies
 Premature, late preterm (34-36 6/7), early term (37-38 6/7) may struggle w/ bf
 Need many opportunities to develop skill of latching and transferring milk
 Premies do better on human milk
o Better cardiac performance
o Bm for the first 28 days associated with greater nuclear gray matter volume
o Have fast brain maturity w/ bf
o Decreases NEC and mortality
 Can fortify BM w/ cows milk or donor breast milk
 Premies atg breast have better suck swallow coordination and oxygenation and resting
energy expenditure than bottle fed
 Bf initiation should be based on cardioresp stability, maturity, age, wt
 Encourage premie moms to feed BM
 the Preterm Infant Breastfeeding Behavior Scale (PIBBS) individual aspects include
o rooting
o areola graps
o latched on
o sucking
o longest sucking burst
o swallowing

Very low birth wt (vlbr) and breastmilk

 BM helps increase bayley mental development index and psychomotor index and
behavior scale
 Decreases re-hospitalization
Nicu babies and breastmilk
 Decreases sepsis
 Increases maturation of intestinal barrier

Babies w/ Down Syndrome often struggle w/ bf due to

 Low tones - cues
 Depressed reflexes (hard to latch on) - gape
 Hypotonic perioral muscles, weak suck, can decrease mom’s supply – piston, ration,
sustain
 Skeletal abnormalities of mouth and skull will decrease volume of oral cavity
 Improvement in sucking can develop overtime!
Helpful corrective interventions for positioning babies w/ difficulty sustaining a feed
 Individualized positions
 Hold baby to assure maximum tone
 Provide sensory input to mouth and muscle tonning exercises
 Individualize hand hold to connect the baby and the breast

Cleft palate/lip
 Longer duration of feeding w/ bf can lower Otis media
 Making a seal, creating a vacuum, sustaining feed are the challenges
 Placing breast into opening can and repositioning can help
Guiding Principles
1. Remove Milk to Make Milk
2. Infant requires nourishment to remove milk
3. Separation due to work/school
Remove Milk to Make Milk
 Expression in on hr after birth for highest milk volume (thu week 8)
 Hand expressed milk has higher calories than pumped milk
 Early hand expression with later pump expression yielded milk that exceeded norms for
fat and energy
 Using pump/hand expression to build milk supply
o Express w// baby near or kmc
o Double stim
o Collect milk on breast while nursing the other
o Guided imagery
o Power pumping ofr a day or two
o Stim, 5 min pause, stim, 5 min pause, stim 5 min pause

Galactogogues = substances believe to increase milk production

 Insufficient data, not recommended, can increase some serum levels
 Some providers might recommend these before assessing problems
 Prescribing herbs/drugs is not in scope of LC
 Fenugreek
o May cause reduced absorption of medications
o Worsening asthma, diarrhea, maple smelling urine, perspiration
o Cross reaction if allergic to chickpeas, peanuts, legumes
 o Can decrease blood coag and serum glucose
o No stats that it increases prolactin or milk volume
 Reglan (metoclopramide)
o Does not improve bm volume
 Domperidone
o Does not increase bm volume
o Not legal in us

Relactation (Follows pregnancy, not necessarily bf_

 Variables include
o Ability to produce milk
o Baby’s wiliness to nurse
o Length of time it will take to produce milk
o Not easy can have negative emotions attached to it
o Good for emergencies

Induced Lactation (no prior pregnant)

 Possible
 Can be used for transgendered women
 Requires time and effort
 Almost never results in full milk supply
 Works when the focus in on the experience and not the amount of milk
Don’t look for magic bullet with increasing milk, rather assess:
 All aspects of comprehensive risk assessment tool
 How often baby is fed/what is being fed
 Milk expression?
 Effective feeding/expression?
 How much milk being transferred at breast (observe feeding and do pre and post wts)
 Is there a need for pediatric and maternal eval?

Infant requires nourishment to remove milk

When thinking of supplemental feeding device consider:

 Cost and availability
 Ease of use
 Ease of cleaning
 Stress to infant
 Whether milk volume can be fed in 20-30 mins
 Is plan short or long-term
  Family preference
 Expertise of staff to teach/supervise plan
 Method enhances bf skills
 Safety and efficacy
 Parents able to us device safely
Issues w/ when/if using bottles:
 Healthy babies fed at breast, more likely to feed at 6 mo
 Bf support offered in NICU before using bottles
 Bottle feeding may alter self-regulation intake, attributing to obesity, higher wt gain
velocity, BMI
 Bottle size may be a modifiable risk factor
Cup feeding for premies
 Cup feeding results in
o Less HR increase
o Better oxygenation
o Infant paces feeding
 Preferred method of WHO/UNICEF
 Inexpensive
Regardless of supplemental method, its still detrimental to BF

Birth control
 Should wait 24 mo after live birth to get pregnant again
 BC extends beyond efficacy, method must be appropriate for woman’s BF expectations
(ADM protocol 13)
 Lactation Amenorrhea Method’s 3 questions (LAM) if yes to any of these chances of
pregnancy is significant
o Baby younger than 6 mo
o Is there food or suckling except at breast
o Has menses returned?
 Menses return
 o Difficult to predict timing
o Ovulation can occur before return
o Can decrease supply
 Other forms of BC
o Women that used combined oral contraceptives (vs progesterone only) were
least likely to continue BF for 4 months
o Hormone BC women more likely to have concerns about milk supply
o Barrier and NFP considered okay
o UIDs placed in PP do nnot affect BF

Environment exposures and milk

 Toxic exposures to infant largely in utero, minimally in milk
 Some populations could be at risk

5A
Breastfeeding and Prenatal Teaching
 Should be taught the importance of ex bf
 Risk reduction does not equal prevention
 Teach
 Give pp bf community resources
 importance of frequent feeding and having enough milk info
 responsive feeding
 rooming in
 skin to skin

NOTE: Black women have lower BF rates than white women, also have higher cancer rates

To support Ex BF we need:
 community, task forces, coalitions
 focus on support, reach out before they reach out to us
 anticipatory guidance better than reactive support
 face to face support
 social support in informal settings

Common newborn attributes

 no apparent schedule to their life
 night feeding
 frequency days for baby to catch up
4-6 mo: distractible
 May need to move to quieter place
 Regular naps?
 Separation anxiety
 Night feedings?
 Teething
o Sore nipples can happen when baby’s saliva hanges and gets new enzymes
around the same age as teething
o Babies may nurse much more or much less
o Offer cold “teethers” before nursing to “numb” mouth
o If baby is nursing less and milk is causing compression maintain milk supply by
relieving fullness
o Babies may also have runny noses and difficulty breathing at this time

6-9 months
 Mobile
 Teething
 Regular naps?
 Night feedings?
 Playful
 Long periods of concentration
 Biting: Need to explore why
o Watch baby closely and take off breast before biting starts. Calmly say “No”
o Avoid big reactions
o End feeding
o Offer breast at next regular feeding

9-12 months
 Stand and walk
 Regular mealtimes and snack nursings
 Nursing before bed and naps
 Breastfeeding through the first year …..
o Supports toddler energy and growth by fostering a shared mother-infant
regulation of toddler food intake.
o Promotes a pattern of mother-child interaction during feeding that
acknowledges the child’s role in regulating food intake.

After 15 months
 Part of self image
 Have a name for public breastfeeding

After 2 yrs
  More closet in US
 Normal in other cultures
 Its changing!

Three human strategies for ending Bf

 Parent led
 Baby led
 Society led

Parent led
 Choose least favorite nursing
 Substitute for something equally good in childs eyes
 Watch for reactions both physical and emotional
 Wait and repeat

Baby led
 Babies older than 12 mo
 Stop offering to nurse, change to on request only

Society led
 Historically weaning was 2-3 to 7 years
 Same for everyone in society
 Everyone knows and expects
 Ritual and celebration

As a counselor
 Not a matter of when, but what feelings about ending bf
 Understand difference between
o Stopping trying to make bf work
o A planned ending of bf
o Unplanned ending of bf
o Acknowledge emotions and be a good listener
Nursing strike
 Sudden
 There is milk still
 Not the end of bf
 Reasons can be obscure but there is something wrong in babys life

Reasons for strikes

 Stuffy nose
 Teething
 Ear infection
 Prefers bottle
 Biting and yelling
  Reaction to being left to cry it out
 Family stress
 Separation

How to end a nursing strike

 Identify and resolve problem
 Lots of support
 Lots of skin to skin
 Don’t force
 Avoid bottle
 Offer breast to sleeping bb
 Try peer pressure

BF positions (review pics p.198)

 Cradle
 Cross cradle
 Football/clutch
 Semi reclining/laid back
o Helpful when milk supply is large
 Side lying
 Australian
o Helpful for large milk supply

Alternate Massage/Breast Compression

 Technique to increase flow of milk while feeding
 Helpful for down syndrome babies, premature, cleft palate

What to do if baby is mistakenly fed another’s BM

 Inform mom
 Ask her how it was expressed and handled
 Ask if she would be willing to share full medical hx (meds, diseases, bleeding nipples etc)
 Inform parents of child fed BM, have them tell ped
 Hep B and C cannot be transmitted in milk

Review LAT
Review Feeding Observation Appendix B p. 194
Review Hand expression steps p.241
Review terms p.274
Review Medical indication for immediate medical attention p. 313