BREASTFEEDING EDUCATION IN UNDERGRADUATE NURSING PROGRAMS. A Project. California State University, Sacramento

Transcription

1 BREASTFEEDING EDUCATION IN UNDERGRADUATE NURSING PROGRAMS A Project Presented to the faculty of the Department of Nursing California State University, Sacramento Submitted in partial satisfaction of the requirements for the degree of MASTER OF SCIENCE in Nursing by Martel Elizabeth Costa SPRING 2012

2 BREASTFEEDING EDUCATION IN UNDERGRADUATE NURSING PROGRAMS A Project by Martel Elizabeth Costa Approved by:, Committee Chair Dr. Alexa Curtis Date ii

3 Student: Martel Elizabeth Costa I certify that this student has met the requirements for format contained in the University format manual, and that this project is suitable for shelving in the Library and credit is to be awarded for the project., Department Chair Dr. Carolynn Goetze Date Department of Nursing iii

4 Abstract of BREASTFEEDING EDUCATION IN UNDERGRADUATE NURSING PROGRAMS by Martel Elizabeth Costa When nurses educate new mothers on breastfeeding, the quality and content of their teaching influences a mother s decision to breastfeed and for how long. Thus, it is important that nursing students receive comprehensive breastfeeding instruction in their nursing programs to be proficient at assisting new mothers during clinical rotations or upon graduation. According to researchers, however, nursing schools have failed to adequately train students in breastfeeding education, citing students knowledge deficits as one of their concerns. At Sacramento State University s School of Nursing, thirdsemester undergraduate nursing students are taught breastfeeding content in obstetrical nursing lecture and must complete 45 hours of related clinical experience. A student survey revealed that very few of them were completely satisfied with the breastfeeding instruction they had received. In addition, nearly 40% of those who had not yet completed their clinical rotation stated that they felt insecure to only somewhat confident in their ability to educate breastfeeding mothers. To remedy any possible gaps in breastfeeding instruction, four online breastfeeding modules were developed to assist students in obtaining the knowledge required to achieve lactation competency and allow iv

5 them to review the information as often as needed. ASBSN students will evaluate the modules in an upcoming school session, and it is anticipated that they will be successful in helping prepare students to educate mothers on breastfeeding., Committee Chair Dr. Alexa Curtis Date v

6 ACKNOWLEDGEMENTS I gratefully acknowledge the assistance of Dr. Brenda Hanson-Smith with the development of this project. vi

7 TABLE OF CONTENTS Page Acknowledgements vi INTRODUCTION Problem.. 1 Purpose.. 2 Benefits. 2 BACKGROUND OF THE STUDY Major Themes 3 Confirmed Findings... 4 Inconsistencies/Gaps.. 5 OVERVIEW OF PROJECT... 7 Intent of Project. 7 Process... 7 Conception of the idea Persuading others of the project value. 9 Development of project materials 9 Implementation 10 Number of People Involved Products for Project 11 FINDINGS AND INTERPRETATIONS vii

8 Appendix A. Undergraduate Breastfeeding Questionnaire.. 15 Appendix A1. Results of Undergraduate Breastfeeding Questionnaire Appendix B. Evaluation of Breastfeeding Modules. 22 Appendix C. Breastfeeding Modules References.. 94 viii

9 1 Introduction Nurses who work in obstetrics are responsible for educating new mothers on breastfeeding. The quality and content of their teaching can affect whether a new mother chooses to breastfeed her infant and for how long. Consequently, it is essential that nursing students planning to work with childbearing families receive sufficient education and training to effectively support breastfeeding mothers. Researchers, however, have uncovered problems in the clinical breastfeeding practice of undergraduate nursing students, citing students knowledge deficits and difficulty with assisting mothers with breastfeeding among their concerns. Since the advantages of breastfeeding are far reaching, benefitting mother and child, families, communities, and even the economy (Spatz, Pugh, & The American Academy of Nursing Expert Panel on Breastfeeding, 2007), it is imperative that undergraduate nursing programs address the problems related to breastfeeding education. Problem At Sacramento State University s nursing program, breastfeeding content is taught in obstetrical nursing lecture. Students are also required to complete 45 hours of related clinical experience. However, competency at breastfeeding education is not one of the stated objectives. Rather, according to the clinical syllabus, Students will spend a total of 45 laboratory hours applying knowledge of the childbearing family mastering assessment skills, perinatal and newborn procedures, and exploring community services for pregnant families (Sacramento State University, 2011). If nursing students do not receive adequate breastfeeding instruction and practice to become competent at educating

10 2 breastfeeding mothers, they will not be able to provide effective and accurate breastfeeding support. Purpose Four breastfeeding modules were developed for the purpose of providing comprehensive educational materials on various concepts related to breastfeeding to third-semester undergraduate nursing students enrolled in the maternal-newborn nursing course N136 and the corresponding clinical rotation N137. The content of the modules was specifically chosen to prepare these students to be proficient in the obstetrical skills assessment setting prior to working with breastfeeding mothers in the hospital. Benefits The benefits which result from using the breastfeeding modules to educate Sacramento State nursing students are potentially far reaching. Nursing students will gain confidence and competence in their ability to educate breastfeeding mothers in the clinical setting. The mothers increased knowledge of breastfeeding and ability to breastfeed effectively makes them prone to breastfeed for a longer duration, resulting in significant health benefits for both the mother and infant. Society benefits as well. If 90 percent of families breastfed exclusively for 6 months, this would prevent the deaths of nearly 1,000 infants and save the United States $13 billion per year (U.S. Department of Health and Human Services Office on Women s Health, 2011).

11 3 Background of the Study Major Themes Much of the available research focused on undergraduate nursing students lack of knowledge surrounding breastfeeding. For instance, Bernaix (2000) stated that academic preparation within nursing schools fails to adequately educate nurses about breastfeeding. In one study, 69% (n=201) of nurses stated that they had either not been taught or did not remember having been taught breastfeeding management in their nursing program (Anderson & Geden, 1991). Lewinski (1992) reported that less than 20 percent of the practicing nurses surveyed considered their own basic nursing education as a source of breastfeeding information. And Spatz, Pugh, and The American Academy of Nursing Expert Panel on Breastfeeding (2007) claim that nursing programs across the United States currently lack comprehensive breastfeeding content in their curricula. Another prevalent theme throughout the research is that the insufficient breastfeeding training in nursing programs can lead to inadequate, inappropriate, or no breastfeeding assistance and advice for new mothers, which often results in mothers choosing not to breastfeed their infants (Spatz, 2005). According to Wellstart International (2004, p.1), Lack of knowledge of lactation management among health care providers is one contributing factor of failure to reach breastfeeding rates set by the U.S. government for the Year 2000/2010 National Health Objectives. An important reason for this lack of knowledge is that schools of medicine, nursing, and nutrition are not integrating lactation management education into their curricula. Miller, Cook, Brooks, Heine, and Curtis (2007) also stressed this point when they wrote that women s

12 4 decisions of whether or not to breastfeed are based in part on information provided by their health care providers, many of whom lack sufficient knowledge about breastfeeding. Freed, Clark, Harris, & Lowdermilk (1996) elaborate on this theme. In their study they found that despite students lack of fundamental breastfeeding knowledge and limited clinical experience with breastfeeding education, many of them expressed a false confidence in their own abilities and perceived themselves as effective in assisting breastfeeding patients. When these students finish nursing school and go out into practice, chances are they will give incorrect advice to breastfeeding patients but will be confident in the opinions they express. Rather than seek assistance from more knowledgeable and experienced nurses such as lactation consultants, these students will assume that the breastfeeding patients they have counseled will benefit from the information taught to them. This could have deleterious effects for new mothers who are learning how to breastfeed, who may not be able to distinguish correct from inappropriate advice (Freed et al., 1996). Despite the students good intentions, their erroneous advice could result in a poor breastfeeding outcome for both mother and child. Furthermore, if these students are not aware of the gaps in their breastfeeding knowledge, it is possible that their instructors may also be unaware of their inadequate training as well (Freed et al., 1996). Confirmed Findings Some of the research articles addressed specific areas in which undergraduate nursing students lacked fundamental breastfeeding knowledge. For example, one study found that the most common mistakes made by undergraduate nursing students

13 5 performing breastfeeding instruction included distinguishing the infant consciousness state fit for feeding, knowing when to stop feeding, knowing which behavioral cues signal hunger or satiety in the infant, maternal posture (cradle and football holds, and side-lying), latching on techniques, helping the mother correctly remove the infant from the breast, and overriding test categories such as sepsis and health teaching (Chiu, Gau, Kuo, & Chung, 2003). Another study by Spear (2005) found that nursing programs need to teach more in-depth and focused breastfeeding content, specifically with regard to mastitis, stimulation and maintenance of lactation, the nutritional needs of mothers and infants, and the breastfeeding recommendations promoted by the American Academy of Pediatrics (AAP). A third study (Freed et al., 1996) involving students who had completed their clinical maternity rotation and had attended at least one lecture related to breastfeeding had found that over one-quarter of the students had not learned basic breastfeeding information, such as the knowledge that breastfeeding is the most beneficial form of infant nutrition and that it protects against many illnesses such as otitis media. Furthermore, over half the students did not know that formula supplementation during the first few weeks of an infant s life causes many mothers to stop breastfeeding altogether. Inconsistencies/Gaps Several gaps were noted in the literature. Some researchers did not focus solely on undergraduate nursing students and the lack of sufficient breastfeeding education in nursing programs. Instead, they examined the inability of obstetrical nurses to effectively support breastfeeding mothers in the hospital, pointing to inadequate breastfeeding

14 6 training in both their nursing programs and on-the-job as causes of the problem. For example, Chen, Shu, and Chi, (2001) showed in their study that school education and onthe-job training did not adequately address breastfeeding. In addition, Hayes (1981) found that the breastfeeding information which nurses learn in nursing school and through work experience is not sufficient to assist new mothers. By attributing insufficient breastfeeding knowledge to two causes, it is harder to distinguish the role that each one plays in contributing to the lack of adequate training. Another inconsistency was the lack of a consensus within the research on how to solve the deficit in breastfeeding education within nursing schools. Some researchers proposed the use of an assessment tool, such as the Competency-Based Clinical Performance Examination Model developed by Chung et al. (2000). Using this tool, educators could evaluate students performance and make the necessary changes to teaching content and/or clinical design to address the learning needs of their students (Chiu et al., 2003). Other researchers recommended that nursing schools integrate a case study course into their curricula to assist students with meeting the educational needs related to breastfeeding (Spatz, 2005). Clearly there is a need for standardized breastfeeding education curricula to insure that all undergraduate nursing students are taught similar core breastfeeding concepts regardless of the nursing program attended. The Association of Women s Health, Obstetric and Neonatal Nurses (AWHONN) (2007) proposes nursing curriculum content in their Position Statement on Breastfeeding, but the recommendations are broad and the specific topics are not defined.

15 7 Overview of Project Intent of Project The breastfeeding module project was developed for use as an online teaching tool that would provide undergraduate nursing students enrolled in a maternal-child course with extensive information on the fundamentals of breastfeeding. After completing these modules, students would have the training needed to assist a mother with breastfeeding and to address many of the basic breastfeeding problems that can arise. In addition, it would give students the skills required to work on an obstetrical unit in the hospital upon graduation. The breastfeeding modules were modeled after the online fetal monitoring modules currently in use in N136, Sacramento State University s maternal-child nursing course. Process Conception of the idea. The idea of developing online breastfeeding modules was conceived while working as a teaching assistant to undergraduate nursing students completing their obstetrical (OB) clinical rotation. Some of the students expressed that they needed additional training to feel competent at assisting new mothers with breastfeeding. After dialoging with OB faculty, it was decided that students could learn breastfeeding content in the same way they were learning fetal monitoring content, that is, through online modules. One advantage to using online modules is that students can go back and review the material as often as is needed. To prepare to write the breastfeeding modules, the fetal

16 8 monitoring modules were reviewed for design and content and a one-week breastfeeding seminar was attended to become certified as a Lactation Educator. Online breastfeeding modules have been used in other locales as well. A health care team at the University of Missouri Columbia Sinclair School of Nursing developed online breastfeeding modules for use by nurses, physicians, and students in order to improve their lactation competencies as well as to positively impact their attitudes regarding breastfeeding (Miller et al., 2007). To validate the perceived need for a more comprehensive learning program on breastfeeding at Sacramento State University s School of Nursing, a survey was conducted to examine the design of the school s breastfeeding instruction program and to obtain students opinions regarding whether the program had adequately prepared them to work as breastfeeding educators. Sixty-four third-semester undergraduate obstetrical nursing students were asked to complete a survey (see Appendix A) to determine the quality and content of breastfeeding instruction and explore students perceptions regarding competency at teaching breastfeeding. Some of those surveyed had completed their obstetrical clinical rotation, while others were only a few weeks into their rotation. In addition, some of the students had previous experience with breastfeeding due to having children of their own. Survey results (see Appendix A1) revealed that very few of the students (3% of those currently doing their clinical rotation and 12% of those who had finished their rotation) were completely satisfied with the breastfeeding instruction they had received. There was no agreement between the students as to which breastfeeding topics they had

17 9 received instruction on. In addition, of those students who had not yet completed their clinical rotation, nearly 40% stated they felt insecure to somewhat confident in their ability to educate breastfeeding mothers. These results point to a need for more comprehensive breastfeeding instruction in Sacramento State University s maternal-child nursing course. Persuading others of the project value. After the initial discussion with OB faculty regarding the student need for enhanced breastfeeding training, an OB content expert (who is also one of the maternalchild course instructors) reviewed drafts of the first two breastfeeding modules, pointed out areas needing improvement, and encouraged moving forward with the other modules. OB faculty were also given copies of research articles highlighting the need for more comprehensive breastfeeding content in nursing curricula to support development of the breastfeeding modules. The results from the survey administered to undergraduate obstetrical nursing students further validated the need for enhanced breastfeeding instruction. Development of project materials. Before the project could be started, the undergraduate obstetrical nursing students first had to be observed in the clinical setting to determine what was lacking in their breastfeeding training. Then, using the fetal monitoring modules as a template, four breastfeeding modules were designed containing clearly identified learning objectives, relevant tables and illustrations, and post-tests to evaluate student learning. A decision was made regarding which breastfeeding topics to include after examining student needs,

18 10 completing the Lactation Educator certification seminar, and doing an extensive review of academic breastfeeding literature. Implementation. Once the breastfeeding modules have been reviewed and approved for use by the OB faculty, they will be incorporated into the undergraduate obstetrical nursing course curriculum (N136). Students will be required to complete the modules prior to beginning their obstetrical clinical rotation. This would give them the opportunity to study the content, assess their knowledge using the module post-tests, and test their skills in the skills lab. Any needed remediation could be done before they work with breastfeeding mothers. The modules will first be utilized in an upcoming summer session by ASBSN students studying obstetric and pediatric nursing content. These students will evaluate the modules and any recommended improvements will be made prior to their use in N136. Number of People Involved There were many individuals who were either directly or indirectly involved in the development of the breastfeeding module project. The project could not have been launched without the prior approval of the OB faculty. In addition, the OB content expert reviewed the material for accuracy and determined whether any essential breastfeeding topics were inadvertently omitted. Furthermore, the feedback provided by 64 N136 students on the survey substantiated the need for a more comprehensive breastfeeding instruction program in the N136 curricula. And finally, the anticipated evaluation of the

19 11 modules by 30 ASBSN students will assist in assessing their effectiveness in preparing students to facilitate breastfeeding in the mother-infant dyad. Products for Project The specific products utilized in the modules include: a list of topics at the beginning of each module identifying the module s contents, learning objectives which specify the knowledge and skills that students should be able to exhibit following completion of each module, tables and figures illustrating concepts discussed, post-test evaluations to measure the degree of learning, and a breastfeeding algorithm that students can use to guide their actions in the OB clinical environment.

20 12 Findings and Interpretations At this time it is unknown whether the breastfeeding module project fulfilled its intended purpose. Since the project was completed mid-semester, undergraduate obstetrical nursing students did not have an opportunity to evaluate it prior to their OB clinical rotation. The project s effectiveness will be assessed after the modules have been implemented and evaluated by ASBSN students during Sacramento State University s upcoming summer school session. The evaluation tool (see Appendix B) that will be used this summer was constructed using qualitative and quantitative, open- and closed-ended questions. The answers were formatted in various styles, including Likert-scale, yes-no answer, and fillin-the-blank. Results from the evaluation will be examined by OB faculty and the necessary modifications will be made to the modules content prior to their use in the fall semester N136 course. While it is important to establish student nurses knowledge levels with regard to breastfeeding, being knowledgeable does not always equate to competent performance within a clinical setting. Chiu et al. (2003) maintain that it is not enough to evaluate clinical ability by knowledge alone. Students practical nursing skills should also be evaluated. This is one of the limitations of the breastfeeding module project. The project addresses only one of the requirements for achieving lactation competency, namely, knowledge. Students also need to be given ample opportunity to practice breastfeeding instruction using breastfeeding equipment (e.g., hospital-grade and nonhospital-grade electric breast pumps, nipple shields, and supplemental nurser systems) (Spatz, 2005) and

21 13 be given opportunities for situational practice or role-play in class (Chiu et al, 2003). Furthermore, since students may have limited opportunity to educate breastfeeding mothers within the hospital, they would gain additional experience through either making home visits or telephone calls to these mothers (Freed et al., 1996), spending the day with a midwife (Spear, 2005), or assisting at a Women, Infants, and Children (WIC) agency. Through these experiences, students could become more knowledgeable about issues that commonly arise during the first weeks of breastfeeding. Despite their limitations, online breastfeeding modules have proven to be successful in helping prepare students to educate mothers on breastfeeding. Miller et al. (2007) noted that after students completed the study s online modules, they reported feeling confident in their ability to communicate correct information about breastfeeding to mothers and were able to assist mothers with breastfeeding their infants after delivery. However, additional research on the effectiveness of online breastfeeding modules must be done before they can be endorsed for widespread use. Currently, there is little research available on module use to draw conclusions from. Future studies should examine the benefits of utilizing modules versus other learning methods (i.e., devoting a greater portion of in-class lecture to breastfeeding instruction). In addition, nursing educators need to reach a consensus and establish a standardized breastfeeding curriculum outlining the core breastfeeding concepts that nursing programs are required to teach. In summary, a review of available research concerning nursing students breastfeeding knowledge and clinical abilities revealed that students are inadequately prepared for their role in breastfeeding promotion. Giving inaccurate breastfeeding

22 14 information to new mothers can have far-reaching consequences, affecting key factors such as duration of the breastfeeding experience, potential loss of health benefits to mother and infant with associated healthcare costs, fiscal impact on the family and the community at large, and degree of maternal satisfaction. If we, as a nation, hope to meet the Healthy People 2020 breastfeeding objective (MICH-21) -- to increase the proportion of infants who are breastfed (U.S. Department of Health and Human Services, 2010) -- then future nurses must be properly educated and trained to reach this goal. Likewise, nursing instructors must also regularly monitor what knowledge, skills, and experiences their instruction does and does not include and modify instructional content and methods accordingly.

23 15 Appendix A Undergraduate Breastfeeding Questionnaire 1. Do you have previous experience with breastfeeding? Yes No 2. Prior to beginning your OB clinical rotation, were you given an opportunity to practice breastfeeding instruction using breastfeeding equipment (i.e., hospitalgrade and nonhospital-grade electric breast pumps, nipple shields, supplemental nurser systems)? Yes No 3. Prior to beginning your OB clinical rotation, were you given an opportunity either in class or in the simulation lab for situational practice or role-play using hypothetical breastfeeding scenarios? Yes No 4. How many times did you assist new mothers with breastfeeding education during your OB clinical rotation? (circle answer) >5 5. Did you have opportunities to teach breastfeeding mothers outside of the hospital setting? Yes No If so, where? 6. Which breastfeeding topics have you received instruction on in either your OB class or in clinical rotation? (check those boxes which apply) Sepsis Benefits of breastfeeding Feeding positions (cradle, side-lying, football) Behavioral cues which indicate that the baby is hungry

24 16 Latch-on techniques Teaching mother how to remove infant from the breast Common problems in the early days/weeks of breastfeeding (i.e., nipple pain) Pacifier use Maternal nutrition during lactation Cesarean births Late-preterm infants Stooling patterns and infant weight gain Working with sleepy/hysterical infants Teething Milk storage guidelines Breast pumps Fertility and lactation Culture and breastfeeding Breast engorgement 7. How satisfied are you with the quality of the breastfeeding instruction you received in your OB class? (circle one) Very satisfied Somewhat satisfied Dissatisfied Very dissatisfied 8. How confident do you feel in your ability to effectively educate breastfeeding mothers? (circle one) Very confident Somewhat confident Insecure Very insecure 9. What would have enhanced your ability to provide breastfeeding education to new mothers? (can check more than one box) More in-class instruction on breastfeeding More opportunities for hands-on practice with breastfeeding equipment More opportunities for role-play or situational practice using hypothetical breastfeeding scenarios

25 17 Increase the number of weeks spent in OB clinical rotation More opportunities to work with nursing mothers outside of the hospital setting None of the above. I am satisfied with the breastfeeding instruction I received. 10. Comments:

26 18 Appendix A1 Results of Undergraduate Breastfeeding Questionnaire (N = 64) Survey Questions (n = clinical in progress, n = clinical completed) n (30) % n (34) % Previous experience with breastfeeding Opportunity to practice with breastfeeding equipment Opportunity for situation practice/role-play No. of times assisted mothers with breastfeeding in clinical 12 (1) 40 8 (2) 24 Opportunity to teach breastfeeding outside hospital setting Breastfeeding topics that students have received instruction on: Sepsis Benefits of breastfeeding Feeding positions Behavioral cues indicating baby is hungry Latch-on techniques Teaching removal of infant from breast Common problems early on in breastfeeding Pacifier use Maternal nutrition during lactation Cesarean births Late-preterm infants Stooling patterns and infant weight gain Working with sleepy/hysterical infants Teething Milk storage guidelines Breast pumps Fertility and lactation Culture and breastfeeding Breast engorgement

27 19 Results of Undergraduate Breastfeeding Questionnaire Survey Questions (n = clinical in progress, n = clinical completed) n % n % Satisfaction with quality of breastfeeding instruction: Very satisfied Somewhat satisfied Dissatisfied Very dissatisfied Confidence in ability to educate breastfeeding mothers: Very confident Somewhat confident Insecure Very insecure Enhancing student ability to provide breastfeeding education: More in-class instruction on breastfeeding More opportunities for practice with breastfeeding equipment More opportunities for situation practice/role-play Increase number of weeks spent in OB clinical rotation More opportunities to work with mothers outside hospital setting None of the above (satisfied with breastfeeding instruction received)

28 20 Undergraduate Students with Previous Breastfeeding Experience (N = 14) Survey Questions (n = clinical in progress, n = clinical completed) n (6) % n (8) % Satisfaction with quality of breastfeeding instruction: Very satisfied Somewhat satisfied Dissatisfied Very dissatisfied Confidence in ability to educate breastfeeding mothers: Very confident Somewhat confident Insecure Very insecure

29 21 Undergraduate Students with No Previous Breastfeeding Experience (N = 50) Survey Questions (n = clinical in progress, n = clinical completed) n (24) % n (26) % Satisfaction with quality of breastfeeding instruction: Very satisfied Somewhat satisfied Dissatisfied Very dissatisfied Confidence in ability to educate breastfeeding mothers: Very confident Somewhat confident Insecure Very insecure

30 Appendix B 22 EVALUATION OF BREASTFEEDING MODULES 1. Were the objectives at the beginning of each module clearly stated? Yes No 2. Did the content of the modules support the stated objectives? Yes No 3. Was the pathophysiology of lactogenesis clearly identified? Yes No 4. Was the description of the latch-on technique clear and easy to understand? Yes No 5. Was there enough information on cultural norms? Yes No 6. Did the content of the modules support clinical practice? Very much Somewhat A little Not at all 7. Give examples of how you used the content in clinical practice: 8. Did the post-test reinforce the information you learned from the modules? Yes No 9. What did you like most about the modules? 10. What would you change?

31 Appendix C 23 Breastfeeding Modules LIST OF TOPICS BY MODULE Module #1 Breast Structure Pregnancy Changes Lactogenesis Hormonal Influences o Let-Down Reflex ( Milk Ejection Reflex or MER ) Galactopoiesis Breast Assessment of Mother Oral Assessment of Newborn Breastfeeding Behaviors and Indicators Biological Specificity of Breastmilk Module #2 Skin-to-Skin Care Feeding Positions Latch-on Mother s Nipples and Breast Problems Baby Problems That May Cause Difficulty With Latch-on Late-Preterm Infants Nipple Shields Cesarean Births Breast Engorgement LATCH Documentation Effective, Encouraging One-Liners for the Nurse (Effective Nursing Communication) Breast Storage Capacity and Milk Supply

32 Module #3 Common Problems in the Early Days/Weeks o Baby is Not Latching, Sucking or Feeding Effectively o Torticollis (Tilted Jaw) o Supplementation Guidelines Nipple Pain Pacifier Use Stooling Patterns Infant Weight Gain Multiple Infants Bed Sharing Breast-Related Problems o Plugged Ducts o Mastitis o Thrush Teething What to Do When Baby is Sleepy/Hysterical 24 Module #4 Milk Storage Guidelines Breast Pumps o Recommended Technique o Common Pumping Problems Hand Expression Breast Shells Feeding-Tube Devices Maternal Nutrition During Lactation o Foods That Pass Into Milk Cleft Lip and Breastfeeding Fertility and Lactation Culture and Breastfeeding o Colostrum o Hot and Cold Foods Baby Friendly Hospitals Ten Steps Criteria

33 LIST OF DIAGRAMS BY MODULE 25 Page Module #1 1. Structure of the breast Microscopic structure of breast tissue Anatomy of the lactating breast Anatomy of the breast Nipple surrounded by Montgomery s tubercles The pinch test 8 7. An inverted nipple 9 8. A bubble palate The frenulum Cleft palate Anatomy of breastfeeding Module #2 1. Skin-to-skin contact Infant feeding positions.4 3. The sniff position The latch-on technique Correct positioning of infant during latch-on Nipple shields 9

34 Page 26 Module #3 1. Torticollis Sore, cracked nipple Breast shells The double cradle hold The cradle and clutch hold The double clutch hold or football hold Candidiasis (thrush) of the breast. 14 Module #4 1. Various parts of a basic breast pump 4 2. Hand expression 6 3. Side view of hand expression Breast shells Feeding-tube device Supplemental Nursing System by Medela 8 7. Cleft palate obturator Palatal obturator in infant s mouth... 11

35 27 LIST OF TABLES BY MODULE Page Module #1 1. Composition of human colostrum and mature breastmilk 12 Module #2 1. Positive and negative elements of infant feeding positions LATCH: Breastfeeding documentation system Module #3 1. Characteristic stool changes over time Newborn voidings Safety issues for breastfeeding and bed sharing Self-care for treating a plugged duct Infant sleep/wake states with implications for breastfeeding Module #4 1. Breastmilk storage guidelines for preterm or sick infants 2 2. Storage duration of fresh human milk for use with healthy full term infants... 3

36 28 Module #1: Anatomy and Physiology of Lactation Module Topics Breast Structure Pregnancy Changes Lactogenesis Hormonal Influences o Let-Down Reflex ( Milk Ejection Reflex or MER ) Galactopoiesis Breast Assessment of Mother Oral Assessment of Newborn Breastfeeding Behaviors and Indicators Biological Specificity of Breastmilk Objectives After reviewing the information contained within this section, the student will be able to: 1) Describe the basic anatomy of the female breast as it relates to lactogenesis. 2) List the various changes a woman s breasts undergo during pregnancy and the hormones responsible for those changes. 3) Define lactogenesis, describe its two stages, and list the maternal conditions that can affect lactogenesis. 4) List the hormones which influence lactation and each of their functions. 5) Describe the Milk Ejection Reflex. 6) Define galactopoiesis. 7) Explain how to conduct a breast assessment of a mother and describe atypical findings. 8) Name three anatomical conditions of a newborn s mouth that can be problematic for breastfeeding. 9) List the infant cues a mother should watch for which signal the infant s readiness to breastfeed. 10) Give examples illustrating how human breastmilk is species specific. 1

37 29 Breast Structure The human female breast contains glandular, fibrous, and adipose tissue. The glandular tissue is comprised of basic units known as acini or alveoli. These units are arranged in a series of lobes, with each lobe consisting of clusters of alveoli around small ductules which terminate at each cluster. There are 15 to 20 lobes in each breast, with each lobe containing between 10 and 100 alveoli. Diagram 1: Structure of the breast. Diagram 2: Microscopic structure of breast tissue. Myoepithelial cells, which surround each alveolar cluster, are contractile cells responsible for milk ejection into the ductules. The ductules from several lobules merge into larger ducts. It was once believed that these ducts then joined together to form lactiferous sinuses, reservoirs for milk collection, behind the nipple and areola (see Diagram 3). However, recent research has revealed that ducts do not widen into sinuses as previously thought. Instead, milk is stored in the alveolar lumina until the letdown reflex signals the myoepithelial cells to contract and eject the milk. 2

38 30 Diagram 3: Old schematic diagram of a breast containing lactiferous sinuses, and an updated, modified diagram based on recent research. 3

39 31 Diagram 4: Anatomy of the breast. Between and around the lobes is a thick layer of adipose tissue. The amount of adipose contained within women s breasts varies from person to person. However, the amount of adipose tissue does not affect a woman s breast storage capacity or her ability to produce milk. The areola, the heavily pigmented area surrounding the nipple, contains Montgomery s tubercles (see Diagram 3), which consist of mammary milk glands and sebaceous glands. Diagram 5: Nipple surrounded by Montgomery s tubercles. 4

40 Montgomery s tubercles play an important role in breastfeeding. Since many lactating women experience visible milk emission from them, it is believed that they serve as a scent organ, providing sensory stimulation to the newborn to guide him to the nipples. In addition, Montgomery s tubercles aid in stimulating the nipples and increase the newborn s intake of colostrum (the thin, yellowish fluid produced by the mammary glands after childbirth). Women with numerous Montgomery s tubercles have babies that latch on more quickly, suckle more actively after latching on, and gain more weight in the first few days of life. 32 Pregnancy Changes A woman s breasts undergo several changes during pregnancy. Her breasts increase in size, the skin appears thinner and superficial veins becoming more prominent, the areola increases in diameter and pigmentation, Montgomery s glands enlarge, and the woman s nipples become more erect. Breast growth during pregnancy is stimulated by various hormones. Serum prolactin levels stimulate nipple growth, and serum placental lactogen causes the areola to grow in diameter. In addition, estrogen causes the ducts within the breast to proliferate and differentiate, while progesterone causes the lobes, lobules, and alveoli to increase in size. Mammary growth is the result of the combined effort of adrenocorticotropic hormone (ACTH), growth hormone, prolactin, and progesterone. Lactogenesis Lactogenesis is the transition that occurs from pregnancy to milk formation by the mammary glands as the breasts prepare for lactation. During the first half of pregnancy, elevated levels of estrogen cause the ducts within the breast to grow and proliferate. In addition, the increased progesterone levels stimulate the lobules and alveoli to develop. In the second half of pregnancy, the secretion of colostrum into the acini or alveoli accelerates, causing them to become distended. This secretory process is held in check by the increased levels of progesterone secreted by the placenta. Lactogenesis occurs in two stages. Lactogenesis, stage I (or lactogenesis I) involves the period from midpregnancy to late pregnancy and involves the secretory differentiation of the mammary gland in preparation for breastfeeding. Lactogenesis II commences after the delivery of the placenta and is triggered by the resulting rapid drop of serum progesterone. With the onset of Lactogenesis II, there is copious secretion of breastmilk. 5

41 Lactogenesis can be delayed or impeded by various maternal conditions. These include cesarean birth, Type I diabetes, analgesia with labor, obesity, polycystic ovary syndrome, gestational ovarian theca lutein cysts, stress, and placental retention. 33 Hormonal Influences In general, hormones drive the onset of copious milk secretion after birth. However, for milk production to continue, the mother must initiate breastfeeding. Progesterone Progesterone is essential to maintaining pregnancy and remains high throughout pregnancy until its rapid drop following expulsion of the placenta after delivery. The high levels of progesterone inhibit lactation during pregnancy by hindering the ability of prolactin to act at the alveolar level. Progesterone s inhibiting influence is so strong that the onset of lactation will be delayed if placental fragments are retained following birth. Following expulsion of the placenta, lactogenesis is triggered by the rapid fall of progesterone in combination with constant prolactin levels. Prolactin is the principal hormone in maintaining milk production once lactation is initiated. Prolactin Prolactin plays a key role in both the initiation and maintenance of milk production. During pregnancy, it stimulates cell proliferation and maturation in the mammary ducts and alveoli and also promotes an increase in breast mass. Post pregnancy, a nursing infant causes the release of prolactin via nipple stimulation and milk removal from the breast, resulting in continued milk production. If a woman chooses not to breastfeed, the prolactin levels return to prepregnancy levels within 7 days postpartum. Prolactin also delays when ovulation resumes again postpregnancy by inhibiting the ovaries response to follicle-stimulating hormone. Cortisol Cortisol works together with prolactin on the mammary system. High levels of cortisol can result in a delay in lactogenesis. Thyroid-Stimulating Hormone Thyroid-stimulating hormone, which has been found to markedly increase on the third to fifth postpartum days, promotes mammary growth and lactation. Prolactin-Inhibiting Factor Prolactin-inhibiting factor (PIF) stimulates the release of the neurotransmitter dopamine, which causes a decrease in prolactin secretions. This, in turn, leads to a reduction in breast milk 6

42 production. Nipple stimulation and milk removal cause PIF and dopamine to be suppressed, resulting in increased prolactin levels and milk production. Oxytocin Oxytocin has several important functions. It is responsible for the milk-ejection reflex (MER) or letdown. As an infant suckles at the breast, oxytocin is released from the posterior pituitary gland into the bloodstream where it travels to the breast and causes myoepithelial cells to contract and force milk from the alveoli into the ducts. Once in the ducts, milk is then available to feed the newborn via the nipple openings. Oxytocin also helps the mother s uterus to contract postpartum. Contractions occur while breastfeeding and up to 20 minutes after the feeding as well. These uterine contractions help to control postpartum bleeding and aid in uterine involution. Oxytocin also contributes to the calmness that mothers experience while breastfeeding. 34 Galactopoiesis Maintenance of the established breastmilk production is known as galactopoiesis. The milk production system within the breasts is based upon supply and demand. As milk is removed from the breasts, this stimulates continued milk production. Conversely, with inadequate milk removal or stasis, breastmilk synthesis tends to diminish. Breastmilk production is governed by the quantity and quality of infant suckling, or in other words, the infant s appetite, rather than the woman s ability to produce milk. Breast Assessment of Mother Inspection Lactation is not affected by the size, symmetry, and shape of the breasts. Typically, it is normal for a woman s breasts to differ in size from one another. However, for a small minority of women, marked asymmetry could indicate that there is inadequate glandular tissue. Women who have underdeveloped breasts, thus lacking breast tissue (hypoplasia), and also have a wide space between breasts (intramammary space) may have problems with an insufficient milk supply. The newborn infants of these women should be monitored closely to ensure that they get an adequate intake of breastmilk. Supplementation with formula may be needed. In addition, women who have undergone breast-reduction surgery are more likely to have problems with lactation than those who have had augmentation surgery. For the woman with large breasts, holding and feeding her infant will not be the same as for women with average-sized breasts. When feeding, she may need to lift her breast and to hold or 7

43 push back part of the breast to enable her infant to grasp the nipple and breathe comfortably while nursing. It is also important to inspect the skin of the breast for any abnormalities. Check skin turgor and elasticity by gently pinching the skin. (Note: women who have been pregnant before tend to have more elastic skin.) In addition, watch for any signs of skin thickening and dimpling of the breast or nipple tissue, which could be an early sign of a tumor. After this portion of the inspection has been completed, it is important to ask the mother whether her breasts had grown during pregnancy as well as whether she has experienced any tenderness and soreness. These signs (breast size, swelling, and tenderness) are good indicators that a woman s breast tissue is functioning adequately and is responsive to hormonal changes. Finally, inspect the woman s nipples, including the areola. Nipple size does not equate to functional ability. Look for any nipple structural abnormality, such as inversion (the nipple is drawn inward within the folds of the areola), that may interfere with functionality. Palpation Begin by palpating the nipple. Taking your forefinger and thumb, compress or palpate the areola between your fingers, focusing on the area just behind the base of the nipple (see Diagram 6). This maneuver, known as the pinch test, simulates the compression that occurs while an infant is breastfeeding and will help you assess nipple function. 35 Figure A: A protracting normal nipple. Figure B: Retraction, in which the nipple moves inward instead of protracting. Diagram 6: The pinch test. 8

44 36 Diagram 7: An inverted nipple. Oral Assessment of Newborn When examining the newborn s mouth, watch for the following anatomical features which can be problematic for breastfeeding: The bubble palate: a concavity in the hard palate. Can cause sore, abraded nipples if the nipple is pulled into the bubble instead of remaining elongated and extending back into the infant s mouth to the juncture of the hard and soft palates. (See Diagram 8). Short frenulum or frenulum is placed too far forward: The frenulum is a fold of mucous membrane that is found midline on the underside of the tongue. It is responsible for anchoring the tongue to the floor of the mouth. If the frenulum is too short or placed too far forward, it can interfere with freedom of tongue movement, negatively affecting an infant s ability to suckle. (See Diagram 9). Cleft lip and palate: A congenital malformation in which there are one or two vertical fissures (clefts) in the upper lip due to incomplete fusion of the structures of the oral cavity and the palatine plates during the embryonic period of life. (See Diagram 10). Diagram 8: A bubble palate. Diagram 9: The frenulum. 9

45 37 Diagram 10: Cleft palate. Breastfeeding Behaviors and Indicators By 24 weeks gestation, fetuses display a suckle reflex. The newborn has a strong suckling ability in the first few hours after birth and for this reason, it is important that they be breastfed during this time. Suckling yields not only milk and calories for the infant. It also facilitates feelings of calm, reduces the heart rate and metabolic rate, and also raises the infant s as well as the mother s pain threshold. The mother should watch for cues from her infant, signaling his or her readiness to breastfeed. It is important that the mother watch the baby, not the clock. An infant should be fed at the earliest signs of hunger, which include wiggling, moving arms or legs, rooting, and putting fingers to mouth. Crying is considered a late sign of hunger. Feeding of the infant should continue until the mother notes cues suggesting satiety (infant s suckling activity ceases, infant falls asleep and lets go on his own). The baby determines the length of the feeding. 10

46 38 Diagram 11: Anatomy of breastfeeding. Biological Specificity of Breastmilk Human breastmilk is species specific, that is, over the course of human existence it has been adapted to meet the nutritional and anti-infective requirements of the human infant. The major components of human milk are protein, fat, and lactose. In addition, it contains nonprotein nitrogen compounds, oligosaccharides, vitamins, and minerals as well as hormones, enzymes, growth factors, and many types of protective agents against disease and allergies. Breastmilk is comprised of approximately 10 percent solids for energy and growth. The remainder is water, which is essential for maintaining hydration. In fact, infants who consume enough breastmilk to meet their energy needs get an adequate amount of fluid to stay hydrated even in hot and dry environments. The composition of breastmilk changes appropriately to meet the needs and age of the infant. For example, preterm mother s milk has a much higher fat concentration than full-term mother s milk, making it much more energy dense. Colostrum, the early milk present the first 3-5 days after an infant s birth, is richer in protein and minerals and contains lower concentrations of carbohydrates, fat, and some vitamins as compared with mature breastmilk (see Table 1). In addition, the fat content of mature breastmilk changes during a feeding, increasing more steeply as more milk is removed from the breast. Additional facts which illustrate that human milk is uniquely suited for human infants: Human milk is easy to digest. 11

47 There is evidence to suggest that the degree of protection an infant receives is directly related to the quantity and duration of breastfeeding. The immune factors found in breastmilk protect the infant from illnesses such as diarrhea, ear infections, neonatal sepsis, and pneumonia. When a mother has been exposed to an illness, the antibodies her body produces in response to the illness are passed to her infant through her breastmilk. Several research studies have revealed that breastmilk enhances brain development: children who were breastfed for at least six months scored significantly higher on intelligence tests than those who had not. 39 Table 1: Composition of Human Colostrum and Mature Breastmilk Constituent (per 100 ml) Colostrum 1-5 days Mature Milk >30 days Energy, kcal Total protein, g Total fat, g Lactose, g Cholesterol, mg Vitamins (Water Soluble): Thiamine, µg Riboflavin, µg Vitamins (Fat Soluble): Vitamin A, µg Vitamin E, µg Note. Adapted from Riordan, J., & Wambach, K. (2010). Breastfeeding and human lactation. Sudbury, Massachusetts: Jones and Bartlett. References Breastfeeding Promotion Advisory Committee. (2007). Breastfeeding: Investing in California s future. Retrieved from BreastfeedingFullDocument.pdf Cleft lip. (2011). Retrieved from Riordan, J., & Wambach, K. (2010). Breastfeeding and human lactation. Sudbury, Massachusetts: Jones and Bartlett. 12

48 40 Post-Test #1 1. The contractile cells within the breast that are responsible for milk ejection into the ductules are: a. Myoepithelial cells b. Ductule cells c. Lactiferous cells d. Leite cells 2. Montgomery s tubercles play an important role in breastfeeding. Which of the following is true? a. They serve as a scent organ, guiding the newborn to the nipples. b. Women with numerous Montgomery s tubercles produce more breastmilk. c. It is not normal to see a milk discharge from Montgomery s tubercles while lactating. d. The number of Montgomery s tubercles a woman has is related to her breast size. 3. You are a nurse on the postpartum unit, assisting a first-time mother, Angela, with breastfeeding her newborn. Angela is concerned that her small breasts will not produce enough milk to feed her baby. You tell her: a. Women with smaller breasts cannot make as much milk as women with larger breasts. b. Your ability to make breastmilk is not determined by your breast size. c. You will need to supplement your feedings with formula so that your baby s nutritional needs are met. d. We will need to monitor your newborn closely to make sure that your baby gets enough breastmilk. 4. Which one of the following hormones is responsible for the milk-ejection reflex, or letdown? a. Prolactin b. Cortisol c. Oxytocin d. Progesterone 13

49 41 5. Mary is a first-time mother learning to breastfeed her newborn. She tells you that she is worried about feeding her baby when she goes home. She does not know when her baby is hungry and ready to feed, because sometimes he has to be woken up to nurse. You explain to her: a. Your baby will cry to indicate when he is hungry. b. Your baby should be fed when he starts to wiggle, move his arms or legs, or put his fingers to his mouth. c. Feed your baby every four hours to ensure that he gets enough to eat. d. Breastfed babies don t need to feed as frequently as formula fed babies. 14

50 Module #2: Intrapartum.. Care/Breastfeeding 42 Module Topics Skin-to-Skin Care Feeding Positions Latch-on Mother s Nipples and Breast Problems Baby Problems That May Cause Difficulty With Latch-on Late-Preterm Infants Nipple Shields Cesarean Births Breast Engorgement LATCH Documentation Effective, Encouraging One-Liners for the Nurse (Effective Nursing Communication) Breast Storage Capacity and Milk Supply Objectives After reviewing the information contained within this section, the student will be able to: 1) State the advantages associated with skin-to-skin contact. 2) Identify the four ways to position the infant at the mother s breast. 3) List the steps involved in facilitating a latch-on. 4) Explain the various breast anomalies that may make it difficult for the infant to breastfeed. 5) Describe some problems babies may experience that can interfere with latch-on. 6) Define late-preterm infants and list the characteristics associated with them. 7) Cite the reasons for using nipple shields. 8) Describe how to facilitate breastfeeding with a mother who has had a cesarean birth. 9) Name the treatments for breast engorgement. 10) Identify how breastfeeding differs for women with a small milk storage capacity as compared to women with a large milk storage capacity. 1

51 43 Skin-to-Skin Care Ideally, the best time for the first breastfeedings to occur is within the first hour after birth. The infant is placed on the mother s abdomen close to her breasts in skin-to-skin contact. This involves placing the baby directly on the mother s bare chest and covering him or her with a warmed blanket. When skin-to-skin contact is established shortly after birth, the infant is alert and can crawl, stimulated by the mother s touch, across her abdomen to her breast. Then the baby will smell, mouth, and lick the mother s nipple, latch on to her breast, and feed. There are many advantages associated with skin-to-skin contact: Helps maintain stable temperatures in the baby Longer duration of exclusive breastfeeding Helps decrease maternal stress and there is greater satisfaction with breastfeeding Newborn exhibits less stress from the birth, cries less Mother has greater desire to hold her infant Baby is better able to smell the natural scent of his mother s milk Infant experiences less pain and cries less during painful procedures (i.e., blood collection) Diagram 1: Skin-to-skin contact. 2

52 44 Feeding Positions There are various ways to position the infant at the mother s breast when it is time to breastfeed. The most commonly taught techniques are the cradle, the cross-cradle (across-the-lap), the football (or clutch or under the arm), and the side-lying position (see Diagram 2). Each feeding position has positive and negative elements: Position Positive Elements Negative Elements Cradle Classic position Most often used Football or Provides good head control clutch Easy to see infant s mouth Good position for low birth weight or weekers Avoids incision from Cesarean birth Allows mother to bring baby to the breast easily Cross-cradle Provides control of baby s head Allows mother to bring baby to the breast easily Side-lying Minimizes fatigue by enabling mother to rest better Difficult to control baby s head (tends to wobble around on mother s arm) Teaching and coaching needed Baby s bottom needs to be against the back of mother s chair to provide adequate room to breastfeed properly Some mothers are not comfortable holding their babies in this position Mothers may fear that baby could be smothered in this position Difficult for mother to see to assist the baby with attaching to the breast Note. Adapted from Riordan, J., & Wambach, K. (2010). Breastfeeding and human lactation. Sudbury, Massachusetts: Jones and Bartlett. Table 1: Positive and Negative Elements of Infant Feeding Positions. 3

53 45 Diagram 2: Infant feeding positions. 4

54 46 Latch-on When a new mother has problems with breastfeeding, achieving optimal latch and positioning is often times the only remedy that is needed. However, there are a variety of methods, each with its own technique, for achieving a proper or good latch and/or positioning. No single technique has been proven to be better than the rest. One technique used by hospitals to facilitate positioning and latch-on contains the following steps: 1. Establish skin-to-skin contact between mother and infant 2. Place infant in either cross-cradle, football, or side lying position. 3. Using pillows for support make sure baby s abdomen is facing the mother s chest at the level of her breast. 4. If using cross-cradle position, have the mother place one hand behind the infant s neck and shoulders and use the other to support the breast behind the areola. 5. Align the baby s nose with the mother s nipple and slightly extend back the infant s neck in a sniff position. Diagram 3: The sniff position. 6. Stimulate the rooting response. 7. Once the infant s mouth is fully open, swiftly move the baby chin first onto the breast, making sure the infant grasps as much areola as possible. 8. The infant should latch on off-center to the nipple (see Diagram 3). 5

55 47 Diagram 4: The latch-on technique. Diagram 5: Correct positioning of infant during latch-on. 6

56 48 Mother s Nipples and Breast Problems Sometimes the mother s breast anatomy makes it difficult for the infant to breastfeed. For example, the mother s nipples may be too big for the baby to take the entire nipple and some of the surrounding areola into the mouth. In such a case, the mother will need to wait for the baby to grow into her nipple size, feeding the baby her pumped milk in the meantime. Other breast-related problems women may have include: flat, inverted, or retracted nipples (makes it difficult for the infant to attach) large breasts (hard to deal with the large breasts and the newborn at the same time) Women with large breasts may be able to resolve the challenge of breastfeeding simply by finding a position that works for them, such as using a side lying position to support both the baby and the breast. Nipple problems, however, may require the intervention of a lactation consultant. Baby Problems That May Cause Difficulty with Latch-on Some problems babies may experience that can interfere with latch-on are: cleft lip and palate* a short frenulum* a bubble palate* painful mouth difficulty breathing (i.e., stuffy nose, swollen nares, obstructed nares, and weight of the breast on baby s chest) pain resulting from surgical intervention or birth trauma (i.e., fractured clavicle, sore head, hematoma, forceps marks, vacuum extraction trauma, cranial suture out of line, and circumcision) being drugged from the labor medications given to the mother obnoxious stimuli (i.e., smell of perfume, soaps, body lotions, or room deodorizers; loud noises; pressure on the back of the head, causing the baby to worry that his nose will become blocked) previous negative breastfeeding experiences, causing an aversion to the breast *(see diagrams in Module #1) 7

57 It is important to conduct an assessment of the infant, the mother s nipples and breast structure, and the breastfeeding environment to note abnormal findings or variations that may impede effective breastfeeding. 49 Late-Preterm Infants Late-preterm infants are born between 34 completed weeks and less than 37 completed weeks. These infants are unique in that they are not considered preterm unless they have medical problems, but they do not behave as full-term infants would. Often, late-preterm infants are treated as though they were full-term infants even though their risk for complications is the same as for infants born prematurely. Late-preterm infants may exhibit the following characteristics: Neurologic disorganization and poor state control (in other words, they can go from being in a highly alert state to deep sleep rapidly) Poor muscle tone or floppiness Poor temperature control due to having less body fat Immature rooting and suckling They require considerable time and effort before they can breastfeed effectively, and as a result, they are at risk for high bilirubin levels, hypoglycemia, dehydration, and insufficient weight gain. To optimize the late-preterm infant s ability to feed well when awake, the following interventions are recommended: skin-to-skin (kangaroo) holding keeping them warm allowing longer periods of rest between feedings limiting stimulation Mothers with late-preterm infants will need to pump after each breastfeeding in order to establish milk production. This expressed milk can then be given to the infant if the infant is not able to obtain enough milk through breastfeeding alone. 8

58 50 Nipple Shields Nipple shields are used for a variety of reasons: flat or inverted nipples preterm babies who have trouble latching and maintaining suction babies who have developed a preference for a bottle nipple and consequently, refuse the breast can preserve the breastfeeding relationship while the baby learns to breastfeed (shortterm use) Women who have been advised to use a nipple shield need to pump their milk four to six times a day after breastfeeding to establish a milk supply. The baby will need to be weighed twice a week and diaper counts done, monitoring for stools and wetness. Once it has been determined that the baby is gaining well (about an ounce a day), the mother can then gradually wean off pumping provided that the baby continues to gain appropriately. To apply a nipple shield, put a thin layer of water around the inside of the brim of the nipple shield. Then turn up the brim of the shield, and turn half of the teat of the shield in on itself. Finally, position the shield where it is centered over the nipple, and gently pat down the brim. Diagram 6: Nipple shields. 9

59 51 Cesarean Births In the United States, more than 20 percent of the births are by cesarean, and the number is rising. The rate and duration of breastfeeding is approximately the same between mothers who delivered by cesarean and mothers who had a vaginal birth. Regardless of the manner of birth, it is the mother s commitment to breastfeeding which determines the duration. Nevertheless, cesarean births do have an impact on breastfeeding. They are associated with delayed lactogenesis as well as a delay in initiating breastfeeding. This may be the result of the additional time it takes to recover from major surgery, the accompanying pain and stress, and the additional risks involved as compared to an uneventful vaginal birth. When working with a mother who has had a cesarean birth, it is important to carry out the following recommendations to facilitate effective breastfeeding: Assess the degree of physical comfort of the mother and administer pain medication as needed. Assess the degree of the mother s awareness. Wait until she is alert and able to hold her baby before initiating breastfeeding. Ask the mother how she would like to hold her baby. Some mothers are hesitant to hold the baby until they have been reassured that doing so will not require touching or putting pressure on the incision site. Suggest to the mother that she use the football hold initially to breastfeed her baby, so as to avoid the sensitive incision area. As her pain subsides, she can be encouraged to try other infant feeding positions. The side-lying position is generally comfortable by the second or third day postpartum. If breastfeeding is delayed, provide the mother with a breast pump. If breastfeeding cannot be initiated because the baby is lethargic from exposure to analgesia or anesthesia, reassure the mother that a delay in feeding will not deter breastfeeding. Her milk supply will merely be established slightly later than it would be following a vaginal birth. 10

60 52 Breast Engorgement Breast engorgement is a common problem in the early days after birth as milk production increases rapidly under the influence of hormonal shifts. For most women, breast engorgement is greatest from 3 to 5 days after birth and then it slowly recedes. Some women, however, have reported having engorgement that lasts two weeks. Encourage the mother experiencing breast fullness that it is a transitory indication of milk production and will eventually regulate to meet the infant s needs as the baby breastfeeds. Uncomfortable breast engorgement can be caused by several situations: Supplements Delayed initiation of breastfeeding Breastfeeding infrequently Time-limited feedings Removing the infant from the first breast to ensure that the baby feeds from both breasts at every feeding Breast implants Multiparous birth The various treatments for engorgement are: Medications Heat treatments, such as warm compresses or warm showers. Heat treatments should be done before breastfeeding. Cold treatments, such as cold compresses, frozen vegetable bags wrapped in a towel, and cold gel packs. Cold treatments should be done after breastfeeding. Cabbage compresses, using fresh cabbage leaves that are cold or room temperature Breast massage and hand expression of milk Ultrasound (used for both plugged ducts and engorgement) Pumping No matter what treatment is used, breast engorgement will slowly and inevitably resolve on its own. However, to avoid painful engorgement, the mother should be encouraged to breastfeed frequently. 11

61 53 LATCH Documentation The LATCH charting/documentation system is used by hospitals to assess when a referral to the lactation consultant is needed, assist with determining acuity in staff assignments, and alert the physician to those mother-infant dyads requiring earlier follow-up. The LATCH term is an acronym: L = how well infant latches on to breast A = how many audible swallows are heard T = type of nipple the mother has after stimulation C = how comfortable the mother s breast/nipples feel H = how much help the mother needs in holding/positioning infant on breast Using the LATCH chart, the initial breastfeeding session and at least one breastfeeding session every 8 hours should be observed and assessed. Then based on what has been observed, a number should be assigned and documented in each category. Add the numbers from each category; the total score ranges from A score 7 may require a referral to the lactation consultant for extra support. 12

62 Table 2: LATCH: Breastfeeding Documentation System D. Jensen, Sacred Heart Medical Center, Eugene, OR 54 Assessment Categories L LATCH Too sleepy or reluctant No latch achieved No sucking elicited Repeated attempts needed to sustain latch Nipple held in mouth throughout feeding Active rooting noted Grasps breast easily Tongue down Lips flanged Stimulation needed to elicit sucking reflex Rhythmical sucking A AUDIBLE SWALLOWING None A few, with stimulation Spontaneous and intermittent < 24 hrs of age Spontaneous and frequent > 24 hrs of age T Inverted Flat Everted at rest TYPE OF NIPPLE Everted after stimulation C Engorged Filling Soft COMFORT (Breast/Nipple) Cracked, bleeding, large blisters or bruises Severe discomfort Reddened/small blisters or bruises Mild/moderate discomfort Non-tender H HOLD (Positioning) Full assist, staff holds baby Assistance needed to correctly position infant at breast and maintain latch No assistance needed to correctly position infant at breast 13

63 55 Effective Nursing Communication (Effective, Encouraging One-Liners for the Nurse) Breastfeeding can be challenging, so it is important to use motivational messages and dialogue when talking with a new mother. Possible phrases to use with a new mother are: You probably noticed your breasts are getting ready to feed your baby. Your breasts are perfect for feeding your baby. You can do this. Breastfeeding can be challenging in the beginning, but it will get easier. Don t quit easily. It is so important for you and your baby. Good for you for deciding to breastfeed your baby! You are making lots of good milk for your baby. You are very responsive to your baby s need to be close and breastfed often. You look so comfortable and peaceful holding your baby skin to skin! 14

64 56 Points to remember: Tell the mother how she will benefit from breastfeeding. Don t preach about the benefits to the baby. Most mothers know that breastfeeding is best, and they will frequently tune out messages that emphasize this. Acknowledge the mother s concerns with genuine interest. Breast Storage Capacity and Milk Supply The milk storage capacity of the breasts varies greatly between women, ranging from 80 to 600 ml. It is important to note that mothers working with a small storage capacity make as much milk (~750 ml) over a 24-hour period as those with a large storage capacity. They simply breastfeed more frequently, because the breast has fewer secretory cells and is not able to store large amounts of breastmilk between feedings. During the first few weeks postpartum, many mothers worry that they will not have enough milk to feed the infant. It is the most common reason that mothers choose to wean their infants early and supplement the feedings with formula. However, actual milk production insufficiency is quite rare. Most mothers have sufficient lactation capacity to make at least one third more milk than their infant normally takes. Nonetheless, the mother must be sure to drain about 67 percent of the milk from her breasts most of the time by either nursing the baby or expressing the milk. Otherwise, the rate of milk production will slow down to meet the lowered demand and total daily production will fall. In other words, milk supply equals demand. 15

65 57 References Bliss, M. C., & Risingsun, K. (2008). Protocol for Perinatal: Breastfeeding. Unpublished manuscript, Sutter Health Sac Sierra Region. Pessl, M. M., & Maxwell, K. (2011, April). Professional education in breastfeeding and lactation. In M. M. Pessl (Chair), Professional education in breastfeeding and lactation with lactation educator track. Symposium conducted at the meeting of Evergreen Perinatal Education, Berkeley, California. Riordan, J., & Wambach, K. (2010). Breastfeeding and human lactation. Sudbury, Massachusetts: Jones and Bartlett. 16

66 58 Post-Test #2 1. You are assisting a new mother with breastfeeding her first baby. Which breastfeeding position would be least recommended for her to use until her baby is older and has better head control? a. Football or clutch b. Side-lying c. Cradle d. Cross-cradle 2. A mother that you are caring for is having difficulty breastfeeding her infant due to her large nipple size. You advise her by saying: a. You will need to wait for your baby to grow into your nipple size. In the mean time, you will need to supplement with formula. b. You won t be able to breastfeed due to your nipple size. c. You will need to wait for your baby to grow into your nipple size. In the mean time, you will need to feed the baby pumped milk. d. I will fit you for a nipple shield, and we can use that until the baby grows into your nipple size. 3. Late-preterm infants are born between 34 completed weeks and less than 37 completed weeks. Which one of the following applies to them? a. Mature rooting and suckling b. Good muscle tone c. Poor temperature control due to having less body fat d. Their risk for complications is the same as for full-term infants. 4. Mrs. De la Cruz has just been brought to the postpartum unit following a cesarean birth. She is anxious to begin breastfeeding her baby. You say to her: a. What is your pain level? b. Your baby is still sleepy from anesthesia. We ll need to unwrap his blanket and stimulate him in order to feed. c. To breastfeed comfortably with your incision, it s best to hold your baby in the cross-cradle position. d. We need to get your baby to breastfeed right away. A delay in feeding will affect your ability to breastfeed. 17

67 5. Which of the following treatments is appropriate to use for engorgement? a. Warm compresses b. Cold compresses c. Pumping d. Cabbage compresses e. All of the above 59 18

68 Module #3: Postpartum Care 60 Module Topics Common Problems in the Early Days/Weeks o Baby is Not Latching, Sucking or Feeding Effectively o Torticollis (Tilted Jaw) o Supplementation Guidelines Nipple Pain Pacifier Use Stooling Patterns Infant Weight Gain Multiple Infants Bed Sharing Breast-Related Problems o Plugged Ducts o Mastitis o Thrush Teething What to Do When Baby is Sleepy/Hysterical Objectives After reviewing the information contained within this section, the student will be able to: 1) Name the conditions/circumstances that can cause latch and suck problems early on in breastfeeding. 2) State what the nurse should do if a comfortable latch cannot be achieved after a few attempts. 3) Define torticollis. 4) Identify the various treatments for nipple pain. 5) List some of the problems that have been linked to the routine use of pacifiers. 6) Recognize the normal stooling and urinating patterns associated with an infant s first month of life. 7) Describe the positions a mother can use to nurse two infants simultaneously. 8) List circumstances in which bed sharing with the infant would not be safe. 9) Name several self-care methods for treating a plugged duct within the breast. 10) Identify the symptoms associated with mastitis as well as the risk factors which predispose a mother to mastitis. 11) Describe thrush and how it is acquired. 12) List the recommended methods to keep a teething baby from biting the mother s breast while nursing. 13) Describe the infant sleep/wake states and the implications each has for breastfeeding. 1

69 Common Problems in the Early Days/Weeks 61 Skin-to-skin contact for a sustained amount of time immediately after birth and for many hours every day thereafter has been found to be the most effective, evidence-based strategy to: normalize mother-baby behavior support normal lactogenesis avoid breast and nipple pain ensure the production of an abundant milk supply assure that the newborn has adequate nutrition, hydration and comfort, and enhance the mother s confidence and ability to breastfeed and take care of her baby Baby is Not Latching, Sucking, or Feeding Effectively When a newborn does not latch and suck effectively, it can be immensely frustrating for the mother, health professionals, and especially the baby. There are several conditions that can cause latch and suck problems early on in breastfeeding: Immaturity or prematurity Illness Birth injuries Facial or jaw asymmetry Jaundice Short frenulum Cleft lip or palate Epidural anesthesia or analgesia Use of instruments to assist in delivery of infant Long, difficult labor Cesarean surgery Latching difficulties which result from prematurity, illness, or facial or oral structural anomalies (i.e., short frenulum, cleft lip or palate) require the intervention of a lactation specialist and other health professionals. The mother will need to collect her milk frequently by hand-expression and/or pumping, and her milk will need to be fed to the baby using a carefully selected feeding device. When a baby cannot latch on properly due to being drugged from birth medications, it is best to be patient and give the infant expressed colostrum or breastmilk until the infant has metabolized the drugs and is able to coordinate sucking, swallowing, and breathing smoothly. Mother and baby should be kept together, skin-to-skin, as much as possible during this waiting period. If the baby is only able to latch in one posture or position or on one breast, assist the mother in using that posture, position, or breast frequently. To avoid any problems due to milk stasis with 2

70 the other breast, it is important to express milk from that breast until the baby gradually improves in skill and is able to breastfeed in other postures, positions, and from both breasts. If a baby experiences difficulty with latching due to the mother s breast or nipple size or structure, the nurse can implement gentle mechanical strategies in order to alter the breast or nipple shape enough to enable latching and sucking. Some of these strategies include briefly using a breast pump or nipple extender device to draw out the nipple and short-term use of a nipple shield. Consultation with a lactation specialist may be advised. When an infant latches or sucks in such a way that there is insufficient milk intake, or the mother experiences pain or nipple damage, remove the baby from the breast and try again using a different technique or position. When a baby has latched on correctly, the nipple tip rests deeply in the baby s mouth, anterior of the hard-soft palate juncture. If a baby takes only the nipple tip, sucking will compress the nipple tip against the hard palate, leading to nipple pain and damage as well as a restricted milk flow through the milk ducts. If a comfortable, effective latch cannot be achieved after a few tries, it is best to enlist the help of a lactation consultant so as to avoid causing nipple damage due to repeated attempts. 62 If a comfortable, effective latch cannot be achieved after a few tries, it is best to enlist the help of a lactation consultant so as to avoid causing nipple damage due to repeated attempts. Fear of nipple pain and damage can quickly hamper a mother s willingness to continue attempting to breastfeed. 3

71 Torticollis (Tilted Jaw) 63 Torticollis is the development of asymmetrical mandibles and/or tilted jaws due to a cramped intrauterine environment. With torticollis, latching on to the mother s breast can be difficult for the infant. A baby with torticollis consistently turns his head to one side (usually right) and tilts to the other side (usually left) because of a tight, contracted muscle. Other signs include misalignment of the eyes and ears, one ear cupped forward and asymmetry of the jaws. The baby will typically prefer to breastfeed on one side and may exhibit other difficulties with feeding. Torticollis can resolve over time through the use of techniques that gently stretch the muscle on the affected side. Diagram 1: Torticollis. 4

72 Supplementation Guidelines 64 Hospital protocols vary with regard to when supplementation with pumped breastmilk or formula is to be started (i.e., 12, 18, or 24 hours) when a baby cannot latch on to the breast. Full-term infants are born with additional extracellular fluid that will help keep them hydrated in the first few days following birth. If no breastmilk is available and the infant is fed a commercial infant formula via a bottle, it is recommended that an angled bottle, rather than a straight bottle, be used to decrease the need for burping the infant. However, standard formula can be fed by small cup or spoon as well. It is not safe to heat formula in a microwave. The liquid does not heat evenly and can cause burns if given to the baby. In addition, it is dangerous to prop the bottle to feed an infant who is lying down. The infant may aspirate formula while sleeping and lying flat places the infant at risk for ear infections (formula/milk that pools in the pharynx is a medium for bacterial growth). For these reasons, it is important that the mother hold and cuddle the baby during all feeds and for a short while afterwards. Nipple Pain Nipple pain is a common concern during the early postpartum period. It is a primary cause of early discontinuation of breastfeeding. There are two types of nipple soreness: Transient soreness: During the first week postpartum, the mother may experience nipple pain or discomfort, lasting about seconds, as the baby latches on to the breast and draws the breast deep into his mouth. The period of discomfort usually peaks between the third and sixth days and resolves after that. Prolonged, abnormal pain: For some women, they have prolonged, unabated nipple pain that lasts beyond the first week. This condition requires assessment to determine the underlying cause and intervention to treat the problem. 5

73 The occurrence of nipple pain is not related to whether a mother did prenatal nipple preparation, her skin color, or her hair color. Early nipple pain typically occurs more often with first-time mothers. While some hospital personnel may advise new mothers to limit the length of their feedings in order to prevent sore nipples, placing a time limit of the length of each feeding can be harmful. It does not prevent the eventual development of nipple soreness, the baby may not receive a sufficient volume of milk and the higher-calorie hindmilk with a short feed time, and the mother may risk damage to the nipple skin by repeatedly removing the baby from the breast by breaking the baby s suction. Early nipple pain is usually the result of unusual mechanical pressures on the nipple skin, as demonstrated by a changed shape of the nipple (peaked, wedge shaped, white crease across the tip, wounds on the frontal surface) after the infant releases from the nipple post feeding. After a normal feeding, the nipple shape should be the same as before the feed began. It should also be intact and wet with milk. There are various treatments for nipple pain: Instruct the mother to nurse on the least sore side first. Correct the infant s positioning and latch by releasing the infant from the breast and starting over. If one position is not comfortable, try holding the baby in a different position (vertically, horizontally, or at a 45-degree angle) to improve the latch or suck. Varying the infant s position will change where pressure is applied to the nipple. Briefly place a nipple shield over the nipple to protect it from further damage. Have the mother wear breast shells (see Diagram 3) between feedings to keep clothing from rubbing on the damaged nipple. Rinse a cracked or abraded nipple with clean water after every feeding to prevent infection. Encourage frequent hand washing, especially before handling the breasts and nipples. A thin coating of a topical antibiotic can be applied to the cracked nipple area to prevent infection (the use of a topical antibiotic has not been found to cause any adverse effects on the infant). Do not use nipple ointments, creams, antiseptics, tea bags, wound dressings, foodbased oils, or gels to prevent or treat sore nipples. However, air-blocking products, such as purified lanolin or hydrogels, may be used to increase the mother s comfort, provided that no infection is present in or on the nipple skin. It is important to note that rubbing expressed milk into broken nipple skin does not help the wound to heal faster. On the contrary, it may cause harm by spreading bacteria into the wound. 6 65

74 66 Diagram 2: Sore, cracked nipple. Diagram 3: Breast shells. Pacifier Use Pacifiers are commonly used to deliberately postpone or stretch out the time between breastfeeding sessions. The routine use of pacifiers with breastfed infants has been linked to the following: A reduction in the infant s total time at the breast. Dental and orthodontic problems. An increase in infections, such as oral thrush. Accidents and injuries, including choking. Delayed or altered brain development, speech development, and behavior. Problems with attachment and maturation. The American Academy of Pediatrics recommends that the use of pacifiers be avoided until breastfeeding is well established. However, breastfeeding mothers should be made aware of the documented risks of pacifier use so that they can make an informed decision as to whether they want to use them. 7

75 67 Stooling Patterns The stools of a breastfed newborn go through many predictable changes. The newborn passes thick, tarry black (meconium) stools in the first few days after birth. Over time the stools gradually lighten in color, becoming greenish to yellow. Their consistency changes as well; they become less sticky, softer, and more liquid. If infant formula is given, the stools become darker, have larger and firmer curds, and are more odorous. The following charts outline the infant s normal stooling and urinating patterns. Table 1: Characteristic Stool Changes Over Time Time Period Type of Stool Number per Day Amount 0-6 days Meconium, transitional, milk stool 2+ Scant to copious 7-28 days Milk stool Scant 29+ days Milk stool 1 every 4-12 days* Copious *Occasionally older infants may go as long as 3-4 weeks between copious stools. Note. Adapted from Bliss, M. C., & Risingsun, K. (2008). Protocol for Perinatal: Breastfeeding. Unpublished manuscript, Sutter Health Sac Sierra Region. Table 2: Newborn Voidings (The following are the minimum number of voiding for a newborn) Day of Life Minimum Voiding Note. Adapted from Bliss, M. C., & Risingsun, K. (2008). Protocol for Perinatal: Breastfeeding. Unpublished manuscript, Sutter Health Sac Sierra Region. 8

76 68 Infant Weight Gain A person s weight increases faster in infancy than at any other time of his or her life. For the most part, infants double their birth weight by the time they reach 5 months of age, triple it by 1 year of age, and quadruple it by 2 years of age. The average weight of a newborn ranges from lb. Following birth, infants lose the excess fluid they were born with which amounts to 5 to 10 percent of their birth weight. Their weight stabilizes within a few days. The weight patterns of infants who are formula-fed are different than the patterns of infants who are exclusively breast-fed. For the first few months of life, their weights are similar. However, formula-fed infants begin to weigh more than breast-fed infants at 3 to 4 months of age. Multiple Infants Many expectant parents of multiples are uncertain whether it is possible to breastfeed multiple infants. Research and case studies have shown that most mothers of multiples are able to produce most or all of the breastmilk needed to feed two to four infants. There are numerous benefits to breastfeeding twins, triplets, and other higher-order multiples: Breastfeeding offers the best nutrition and immunological protection to infants who are often preterm or otherwise compromised. Breastfeeding helps ensure that the mother interacts frequently with each baby. The frequent feedings give the mother many opportunities to sit or lie down to rest while she breastfeeds. Diagrams 4-6 illustrate several positions a mother can use to nurse two infants simultaneously. When showing a mother how to position her infants to breastfeed simultaneously, it is important to use pillows to stabilize the two babies. The mother can use pillows either from the hospital or from home or use special pillows specifically designed for feeding multiples. Using the pillows, each baby should be positioned so that the hips are significantly lower than the head. 9

77 69 Diagram 4: The double cradle hold. Infants held in this position are crisscrossed in the mother s lap. Diagram 5: The cradle and clutch hold. One infant is positioned in a clutch/football hold under the mother s arm while the other infant is in the cradle position. Diagram 6: The double clutch hold or football hold. The head of each infant is positioned facing the breast and the bodies are positioned under the mother s arms. 10

78 70 Bed Sharing The safety of mother-infant bed sharing has been the subject of much debate. Parents are often confused about whether it is safer for the infant to sleep in the crib or in the parent s bed. Since the majority of exclusively breastfeeding mothers will bring their babies into their beds either all or some of the time, it is essential that the safe and unsafe conditions of shared sleep be reviewed. Do Practice Safety During Bed Sharing If Do Not Bed Share All Night If Bed partners: Exclusively breastfeeding mother Conscious decision by both parents to bed share Nonsmoking (never smoke) Sober and drug free Parents of the baby No pets Baby s position: Baby on his back (supine) Baby unwrapped, free to wiggle and move Bedding/sleep surface: Firm, flat, clean mattress No holes, spaces, or places that could trap baby Tightly fitting sheets under baby No pillows or blankets near baby s face No thick duvets or comforters Room comfortable temperature, not overheated Bed partners: Formula feeding or supplementing with formula Accidental bed sharing Any tobacco smoking, even outside Alcohol and/or drug use Nonparents; siblings Animals Baby s position: Baby in prone or side-lying position Baby is swaddled or bundled in a blanket Bedding/sleep surface: Couch or sofa; arm chair; soft or saggy mattress; waterbed Holes, spaces, or places that could trap baby Loose sheets or blankets under baby Pillows or blankets around baby Thick covers on or over baby Overheated room Note. Adapted from Riordan, J., & Wambach, K. (2010). Breastfeeding and human lactation. Sudbury, Massachusetts: Jones and Bartlett. Table 3: Safety Issues for Breastfeeding and Bed Sharing 11

79 71 Breast-Related Problems Plugged Ducts The specific cause of plugged ducts within the breast is unknown. However, they typically occur with mothers who produce an abundant amount of breastmilk and who do not drain each breast adequately. The symptoms associated with a plugged duct are: Complaints of heat, tenderness, and possible redness in one location of the breast, or A palpable, well-defined lump without a generalized fever. It is important to treat plugged ducts, because ignoring them or leaving them untreated can lead to mastitis. Usually, the mother can treat a plugged duct herself through self-care measures (see Table 4). An antibiotic is necessary only if the plugged duct progresses to a fever and mastitis. Some factors that have been implicated in the development of plugged ducts are skipping a feeding (resulting in incomplete drainage), a constricting bra, poor nutrition, and stress. Table 4: Self-Care for Treating a Plugged Duct Continue to breastfeed often. Begin feeding on the affected breast to promote drainage. Depress the breast during the feed to prevent plugged ducts. Massage the affected breast before and during feeding to stimulate flow of milk. Support the breast with a cupped hand and use firm massage, starting at the periphery of the breast, using thumb to encourage flow of milk while baby suckles. (Another option is to massage the breast in a hot shower or bath.) Outside of the shower, try using an electric vibrator (on low setting). Soak the affected breast(s) by leaning over a basin of warm water, and gently massaging them. Change position of the infant during feedings to ensure drainage of all the sinuses and ductules in the breast. At least one position should result in the baby s nose being pointed toward the site of the plugged duct. Avoid any constricting clothing, such as an underwire bra or the straps on a baby carrier. Try taking lecithin, an oily substance, 1 T/day (found in health food stores). Note. Adapted from Riordan, J., & Wambach, K. (2010). Breastfeeding and human lactation. Sudbury, Massachusetts: Jones and Bartlett. 12

80 Mastitis 72 Mastitis is usually a benign, self-limiting infection that can develop during the early postpartum weeks after the mother returns home. The initial symptoms, which may lead the breastfeeding mother to believe that she has the flu, include fatigue, localized breast tenderness, headache, and flulike muscle aches. Following these symptoms, the mother typically develops a fever, a rapid pulse, and the appearance of a hot, reddened, and tender area on the breast. The infection is usually unilateral and located in the upper outer breast quadrant, but it can occur anywhere on the breast. Symptoms last approximately 2 to 5 days, and the mother should continue to nurse her infant during this time to hasten recovery. In addition, treatment involves applying moist heat to the affected area, increasing fluid intake, taking pain medication as needed (acetaminophen, ibuprofen), bed rest, and taking antibiotics as prescribed. The risk factors which predispose a mother to mastitis are: Stress and fatigue (due to circumstances which cause fatigue above and beyond the normal stresses of taking care of the infant) Cracked or fissured nipples and nipple pain Plugged or blocked ducts Abundant milk supply and/or decrease in the number of feedings Engorgement and stasis Constriction from tight bra or sleeping position Using a manual pump Poor maternal nutrition Thrush If a mother has been breastfeeding painlessly and then rapidly develops extremely sore nipples, burning or itching, and shooting pain within the breast, candidiasis (thrush) should be suspected as the cause. The nipples and areola become inflamed, appearing deep pink in color, and sometimes present with tiny blisters. An infant s mouth can become infected with Candida during a vaginal birth, and this infection can then be passed on to the mother s breast and nipple during breastfeeding. Recurrent infection can be caused by pacifiers and bottle nipples that are used by an infant with thrush. They should be replaced or boiled after each exposure in the infant s mouth. 13

81 To treat an infant for thrush, an antifungal medication (such as nystatin) is placed into the mouth via a medicine dropper after feedings and is then swabbed over the mucosa, gums and tongue. The mother treats the infected areola and nipple area by applying an antifungal topical cream or lotion before and after every feeding. If the infant has a diaper rash from Candida as well, the antifungal cream can also be applied to the entire diaper area. The mother may also have a vaginal yeast infection requiring treatment with an antifungal intravaginal preparation Diagram 7: Candidiasis (thrush) of the breast. Teething Many new mothers only plan to breastfeed their infants up to the time when new teeth come in (around six months of age). However, with the American Academy of Pediatrics now recommending that babies be nursed for at least a year, there are practical ways to manage teething and breastfeeding. When a baby is cutting teeth, the gums may become swollen and sore. To relieve the discomfort, the infant may chew on the mother s nipple in the same way he chews on everything else. A baby who is latched on properly and is actively nursing cannot bite the breast. Biting is most likely to occur at the end of a feeding, when the baby is full and loses interest in nursing. The following suggestions may keep a baby from biting: 1. Sometimes babies will bite to get their mother s attention. To discourage this, it is important to focus on the baby while breastfeeding by maintaining eye contact, talking to him, and touching him as he nurses. 14

82 2. Since an infant will tend to bite towards the end of a feeding, the mother should watch for cues that the baby is finished nursing. Some babies will become restless, pull off the breast, and begin to look around. Others may tense their jaws just before they bite down. Remove the infant from the breast when he shows these cues before he has a chance to bite. 3. Make sure that the infant is latched on correctly. The mouth should be open wide, and the baby should be pulled in close to ensure that the nipple is far back in the mouth. Sometimes as the infant becomes sleepy with nursing, the nipple will pull back in his mouth which may cause him to bite reflexively as he feels the nipple slipping away. 4. Don t force the baby to nurse. 5. To help the baby settle down to nurse, keep distractions to a minimum. Dim the lights, turn off the TV, lie down in a quiet room, or play soothing music. 6. Sometimes infants will bite down while nursing if they have nasal congestion and are having trouble breathing. The pediatrician can recommend treatment options to clear the congestion, making breastfeeding easier. 7. Since some babies will bite out of frustration when the mother s milk supply falls, she should try to keep her milk supply plentiful. If the baby does bite the mother, she should not pull him off her breast, which may cause damage to the nipple. Instead, pull him in close with his nose pressed against the breast. This will force him to open his mouth, releasing the nipple, so he can breathe. Another way to release the infant from the breast is to slip a finger in between his gums or teeth to get him to open his mouth. If the infant continues to bite with subsequent feeds, the mother should stop the feeding, say in a firm voice, No, that hurts Mommy! and set the infant down on the floor. The baby will soon learn that if he wants to nurse, he cannot bite

83 What to Do When Baby is Sleepy/Hysterical 75 Table 5 reviews the various infant sleep/wake states and how each state impacts breastfeeding. Infant State Description Implications for Breastfeeding Deep or quiet sleep Closed eyes with no eye movement; regular breathing Only intense stimuli will arouse Relaxed Do not attempt to feed Absent body movements with occasional isolated startles Light or active sleep Closed eyes with rapid eye More easily aroused by stimuli movements Not alert enough to feed Irregular breathing Sucking, smiling, grimacing, yawning Some slight muscular twitching of the body Most infant s sleep is in this state Drowsy May have eyes open Stimuli may arouse infant but Irregular breathing may return to sleep Variable body movements with mild startles May enjoy nonnutritive sucking Relaxed Quiet alert Eyes bright and wide open Interacts with others Responsive to stimuli Excellent time to initiate Minimal body activity breastfeeding before becomes fussy and agitated Active alert Eyes open Comfort (change diaper, hold, Rapid and irregular breathing talk quietly) More sensitive to stimuli and discomfort Initiate breastfeeding before progression to crying Active Crying Eyes open or tightly closed Comfort (hold, swaddle, talk Irregular breathing quietly, rock) before attempting Crying, very active to breastfeed Uncoordinated, thrashing movement of extremities Note. Adapted from Riordan, J., & Wambach, K. (2010). Breastfeeding and human lactation. Sudbury, Massachusetts: Jones and Bartlett. Table 5: Infant Sleep/Wake States with Implications for Breastfeeding. 16

84 In the hospital, the nurse can employ the following tactics when working with a mother and her sleepy newborn who breastfeeds infrequently: 76 Encourage and facilitate skin-to-skin contact between mother and infant. Reassure the mother who had maternal analgesia that the baby s sleepiness may be due to the analgesia to which he was exposed before birth. Encourage the mother to offer the breast to the infant whenever the infant is awake. Suggest to the mother that she allow the baby to nurse from the first breast until he has let go on his own before trying to nurse him at the second breast. Provide the mother with information on resources for breastfeeding support within her community. References Riordan, J., & Wambach, K. (2010). Breastfeeding and human lactation. Sudbury, Massachusetts: Jones and Bartlett. Smith, A. (2012). Teething and biting. Breastfeeding Basics. Retrieved from 17

85 Post-Test # Mrs. Smith is brought to the postpartum unit following a cesarean birth. She expresses her frustration to you that her baby is too lethargic to breastfeed right away and wonders if it is from the birth medication. You say to her: a. It s important to allow your baby to metabolize the birth medication before trying to breastfeed. I ll place him in the bassinet next to you and we ll try to breastfeed when he s more alert. b. It s important to allow your baby to metabolize the birth medication before trying to breastfeed. He needs to be kept skin-to-skin with you during this waiting period. c. It s important that you rest. I ll take the baby to the nursery so you can try to sleep. d. You shouldn t be frustrated. It s normal for a baby to be lethargic following a cesarean birth. 2. You are assisting Ms. Gonzales with trying to breastfeed her infant for the first time. You know the proper technique to facilitate a latch, and the baby is alert and is rooting when stimulated. You have tried to get the baby to latch on correctly, but the mother experiences nipple pain with each attempt to latch. Your next intervention would be to: a. Try a few more times to facilitate a latch, and then make a referral to a lactation consultant. b. Stop trying to achieve a latch, and enlist the help of a lactation consultant. c. Get a nipple shield for the mother, and continue with trying to facilitate a latch. d. Reassure the mother that nipple pain is normal, and continue with trying to facilitate a latch. 3. Pacifiers are routinely used with breastfed infants to deliberately postpone or stretch out the time between breastfeeding sessions. Which of the following statements is not true regarding their use: a. Infants can have dental and orthodontic problems when they are older. b. If a mother chooses to use a pacifier, it can be introduced at any time. c. Infants can have delayed or altered brain development, speech development, and behavior. d. Pacifiers cause an increase in infections, such as oral thrush. 18

86 4. Your breastfeeding patient on the postpartum unit complains of having a palpable, welldefined lump in her right breast that she just noticed that morning. You palpate the lump, and then: a. Call her doctor to report the lump, expressing concern that it may be breast cancer. b. Advice the patient that breast lumps sometimes occur with breastfeeding and it will resolve on its own. c. Take the mother s temperature. d. Advise the mother to only breastfeed the baby with the left breast. 5. When working with a breastfeeding mother and her sleepy newborn who breastfeeds infrequently, which intervention is not appropriate for the nurse to utilize? a. Encourage the mother to offer the breast to the infant whenever the infant is awake. b. Advise the mother that she must feed the infant from both breasts at each feeding. c. Provide the mother with information on resources for breastfeeding support within her community. d. Suggest to the mother that she allow the baby to nurse from the first breast until he has let go on his own before trying to nurse him at the second breast

87 Module #4: Miscellaneous 79 Module Topics Milk Storage Guidelines Breast Pumps o Recommended Technique o Common Pumping Problems Hand Expression Breast Shells Feeding-Tube Devices Maternal Nutrition During Lactation o Foods That Pass Into Milk Cleft Lip and Breastfeeding Fertility and Lactation Culture and Breastfeeding o Colostrum o Hot and Cold Foods Baby Friendly Hospitals o Ten Steps Criteria Objectives After reviewing the information contained within this section, the student will be able to: 1) State the storage duration guidelines for breastmilk for healthy, full term infants. 2) Describe how to safely thaw breastmilk. 3) Describe the recommended technique for using a breast pump. 4) List the most common problems associated with the use of a breast pump. 5) Explain the technique involved in hand expression. 6) Discuss the rationale for using breast shells. 7) List the situations in which feeding-tube devices would be recommended. 8) List the specific foods which, when they pass into breastmilk, may cause allergic responses in infants. 9) Identify the symptoms associated with a possible food allergy in the infant. 10) Describe how cleft lip impacts breastfeeding. 11) Explain how breastfeeding affects a woman s fertility and identify the factor(s) which cause the return of fertility. 12) Discuss the cultural beliefs regarding colostrum and hot and cold foods. 13) Discuss the rationale behind the development of the Baby Friendly Hospital Initiative. 1

88 80 Milk Storage Guidelines Guidelines for Storing Breastmilk: Wash hands before expressing or handling breastmilk. Store collected milk in clean containers, such as screw cap bottles, hard plastic cups with tight caps, or heavy-duty bags that fit directly into nursery bottles. Ordinary plastic storage bags or formula bottle bags should not be used to store milk, as these could easily leak or spill. If the breastmilk will be delivered to a child care provider, the container should be clearly labeled with the child s name and date. The milk should be clearly labeled with the date it was expressed. Be sure to use the oldest milk first. Fresh milk should not be added to already frozen milk within a storage container. Milk that is leftover from a used bottle should not be saved for use at another feeding. Safely Thawing Breastmilk: Frozen breastmilk can be defrosted by either placing the container in the refrigerator (as time permits) or by swirling it in a bowl of warm water. Do not use a microwave to thaw or heat bottles of breastmilk. o Microwave ovens do not heat liquids evenly, and this could result in scalding of the baby or damage to the milk. o If bottles are left too long in the microwave, they may explode. o The nutrient quality of the expressed milk can be destroyed by the excess heat of the microwave. Once breastmilk has been thawed, it should not be re-frozen. Table 1: Breastmilk Storage Guidelines for Preterm or Sick Infants Type of Breastmilk Room Temp Refrigerator Home Freezer -20º Freezer Freshly Expressed Breastmilk 1 hour 48 hours 6 months 12 months Thawed Breastmilk Do not store 24 hours Never refreeze Never refreeze Note. Adapted from Bliss, M. C., & Risingsun, K. (2008). Protocol for Perinatal: Breastfeeding. Unpublished manuscript, Sutter Health Sac Sierra Region. 2

89 81 Table 2: Storage Duration of Fresh Human Milk for Use with Healthy Full Term Infants Location Temperature Duration Comments Countertop, table Room temperature (up to 77ºF or 25ºC) 6-8 hours Containers should be covered and kept as cool as possible; covering the container with a cool towel may keep milk cooler. Insulated cooler bag 5-39ºF or -15-4ºC 24 hours Keep ice packs in contact with milk containers at all times, limit opening cooler bag. Refrigerator 39ºF or 4ºC 5 days Store milk in the back of the main body of the refrigerator. Freezer compartment of a refrigerator Freezer compartment of refrigerator with separate doors Chest or upright deep freezer Freezer 5ºF or -15ºC 2 weeks 0ºF or -18ºC 3-6 months -4ºF or -20ºC 6-12 months Store milk toward the back of the freezer, where temperature is most constant. Milk stored for longer durations in the ranges listed is safe, but some of the lipids in the milk undergo degradation resulting in lower quality. Note. Adapted from Academy of Breastfeeding Medicine. (2004) Clinical Protocol Number #8: Human Milk Storage Information for Home Use for Healthy Full Term Infants [PDF-125k]. Princeton Junction, New Jersey: Academy of Breastfeeding Medicine. Available 3

90 Recommended Technique Breast Pumps Before using the pump, elicit the milk-ejection reflex (let-down) to maximize the amount of breastmilk obtained. The most effective means of stimulating let-down is by massaging the breast with a hot, wet cloth. 2. Use only as much vacuum as is needed to keep the breastmilk flowing and remain comfortable. 3. Before and during pumping, massage the breast in quadrants to increase intramammary pressure (thereby increasing milk yield). 4. Allow adequate time to pump, so as to avoid becoming anxious. Psychologic stress can inhibit the milk-ejection reflex. 5. To optimize the fit between the breast and pump, use inserts or different sized flanges (see Diagram 1) if needed. 6. Avoid long periods in which there is uninterrupted vacuum. 7. When the milk flow is minimal or stops altogether, stop pumping so as to reduce tissue injury. Diagram 1: Various parts of a basic breast pump. 4

91 Common Pumping Problems 83 The most common problems associated with pumping are: Sore nipples. This problem can be minimized by: o Using the lowest amount of vacuum needed to obtain milk o Applying vacuum only after the breastmilk begins to flow o Interrupting the vacuum frequently so as to decrease or avoid pain while still maintaining the flow of milk o Switching back and forth between breasts frequently as the milk flow slows (when using single-sided pumping) o Making sure that the flange fits properly the nipple tunnel is not too small for the nipple entering it or too large to be effective o Pumping for shorter periods of time Obtaining only small amounts of milk with each pumping session o This usually occurs when the milk-ejection reflex has not been elicited. o Note: Increasing fluid intake does not usually increase the amount of breastmilk produced. o Time pumping sessions when milk yield is greater (i.e., pump midway between feedings rather than at the end of a feeding, pump first thing in the morning) Erratic or delayed milk-ejection reflex (this is common, particularly when the mother is first learning to use a pump) Milk supply gradually dwindles over a long-term course of pumping (this is not unusual with extended pumping) Hand Expression Using hand expression to obtain breastmilk has many advantages over using breast pumps: Hand expression costs nothing to use. The mother may trigger a more effective milk ejection reflex through the use of her own hands. There is no equipment involved and the mother s hands are always available. The hands compress the breast to remove milk. 5

92 84 Diagram 2: Hand expression. Diagram 3: Side view of hand expression. A step-by-step outline of the technique used in hand expression: 1. Wash hands and any collection equipment to be used. Sit comfortably, and place the collection cup under the breast. Apply warm, moist towel to enhance milk flow. Massage breasts and nipples to stimulate milk ejection reflex. Use gentle pressure using a circular motion, moving around the breast. 2. Squeeze the breast gently, rolling the hands forward from the chest toward the nipple. (Be sure not to slide the fingers down the breast so as to avoid inadvertently bruising or abrading the skin.) 3. Place thumb and forefingers approximately 1 to 1½ inches behind the nipple and press into the breast. 4. Press inward toward the chest wall squeezing gently with a slight rolling action toward the nipple. Release pressure and repeat as needed to obtain milk. If pain results, something is wrong and the mother should be observed in order to identify what may be causing the mother discomfort. 6