Breastfeeding update
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Breastfeeding update

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This was a talk that I gave to the Maryland Chesapeake Chapter of National Association of Pediatric Nurse Practitioners to update them on breastfeeding issues.

This was a talk that I gave to the Maryland Chesapeake Chapter of National Association of Pediatric Nurse Practitioners to update them on breastfeeding issues.

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  • 45% agreed that “A mother who breastfeeds has to give up too many lifestyle habits 31% agreed that “Babies ought to be fed cereal or baby food by 3 months of age” 31% thought “one year old children should not be breastfed by their mothers” 27% thought “It is embarrassing for a mother to breastfeed in front of others”
  • Based on the change in the rate of lactose excretion

Breastfeeding update Breastfeeding update Presentation Transcript

  • Breastfeeding Update Jane Johnston Balkam, RN,CS, CPNP, IBCLC Maryland-Chesapeake NAPNAP November 6, 2003
  • Potpourri Everything you always wanted to know
  • For Those Needing More Basic or Detailed Information
    • Beginning Lactation Management CD-ROM from NAPNAP Annual Conference April, 2003
    • Faculty
      • Kittie Frantz, RN, CPNP
      • Brigitte Paine, RN, CPNP, IBCLC
    • Order from: www.digitellinc.com
  • Major Themes of Talk
    • Milk Supply Issues and their Application to:
      • Building a good milk supply
      • Milk supply issues for women who have had breast reduction surgery
      • Milk supply issues for women who return to work
    • Other current issues
  • American Academy of Pediatrics Recommendations
    • “ Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth.”
    • “ Gradual introduction of iron-enriched solid foods in the second half of the first year should complement the breast milk diet.”
    • (AAP, 1997)
  • Healthy People 2010 Goals
    • Increase the proportion of mothers who breastfeed their infants to:
      • 75% in the early postpartum period
      • 50% at 6 months
      • 25% at 1 year
      • (DHHS, 2000)
  • How Are We Doing?
    • Current Prevalence (NIS data)
      • Data from 3 rd Q National Immunization Survey Data from CDC
      • Subset of women asked questions about breastfeeding
      • Looked at exclusive breastfeeding as well as ever breastfed and duration information
  • NIS Study Results
    • 727 children ever breastfed, 709 for exclusive
      • 65.1% (95% CI: 59.5%-70.7%) of children ever breastfed
      • 27.0% (95% CI: 21.7%-32.3%) continued to receive breast milk 6 months
      • 12.3% (95% CI 8.9%-15.7%) continued to receive breast milk until 12 months of age
    • (Li,et.al., 2003)
  • NIS Study Results
    • Exclusive Breastfeeding
      • 59.3% (95% CI: 53.7%-64.9%) at seven days of age
      • 7.9% (95% CI: 5.0%-10.8%) at 6 months of age
    • Study also showed that non-Hispanic blacks have the lowest rates of breastfeeding initiation and continuation
    • (Li, et.al., 2003)
    • Any and exclusive breastfeeding by age, NIS, July-September 2001 (Li, et. al., 2003)
    • Racial/ethnic disparities in breastfeeding (mean and 95% CI), NIS, July-Sept. 2001 (Li, et.al., 2003)
  • NIS Study Results
    • Comparison with data from 3 rd National Health and Nutrition Examination Survey (NHNES) 1988-1994
      • BF initiation  54% to 65%
      • Continuation of any BF  22% to 27% at 6 months and  9% to 12% at 12 months
    • (Li, et.al., 2003)
  • Public Perceptions of Breastfeeding Constraints
    • Perceptions that shape women’s decisions on initiation and duration of breastfeeding
    • Healthstyles 2000 Survey, based on 3 mailed survey questionnaires
    • Survey conducted by DDB Needham worldwide (an ad agency), their follow-up survey and a Porter/Novelli survey
    • Agreement with statement suggests a potential barrier
    • Analysis done by CDC Maternal Child Nutrition Branch (Li,et.al.,2002)
  • Public Perceptions of Breastfeeding Constraints
    • Survey uses quota sampling to generate a list of 5000 adults who represent a cross-section of US adults
    • Sample is stratified on age, sex, marital status, race/ethnicity, income, region, household size, and population density
    • (Li, et.al.,2002)
  •  
  • Public Perceptions of Breastfeeding Constraints
    • Other Findings
      • Perceptions did not differ significantly between men and women
      • Blacks were more likely than whites to have negative perceptions
      • Negative perceptions were also more common among people with lower household incomes and those with less education
      • (Li, et.al, 2002)
  • National Breastfeeding Awareness Campaign
    • Sponsored by DHHS with the support of the Ad Council
    • Approach based on focus group research
    • Will move away from talking just about the benefits of breastfeeding to talk about the risks of not breastfeeding
    • Panel of experts reviewed content for accuracy
    • Will launch soon and last 3 years
  • Why Does It Matter?
    • Health Care costs of Formula-Feeding in the First Year of Life
      • Only 3 illnesses considered
      • After adjusting for confounders:
        • 2033 excess office visits
        • 212 excess days of hospitalization
        • 609 excess prescriptions per 1000 never-BF infants when compared with infants exclusively BF for at least 3 months
      • Additional HC services cost $331-$475 /never BF
      • (Ball & Wright, 1999)
  • Physiology of Lactation
    • Lactogenesis I, the initiation of lactation depends on
      • Growth of glandular tissue (mammogenesis)
      • Differentiation of the mammary secretory epithelial cells (lactocytes) during pregnancy
    • Lactogenesis II, the onset of copious milk production is closely associated with factors controlling the birth process
    • (Hartmann, et.al., 2003)
  • Pregnancy
    • Breast prepares for lactation
    • Increase in numbers of alveolar buds
    • Differentiated alveoli become more evident
    • Cellular hypertrophy occurs
    • Varies in both amount and pattern of growth in women
    • Growth stabilizes in most women by 22 weeks gestation (Hartmann, et.al.,2003)
  • Lactogenesis I
    • Development of the capability to produce milk-specific components, lactose, casein, and  -lactalbumin
    • Secretion is not discharged and components are reabsorbed
    • Since lactose is not metabolized in the blood it is cleared in the urine
    • (Hartmann, et.al.,2003)
  • Lactogenesis I
    • Since the breast is the major source of lactose in the body, the concentration of lactose in the urine can be used as an indicator of lactogenesis I
    • (Hartmann,et.al.,2003)
  • Lactogenesis I
    • Onset of lactogenesis I is highly variable
    • Occurs as early as 10 weeks and as late as 22 weeks
    • Most women have achieved lactogenesis I by 22 weeks gestation
    • (Hartmann,et.al.,2003)
  •  
  • Birth
    • Little milk produced immediately after birth, regardless of length of gestation
    • 37-169 g/d of colostrum produced in first 48 hours after birth regardless of length of gestation
    • (Hartmann,et.al.,2003)
  • Lactogenesis II
    • Initiation of copious milk secretion
    • Precedes the mother’s sensation of milk coming into the breast
    • Sensation of fullness occurs between 24-102 hours post birth
    • Mean 59 to 64 hours
    • Most critical stage of lactation
    • (Hartmann, et.al.,2003)
  • Lactogenesis II
    • Requires adequate levels of prolactin, insulin, and adrenocorticoid hormones
    • Triggered by withdrawal of circulating progesterone post birth following delivery of the placenta
    • Concentration of milk components changes, lactose and citrate 
    • protein and sodium 
    • (Hartmann, et.al.,2003)
  •  
  • Factors That Inhibit or Delay Lactogenesis II
    • Factor
    • Inhibits
    • Retained placental fragments
    • Milk not removed
    • Delays
    • Insulin-Dependent Diabetes
    • Obese mothers
    • Prolactin Insufficiency
    • Cesarean
    • Breasts not emptied
    • Inadequate stimulation
    • (Hartmann, et.al., 2003)
    • Cause
    • Elevated progesterone
    • Autocrine inhibition
    • Unknown (  glucose uptake)
    • Unknown (  progesterone )
    • Prolactin switches on milk specific genes
    • No labor-disturbed hormones
    • Frequency of nursing
    • Infant not sucking vigorously or frequently
  • Establishment of Lactation
    • Mothers of term infants who breastfeed on demand produce 556 to 705 g of milk a day on day 6 postpartum.
    • Mothers of preterm infants can produce 20-550 g/d by day 5 postpartum if pumping
    • Important to establish a high level of milk production (> 440 g/d) through either early,frequent breastfeeding or milk expression during lactogenesis II
    • (Hartmann,et.al.,2003)
  • Prolactin
    • Adequate levels required for Lactogenesis II
    • Normally secreted by the anterior pituitary gland at a low basal rate
    • Secretion suppressed by prolactin inhibiting factor (dopamine the main constituent)
    • Levels cycle and are highest during sleep
    • Normal range 1-20  g/L nonpregnant, up to 300  g/L during pregnancy
    • Suckling,stress,dehydration,exercise,sexual intercourse and sleep  rate
    • (Pena & Rosenfeld, 2001)
  • The Infant’s Role
    • Infant needs to be an alert, active participant
    • Must be willing to latch on to his/her mother’s breast and suck
    • Must coordinate suck-swallow-breathe
    • Must have enough energy to suck
    • Excellent discussion of assessment of mother and infant in: Cadwell, et.al.,Maternal and Infant Assessment for Breastfeeding and Human Lactation, 2002.
  • Supplementation with Formula or Solids
    • Study of change in pattern & duration of BF associated with the introduction of solids and formula
      • In infants given formula, as soon as regular formula feeds started, the breastfeeding frequency and suckling duration declined swiftly
      • The younger an infant was at the start of regular formula feeds, the shorter the BF duration
      • Intro. of solids associated with no or minor changes in BF frequency and duration
      • (Hornell, et.al., 2001)
  •  
  • Breastfeeding After Breast Reduction Surgery
    • Breastfeeding is possible for many woman after breast reduction surgery and should be encouraged and supported
    • Close monitoring of the infant’s hydration status and growth are critical
  • Defining Your Own Success: Breastfeeding After Breast Reduction Surgery Diana West La Leche League 2001
  • Implications of Reduction Mammoplasty for Lactation
    • Type of Surgery is a major variable
      • Major nerve damage can interfere with neurohormonal reflex arc
      • Some milk ducts severed
      • More likely if nipple repositioned
      • Techniques to minimize scarring result in more damage to nerve and glandular tissue (West, 2001)
  •  
  • Implications of Reduction Mammoplasty for Lactation
    • Inferior Pedicle (McKissock) Technique
      • Respects ducts and lobes necessary for milk production
      • Minimal compromise of the important 4 th intercostal nerve
      • Nipple/areolar complex remain intact
      • Most popular technique used in North America
      • (West, 2001)
  • Other Surgical Techniques Reduction Mammoplasty
    • Liposuction
      • Rarely used
    • Periareolar (“Round Block”)
      • Less visible scarring
      • Can also spare blood & nerve supply
      • (West, 2001)
  • Other Surgical Techniques in Reduction Mammoplasty
    • Superior Pedicle Technique
      • Involves removal of wedges of tissue from lower breast
      • Significant impairment of lactation likely
    • Free Nipple Graft
      • Most damaging
      • Nipple/areola complex completely removed
      • (West, 2001)
  • Implications of Reduction Mammoplasty for Lactation
    • Unpredictable outcome
    • Never “all or nothing”
    • Results are usually better if 5 years have elapsed since surgery
    • (West, 2001)
  • Lactation Capability
    • Full Milk supply
    • Partial Milk supply
    • Absence of milk supply
    • Not possible to know ahead of time
  • Range of Feeding Methods
    • Feeding at the breast
    • Feeding at the breast with an at-the-breast supplementer
    • Feeding with artificial feeding devices
  • Possible Breastfeeding Outcomes
    • Milk supply is high and remains high
    • Milk supply is initially high and then decreases
      • Initial supply endocrine driven
      • Supply can decrease when comes under control of autocrine system if nerve response impaired
    • Low milk supply from the beginning
      • Minimal functional tissue remains
  • Determining When Supplementation is Necessary
    • Close monitoring of baby is essential
    • Assessment Chart
    • Record of wet and soiled diapers
    • Signs of dehydration
    • Calculate baby’s acceptable weight loss
    • Weigh baby once daily
  • Supplementation Needed
    • Loss of more than 8% of body weight
    • Gaining less than ½-1 oz.(14-28 g)/day after the 4 th day
    • Failure to regain birth weight by 2-3 weeks
    • Insufficient wet and soiled diapers
    • Signs of dehydration
    • (West, 2001)
  • Strategies to Increase Supply
    • Principle of “supply and demand”
    • May take 2-3 days possibly up to a week to increase production
    • Breastfeed more frequently (1 st choice)
    • Breast compression while feeding
    • Increase frequency or duration of pumping if at work or baby not nursing
    • Use of galactagogues or other techniques
  • Galactagogues
    • Substances taken to increase milk supply
    • Herbal remedies vs. prescription medication
    • Each culture has their own
    • Should not be your first choice when helping mothers with milk supply issues
    • Vary in safety and effectiveness
  • Galactagogues
    • Concern about side effects and interactions with other medications
    • Herbal preparations may vary in strength and purity
    • Lack of standards for dosing herbals
    • Little scientific research
  • Types of Galactagogues
    • Herbal preparations
      • Potent chemicals
      • Not harmless because they are natural
    • Nutritional
      • Oatmeal
      • Brewer’s Yeast
    • Prescription
      • Felt to be most effective
      • (West, 2001)
  • Herbal Galactagogues
    • Fenugreek (Leguminosae Trigonella foenum-graecum)
      • Sold as dried, ripe seed and extracts
      • Used as artificial flavor for maple syrup
      • FDA list of Generally Regarded As Safe
      • Maple syrup odor in urine & sweat
      • High doses may produce hypoglycemia
      • Usual dose: 2-3 capsules (580-610 mg) 3 times/day
      • Reputation widespread but undocumented
      • (Hale, 2000)
  • Galactagogues
    • Blessed Thistle (Cnicus Benedictus)
      • Contains numerous chemicals
      • Used to treat many ailments, especially gastrointestinal since 16 th century
      • Reported anecdotally to be most effective when taken with fenugreek
      • No formal research studies exist
      • Usual dosage: 3-4 capsules, 3 times/day
      • (West, 2001;Hale, 2000)
  • Galactagogues
    • Other Herbal Preparations
      • Goat’s Rue (Galega Officinalis)
      • Alfalfa (Medicago sativa)
      • Nettle (Urtica urens or Urtica dioica)
      • European Vervain (Verbena officinalis)
      • Dill seed (Peucedanum graveolens)
      • Discussed in more detail in West, 2001
      • No scientific research to support use of any of these compounds
  • Nutritional Galactagogues
    • Oatmeal
      • May be just a “comfort food”
      • No scientific evidence of an effect
    • Brewer’s Yeast
      • Contains protein, B vitamins, iron and minerals
      • May cause gassiness and can exacerbate thrush
      • No scientific evidence
      • (West, 2001)
  • Prescription Galactagogues
    • Domperidone (Motilium)
      • Effects milk supply by suppressing dopamine (a prolactin inhibitor)
      • Endorsed by Dr. Jack Newman
      • Can not be purchased in the U.S.and not FDA approved for use as a galactagogue
      • AAP has approved for use in nursing mothers
      • Therapeutic dose: 20-40 mg, 3-4 times/day
  • Metaclopramide (Reglan, Maxeran)
    • Usually prescribed for reflux
    • Also blocks dopamine
    • Clinical studies have shown that it can  milk supply dramatically
    • Can cause significant CNS side effects, especially depression
    • Should not be taken for > 4 wk, taper after 1 week
    • AAP lists as a drug, “whose effect on nursing infants is unknown but may be of concern”
    • ( West, 2001)
  • Chinese Ear Acupressure
    • Form of Traditional Chinese Medicine
    • After diagnosis, the seed of the vaccaria segetalis plant is taped tightly to a particular acu-point
    • The patient can then apply pressure 2 or 3 times daily to increase milk supply
    • Hong Yun, MD from Beijing, China conducting studies in this area
  • Returning to Work
  • Breastfeeding and Employment
    • Growing numbers of U.S. women of childbearing age in the workforce
      • 58% of women > 20 years old in 2000 (Meeks, 2001)
    • Infant Feeding Practices Study 1993
      • Expecting to work PT   or  in BF relative to those who did not expect to work (OR =.83 and .89, P > .50)
      • Expecting to work FT  probability of BF (OR =.47, P < .01) (Fein & Roe, 1998)
  • Breastfeeding and Employment
    • Infant Feeding Practices Study 1993
      • Working full-time at 3 months postpartum  BF duration by an average of 8.6 weeks (P < .001)
      • Working part-time (4 hr or less) did not affect duration of BF
      • Part-time work of more than 4 hr/day decreased duration less than full time work
      • (Fein & Roe, 1998)
  • Breastfeeding and Employment
    • Infant Feeding Practices Study simultaneous analysis of competition between employment and infant feeding practices
    • Finding: When considered simultaneously, the duration of work leave contributes significantly to the duration of breastfeeding. Each week of work leave  BF duration by almost ½ week (Tobit Coefficient 0.55 p  .05) (Roe, et.al., 1999)
  • NIH Lactation Program
    • Started as Pilot Program in 1998
    • Success in helping women to breastfeed to 6 months led to permanent program
    • Served over 300 women in FY 2003
  • NIH Lactation Program
    • Enroll during prenatal period
    • Program provides maternity leave telephone support
    • Return to work consultation
    • Ongoing support once returned to work
    • Breastfeeding Rates (past 4 years)
      • 60-66% BF  6 mo. of age
      • 9-21% BF  12 mo. Of age
  • During Maternity Leave
    • Establish and maintain a good milk supply
    • Introduce occasional bottles when infant is about 4 weeks old
    • Gerber NUK type nipples
    • Discuss need to pump with supervisor at work
  • Options
    • Exclusive breastfeeding
    • Partial weaning
    • Formula feeding
  • Preparing to Return
    • Establish adequate milk supply
    • Stockpiling lg. quantities not recommended-give freshest milk possible
    • Decision whether to pump at work
    • How often to pump
    • Where to pump
    • Storing the milk
  • Pumping at Work
    • Pump about every 3 to 4 hours
    • Most people need to pump 2 to 3 times daily to maintain full supply
    • Pump for 10-15 minutes at each session
    • Recent research showing best outcome with higher frequency stimulation and lower frequency expression vacuum curves (Kent, et.al., 2003)
  • Manual Pumps
    • You provide the power
    • Pump one breast at a time
    • Requires 15 to 20 minutes to empty breast
    • Recommended for occasional relief bottle, relief of engorgement, or missed feeding
    • Vary in quality and effectiveness
  • Small Electric or Battery-Operated Pumps
    • Power provided by small electric motor, look for auto-cycling
    • Requires 10 to 15 minutes to empty breast
    • Recommended for occasional relief bottle, relief of engorgement, or missed feeding
    • Not designed to handle all day every day use during fulltime employment
    • Vary greatly in quality and effectiveness
  • Heavy-Duty Electric Pump
    • Can be rented or purchased
    • Double pumping and auto-cycling
    • Require 10 to 15 minutes to empty both breasts
    • First choice for use if employed full time or collecting milk for a premature or sick infant
  • Weaning
    • Make it a slow gradual process
    • If pumping twice a day a work, cut back to pumping once a day
    • Sometimes woman will need to cut back on number of minutes she is pumping before dropping pumping sessions
    • Encourage to drop nursing sessions at home last
  • Vitamin D Supplementation
    • April 2003 AAP recommendation to add 200IU/day to every infant’s diet
    • Concern in lactation community that women will think their milk is “not good enough”
    • Important to explain that this is a precaution because of a slight  in cases of rickets and  in sunlight exposure
    • Support breast as best (Heinig, 2003)
  • Environmental Toxins in Human Milk
    • Headlines reporting toxins in breastmilk
    • Environmental Working Grp. decided use of human milk was most economic and non-invasive way to study environmental chemical levels in the general population
    • All women are at risk of exposure
    • Babies are exposed in utero
    • (Lawrence, personal communication, 2003)
  • Environmental Toxins in Human Milk
    • No data showing levels in cow’s milk, water, formula
    • No indication that breast milk contributes substantially to exposure
    • Benefits of breast milk far out way the risks of exposure
    • (Lawrence, personal communication, 2003)
  • Questions and Concerns