BreastfeedingNutrition 526

Ginna Wall, RN, MN, IBCLCgwall@u.washington.edu

University of Washington Medical Center Lactation Services

University of Washington Medical Center

Lactation Services

Nancy Estill, Louise Peterson, Ginna Wall, Christy Shaw, Barb Lautman

RNs, International Board Certified Lactation Consultants

Objectives• Describe the function of placental hormones,

oxytocin, and prolactin in the breastfeeding process

• Describe the let down reflex and list factors that may interfere or enhance this reflex

• Recognize major contraindications to breastfeeding

• Recognize factors that contribute to successful initiation and maintenance of breastfeeding

• Describe correct positioning and latch on for successful early breastfeeding

1.Prepared mammary epithelium

2.Progesterone withdrawal

3.Maintained plasma prolactin

4.Removal of milk within an undefined interval after birth

The Most Important Factors For Good Milk

Supply:

Levels rise in pregnancy

Prolactin

Prolactin Hormone

• Helps women respond to stress of perinatal period

• Suckling is the most effective stimulus for prolactin release

• Direct stimulation of the nipple is necessary for prolactin release

• Prolactin levels rise as long as stimulation continues

Prolactin = for milk production

Prolactin

Oxytocin

Electron micrograph of alveoli

Each alveolus

opens into a ductule that leads to one

main lactiferous

duct

Let Down or Milk Ejection Reflex

• Effective milk removal depends on the ejection reflex

• Duct diameter increases 50%

Milk duct before letdown

Milk duct after letdown

Baby crawls to breastOpens and closes hands

Massages the breastHand movements cause as

high an oxytocin rise as sucking

Early Post-birth Events

Keep baby in skin contact with mother

Skin-to-skin contact encourages oxytocin release

• Oxytocin:

–Promotes milk

–Promotes mothering behaviors

–Alleviates pain

• Released with nipple stimulation• Released in surges, lasting about 1-2

minutes• Contracts muscle cells

–Causes uterine contractions, causing involution

–Causes contractions of the muscle cells surrounding alveoli and ducts in the breast, causing milk “let down” or “milk ejection reflex”

Oxytocin in the bloodstream

Oxytocin Effects: Opposite of “Fight or Flight” Response

• Lowers heart rate

• Lowers blood pressure

• Lowers blood cortisol

• Stimulates endorphins

• Affects metabolic actions

– Contracts pyloric sphincter

– Releases insulin and cholecystokinin

Oxytocin In The Brain Affects Social Behavior

• Women who have high levels of oxytocin– Produce more milk– Breastfeed longer– Are more tolerant of repetitious, boring

tasks– Demonstrate more “social” behavior –

better listeners– Women become more social and retain

those traits if they continue breastfeeding

The Let Down Reflex

• List factors that interfere with this reflex

• List factors that enhance this reflex

Cholecystokinin stimulates oxytocin

• Food for mother

Is it ever NOT a good idea to breastfeed?

Contraindications to Breastfeeding:

• Maternal: HIV, HTLV-1, Herpes lesion on the nipple, Some drugs (cocaine, methamphetamine, radioactive drugs)

• Infant: Galactosemia, PKU (partial breastfeeding may be possible)

Factors that contribute to successful initiation and maintenance of breastfeeding

• 1991 WHO/UNICEF: Baby Friendly Hospital Initiative, “Ten steps to successful breastfeeding”

• Certified 14,500 hospitals in 125 countries• 40+ US hospitals• In WA State:

– Evergreen– St Mary’s– Okanogan– Tacoma General– And in 2008: UWMC!– And Group Health!

Baby Friendly Hospital:What are the “Ten Steps?”

Have a written breastfeeding policy that is routinely communicated to all health care staff.

Train all health care staff in skills necessary to implement this policy.

Inform all pregnant women about the benefits and management of breastfeeding.

Help mothers initiate breastfeeding within an hour of birth.

Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.

“Ten Steps,” continued…

Give newborn infants no food or drink other than breastmilk, unless medically indicated.

Practice "rooming in" by allowing mothers and infants to remain together 24 hours a day.

Encourage breastfeeding on demand. Give no artificial teats, pacifiers, dummies, or

soothers to breastfeeding infants. Foster the establishment of breastfeeding

support groups and refer mothers to them on discharge from the hospital or birthing center.

Does “Baby Friendly”Make a Difference?

• Promotion of Breastfeeding Intervention Trial

• 30 hospitals, randomized to receive Baby-Friendly training, or continue routine practices

• 17,000 mother-baby pairs

• Followed for 1 year

“PROBIT” ResultsKramer, JAMA, Jan 2001

6.4%

43.4%

11.4%

19.7%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Exclusive BF at 3 mos Any BF at 1 year

No BFHI

BFHI

Baby-Friendly Hospital Initiative:

Reduction in GI Infections and Allergies

Kramer, JAMA, Jan 2001

13.2%

9.1%

6.3%

3.3%

0%

5%

10%

15%

GI Infections Atopic Eczema

No BFHI

BFHI

“Maternity Care Practices:Implications for Breastfeeding”

• Surveyed 1085 women who intended to breastfeed for more than 2 months

• Assessed 5 Baby-Friendly practices:

1. Breastfeeding initiation

2. Supplements

3. Rooming-in

4. Breastfeeding on demand

5. Pacifiers

DiGirolamo, Grummer-Strawn, and Fein, BIRTH 28:2, 94, June 2001

DiGirolamo, BIRTH, June 2001 35

Percentage of women who stopped breastfeeding Percentage of women who stopped breastfeeding before 6 weeks, by specific hospital practicesbefore 6 weeks, by specific hospital practices

0%

5%

10%

15%

20%

25%

BF Initiation Introduction ofSupplements

Rooming In BF on Demand Use ofPacifiers

Specific Hospital Practices

% W

ho

Sto

pp

ed B

F

Not Baby Friendly Baby-Friendly

Percentage of women who stopped breastfeeding Percentage of women who stopped breastfeeding before 6 weeks, by number of Baby-Friendly before 6 weeks, by number of Baby-Friendly Hospital Initiative practices they experiencedHospital Initiative practices they experienced

DiGirolamo, BIRTH, June 2001DiGirolamo, BIRTH, June 2001% STOPPED

BF 5.1%

9.0%

13.6%

18.5%

23.6%

32.1%

0%

5%

10%

15%

20%

25%

30%

35%

0 1 2 3 4 5Number of Baby-Friendly Practices Reported

Philipp, PEDIATRICS, Sep 2001 37

“BFHI Improves Breastfeeding Initiation Rates in a US Hospital Setting”

• Boston Medical Center• inner-city teaching hospital • 1800 births per year• 15-bed Level III NICU• primarily poor, minority, immigrant families

• Implemented Baby-Friendly policies over a 3-year period

• Reviewed 200 randomly selected medical records from each of the 3 years

Philipp, PEDIATRICS, Sep 2001 38

BFHI IMPLEMENTATION:EFFECTS ON BREASTFEEDING

TRENDS86.5

74

33.5

58

77.5

34

64

28.5

5.50

20

40

60

80

100

Before During After

Bre

astf

eedi

ng R

ates

Breastfeeding Initiation Rates

Breastfeeding Initiation Rates Among African-Americans

Exclusive Breastfeeding Rates

ABCs of Helping Mothers to Breastfeed

• A is for Attachment of baby’s mouth to mother’s breast (“latch”)

• B is for Breastmilk (transfer of milk from breast to baby, and how to establish a good supply)

• C is for Confidence (tell her what a good mother she is!)

A Good Latch

• Nipple completely disappears

• Lips are flanged out

• Angle of baby’s lips is about 120 degrees

Latch Scoring Practicewith video:

Jane Morton MD: “15 minutes of breastfeeding help”

How parents can tell that baby is getting enough

• Stooling and urination patterns– Meconium first day (one or more)

Stooling and urination patterns

• Transitional stool day 2-4 (usually one or more each day)

Stools when milk is "in”

• By day 4: 4 stools each day (not just a stain in the diaper)

• Frequent bowel movements for the first 4-6 weeks

Common Problems

• Sore nipples• Engorgement• Low milk supply• Preterm and “late preterm” infants• Questions about drugs• Working outside the home• Infant sleep, crying, temperament issues• Relationships, social isolation

Test Weighing

• Use “integrating” digital scale

• Reweigh promptly in exactly the same way

• 1 gram = 1 ml milk

Double-Pumping Single-Handedly

Breastfeeding Support Services in King County

Finding Breastfeeding Support Services in the US

breastfeeding.com

ilca.org

iblce.org