Best Practices for Breastfeeding Evidenced Based Recommendations. Section I: Background

Transcription

1 Best Practices for Breastfeeding Evidenced Based Recommendations Section I: Background Breast milk is the preferred nutrition for human infants. Breastfeeding is the single most powerful and well documented preventative modality available to healthcare providers to reduce the risk of common causes of infant morbidity. Benefits of breastfeeding to infants include (but are not limited to) lower rates of death from both injury and sudden infant death syndrome, allergies, asthma, respiratory infections, gastrointestinal infection, necrotizing enterocolitis, childhood cancers, type I and II diabetes, obesity, neglect, and pre and postmenopausal breast cancer. The infants also have higher intelligence quota, improved vaccine response and better oral/dental health. Benefits to mother include lower risk of breast cancer, ovarian cancer, hypertension, metabolic disease, reduced rates of smoking, and suppression of fertility resulting in optimal child spacing. Most of these benefits have a dose response, the longer that breastfeeding is continued the more benefits mother and infant will incur. This dose response is seen when breastfeeding is continued beyond the first year. There is an increased mortality when breastfeeding is discontinued before 3 years of age. Exclusivity for the first 6 months of life is another important marker in the mother-infant dyad to receive these benefits. Hospital practices have been shown to greatly impact exclusivity and duration of breast feeding. Implementation of the World Health Organization/UNICEF s Baby-Friendly Hospital Initiative is an effective intervention of 10 steps to improve breastfeeding rates (both duration and exclusivity) at hospital discharge and longterm. Women who deliver at Baby-Friendly Hospitals are six times more likely to meet their exclusive breastfeeding goals than those from hospitals that are not Baby-Friendly. All 13 Indian Health Service obstetric facilities have been designated Baby-Friendly. As a result of this initiative, breastfeeding initiation rates at most of these IHS facilities are now consistently in the 90th percentile for breastfeeding, and exclusive breastfeeding rates have continued to climb. Within the 10 steps is a requirement for staff training. The CDC has found that maternity nurses most often lack the education and training to properly assist women with breastfeeding. Women who give birth at hospitals where International Board Certified Lactation Consultants (IBCLC) are employed are 2.28 times more likely to be breastfeeding at discharge, when the mother is a Medicaid recipient women are 4.13 times more likely to be breastfeeding at discharge from the hospital. Primary care settings that employ an IBCLC have been shown to increase the duration of breastfeeding. Breastfeeding results in lower healthcare costs. If 90% of US families could comply with medical recommendations to breastfeed exclusively for 6 months, the United States would save $13 billion per year. There is also a direct financial benefit to families as they incur lower costs associated with the purchase of formula, feeding supplies, and clean water which can be a large financial burden to families in remote villages of Alaska. These guidelines are supported by recommendations by the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, World Health Organization, Centers for Disease Control and Prevention, American College of Nurse-Midwives, National Association of Pediatric Nurse Practitioners, Association of Women's Health Obstetric and Neonatal Nurses, and Academy of Breastfeeding Medicine.

2 Section II: Management 1. The Alaska Native Medical Center staff will actively support breastfeeding as the preferred method of providing nutrition to infants and thus support measures to adhere to the 10 steps of the Baby-Friendly Hospital Initiative (Appendix I). 2. On a biannual basis a multidisciplinary team will review and update this policy or when new research necessitates a change in policy. 3. This policy will be communicated to all healthcare staff on an annual basis. 4. Alaska Native Medical Center does not accept free formula or free breast milk substitutes. Nursery or Neonatal Intensive Care Unit discharge bags offered to all mothers will not contain infant formula, coupons for formula, logos of formula companies, or literature with formula company logos. 5. Alaska Native Medical Center health professionals will attend educational sessions on lactation management and breastfeeding promotion to ensure that correct, current, and consistent information is provided to all mothers wishing to breastfeed. We will refer to the Baby-Friendly Hospital Initiative (Appendix II) education requirements as a guide. 6. All women of childbearing years (15-55) will be asked about their lactation status on admission to the hospital. If being admitted to a floor other than MBU a consult with an IBCLC will be routinely ordered to help preserve lactation during the hospital stay. 7. If women are seen in the Emergency Room (or other locales) for breastfeeding complications (i.e. mastitis) on an outpatient basis, a referral for follow up to the lactation department will be made. 8. Most procedures and surgeries undergone by lactating women do not necessitate the cessation of breastfeeding. In most instances breastfeeding can continue uninterrupted. When contrast media is required, the Alaska Native Medical Center will refer to the American College of Radiologist s Manual on Contrast Media section on safety during lactation (Appendix III). PRENATAL CARE 9. A pregnant woman s desire to breastfeed will be documented in her medical record. She will be provided counseling throughout her prenatal care about the benefits to breastfeeding, management of breastfeeding, and risks associated with formula use as outlined in Appendix IV. The completion of this education will be appropriately documented in her medical record. 10. Mothers will be encouraged to exclusively breastfeed for the first 6 months of life unless medical contraindications exist (Appendix V). The method of feeding will be documented in the medical record of every infant. a. Exclusive breastfeeding is defined as providing breast milk as the sole source of nutrition.

3 b. Exclusively breastfed babies receive no other liquids or solids with the exception of oral medications prescribed by a medical care provider for the infant. 11. As illicit drug use during lactation can have negative developmental effects for newborns, the recommendations of Alaska Native Medical Center will be based on a woman s ability to maintain sobriety and will be made on a case-by-case basis. Recommendations for who is an appropriate candidate to whom breastfeeding should be recommended can be found in Appendix VI. HOSPITAL CARE OF THE MOTHER-INFANT DYAD 12. Mothers can begin to express colostrum during the outpatient ripening phase when undergoing induction of labor for medical conditions with high risk for hypoglycemia of the newborn such as gestational diabetes. On each day of induction mothers will be instructed to hand express colostrum for minutes and collect the colostrum for use in the initial postpartum period if it becomes necessary to supplement the newborn. 13. All term newborns, if baby and mother are stable, will be placed skin-to-skin with the mother at birth. Newborns should be left skin-to-skin until after the first feeding has been accomplished. The nurse should assist the mother-infant dyad with establishing the latch when necessary. Post-cesarean-birth babies will be encouraged to breastfeed as soon as possible, potentially in the operating room or recovery area (Appendix VII). The administration of vitamin K and prophylactic antibiotics to prevent ophthalmia neonatorum should be delayed for the first hour after birth to allow uninterrupted mother infant contact and breastfeeding. If the newborn requires assessment at the warmer or is taken to the NICU he/she should be returned and placed skin-to-skin as soon as medically stable. 14. Nursing staff will offer each mother further assistance with breastfeeding within 6 hours of delivery. The mother should be guided so that she can help the newborn latch onto the breast properly. 15. Each newly delivered mother-infant dyad will have a short 1-2 minute courtesy visit with an IBCLC within 24 hours of delivery to determine her lactation acuity level (Appendix VIII). After the initial courtesy visit, the mother-baby nurse should continue to monitor the dyad s lactation acuity level to determine a change in status and notify the IBCLC as necessary. Acuity level 1 should be managed by the mother-infant nurse. Acuity level 2 and 3 should be followed by at least one full visit with an IBCLC. 16. The breastfeeding mother infant dyad will be encouraged to remain together throughout their hospital stay, including at night (rooming-in). Skin-to-skin contact will be encouraged as much as possible while the mother is awake, with a goal to spend at least 8 hours a day in skin-to-skin contact.

4 17. A breastfeeding assessment, teaching, and documentation will be done on each shift. Each feeding will be documented. Every shift, a direct observation of the baby s position and latch during feeding will be performed and documented using the LATCH scoring system by the nurse. 18. During the hospital stay breastfeeding mothers will be instructed about: a. Proper positioning and latch-on b. Nutritive suckling and swallowing c. Milk production and release d. Frequency of feeding with an expected number of feeds of 8 to 12 times each 24 hours, with some infants needing to be fed more frequently. e. Feeding cues and how to use them as indicators of the baby s readiness to feed f. Hand expression of breast milk g. How to assess if an infant is adequately nourished h. Reasons for contacting the healthcare professional These skills will be taught to primiparous and multiparous women, provided in written form, and reviewed before the mother goes home. 19. Time limits for breastfeeding on each side will be avoided with the healthy newborn. Infants can be offered both breasts at each feeding but may be interested in feeding only on one side at a feeding during the early days. 20. Pacifiers will not be given to normal full-term breastfeeding infants. Preterm infants in the Neonatal Intensive Care or infants with specific medical conditions (e.g., neonatal abstinence syndrome) may be given pacifiers for non-nutritive sucking. Newborns undergoing painful procedures (e.g., circumcision) may be given a pacifier as a method of pain management during the procedure. The infant will not return to the mother with the pacifier. 21. For minor procedures (such as circumcision) not requiring sedation or general anesthesia, the infant should continue to be fed normally. Infants are more likely to tolerate minor procedures when the usual feeding pattern is maintained. They will be more comfortable when they have eaten in a normal routine. Without anesthesia, even if the patient is sleeping during the procedure, the upper airway reflexes are intact, and infants will be able to naturally protect their airways. 22. The Alaska Native Medical Center encourages the use of breastfeeding during painful procedures, such as the heel stick procedure for the newborn metabolic screening tests. When it is not practical to breastfeed during the procedure such as during circumcision, the mother will be encouraged to hand express breast milk to provide in place of sucrose for pain relief. 23. Routine blood glucose monitoring of full-term healthy appropriate-for-gestational-age infants is not indicated. Assessment for clinical signs of hypoglycemia and dehydration will be ongoing. 24. Routine use of nipple creams, ointments, or other topical preparations will be avoided unless such therapy has been indicated for a dermatologic problem. Mothers with sore nipples will be observed for latch-on techniques and will be instructed to apply expressed colostrum or breast milk to the areola/nipple after each feeding before recommending nipple creams/ointments.

5 25. Nipple shields or bottle nipples will not be routinely used to cover a mother s nipples, to treat latch-on problems, or to prevent or manage sore or cracked nipples or used when a mother has flat or inverted nipples. Nipple shields will be dispensed by the lactation consultant and after other attempts to correct the difficulty have failed. SUPPLEMENTATION 26. After 24 hours of life, if the infant has not latched-on or fed effectively, the mother will be instructed to begin to massage her breasts and hand express colostrum into the baby s mouth during feeding attempts. Skin-to-skin contact will be encouraged. Parents will be instructed to watch closely for feeding cues and whenever these are observed to awaken and feed the infant. If the baby continues to feed poorly, hand expression by the mother or a double set-up electric breast pump will be initiated and maintained approximately every 3 hours, or a minimum of eight times per day. The mother will be reminded that she may not obtain much milk, or even any milk, the first few times she attempts expression. Until the mother s milk is available, a collaborative decision should be made among the mother, nurse, and healthcare professional regarding the need to supplement the baby. Each day, the responsible healthcare professional will be consulted regarding the volume and type of supplement. 27. If the baby is still not latching on well or feeding well when discharged to home, the feeding/expression/supplementing plan will be reviewed in addition to routine breastfeeding instructions. A follow-up visit or contact will be scheduled within 24 hours. Depending on the clinical situation, it may be appropriate to delay discharge of the couplet to provide further breastfeeding intervention, support, and education. 28. No supplemental water, glucose water, or formula will be given unless specifically ordered by a healthcare practitioner. Informed consent should be obtained prior to non-medically indicated supplementation. 29. Those parents who, after appropriate counseling, choose to formula feed their infants will be provided with face-to-face individual instruction, a demonstration, and will return demonstrate showing competency in preparation of powdered infant formula prior to hospital discharge. 30. Infant indicators for supplementation in term newborns a. Asymptomatic hypoglycemia that is unresponsive to appropriate frequent breastfeeding. b. Clinical and laboratory evidence of significant dehydration that is not improved after skilled assessment and proper management of breastfeeding. c. Weight loss of 8 10% accompanied by delayed lactogenesis II (day 5 or later) d. Delayed bowel movements or continued meconium stools on day 5 e. Insufficient intake despite an adequate milk supply (poor milk transfer) f. Hyperbilirubinemia g. Breastfeeding-associated jaundice which is associated with starvation where breast milk intake is poor despite appropriate intervention h. Breast milk jaundice when levels reach 20 mg/dl in an otherwise thriving infant and where a diagnostic and/or therapeutic interruption of breastfeeding may be helpful

6 i. When macronutrient supplementation is indicated 31. Maternal indications for supplementation in term newborns a. Delayed lactogenesis II (day 3 5 or later) and inadequate intake by the infant b. Retained placenta (lactogenesis probably will occur after placental fragments are removed) c. Sheehan s syndrome (postpartum hemorrhage followed by absence of lactogenesis) d. Primary glandular insufficiency, occurs in less than 5% of women (primary lactation failure), as evidenced by poor breast growth during pregnancy and minimal indications of lactogenesis e. Breast pathology or prior breast surgery resulting in poor milk production f. Intolerable pain during feedings unrelieved by interventions 32. Mothers who are separated from their sick or premature infants will be: a. Instructed on how to use skilled hand expression and the double set-up electric breast pump with hands on pumping. b. When the infant is taken directly to the NICU from the birth the RN will help the mother begin hand expression within one hour or as soon as mother is medically able. Instructions will include expression at least eight times per day or approximately every 3 hours for 15 minutes (or until milk flow stops, whichever is greater) around the clock and the importance of not missing an expression session during the night. c. Encouraged to breastfeed on demand as soon as the infant s condition permits d. Taught proper storage and labeling of human milk AT DISCHARGE 33. Before leaving the hospital breastfeeding mothers should be able to a. Position the baby correctly at the breast with minimal or no pain during the feeding b. Latch the baby to breast properly c. State when the baby is swallowing milk d. State that the baby should be nursed a minimum of 8 to 12 times a day until satiety, with some infants needing to be fed more frequently e. State age-appropriate elimination patterns (at least five urinations per day and three to four stools per day by the fourth day of life) f. List indications for calling a healthcare professional g. Manually express milk from their breasts 34. All breastfeeding newborns will be referred to a health care professional for a visit on the third to fifth day of life or within 24 to 72 hours of discharge. 35. Prior to going home, mothers will be given the names and telephone numbers of community resources to contact for help with breastfeeding, including the hospital s lactation department.

7 SUMMARY OF RECOMMENDATIONS: The following conclusions are based on good and consistent scientific evidence (Level A): Exclusive breastfeeding for newborn infants, unless medically contraindicated, because of its proven benefits for both infants and mothers. Optimal duration of exclusive breastfeeding is 6 months versus 3-4 months due to protection from gastrointestinal infections in the infant and prolonged lactational amenorrhea and improved weight loss for the mother. Hospitals that adhere to the Baby-Friendly Hospital Initiative help promote longer duration and exclusivity of breastfeeding. A combination of prenatal and postnatal educational and support programs that promote breastfeeding improve duration and exclusivity of breastfeeding. Early skin-to-skin care to improve breastfeeding rates at 3-4 months and improved infant interaction with mother. Training of hospital staff in breastfeeding promotion and protection results in an increase in breastfeeding duration. For minor procedures not requiring sedation or general anesthesia feed the infant normally. The following conclusions are based on limited or inconsistent scientific evidence (Level B): The lactation acuity level should be used to determine the level of care the breastfeeding dyad will require. Breastfeeding woman should be informed of the risks and benefits of continuing to breastfeed after exposure to contrast media with evidence not supporting a routine policy of pump and dump for 24 hours after exposure. Applying nothing or just expressed breast milk may be equally or more beneficial in the shortterm experience of nipple pain than the application of an ointment such as lanolin. Hand expression in the early postpartum period appears to improve eventual breastfeeding rates at 2 months after birth compared with breast pumping. An optimal supplemental feeding device has yet to be identified. No method is without risks and benefits. Breastfeeding should be initiated as soon as possible after birth. The longer the time between delivery and first feeding the greater the chances of formula use. The following recommendations are based primarily on consensus and expert opinion (Level C): Recommendations for breastfeeding in the drug dependent woman. Best practices for breastfeeding support following cesarean delivery. All breastfeeding infants should have a visit with a healthcare provider within hours after discharge. Pacifier use should be avoided in the early neonatal period and until breastfeeding is well established as it has a detrimental effect on breastfeeding duration and exclusivity.

8 References Academy of Breastfeeding Medicine. (2009). ABM Clinical Protocol #3: Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2009 (Accessed 1/6/15) Academy of Breastfeeding Medicine. (2010). ABM Clinical Protocol #7: Model Breastfeeding Policy (Revision 2010). (Accessed 1/6/15) 0Policy.pdf Academy of Breastfeeding Medicine. (2009). ABM Clinical Protocol Number #19: Breastfeeding Promotion in the Prenatal Setting. (Accessed 1/6/15) %20Breastfeeding%20Promotion%20in%20the%20Prenatal%20Setting.pdf Academy of Breastfeeding Medicine. (2009). ABM Clinical Protocol #21: Guidelines for Breastfeeding and the Drug-Dependent Woman. (Accessed 1/6/15) Academy of Breastfeeding Medicine. (2012). ABM Clinical Protocol #25: Recommendations for preprocedural Fasting for the Breastfed Infant: NPO Guidelines Altuntas, N., Kocak, M., Akkurt, S., Razi, H., & Kislal, M. (2014). LATCH scores and milk intake in preterm and term infants: a prospective comparative study. Breastfeeding Medicine, Not available, ahead of print. doi: /bfm American Academy of Pediatrics (2009). Sample Hospital Breastfeeding Policy for Newborns. (Accessed 1/6/15) cy_final.pdf American Academy of Pediatrics. (2012). Policy statement: breastfeeding and the use of human milk. Pediatrics, 129(3) e827-e841. American College of Obstetricians and Gynecologists. Committee Opinion: Breastfeeding in Underserved Women: Increasing Initiation and Continuation of Breastfeeding. August 2013, 570. Baby Friendly USA. (2010). Guidelines and Evaluation Criteria for Facilities Seeking Baby-Friendly Designation. (Accessed 1/6/15). Becker GE, Cooney F, Smith HA. Methods of milk expression for lactating women. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD DOI: / CD pub3 -

9 Castrucci et al., A Comparison of Breastfeeding Rates in an Urban Cohort, Journal of Public Health Management 2006, 12, 6, Centers for Disease Control and Prevention. (2009). Maternity practices in infant nutrition and care survey results. (Accessed 1/7/15) Chung, M., Raman, G., Trikalinos, T., Lau, J., & Ip, S. (2008). Interventions in primary care to promote breastfeeding: an evidence review for the US preventative services task force. Annals of Internal Medicine, 149(8), Dennis CL, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD DOI: / CD pub2. Howard, C., Howard, F., Lanhear, B., Eberly, S., deblieck, E., Oakes, D., & Lawrence, R. (2003). Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics, 111(3), Indian Health Service. (2014). All 13 IHS obsteric facilities designated as Baby-Friendly. (Accessed 1/28/15) edbabyfriendly/ Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, Trikalinos T, Lau J. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Evidence Report/Technology Assessment No. 153 (Prepared by Tufts-New England Medical Center Evidence-based Practice Center, under Contract No ). AHRQ Publication No. 07-E007. Rockville, MD: Agency for Healthcare Research and Quality. April Kramer, M., et al. (2001). Promotion of breastfeeding intervention trial: a randomized trial in the republic of Belarus. Journal of American Medical Association, 285(4), Kramer M., & Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD DOI: / CD pub2. Kurinij, N., & Shiono, P. (1991). Early formula supplementation of breastfeeding. Pediatrics, 99(4), Mannel, R., Martens, P., & Walker, M. (2013). Core curriculum for lactation consultant practices (3rd ed.).burlington, MA: Jones and Bartlett Learning. Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD DOI: / CD pub3

10 Taddei, J., Westphal, M. Venancio, S., Bogus, C., & Souza, S. (2000). Breastfeeding training for health professionals and resultant changes in breastfeeding duration. Sao Paulo Medical Journal, 118(6), Thurman, S., & Allen, P. (2009). Integrating lactation consultants into primary health care services: are lactation consultants affecting breastfeeding success? Pediatric Nursing, 34(5),

11 Appendix I The Ten Steps to Successful Breastfeeding 1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within 1 hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants. 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. 7. Practice rooming-in allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them, on discharge from the hospital or clinic. Appendix II Baby-Friendly Hospital Initiative s 20-Hour Course Topics 1. The Baby-Friendly Hospital Initiative a part of the Global Strategy 2. Communication Skills 3. How milk gets from the breast to the baby 4. Promoting breastfeeding during pregnancy 5. Birth practices and breastfeeding 6. Helping with a breastfeed 7. Practices that assist breastfeeding 8. Milk Supply 9. Supporting the non-breastfeeding mother and baby 10. Infants and mothers with special needs 11. Breast and nipple concerns 12. If the baby cannot feed at the breast 13. On-going support for mothers 14. Protecting breastfeeding 15. Making your hospital or birth center Baby-Friendly Appendix III ACR Manual on Contrast Media: Administration of Contrast Media to Women Who Are Breast-Feeding Imaging studies requiring either iodinated or gadolinium-based contrast media are occasionally required in patients who are breast feeding. Both the patient and the patient s physician may have concerns regarding potential toxicity to the infant from contrast media that is excreted into the breast milk. The literature on the excretion into breast milk of iodinated and gadolinium-based contrast media and the gastrointestinal absorption of these agents from breast milk is very limited; however, several studies

12 have shown that the expected dose of contrast medium absorbed by an infant from ingested breast milk is extremely low. Iodinated X-ray Contrast Media (Ionic and Nonionic) Background The plasma half-life of intravenously administered iodinated contrast medium is approximately 2 hours, with nearly 100% of the media cleared from the bloodstream in patients with normal renal function within 24 hours. Because of its low lipid solubility, less than 1% of the administered maternal dose of iodinated contrast medium is excreted into the breast milk in the first 24 hours. In addition, less than 1% of the contrast medium ingested by the infant is absorbed from its gastrointestinal tract. Therefore, the expected systemic dose absorbed by the infant from the breast milk is less than 0.01% of the intravascular dose given to the mother. This amount represents less than 1% of the recommended dose for an infant being prescribed iodinated contrast material related to an imaging study (usually 1.5 to 2 ml/kg). The potential risks to the infant include direct toxicity and allergic sensitization or reaction, which are theoretical concerns but have not been reported. The likelihood of either direct toxic or allergic-like manifestations resulting from ingested iodinated contrast material in the infant is extremely low. As with other medications in milk, the taste of the milk may be altered if it contains contrast medium. Recommendation Because of the very small percentage of iodinated contrast medium that is excreted into the breast milk and absorbed by the infant s gut, we believe that the available data suggest that it is safe for the mother and infant to continue breast-feeding after receiving such an agent. Ultimately, an informed decision to temporarily stop breast-feeding should be left up to the mother after these facts are communicated. If the mother remains concerned about any potential ill effects to the infant, she may abstain from breast-feeding from the time of contrast administration for a period of 12 to 24 hours. There is no value in stopping breast feeding beyond 24 hours. The mother should be told to express and discard breast milk from both breasts during that period. In anticipation of this, she may wish to use a breast pump to obtain milk before the contrast-enhanced study to feed the infant during the 24-hour period following the examination. Gadolinium-Based Contrast Agents Background Like iodinated contrast media, gadolinium-based contrast media have a plasma half-life of approximately 2 hours and are nearly completely cleared from the bloodstream in patients with normal renal function within 24 hours. Also similar to iodinated contrast media, gadolinium-based contrast media are excreted into the breast milk. It is likely that the overwhelming bulk of gadolinium excreted in the breast milk is in a stable and chelated form. Less than 0.04% of the intravascular dose given to the mother is excreted into the breast milk in the first 24 hours. Because less than 1% of the contrast medium ingested by the infant is absorbed from its

13 gastrointestinal tract, the expected systemic dose absorbed by the infant from the breast milk is less than % of the intravascular dose given to the mother. This ingested amount is far less than the permissible dose for intravenous use in neonates. The likelihood of an adverse effect from such a minute fraction of gadolinium chelate absorbed from breast milk is remote). However, the potential risks to the infant include direct toxicity (including toxicity from free gadolinium, because it is unknown how much, if any, of the gadolinium in breast milk is in the unchelated form) and allergic sensitization or reaction. These are theoretical concerns but none of these complications have been reported. As in the case with iodinated contrast medium, the taste of the milk may be altered if it contains a gadoliniumbased contrast medium. Recommendation Because of the very small percentage of gadolinium-based contrast medium that is excreted into the breast milk and absorbed by the infant s gut, we believe that the available data suggest that it is safe for the mother and infant to continue breast-feeding after receiving such an agent. Ultimately, an informed decision to temporarily stop breast-feeding should be left up to the mother after these facts are communicated. If the mother remains concerned about any potential ill effects to the infant, she may abstain from breast-feeding from the time of contrast administration for a period of 12 to 24 hours. There is no value in stopping breast feeding beyond 24 hours. The mother should be told to express and discard breast milk from both breasts after contrast administration until breast feeding resumes. In anticipation of this, she may wish to use a breast pump to obtain milk before the contrastenhanced study to feed the infant during the 24-hour period following the examination. Prenatal Breastfeeding Education Session Outline Appendix IV Session 1 RN Interview: o Explore plans about infant feeding. Review past infant feeding plans and duration of feeding. o Review benefits of breastfeeding for babies and mother, differences between formula and human milk Session 2 New Prenatal visit: o Review why breastfeeding is important o Perform breast exam Session weeks: o Discuss dietary and health concerns and their potential or lack of impact on ability to breastfeed o If mother is a cigarette smoker review breastfeeding s protective effect o Explore social support and discuss myths she has heard about breastfeeding Session weeks: o Encourage women to identify breastfeeding role models by talking with family, friends, and colleagues who have breastfed successfully o Importance of exclusive breastfeeding o Empower women and their families to have the birth experience most conducive to breastfeeding Review narcotic, nitrous oxide, and epidural effects on breastfeeding newborn

14 Session weeks: o Session will be done by lactation consultant or educator during customer-owner s diabetes testing. o Demonstrate how to hold the breast and positions of the baby such as cradle, crosscradle, and the clutch hold. o Review benefits of breastfeeding, early supply/demand, feeding on demand, frequency of feedings, feeding cues, how to know an infant is getting enough to eat, and the importance of a good latch. Session weeks: o Recommend attending a formal breastfeeding course for the woman and her partner o Explore plans to return to work, childcare plans and ability to maintain breast milk while away from infant. Session weeks: o Assure that the woman has information on how to get breastfeeding help. o Provide anticipatory guidance on topics such as engorgement, growth spurts, and nighttime feedings. Session weeks: o Review the physiology of breastfeeding initiation, the importance of skin-to-skin, early feeding, frequent feedings, and the impact of supplementation. o Discuss support of breastfeeding in the event of a cesarean section. Session weeks: o Teach hand expression. Appendix V Breastfeeding Contraindications: 1. Mothers who are human immunodeficiency virus positive 2. Mothers currently using illicit drugs (e.g., marijuana, cocaine, heroin) unless specifically approved by the infant s healthcare provider on a case-by-case basis 3. Mothers taking certain medications. Most prescribed and over-the-counter drugs are safe for the breastfeeding infant. Some medications may make it necessary to interrupt breastfeeding, such as radioactive isotopes, antimetabolites, cancer chemotherapy, some psychotropic medications, and a small number of other medications. 4. Mothers with active, untreated tuberculosis. A mother can express her milk until she is no longer contagious. 5. Infants with galactosemia 6. Mothers with active herpetic lesions on the breast(s). Breastfeeding can be recommended on the unaffected breast. (The Infectious Disease Service will be consulted for problematic infectious disease issues.) 7. Mothers with onset of varicella within 5 days before or up to 48 hours after delivery, until she is no longer infectious 8. Mothers with human T-cell lymphotropic virus type I or type II

15 Appendix VI Guidelines for Breastfeeding and the Drug-Dependent Woman Women who meet all of the following criteria under the following circumstances should be supported in their decision to breastfeed their infants: o Women engaged in substance abuse treatment who have provided their consent to discuss progress in treatment and plans for postpartum treatment with substance abuse treatment counselor o Women whose counselors endorse that she has been able to achieve and maintain sobriety prenatally; counselor approves of client s plan for breastfeeding o Women who plan to continue in substance abuse treatment in the postpartum period o Women who have been abstinent from illicit drug use or illicit drug abuse for 90 days prior to delivery and have demonstrated the ability to maintain sobriety in an outpatient setting o Women who have a negative maternal urine toxicology testing at delivery except for prescribed medications o Women who received consistent prenatal care o Stable methadone-maintained women wishing to breastfeed should be encouraged to do so regardless of maternal methadone dose. Women under the following circumstances should be discouraged from breastfeeding: o Women who did not receive prenatal care o Women who relapsed into illicit drug use or licit substance misuse in the 30-day period prior to delivery o Women who are not willing to engage in substance abuse treatment or who are engaged in treatment but are not willing to provide consent for contact with the counselor o Women with positive maternal urine toxicology testing for drugs of abuse or misuse of illicit drugs at delivery o Women who do not have confirmed plans for postpartum substance abuse treatment or pediatric care o Women who demonstrate behavioral qualities or other indicators of active drug use Women under the following circumstances should be carefully evaluated, and a recommendation for suitability or lack of suitability for breastfeeding should be determined by coordinated care plans among perinatal providers and substance abuse treatment providers: o Women relapsing to illicit substance use or licit substance misuse in the day period prior to delivery, but who maintained abstinence within the 30 days prior to delivery Appendix VII Best Practices for Breastfeeding Support Following Cesarean Delivery 1. Early mother infant contact. Avoidance of separation unless dictated by medical indications 2. Early breastfeeding <1 hour after delivery. Can occur in delivery suite or recovery room 3. Regional anesthesia for cesarean delivery 4. Infant positioning to minimize incision discomfort. Use of side-lying, football breastfeeding position. Use of pillow to protect incision site

16 5. Use of regional medication to decrease the need for postoperative narcotics after cord clamping 6. Preferential use of narcotics with less adverse effects on neonatal behavior 7. Frequent breastfeeding and rooming-in such as would be routine for vaginal delivery 8. Protocols for early breast pumping and expression if infant separation is dictated because of medical indication such as prematurity. Should be initiated day of delivery 9. Easy availability of lactation expert for further support and assistance if needed 10. Monitoring for delayed onset of lactation in mother and excessive weight loss in the newborn 11. Education and encouragement of family members in methods of supporting breastfeeding in the new family Lactation Acuity Level Appendix VIII 1. Acuity Level 1 a. Basic breastfeeding education and routine management b. Latch/milk transfer appears optimal c. Maternal decision to routinely supplement d. Maternal decision to pump and feed expressed breast milk e. Mother can latch baby with minimal assistance f. Multiparous mother with healthy-term baby and prior breastfeeding experience. 2. Acuity Level 2 a. Antepartum admission with increased risk for preterm delivery b. Cesarean section delivery c. Delayed breastfeeding initiation (defined as after 1 hour with a routine vaginal delivery and after 2 hours with routine cesarean section) d. Maternal acute illnesses (preeclampsia, cardiomyopathy, postpartum depression, postpartum hemorrhage) e. Maternal age (mother <18 or > 35) f. Maternal chronic conditions (rheumatoid arthritis, systemic lupus erythematosus, hypertension, cancer, history of gastric bypass, obesity) g. Maternal cognitive impairment h. Maternal endocrine disorders i. Maternal medication concerns j. Maternal physical disability k. Maternal readmission (breastfeeding well established and/or not critical issues) l. Maternal request m. Multiparous mother with history of breastfeeding difficulty n. Primiparous mother or first-time breastfeeding mother with healthy-term baby o. Social issues p. Consistent LATCH score < 6 q. Latch difficulties r. Infant readmission (breastfeeding well established and/or not critical issues) s. Newborn birth trauma t. Suboptimal/inadequate milk transfer leading to medical recommendation to supplement 3. Acuity Level 3 a. Abcess/mastitis

17 b. High maternal anxiety c. Induced lactation d. Maternal breast conditions e. Maternal illness/surgery f. Maternal readmission (breastfeeding not well established and/or critical issues) g. Pathologic engorgement h. High-risk infant on MBU (small/large for gestation age, multiples) i. Hyperbilirubinemia j. Infant admission to neonatal intensive care k. Infant congenital anomalies l. Infant illness/surgery m. Infant oral/motor dysfunction n. Infant readmission (breastfeeding not well established and/or critical issues) o. Infant weight loss > 7% of birth weight before discharge.