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.

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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

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

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