Dr. Jennifer Perez, MD, FAAP

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1 Dr. Jennifer Perez, MD, FAAP

2 Explain why mixed feeding is detrimental, especially to the establishment of a milk supply Understanding the cultural aspects of why mixed feeding is so common in certain ethnic groups Nothing to disclose Nothing off label

3 When a baby sucks at the breast, the body releases oxytocin, which stimulated the pituitary to produce prolactin, which in turns, produces more breastmilk The more a baby sucks, the more milk is produced If a baby is supplemented with formula, it will wait longer to suck If the mom becomes engorged there is a negative feedback loop which shuts down production Image from mothersofchange.com

4 Lactogenesis I weeks gestation. Ability to synthesize milk components Endocrine Control-under hormonal control. Will occur whether the mother breastfeeds of not Lactogenesis II hours after birth Endocrine Control-Control-under hormonal control. Will occur whether the mother breastfeeds of not Lactogenesis III: ongoing production/galactopoesis Autocrine Control-will NOT occur without ongoing stimulation From Dr. Sriraman s, MD IBCLC lecture "The Process of Breastfeeding"

5 Autocrine Control As long as milk continues to be removed from the breast, lactation will continue Will be adversely affective by ineffective and/or infrequent nursing/expression, including interruption by supplementation with artificial food Supply and Demand! From Dr. Sriraman s, MD IBCLC lecture "The Process of Breastfeeding"

6 We need to change our Language; Instead of: Are you feeding breast or bottle? We Should be asking: Are you planning to breastfeed your baby? If the answer is no: Did you know that breastfeeding is the standard of care and far superior to any formula? Do you know the risks of formula feeding?

7 When mom answers: Both Ask what her goals are If her goals include any amount of breastfeeding, then we should be discouraging the use of formula until her supply is established Exclusive colostrum feeding in the hospital will help the baby digest formula later Both is not a hospital answer without a medical indication

8 But I don t have any milk yet Image from breastfeedingpinay.wordpress.com

9 How do I know if Baby is getting Enough? Elimination Patterns Day 1 of life: one wet diaper and one stool Day 2 of life: two wet diapers and two stools Day 3 of life: three wet diapers two stools By day 5 (milk is now in), at least 6 wet diapers and 3-4 yellow seedy stools

10 The single bottle is the greatest threat to long term exclusivity Howard et al, Pediatrics 2003; 111 Once formula has been introduced the bacteria in the gut transforms into that of an adults within 24 hours There is programming of the gut flora that occurs when anything is introduced to the infant Breastmilk protective Formula up regulates certain pathways that lead to lifelong problems; obesity, IBD, celiac, etc Non-medically necessary supplementation, especially during the establishment of a milk supply is very detrimental to long term success

11 Early Infant Feeding Decisions in Low-Income Latinas published in Breastfeeding Medicine Latina women have breastfeeding initiation rates of 73%, but only 30% are breastfeeding at 6 months Healthy People 2010 goals is 50% at 6 months Mothers with lower socioeconomics status and those enrolled WIC have even lower initiation rates of 53% initiation and 21% duration at 6 months of age

12 Many of us have experience this; many mothers, particularly Latinas, use a combination of breastfeeding and formula supplementation at initiation, and by two weeks they have no milk Although non-hispanics may also be using this combination feeding method, this appears to be more common in Latinas than in other cultures and in those Latinas who live in the United States in contrast to Latinas in their country of origin

13 They conducted interviews with Latina mothers, before birth and after birth. With those breastfeeding exclusively, bottle feeding exclusively, and combination feeding. They also conducted interviews with the husbands and grandmothers helping to support these mothers

14 They found the 4 following major themes: 1. By giving both breast milk and formula, Latina mothers feel they are insuring the baby gets the best of both -healthy aspects of breast milk and the vitamins in formula They also said that they get mixed messages from medical providers regarding formula supplementation and from receiving formula samples from hospital at discharge

15 2. Breastfeeding is natural but it is associated with problems (or hardship). Many first-time Latina mothers were surprised that breastfeeding causes pain, sore nipples, embarrassment/discomfort in public, and can change the appearance of breasts postpartum Latinas commonly reported that they heard that mothers who ate chile, spicy foods and beans would cause problems in the baby, particularly colic Felt that if mothers do not eat well their milk would be more watery Stressed the importance of drinking atole (cornstarch gruel protein drink) for breastfeeding mothers

16 3. Mothers want to breastfeed, but things can happen to them that are beyond their control. Reasons that milk may not come in or go away: Violation of La Cuarentena Going outside or getting cold exposure to the back Mother s do not seek medical attention for poor or declining milk supply

17 Lack of pumping When mothers go out, they feed formula as opposed to feeding in public or pumping and feeding. Hand pumps are only used rarely and occasionally for engorgement and that milk is usually discarded Some infants were said to have a preference for formula

18 4. Hispanic parents and grandparents want what is best for the baby and give strong messages about cultural beliefs families who were involved with raising animals in Mexico (rancheros) came with a knowledge and appreciation for colostrum and breast milk Mothers reported family members advising supplementation with formula if the infant has excessive crying or is not gordito aka Chubby Coraje or pathologic anger, is believed to spoil breastmilk Susto, a sudden disturbance of emotions, also is believed to affect milk and both are to be avoided

19 Recommendations 1. Providers need to acknowledge the hardships of breastfeeding, but clearly explain to new mothers about the importance of doing it. Emphasize the importance of delayed supplementation and perhaps provide specific recommendations, such as a maximum of one bottle of formula a day and coming to see their provider if they have concerns about perceived insufficient milk supply may also prove helpful.

20 2. Emphasize that breast milk from a mother who is taking vitamins has everything in it needed by the baby initially. Later, they can add vitamins for the baby 3. Ask the mother about her concerns about breastfeeding and breast milk. And ask the mother what she has heard from others about breastfeeding and breast milk. As myths arise, provide her with current medical information to counter the myth

21 4. Emphasize the benefits of feeding pumped milk to the baby rather than discarding it. This should be communicated to mothers and family members 5. Providers should appeal to the traditional family values by including other persons in the family that the mother thinks can support the breastfeeding mother (fathers, grandparents, comadres) especially during the critical period of la cuarentena

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