Transcript Enhancing Breastfeeding Success - MCW Department of Obstetrics

How Obstetricians Can Best Support
Breastfeeding Dyads: Antepartum,
Intrapartum and Postpartum Pearls
August 10, 2016
Lauren Hanley, MD, IBCLC, FACOG
Department of Obstetrics and Gynecology
Massachusetts General Hospital
No conflicts of interest to
disclose.
* I was formula fed. This was
recommended as optimal way to feed
by my pediatrician in 1971.
Objectives
To review how Obstetricians can support women to
achieve their breastfeeding goals during the following
timeframes:
-Antepartum/Prenatal
-Intrapartum
-Postpartum
 To review how and why Skin to Skin supports normal
newborn physiology and enhances breastfeeding
 To review medication usage during lactation and
resources to check safety
 To review available Resources
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Breastfeeding is a public health issue.
Even in developed countries, infants who are
not breastfed face higher risks of infectious
and chronic diseases, and mothers who do
not breastfeed face higher risks of cancer and
metabolic disease.
ACOG Recommendations
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The American College of Obstetricians
and Gynecologists strongly encourages
women to breastfeed and supports each
woman’s right to breastfeed.
The College recommends exclusive
breastfeeding for the first 6 months of
life, with continued breastfeeding as
complementary foods are introduced
through the infant’s first year of life, or
longer as mutually desired by the
woman and her infant.
Committee Opinion No. 658
Photo: Massachusetts Breastfeeding Coalition
Mother’s
breastfeeding
goals
Baby friendly
maternity care
Supportive
family and
friends
Informed
medical
providers
Adequate leave,
workplace
support
Breastfeeding
success!
Your care directly affects a woman’s
breastfeeding success.
Both observational and randomized trials
demonstrate that routine health care practices
can enable mothers to meet their infant feeding
goals – or derail breastfeeding and increase
health risks for mother and child.
What is Baby Friendly?
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Global initiative of the WHO and UNICEF
Implemented in the USA by “BFUSA”
(designating body)
Based on “The Ten Steps to Successful
Breastfeeding: The Special Role of Maternity
Services” 1989
Adherence to the Ten Steps decreases
racial, ethnic, and sociocultural
disparities in Breastfeeding Rates in the US.
HP 2020 goal (births in BF hospital): 8.1%,
we are at 18%!!
The Ten Steps
1. Have a written breastfeeding policy.
2. Train all health care staff.
3. Inform all pregnant women about the benefits and management
of breastfeeding.
4. Help mothers initiate breastfeeding within one hour of birth.
5. Show mothers how to breastfeed and maintain lactation, even if they
should be separated from their infants.
6. Give newborn infants no food or drink other than breastmilk, unless
medically indicated.*
7. Practice rooming in - that is, allow mothers and infants to remain
together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to
breastfeeding infants.
10.Foster the establishment of breastfeeding support groups and refer
mothers to them on discharge from the hospital or clinic.
Breastfeeding Disparities
Ever Breastfed
83
Breastfed at 6 months
Breastfed at 12 months
83.9
83.2
82.4
71.5
66.4
65.6
55.8
51.4
42.3
32.8
35.3
32.6
27.9
16.9
Non-Hispanic white Non-Hispanic black
14.4
Hispanic
Non-Hispanic Asian
Non-Hispanic
Hawaiian/Pacific
Islander
28.8
17.9
Non-Hispanic
American Indian or
Alaskan Native
Maternity Facilities in zip codes with
more Black residents are less likely to
provide Ten Steps Care
60%
46%
39%
28%
26%
13%
Early initiation
Limited use of
Rooming in
supplements
>12.2% Black residents
≤12.2% Black Residents
Lind et al (2014). MMWR Morb Mortal Wkly Rep 63(33): 725-8.
The World Health Organization’s “Ten
Steps to Successful Breastfeeding” should
be integrated into maternity care to
increase the likelihood that a woman
achieves her personal breastfeeding goals.
Committee Opinion No. 658
Maternity care directly affects a woman’s breastfeeding
success
FIGURE 1 Among women who initiated breastfeeding and intended to
breastfeed for >2 months, percentage who stopped breastfeeding before 6
weeks according to the number of Baby-Friendly Hospital Initiative practices
they experienced
DiGirolamo, A. M. et al. Pediatrics 2008;122:S43-S49
Patient-Centered Care
60% of women do not meet THEIR OWN
breastfeeding goals.
CDC/FDA Infant Feeding Practices Survey II, 2008
Antepartum Education:Why is it
important?
• 1997 JHL study found that 23% of expectant
mothers received counseling from OB.
• 1998 JHL study associated antenatal advice
associated with intent to BF (61% vs 35%).
• 2007 Cochrane review: professional support
was effective in prolonging any breastfeeding.
• 2011 BMJ review:breastfeeding promotion
interventions increased exclusive and any BF
@ 4-6 wks & 6 mos.
Antepartum Education: Is it
happening?
• 12/2013 Demirci J, Bogan
D,Holland C et al.
• Breastfeeding discussion @
initial OB visit
• 172 recorded encounters
• BF discussion @ 29% of visits
for mean 39 sec.
• CNM more likely to initiate
discussion than OB residents.
When should we discuss breastfeeding
during prenatal care?
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As soon as possible!
Unless there is a question of miscarriage
During the breast exam
Open ended questions
Decisions are often made prior to pregnancy
or in first trimester
Open ended questions that may facilitate a
discussion about feeding:
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Have you ever thought about how you will
feed your baby?
Are you interested in learning about why
breastfeeding is the healthiest option for you
and your baby?
Do you have any family members or friends
that breastfed their baby?
What are your plans regarding work outside
of the home after the birth?
History/Anticipatory Guidance
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Breastfeeding History
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Other relevant medical/surgical history
Involving partner/other family /social supports
Review resources
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Did she breastfeed in the past?
How long?
Why did she wean?
Classes, Hospital Support (Lactation, nursing,
OB/CNM/pedi)
Community Support
Review hospital practices that will support
breastfeeding
History of Breast Injury or Surgery
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Reduction Mammoplasty
Augmentation Mammoplasty
Lumpectomy or Biopsy
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Especially if significant ducts or nerves are
severed/removed
Greatest concern are periareolar incisions
Previous Treatment for Breast CA
Hx of Trauma, Burns, or Chest Tube (childhood)
Nipple Piercings with Infection or Scarring
Percent breastfeeding at 6 weeks
80
70
73
54
60
41
35
40
20
9
0
Favors breast
No preference
Favors Formula
Health care provider opinion
Physicians
Hospital Staff
Send a clear message to patients:
‘I recommend breastfeeding.’
DiGirolamo et al. Birth 2003;30:94-100
Summary of Antenatal Education
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Discuss breastfeeding early and often
Review benefits for mother and child
Review practices in the hospital that will enhance
success
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Rooming In, Feeding on Demand, Skin to Skin
Unnecessary supplementation, Avoid pacifiers
Support groups and Community Resources
Review how to combine working and breastfeeding/
pumping and how to work with employers.
Breastfeeding Friendly Office
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Posters/Art depicting breastfeeding throughout the
office, multicultural women and children
NO formula marketing/coupons
Sign to remind patients that breastfeeding is
welcomed in the waiting room
Mother’s room for patients and staff
Patient and Staff Education
Community Based Resources/Printed materials
Prenatal Classes
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Families should receive noncommercial,
accurate, and unbiased information so that
they can make informed decisions about their
health care.
Obstetric care providers should be aware that
personal experiences with infant feeding may
affect their counseling.
In addition, pervasive direct-to-consumer
marketing of infant formula adversely affects
patient and health care provider perception of
the risks and benefits of breastfeeding.
Committee Opinion No. 658
Step 4: Help mothers initiate breastfeeding within
1 hour of birth
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Skin-to-skin supports normal physiology of
breastfeeding
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Contact in first hour of life, when infant is
awake and alert, is a “critical period” for
nursing success
Step 4: Initiate feeding within one hour
What about Cesarean Delivery?
AAP Guidelines 2005,
revised 2012
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Healthy infants should be placed and remain in
direct skin-to-skin contact with their mothers
immediately after delivery until the first feeding is
accomplished.
Skin-to-skin supports normal physiology of
breastfeeding
Contact in first hour of life, when infant is awake
and alert, is a “critical period” for nursing success
Remember: a gown, blanket, or bra between
baby and mother is NOT skin to skin!
Cochrane Database Study, 2007, Moore et
al.
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30 studies, 1925 dyads, 29 RCT, diverse
populations
Improved infant glucose levels
Improved rates at 1 & 4 months and total
duration of breastfeeding
Rooming in also increased duration
Skin to skin improved temp and CV stability
Improved maternal attachment
No adverse effects
Skin to Skin MGH Cesarean Section:
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February, 2014 started as a PDSA
Tracking rates and working on documentation
Staff / patient satisfaction
Safety: “Speak Up” model
Anesthesia, OB, Pedi “buy in”
Discuss in preop huddle and postop debrief
Clear drape
Baby to chest after 5 minute APGAR
TEAM effort
Skin to Skin buttons for staff
Actual Size of a Term Newborn’s
Stomach
Teaching tool for learning to
understand the new baby’s needs
www.massbreastfeeding.org
What we do really matters!
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What is the usual protocol in the L&D unit for
skin to skin?
Change takes time, but introducing the idea and
working with staff to accomplish this goal has
excellent science behind it and makes a
difference!
Patient(s) are more satisfied when baby not
“taken away” for weight, exam, injection, eye
ointment etc. (MOM and BABY)
Postpartum Considerations
Where Providers lack confidence
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Peds/OB providers polled about where
deficiencies lie:
 Referral services
 Returning to work/Pumping
 Low Milk Supply
 Breast Pain
 Teaching Basic Skills/Evaluating Latch
Know when, and to whom, to refer – make use
of lactation consultants.
Taveras, E. M., R. Li, et al. (2004). Pediatrics 113(4): e283-90.
What do I tell my patients?
• Skin to skin at delivery, early initiation of
breastfeeding and not using supplementation
without a medical indication can be helpful in
improving breastfeeding success
• What happens in the hospital
matters to helping mother’s meet
their intended breastfeeding goals.
Hospital Practices Tips
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Facilitate skin to skin
Initiate breastfeeding/pumping in delivery room
Room in, demand feeding
Avoid supplementation unless medically
indicated
Avoid early introduction of pacifiers (except for
procedures) and bottle nipples
Medications and
Breastfeeding
Pearls for making the best choices
Golden Rules:
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Reaffirm mother’s goals
Try to enable a scenario where mother is
appropriately treated and no interruption of
feeding occurs
Only rare circumstances where breastfeeding
needs to temporarily or permanently cease
Consult your resources adequately/quickly
Meds: Golden Rules: continued
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Mothers with depression symptoms should
seek treatment. Most of these meds are safe
or can choose one that is safe.
Most drugs are safe in breastfeeding mothers
If drug is not safe, can TEMPORARILY
discontinue until the drug is metabolized. Not
always necessary to stop altogether
Choose drugs with short T1/2, high protein
binding, low oral bioavailability or high
molecular weight.
Resources for Medication compatibility
with breastfeeding
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Lactmed
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Medications and Mother’s Milk, Hale, 2014
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Website
App
Infantrisk.org
App
AAP Committee on Drugs document (more general)
PDR (NO!!) Compiles all packages inserts standard
recs are NOT to take—Poorest source of
information
http://lactmed.nlm.nih.gov
Or Google “LactMed”
Lact Med
FREE!
Medications and Mothers’ Milk
Tom Hale, PhD
Hormonal Methods: General rule is to
avoid estrogens if possible
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Combined OCP, Patch, Ring: all can
decrease milk supply
Progesterone methods have less impact on
milk supply
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Progesterone Implant (3 year)
Progesterone IUD (5 year)
POP
Medroxyprogesterone Injection (3 months)
*Sometimes they can alter milk supply as well
Progesterone Only Methods
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Theoretical risk of introducing too early may
impact full supply being established
Postdelivery decrease in progesterone part of
the physiologic cascade to start
lactogenesis II.
Most experts recommend delay initiating
these methods until full supply is established
(4-6 weeks minimum)
Rarely patients see a drop in supply even
with Progesterone IUD.
Progesterone Methods Failure Rates
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Depot Medroxyprogesterone (IM q 3 months)
Typical failure rate: 0.3%
Progesterone Only Pill: 8-10% (Typical use)
Perfect use: 1%
Implant (Etonorgestrel Rod) Typical use <1%
Also helpful for medically complicated
patients that are not estrogen candidates
Postpartum Checkup: How can we help enhance
breastfeeding duration and exclusivity?
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Have referral/resources for community
support readily available with staff for phone
calls and during appointments
Remind patients to call the office with
questions or problems relating to breast
health at ANY time postpartum even after the
PP exam
Review transition of return to workforce and
plans to highlight the law and offer support
and advice re: expressing at work.
ACA Supporting
Breastfeeding and Lactation
The Affordable Care Act (ACA) has two major
provisions:
 Coverage of comprehensive lactation support and
counseling
 Coverage of costs of renting or purchasing
breastfeeding equipment for the duration of
breastfeeding.
Support of continuation through first year
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Offer to provide a letter for employer
reviewing the medical and economic benefits
for an employee to continue to breastfeed
Better employee retention
Less absenteeism due to sick child
Financially advantageous to retain
breastfeeding employees rather than hire
new employee
Better work satisfaction
Resources/Links
http://acog.org/breastfeeding
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Hypoglycemia
 Near-term infant
 Discharge
 Ankyloglossia
 Supplementation
 NICU graduate
 Mastitis
 Contraception
 Peripartum management  The breastfeedingfriendly physician’s
 Cosleeping
office
 Model Hospital Policy
 Anesthesia and
 Human milk storage
analgesia
 Galactogogues
 The hypotonic infant
Resources for Black Families
ACOG/AAP/ABM
Know Your Local Resources and the
Law
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Lactation consultants
– ILCA.org
Community support
– LLLI.org
– WIC
– Local hospital groups
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Frenotomy providers
Breast specialists
Breastfeeding in Public/Employment Laws
Happy National Breastfeeding Month!
Thank you
Kathy Hartke, MD and Paul Hartke
Cresta Jones, MD
GE
Questions?