Transcript Pointers for Professionals - Perinatal Professionals Consortium

Pointers for Professionals:
The 5 ‘M’s” for Breastfeeding Success
1) Mammals
2) Milk Production
3) Magic Numbers
5) Matching counsel
6) Money!! (last but not least)
by Deanne Francis, RNC, IBCLC, LCCE
We are Expected to be the Experts
“Have concerns?
How the breast works?
How much?
How often?
Is this normal?
How to fix it?
Does your counsel
match mammalian
physiology?
Will it result in eventual
successful breastfeeding
or sabotage it?
How to fit my lifestyle?
“M” #1: We are Mammals!
“There is a reason behind
everything in nature.” Aristotle
We are “carry”
mammals-- like apes
and kangaroos.
We are not “cache”
mammals or “follow”
mammals or “nest”
mammals.
Composition of Milk from
Different Mammals
Species
Human
Content of Milk (%)
Fat
Protein
Lactose
3.8
0.9
7.0
Horse
1.9
2.5
6.2
Goat
4.5
2.9
4.1
Cow
3.7
3.4
4.8
Growth Rate of Different
Mammals’ Offspring
Species
Human
Number of days
to double birth wt.
180
Horse
60
Goat
19
Cow
47
Normal Mammalian Behavior
after Birth
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Mom and baby stay together
Humans should act like ‘carry’
mammals
Lots of skin 2 skin contact
Baby controls the feedings
Non-essential intervention is
postponed
Supplement ONLY if medically
necessary
Skin-to-Skin Contact is
Associated with:
•Babies who are skin with the mother for 1-2
hours after birth:
•Are more likely to latch on
•Are more likely to latch on well
•Will cry less
•Have higher blood sugars
•Have higher skin temperatures
•Will breastfeed longer and more exclusively
Seven Natural Laws for
Nursing Mothers
1. Babies are hardwired to breastfeed.
2. Mother’s body is baby’s natural
habitat.
3. Better feel and flow happen in the
comfort zone.
4. More breastfeeding at first means
more milk later.
5. Every breastfeeding couple has its
own rhythm.
6. More milk out equals more milk
made.
7. Children wean naturally.
(Mohrbacher/Kendall-Tackett 05)
Recommended Reading:
Breastfeeding Made Simple:
Seven Natural Laws for Nursing
Mothers
By: Mohrbacher, N & KendallTackett, K. New Harbinger
Publications. 2005
“M” # 2: Milk Production
What can each of
these breasts
actually DO?
A new breast drawing
for the anatomy books.
(Hartmann and Ramsay)
Old Anatomical Model (Sir Astley Cooper 1840)
Dissection: ducts full of colored wax and
straightened out into lobes
Lactiferous Sinuses (Reservoirs)
Do Not Exist
Normal Milk Volumes
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First 3 days = drops to 15
mls/feed
5 days PP = 500 mls/day
10 days PP = 750 mls/day
14 days PP = 750 – 1000 mls/day
Average = 24 ozs/24 hrs
Twins = 32 ozs/24 hrs
Supply Saboteurs
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Poor or NO advice
Some meds
Some herbs
Visitors
Separation
Delayed BF
Pacifiers
Hormones
Alcohol
Feeding by the clock
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Abnormal breast
configuration
Breast surgery
Cigarettes (25% less
milk with 20% less fat)
Infant oral
abnormalities
OBD
Poor supplementation
plan
Late preterm-no pump
The Perfect Mouth and Nipple
Match-up
Chin Touches First
Importance of a Good Latch -Mom
Importance of a Good Latch- Baby
Evaluate this Latch
On the other hand…….
“M” #3 : Magic Numbers
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Breasts are designed to PRODUCE milk, and ducts
to TRANSPORT milk (both directions) but neither
are designed to STORE milk for any length of
time. Breasts must be drained before reaching
“capacity” to maintain production.
Capacity of breasts is variable.
Size is not the main issue.
Overall production capacity has nothing to do
with “full” capacity
Breasts produce milk fastest when DRAINED.
Question: Should we really counsel all mothers
the same?
Defining Magic Numbers
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Breast fulness: When storage
capacity is reached in an individual
mother’s breasts, milk production
slows. NOTE: Drained breasts make
milk fastest!
Breast storage capacity:
Maximum volume of milk available
to her baby when an individual
mother’s breast is full. Capacity
affects time it takes for breast to fill.
Counsel using Averages
24 hour AVERAGE Production in gms/mls:
Total = 572 – 1016/day (750 av.)
AVERAGE Capacity in gms/mls (when “full”)
Total = 350 gms/mls (combined
breasts)
Assuming two given babies each require 750
mls/day, what counsel would you give the
mother whose capacity is 150 mls total vs
the one whose capacity is 400 mls total?
Individualizing Counsel
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Two studies found that breast
storage capacity in a range of
mothers is 74 – 606 gms.
Largest capacity = 90% of baby’s
daily needs at any one time in both
breasts.
Smallest capacity = 20% of baby’s
daily needs at any one time in both
breasts.
Recommendations:
How to figure it out?
BF mothers = pump test. Decide if
problem is something MOM is doing
or something BABY is doing.
Pump-dependent mothers – 1/wk
keep track of the 24 hr milk volumes
with DOUBLE pumping.
Mohrbacher, N (2011) “The Magic Number and Long-Term Milk
Production.” Clinical Lactation. Vol 2-1. (USLCA jnl)
(Online free at ClinicalLactation.org)
The “4-hour” test
How much milk is mom making?
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Remove milk with a hosp-grade
pump every hour for 4 hours.
3rd + 4th pumping X2 = MP/hr
MP/hr X 24 = Daily milk
production
(Hartmann, Hale and Lai)
Test Weights
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How effective is the baby at milk
extraction?
Using a gm scale, weigh the baby
before the feeding.
Leave the scale on.
Weigh immediately after the
feeding without changing
anything.
Increased gms = volume
consumed
Recommendations cont.
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First morning pumping: Mothers who
expressed 10 oz of milk or more at the first
morning pumping can maintain their milk
production with as little as 5 expressions/d.
Employed mothers: think back to maternity
leave. How many feedings/d did baby need?
That number of expressions/d will keep milk
production stable. How many is baby taking?
How many pumpings to add?
Copy the baby!
Establish and Maintain Mother’s
Milk Supply until BF is Possible
Pump or express milk regularly with
a hospital grade electric pump every
3 hours, or anytime infant feeding is
inadequate or absent. 8X/day
minimum to begin. Start soon!
Delay negatively impacts
milk volumes at 6 wks
 Double pumping
is most effective
 Hand-expression imperative
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http://newborns.stanford.edu
Go
to Breastfeeding then Hand expression.
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The best way to assure that
babies get enough milk in the
first few days (especially
colostrum), or are able to
establish a milk supply with a
pump, is to teach the mother’s
to use their hands effectively.
This website has fabulous
information for professionals
Frequency and Duration of
Expression – Beginning Counsel
Should imitate a healthy newborn.
Will affect volume changes.
Frequency more important than
duration.
100 min/day minimum (average)
15 minutes each time (average)
8 expressions per day (average)
Depends on mother’s “magic numbers”
Simultaneous pumping produces higher
prolactin levels.
Does Pumping Work When
Breastfeeding Doesn’t?
“Mothers who express milk are more likely to breastfeed
to 6 months….the appropriate use of expressed breast
milk may be a means to help mothers to achieve six
months of full breastfeeding while giving more lifestyle
options.”
(Win, 2006 Int’l BF Jnl)
“2/3 of all women return to work after having a baby.
“Company-sponsored lactation programs can enable
employed mothers to provide breast milk for their
infants as long as they wish, thus helping the nation
attain the Healthy People 2010 goals of 50% of
mothers breastfeeding until their infants are 6 mos.
old.”
(Ortiz, 2004 Ped Nurs))
“Extraordinary efforts should be made to use mother’s
own milk.” (Heiman & Schanler, 2006 Early Hum Dev.
Don’t all breast pumps do the
same thing?
Make sure the pump flange is
not a tourniquet!
Correct flange fit
Too tight!
Develop a Milk-Management Strategy
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Rule 1 = Feed the baby!
(well-fed babies breastfeed better)
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Rule 2 = Protect the Milk Supply!
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Rule 3 = Find and FIX the problem.
More Than One Way to Provide
Medically Necessary Supplement
“M” # 4: Matching Counsel to
Natural Laws
1.
2.
3.
4.
5.
Must agree with normal and individual
mammalian physiology/behavior.
Must conform to natural laws.
Interventions should be medically
indicated and appropriate.
Interventions should be designed to result
in eventual successful BF.
Professionals must see the value of both
breastfeeding and breast milk. Help
mother match natural laws to her
individual situation to succeed.
Keep mom and baby together!
Rooming-In
Mothers who room in
and care for their
babies 24 hours/day
have babies that are
better breastfeeders,
are less disorganized,
cry and startle less
frequently, and feed
more frequently than
babies cared for in
central nurseries.
Ten Steps to
Successful Breastfeeding
8.
Encourage breastfeeding on
demand. Whose demand?
Feeding Cues
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The baby may exhibit these cues
several times in 20 to 30 minutes.
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If no response may go back to sleepwhich equals a missed feeding
opportunity
Infants who have had delayed feeds
due to missed feeding cues often
have difficulty latching on subsequent
feeds
Crying is a
late feeding cue
Early cues have been missed.
Infant now in disorganized state.
Tongue retracts with crying.
Important to teach parent feeding
cues as often they think crying is
the feeding cue
When do nurses notice feeding
cues in the nursery?
Nipple Confusion vs Preference
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Several theories on why some
infants have difficulty with
breastfeeding after bottles/pacifiers
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Flow preference
Palatal super/stimulation by nipple
Confusion in tongue movement
Reduced milk supply from pacifier vs
breast sucking.
Difference between shape of mom’s
nipple and bottle nipple.
Practice on the right piece of
equipment
Nutritive vs Non-Nutritive
Suckling.
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Non-nutritive (pretending)
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Rapid, choppy.
Vertical motion
(chewing/munching)
Little swallowing
Nutritive (drinking)
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Slow, rhythmic, Suck/pause
Wide jaw angle
Swallowing
You Can’t MAKE a Baby
Breastfeed. COAX!
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Promote flexion.
Pay attention to cues/maturity.
Oral stimulation – encourage rooting.
Skin to skin.
Rooming in.
Minimize distractions. (JOGNN Nov/Dec ’06)
Stabilize both breast and head.
Appropriate supplementation while
learning.
Be patient. Don’t push or pull jaw
down.
“M” #5: Money!!
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If 90% of US families could
comply with medical
breastfeeding recommendations
for 6 months, the US would save
$13 billion/yr and prevent an
excess of 911 deaths. $10.5
billion with 80% compliance.
Bartick, and Reinhold. 2010 The burden of suboptimal
breastfeeding in the United States: A Pediatric Cost Analysis
Pediatrics.
Human Milk is VALUABLE STUFF
Laws are Becoming More BF Friendly
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17-15-25. Right to breast feed.
The county legislative body may not prohibit a
woman's breast feeding in any location where she
otherwise may rightfully be, irrespective of whether the
breast is uncovered during or incidental to the breast
feeding.
Enacted by Chapter 131, 1995 General Session
76-10-1229.5. Breast feeding is not violation of
this part.
A woman's breast feeding, including breast feeding in
any location where the woman otherwise may rightfully
be, does not under any circumstance constitute a violation
of this part, irrespective of whether or not the breast is
covered during or incidental to feeding.
Enacted by Chapter 131, 1995 General Session
Working Mothers
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55% of women with children
under 3 yrs are in the work
force.
New U.S. Dept. of Labor
requirements for BF mothers.
Signed into law Mar, 2010.
New laws and recommendations
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Employers with >50 employees must
allow women 15 min 2X/d to pump
and provide a private place to do so
(not a bathroom)
Aug. 2012 Affordable Care Act. Health
insurance reform: health plans cover
and eliminate cost sharing for
breastfeeding support, supplies and
counseling.
(Guidelines at: www.hrsa.gov/womensguidlines) (Interim final rule at
http://www.ofr.gov.OFRUpload?OFRData/2011-19684 PI.pdf)
Health Care Provider Information
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Beginning Aug 2012
breastfeeding support by a
board certified lactation
consultant, will be a
“billable” service with no
copay as long you have
billing privileges.
Breastfeeding support
products, such as pumps,
must also be covered.
Billing Codes are Time-Related
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Example:
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Intermountain has Charge 1 – consult
from 1 – 15 min.
Charge 2 – consult from 16 – 30 min.
Up to Charge 4 = 1 hr or longer.
Only one charge/day is allowable.
ICD-9 and CPT codes should be
understood by your billing professionals
Insurance will cover IBCLC coming to
your office to provide service.
Example of billing code
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Primary medical reason and up
to 2 – 3 descriptions:
779.3 Neonatal Feeding Difficulty(initial)
750.0 Ankyloglossia
676.54 Suppressed milk supply
I.E. This baby is not nursing because is
tongue tied and the mother has little milk.
Then, charge based on how much time was
spent face to face (cannot charge for phone
consults).
Excellent Resources
BOOKS
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Medications & Mothers’ Milk 2011 (Hale)
Drugs in Pregnancy & Lactation (Briggs &
Freeman)
Making More Milk (West & Marasco)
Breastfeeding: a Guide for the Medical
Profession 7th Ed. (Lawrence & Lawrence)
Breastfeeding Management for the
Clinician (Walker)
Immunobiology of Human Milk (Hanson)
Excellent Resources
WEBSITES
www.bfmed.org (ABM Protocols)
http://newborns.stanford.edu
(hand expression, etc)
www.toxnet.nlm.nih.gov (go to LactMed)
www.healthcare.gov/news/factsheets/womens
prevention Affordable Care Act
http://www.lowmilksupply.org
www.nursingmothers.com/handexpression
www.breastfeedingoutlook.com)
Nationally Recognized
Guidelines
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Academy of Breastfeeding Medicine
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www.bfmed.org
“International professional organization which
unites physicians to protect and support
breastfeeding and human lactation.”
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Multidisciplinary
International (25 countries)
$150/yr for physician to join
Receive invaluable newsletters
 Yearly international conference
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Journals and Organizations
JOURNALS
Breastfeeding Medicine (ABM)
Journal of Human Lactation (ILCA)
Clinical Lactation (USLCA)
ORGANIZATIONS
WIC (each county)
LLLI La Leche League International
HMBANA – Human Milk Bank Assoc of N.A.
Final “M” = Make it Happen!
 Breastfeeding
is a team
sport.
 For mother, baby and all
support people
involved in their care.
 YOU can
make a difference