Session 9

1. Discuss concerns about “Not enough milk” with mothers. 10 minutes2. Describe normal growth patterns of infants. 3. Describe how to improve milk intake/transfer and milk production. 4. Discuss a case study of “not enough milk”.

Under optimal conditions, mothers produce adequate milk for their babies.

Complete delivery of the placenta causes

drop in progesterone levels, initiating Lactogenesis II.

Mismanagement of feeding routines is highly related to insufficient milk.

Suckling and emptying the breast are essential to adequate milk production. Regulation of milk production in full lactation is based primarily on infant demand.

Maternal age, nutrition, fluid intake, body composition and parity are of little significance in milk production.

Maternal malnutrition does not seem to have an effect on total volume produced.

When there is sufficient milk, baby appears healthy, gains weight and feeds frequently.

Exclusive breastfeeding supports adequate growth in the first six months.

Normal growth patterns in breastfed babies show that breastfed babies grow more rapidly in the first several months compared to formula fed infants.

After the first three to four months the velocity (speed) of growth slows down in the breastfed infant, while the formula fed infant continues to grow at a higher velocity.

With old growth charts frequently it looked like breastfed babies were abnormal and slow to gain because of a change in growth velocity.

New growth charts adopted for the US on 9/10/10.

Based on WHO growth studies and charts (2006). Created from high quality study designed specifically to examine

growth of healthy children in optimal conditions for growth. Breastfed babies predominantly breastfed for at least 4 months and

who were still breastfeeding at 12 months.

Establishes the breastfed baby as the norm for infant growth.

WHO standards provide a better description of physiological growth in infancy. Typical growth patterns seen in the US on old charts may

not be ideal growth patterns New charts available at:

http://www.cdc.gov/growthcharts Training tools for clinicians being developed and will

be posted at the same web site.

A weight loss of more than 7% in the first 72 hours should trigger breastfeeding assessment of mother and baby.

Weight loss of 10% from birth weight is maximum for a breastfed infant and requires close observation and support.

“Formal evaluation of breastfeeding

performance should be undertaken by trained caregivers at least twice daily and fully documented in the record during each day in the hospital after birth…” (p. 499)

“All breastfeeding newborn infants should be seen by a pediatrician or other knowledgeable and experienced health care professional at 3 to 5 days of age.” (p. 499)

Observe baby at breast. Does baby grasp the breast well and suck vigorously?

Question the mother about: breastfeeding patterns use of gadgets such as nipple shields, pacifiers sleep patterns smoking, drug and medication intake, etc.

Consider the following possible contributors: maternal infection, anemia thyroid disease poor release of milk (let-down reflex) anatomical anomalies of mother or baby incomplete delivery of the placenta poor sucking

If the milk is not removed, less milk is made.Factors include: infrequent feeds scheduled feeds short feeds poor suckling poor attachmentStress, lack of confidence, or overwhelmed mother leads to ineffective feeding practices

The baby is poorly attached to the breast and not suckling effectively. The baby may seem restless during a breastfeed and may pull away or tug at the breast.

Breastfeeds are short and hurried or infrequent. The baby is removed from one breast too soon, and

does not receive enough hindmilk.The baby is ill or premature and not able to suck

strongly and for long enough to obtain the milk the baby needs.

Interventions should be appropriate to the identified cause(s) of problem.

Increased nipple stimulation through improved suckling, massage and expression, and/or pumping, may help increase supply.

Treatment plans should include frequent feedings and frequent follow-up contacts.

Listen to the mother and ask relevant questions. Look at the baby - alertness, appearance, behaviour, and

weight chart if available. Observe a breastfeed, using the Breastfeed Observation Aid. Respond to the mother and tell her what you are finding. Use

positive words and avoid criticism or judgments. Give relevant information using suitable language. Offer suggestions that may improve the situation and discuss

whether the suggestions seem possible to the mother. Build the mother’s confidence. Help her to find support for breastfeeding and mothering.

40 - 80% of women who wean during the first 6 months of life cite inadequate milk supply as the reason for weaning.

Mother’s perception of inadequate milk may not indicate an actual supply problem, but rather a misreading of infant behavior.

Teaching mothers to understand infant feeding and fullness cues helps support optimal milk supply and build maternal confidence.

Infant growth in length and weight can offer reassurance that milk transfer is occurring.

Infants of mothers who report concerns about milk supply tend to weigh less at birth, be fussier and poorer feeders.

Babies who are calorically deprived may sleep more and give fewer feeding cues.

When a mother perceives she has insufficient milk she may stop breastfeeding altogether or give the baby formula. Both of these behaviors may result in early cessation of breastfeeding.

Understanding feeding cues, especially that crying is a late feeding cue, may help the mother feed more frequently and make the feedings more satisfying.

Lack of confidence with breastfeeding may be countered with teaching and support for the mother.

Signs of milk ejection may include: Change in suck/swallow pattern of baby to 1:1 or 2:1 with

audible swallowing Longer, slower sucks replace faster more shallow sucks Leakage from opposite breast during nursing Uterine cramping in early postpartum period “Tingling” sensations (not experienced by all mothers) Thirst Feeling of relaxation or peacefulness

Early, on-going skin to skin contact Early, frequent feedings - unlimited by the clock Night feedings Water or formula supplementation for medical indications

only 24 hour rooming-in with frequent feedings on cue Teaching mother about infant behavior and milk

production Educating staff about advantages and management of

breastfeeding

Improve birthing routines to facilitate earliest and most frequent breastfeeding with correct latch and optimal milk transfer.

Increase mothers’ knowledge about breastfeeding and skill in reading newborn behavior cues.

Establish community support networks which identify problems with milk supply early and provide appropriate intervention.

Follow-up the mother and baby to check that the milk production/milk transfer is improving.

Monitoring means to look for signs of improvement that you can point out to the mother – increased alertness, less crying, stronger suck, more urine and stooling, and changes in her breasts such as fullness and leaking.

Monitoring also gives you an opportunity to talk with the mother and see how the changes are working. Build her confidence and encourage things that she is doing well.

If the baby’s weight was very low and supplements were needed, reduce supplements as the situation improves. Continue to monitor the baby for a few weeks after supplements have stopped to ensure milk supply is sufficient.