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reastfeeding Support

and Promotion

Joan Younger Meek, MD, FAAP

AAP Section on reastfeeding


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Management of Breastfeeding

• Breastfeeding initiation

• Recommended breastfeedingpractices

• Weight pattern

• Hypoglycemia

• Jaundice

• Employment


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Breastfeeding Promotion in Physicians’

Office Practices urricu!um

3 Key Educational Tools for Physicians to

Teach New Mothers

• Nutritional parameters

• Hand expression• Latch and positioning


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AAP Po!icy Statement

• Initiate in the rst hour.• Keep newborn and

mother together inrecoery and after.

• !oid unnecessary oralsuctioning.

• !oid traumaticprocedures.

AAP Pediatrics 2012;129:e82!8"1#

Recommended Breastfeeding Practices


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• "#in$to$s#in contact– %romotes physiologic

stability

– %roides warmth

– Enhances feedingopportunities

– Infant crawls to breastand self$attaches

• &elay weights and measurements' itamin K

and eye prophyla(is until after rst feeding• Knowledgeable breastfeeding adocate in

labor ) deliery

Breastfeeding "nitiation

Photo © Joan Younger Meek, MD, FAAP


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•!oid the routine use of supplementsunless there is a true medical indicationand the physician has ordered the

supplement

•!oid the use of paciers in healthy' terminfants' until breastfeeding is well

established *appro(imately +$, wee#s of

age-

Recommended BreastfeedingPractices:


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Medica! "ndications for

Supp!ementation• ery low birth weight or some premature infants• Hypoglycemia that does not respond to

breastfeeding

• "eere maternal illness• Inborn errors of metabolism• !cute dehydration not responsie to routine

breastfeeding or e(cessie weight loss

• /aternal medication use incompatible withbreastfeeding

Academ$ o% &reast%eeding 'edicine (linical Protocol )*: Hospitalguidelines %or the use o% supplementar$ %eedings in the health$term +reast%ed neonate#,---#+%med#org.


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• Encourage at least 0123 feedings per day.

• !lternate the breast that is o4ered rst.• !llow infant to nurse on at least one side untilinfant falls asleep or comes o4 the breast toincrease fat and calorie consumption.

Feeding Pattern


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"nfant Assessment

• Weight 5oss– !erage loss of about 67 oer the rst +1, days.– 5oss greater than 0$287 mandates careful

ealuation of breastfeeding.

• Weight 9ain– Begins with increase in mother:s mil# production by

at least day ,1;.– E(pect gain of 2;1+8 g


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"nfant Assessment

• Prolem– Inade>uate mil# supply or mil# transfer.

• !olution– Weigh infant' feed infant' weigh again.– Ealuate infant at the breast.– ?orrect latch and positioning.

– Improe mil# production and transfer.– Increase fre>uency and duration of

feeding.

Poor "eight #ain


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"nfant Assessment

• E(pect– ,$6 pale or colorless oidsuent stools are common after the rst

month in the healthy breastfed infant.

Elimination Pattern


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"nfant Assessment

• %roper positioning at the breast

• %roper latch and lip closure

• "uAcient areola in infant:s mouth

• ongue e(tends oer lower gums

• !de>uate Caw e(cursion with suc#ling

• E4ectie swallowing motion• ?oordination of suc#$swallow$breathe

Breastfeeding ealuation


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• Dormal ealuation of breastfeedingduring the rst 3,1,0 hours and again at+1; days of age

• !ssess– Infant weight– 9eneral health– Breastfeeding– Jaundice– Hydration– Elimination pattern

Recommended BreastfeedingPractices


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• &o not gie water' Cuice' or solids in therst 6 months.

• Initiate iron supplements only if indicatedclinically in the rst 6 months.• Include iron$rich foods or supplements after

6 months of age.• "upplement with ,88 I itamin & daily.• %roide Fuoride after 6 months if household

water supply is decient *G 8.+ ppm-.• !oid cow:s mil# before 23 months.

Recommended BreastfeedingPractices


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Materna! #rou$!e Signs

• ipple pain

• ipple trauma

Photo © Joan Meek, MD, FAAP


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%eonata! &ypog!ycemia

• o need to monitor asymptomatic low ris#infants for hypoglycemia

• Routine monitoring of healthy term infants

may harm the mother$infant breastfeedingrelationship

• Early' e(clusie breastfeeding meets thenutritional needs of healthy term infantsand will maintain ade>uate glucose leels

AAP; /orld Health rganiation

Academ$ o% &reast%eeding 'edicine


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%eonata! &ypog!ycemia

• Routine supplementation of healthy' terminfants with water' glucose water orformula is unnecessary and may interferewith establishing normal breastfeedingand normal metabolic compensatorymechanisms.

• Healthy term infants should initiate

breastfeeding with +8$68 minutes of lifeand continue feeding on demand.

AAP; /orld Health rganiation;

Academ$ o% &reast%eeding 'edicine


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Materna! #rou$!e Signs

• Engorgement

Photo © Joan Younger Meek, MD, FAAP


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Jaundice and Breastfeeding

• Infants G+0 wee#s gestational age and breastfedare at higher ris#

• "ystematic assessment of all infants beforedischarge for the ris# of seere hyperbilirubinemia

is warranted

• %roide parents with written and erbalinformation about newborn Caundice

• %roide appropriate follow$up based on the time of

discharge and the ris# assessment

AAP u+committee on H$per+iliru+inemia (linicalPractice 3uideline: Pediatrics 200"; 11": 29!*14#


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Management of

&yper$i!iru$inemia• %romote and support successful breastfeeding

• %erform a systematic assessment before

discharge for the ris# of seerehyperbilirubinemia

• %roide early and focused follow$up based onthe ris# assessment



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Primary Pre'ention of Jaundice

• Recommendation ()*– ?linicians should adise mothers to nurse their

infants at least 0 to 23 times per day for the rstseeral days.

• Recommendation ()(– he !!% recommends against routine

supplementation of nondehydrated breastfedinfants with water or de(trose water.

•"upplementation with water or glucosewater will not preent hyperbilirubinemia ordecrease total serum bilirubin leels.



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(isk Assessment for Jaundice

$efore Discharge

• Recommendation +)(– Before discharge assess ris# for seere

hyperbilirubinemia

•Eery nursery should hae formal protocol•Essential for infants discharged before 3 hrs

•Best methodL measure serum ortranscutaneous bilirubin in eery infant

before discharge•%lot on Bhutani cure *perform at same timeas metabolic blood sampling-



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AAP !inica! Practice )uide!ine

•/anagement of Hyperbilirubinemia in theewborn Infant +; or /ore Wee#s of9estation

Nomogram for designation of risk in 2840 we new!orns at "# or more weeks$

gestationa age with !irth weight of 2000 g or more or "% or more weeks$ gestationa

age and !irth weight of 2%00 g or more !ased on the hour&s'e(ifi( serum !iiru!in

)aues*

AAP u+committee on H$per+iliru+inemia. Pediatrics.

200";11":295*14


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Management of Breastfeeding

JaundiceIncrease caloric inta#eIncrease breastfeeding

fre>uency to 28123

feedings


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Breast Mi!k Jaundice

• ,e-nition

– Begins after day of life ;1

– Increased bilirubin reabsorption fromintestine

– 5asts seeral wee#s to months


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Breast Mi!k Jaundice

• Management – !oid interruption of breastfeeding in

healthy term babies.

– o routine indication for water orformula supplementation.

– If bilirubin M38 mg


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%ursing Supp!ementation

+ustration ! -on .e-ourneau


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Mi!k *+pression

• Wash hands before manual or hande(pression.

• se a good$>uality electric pump for

regular e(pression.• /il# storage

– ?hill as soon as possible.

– Refrigerate mil# for up to , days.

– Dree=e for longer storage.


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(eturn to the ,orkp!ace or

Schoo!

• ?ontinued breastfeeding is feasible anddesirable for mother and infant.

• %repare ahead by discussing with theemployer or school personnel.

• &elay introduction of bottles until mil#

supply well established at +1, wee#s.


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*mp!oyed Mother

• Brea#s forfeeding<e(pressing

• %riate' cleanplace to pump

• Refrigeratoror cooler with

ice pac#s tostore and transportmil#

+ustration ! -on .e-ourneau

Wor#place support


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Ado!escents and Breastfeeding

• Highly recommended for adolescent mothers• %renatal education and postpartum support

are essential• !rrange with school personnel to e(press

mil# at school or use on$site child careprogram' if aailable

• /aintain healthy diet with ade>uate calories'2'+88 mg calcium per day' 2; mg iron' and adaily multiitamin


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Summary

• Breastfeeding is the preferred feeding foralmost all infants.

• "#in$to$s#in contact should be initiatedimmediately after deliery.

• "upplementation is rarely indicated andinterferes with successful lactation.

• 9ood breastfeeding techni>ue can help tominimi=e problems.

• ?lose follow$up in the early days andwee#s is essential for breastfeedingsuccess.

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