October 18, 2009
Best Start Resource Centre
Preconference Workshop
Breastfeeding: What’s New?
Hiltrud Dawson, RN, BT, IBCLC
The Best Start Resource Centre
• Provides:
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Networking
Consultations
Training
Resources
• Is a key program
of Health Nexus
• Is funded in part
by the Ministry
for Children and
Youth Services
The Best Start Resource Centre
Breastfeeding Resources
Healthy
Mothers
Healthy Babies
breastfeeding
web course
2-sided desk reference
poster
desk reference on
drinking alcohol
and breastfeeding
fridge magnet
Many other resources
with breastfeeding
information
List of available or adaptable
breastfeeding posters and displays
from other organizations
Topics
1.Pathways to Plenty
2.Gadgets to Achieve Goals
3.Language and Practices
that Promote
Pathways to Plenty
• Mammogenesis and lactogenesis
• Capacity, volume and intake
• Maternal and infant variables
• Effective practices
• Skin-to-skin
• Manual expression
• Baby-led latching
Objectives
• Identify key markers of sufficient milk
production and transfer
• Review effective strategies that promote
sufficient milk production and transfer
Mammogenesis
• Fetus
– Milk line from groin to axilla
– By birth breast tissue with nipple located on both sides
of chest
• Puberty
– Growth of breast
– Growth of ductal system, nipple and areola
• Early Pregnancy
– Enlargement of breast, nipple and areola
– Darkening of areola
– Increased blood supply and warmth
(Neville et al., 2002)
Lactogenesis Stage I
• Mid to late pregnancy
– Production and secretion of colostrum
– By the end of pregnancy: 30 mls per day
Arthur et al.,1991; Cowie 1980; Cox et al 1999
• After birth (up to 36 – 72h)
– Secretion of colostrum
– Increased warmth and size
Lactogenesis Stage II
• Onset of copious secretions of all milk
components (Milk Synthesis)
• Occurs after birth in response to the
decline in pregnancy hormones
• Causes changes in absorption of nutrients
as colostrum changes to mature milk
• Lasts for a few days starting about 36 – 72
hours post birth
(biology of lactation: 342 – 460B; McGill University)
Galactopoeisis
• Maintenance of milk production
• Regulated by hormones and mammary
factors
• Hormone control changes from endocrine
to autocrine
(biology of lactation: 342 – 460B; McGill University)
• The baby is now in the driver’s seat
Prolactin
birth
conception
Not to scale
Progesterone
16 – 22 w
Mammogenesis
36 – 72 h
Lactogenesis I
Endocrine
(hormonal) control
Adapted from
Kellymom.com, 2004
L II
Galactopoeisis
Autocrine (local) control
Autocrine Control – How Does the
Baby Drive the Milk Production?
• Sucking stimulus – nerve endings in nipple
areolar complex – stimulates Prolactin
• Mother-Baby contact – skin-to-skin contact
and feeding – releases Oxytocin
• Alveolar stimulus – cell/breast emptying –
decreases Feedback Inhibitor of
Lactation
How Much Milk is Produced?
• Shortly after feeding (emptying) the
alveloar cells are at maximum secretion
• As the intra-mammary pressure increases
the rate of secretion (production) slows
down
• At some point the pressure is high enough
to slow production to zero and reabsorption of milk begins
Stomach Capacity and Milk Volume
Day
1.
2.
3.
4.
5.
Capacity
5 – 7 mls
10 – 13 mls
22 – 27 mls
36 – 46 mls
43 – 57 mls
Milk Volume/day
10 – 100 mls
200 mls
>400 mls
>600mls
Daly SEJ & Hartmann PE J Hum Lact 11:21-3 (1995)
Post Partum Secreted
Ingested
Per Feed
First 24hrs
First 36hrs
7-14ml
49-96 hours
Day 5
1-6 Months
7-123ml
Gradual
increase
Dramatic
increase
500ml / day
Hartman 1987
Houston et al
1983
45-60ml
750-800ml/day Approx. 90150ml
Daly Owens &
Hartman 1993 /
95
Kent et al 2006
Average Milk Intake of Babies
5-10 ml
15 – 25 ml
30 – 45 ml
60 – 80 ml
Maternal Variables
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Anatomy, breast milk storage capacity
Genetics, surgery, injury …
Attitude, knowledge and comfort level
Body image
Self-efficacy
Support network
Photo by Flickr
Infant Variables
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Gestation, maturity, age
Anatomy
Temperament
State control
Appetite
Photo by Traci Nelson
3 Keys to Success
• Mother and baby
together
• Feed the baby
• Stimulate the milk
supply
Poster by Attie Sandink
Early + Often + Effective = Exclusive
Plan:
Feed the baby
(Protect the baby)
Move the milk
(Promote the supply)
Essence of time
(Support the dyad)
What Works?
• Frequent and effective feeding
• Manual expression
• Skin-to-skin
Picture from
www.mama-knows.com
Baby-led Latching
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Calm, relaxed mother
Quiet, alert baby
Vertical position, skin-to-skin
Pelvic girdle stability and shoulder girdle
stability
• Time, coaching, and assisting/aligning as
needed
Research from Dr. Christina Smilie
Baby-Led Latching Video
• http://www.motheringtouch.ca/node/66
Skin-to-Skin Benefits
• Benefits
– Term and pre-term babies
– Breastfeeding and not breastfeeding babies
• Stable temperature, heart rate, respiratory
rate
• Better physical adaptation to extra-uterine
life
• Cry less
• Sleep better
• Gain weight better
More
exclusive
breastfeeding
More
supplementation
0h
3h
More skin-to-skin contact right after birth
Bramson et al., 2010
Skin-to-skin Video
• http://collections.stfx.ca/abigelow/skin_to_s
kin/skin_to_skin.parents.mp4
Results from Study
• Longer breastfeeding duration
• Increased mothers’ sensitivity to baby
• Decreased feelings of postpartum
depression
• Increased babies’ quiet alert state and
attentiveness
• Enhanced babies’ responsiveness
Bramson et al., 2010
Photo by Traci Nelson
Manual Expression
Benefits of Manual Expression
• Empowers the mother
• Increases available colostrum
• Increases milk production
Manual Expression
• http://newborns.stanford.edu/Breastfeeding
/HandExpression.html
Gadgets to Achieve Goals
• Breastfeeding goals
• Supplementary feeding
• Pumps and gadgets
What Do Mothers Want?
What Do Mothers Want?
Breastfeeding Goals
• Exclusive breastfeeding for 6 months
• Continued breastfeeding for up to 2 years
• The decision to breastfeed is usually made
before pregnancy or in the early part of
pregnancy
• Goals are more flexible and fluid and depend on
past and present experience, the mother and her
available support
What Impacts or Derails the Goals
• Birth
– preterm, maternal or infant complications
• Postpartum - maternal factors
– Fatigue, bf problems, self-efficacy,
• Postpartum – infant factors
– Bf problems, weight loss
• Postpartum – external factors
– Hospital practices, information, support
Who Needs Help?
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Low education
Lack of social support
Younger age
Growing up in a non-breastfeeding culture
History of breastfeeding difficulties
Maternal or infant factors post birth
Examples
• Mother A – gives birth to a full term baby.
Everything goes well until day 11 when her
physician or nurse discovers that the baby is not
gaining weight and is still 10% below birth
weight.
• Mother B – gives birth to a full term baby
following a placental abruption. The baby needs
special care initially then joins mother in her
room, but will not latch and feed.
• Mother C – gives birth to a pre-term baby at 28
weeks. After her discharge she returns to her
home 3 hours drive from Thunder Bay while the
baby remains in NICU.
Pumps and Gadgets - Why
• To keep mother and baby together
• To feed baby
• To stimulate or increase milk supply
Ultimate goal
• Breastfeeding success!
Supplements
• Strongest predictor of breastfeeding failure
or premature weaning
• Why supplement?
• Why NOT supplement?
• What to supplement?
• How to supplement?
• Building confidence
Global Strategy for Infant
and Child Feeding
Infants who are not breastfed, for
whatever reason, should receive
special attention from the health and
social welfare system since they
constitute a risk group.”
WHO (2003)
What to Supplement?
• Mothers own EBM or colostrum
• Donor pasteurized human milk
• Artificial baby milk (cow’s milk-based
formula, soy-based formula)
Informed Decision Making
• “Enabling parents to make fully informed
decisions about infant feeding by providing
them with accurate, evidence-based
information. Information should be
provided early in the pregnancy to allow
sufficient time for questions and dialogue.”
BFI in CHS: A Canadian implementation guide – glossary p83.
Cup or Spoon Feeding
Finger Feeding
From Kathy Venter
Lactation Aid at the Breast
From Kathy Venter
Nipple Shield
From Kathy Venter
Bottle Feeding
Australian Breastfeeding Association
A caregivers guide to the breastfeeding baby
Breast
Pumps
Use pumps carefully:
 right pump for the purpose
 right size horns
 right vacuum pressure
 right timing
 right frequency
From Kathy Venter
Breast Pumps - Electric
Hospital grade &
personal use
Breast Pumps - Manual
Building Confidence
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Good assessment
3 key points
Least intervention to achieve goal
Positive images and language
Ongoing support
References
• Auerbach, K & Riordan, J. (1999) Breastfeeding and Human
Lactation. MA. Jones and Bartlett
• Canadian Institute of Child Health. (1996) National Breastfeeding
Guidelines for Health Care Professionals. Ottawa; Author: P20-22.
• Consultant’s Corner: When Is Supplementation Necessary for the
Breastfed Infant? JHL 1998; 14:143-149.
• Health Canada. Family Centered Maternity and Newborn Care:
National Guidelines, Minister of Public Works and Government
Services. Ottawa 2000. P7.22.
• IlCA. (2005) Evidence Based Guidelines for Breastfeeding
Management During the First Fourteen Days.
• WHO. (2003) Global Strategy for Infant and Child Feeding. WHO,
UNICEF, Geneva
Language and Practices that
Promotes
• Effective communication
• Informed decision making
• Ethical practices
• Breastfeeding promotion
The Message
• Words
• Tone of voice
• Other sounds
• Facial expressions
• Body language
The Recipient
• What is on her mind?
– During pregnancy
– Postpartum
Learning a New Skill
• Volunteer demonstration
The 3 Phases of the
Postpartum Period
Taking In
2 - 3 days
Taking Hold
3 - 14 days
Letting Go
15 days – 6 m
Needs to discuss birth
Needs to discuss
expectations and
reality
Needs to discuss and
understand role
Vulnerable, feels like a Vulnerable to
victim
rejection, mood
swings
Lean on experts,
strong need to be
mothered
Health Canada, 2000
Recognizes baby’s
dependence, still
needs to be mothered
Vulnerability declines,
integrates experience,
begins to feel able to
cope
Needs peer
acceptance, onset of
empowerment
Informed Decision-Making
• Exploration of bias, concerns, beliefs …
• Accurate and consistent information
• Conveying value
Best Start Inc.’s
3-Step Counselling Program
Bryant & Lindenberger, 2000
Step 1
• Ask open-ended questions about
breastfeeding?
Step 2
• Affirm the mother’s feelings
Step 3
• Share appropriate information and refer
the mother to a breastfeeding expert
5 Husbands, 1 Wife and
1 Good Friend
Ethical Practices
• Formula manufacturers ~
food manufacturers
• The WHO Code
• Subsequent WHA
resolutions
• Global Strategy for Infant
and Child Feeding
• Breastfeeding in
Emergencies
Ethical Principles
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Non maleficence
Beneficence
Autonomy
Justice
Professional/patient relationship
Breastfeeding Promotion
• Accurate and consistent information
• Individual information
• Special attention to “at risk” moms and
babies
• Placing the right value on breastfeeding
3 Messages to Keep in Mind
• Breast is NOT Best
• Formula is NOT Second-Best
• It is NOT Only
Mothers Who Breastfeed
Akre, 2010
Normal Body Functions
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Blood pressure
Blood sugar
Bone density
Kidney function
Blood cell count
Lung function
Marketing
Outcome
Evidence
Promotion
Promote
breastfeeding!
• Normalize
breastfeeding by the
way you
communicate.
Thank You!
Hiltrud Dawson
Best Start: Ontario’s Maternal, Newborn
and Early Child Development Resource Centre
Phone: 416-408-2249 or 1-800-397-9567 ext 2250
h.dawson@healthnexus.ca
www.beststart.org