Breastfeeding Update Articles
Breastfeeding and Birth Control
- by Connie Neuner, IBCLC, Breastfeeding Education Coordinator, WV Bureau
for Public Health/Office of Nutrition Services/WIC
Using the wrong kind of oral contraceptive while breastfeeding in the early
months can sometimes bring breastfeeding to a quick end. Since a new nursing
mother may leave the hospital with birth control pills, it is important that she
be prescribed a type that will not interfere with her ability to lactate.
Regular birth control pills, because of the higher amount of estrogen, can
cause a rapid decrease in milk production. Progestin-only contraceptives do not
interfere with milk production. These include progestin-only mini-pills, the
Depo-Provera injection, and Norplant. Ideally, even the use of progestin-only
contraceptives should be delayed until baby is 3 weeks old. After the first four
months the question of which hormonal method of birth control to use for
lactating women is not a concern.
The State Health Department’s Family Planning Program has recently added the
progestin-only oral contraceptive, Micronor, to its list of available
contraceptives. Because of the very high cost of this progestin-only OC, it is
recommended that it only be prescribed for breastfeeding women. Micronor is
being added on a trial basis to test the frequency of demand for such a pill.
Progestin-only Depo-Provera injections are also available through Family
Planning Programs.
According to the Institute for Reproductive Health, the following early
postpartum birth control methods are recommended for lactating women who are not
fully breastfeeding :
Depo-Provera injection
Progestin-only oral contraceptive
Norplant implant
Barrier Methods.
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Breastfeeding Promotion Campaign Goes National
- by Connie Neuner, IBCLC, Breastfeeding Education Coordinator, WV Bureau
for Public Health/Office of Nutrition Services/WIC
From coast to coast "Loving Support Makes Breastfeeding Work" will become a
household slogan! The West Virginia WIC Program will sponsor part of a national
breastfeeding promotion campaign to be "launched" during World Breastfeeding
Week, August 1 through 7. You and your patients will see and hear media messages
encouraging community support for breastfeeding.
Because of the explosion of research during the last fifteen years proving
that human milk for babies is far superior to commercial baby formulas, USDA in
1995 funded a large-scale project designed to:
* improve public and medical support of breastfeeding
* increase breastfeeding rates among WIC participants
* increase referrals to WIC for breastfeeding education and support
The end result of this breastfeeding promotion project is ready to debut this
August. Newly developed client education materials and mass media materials
focus on three breastfeeding issues of concern to women: embarrassment,
competing demands on mothers time, and lack of support. The messages are upbeat
and contemporary. They include practical and reassuring responses to these
concerns.
Support for a mother’s decision to nurse her child is the major theme
throughout these campaign messages. Even though more West Virginia mothers are
choosing to initiate breastfeeding, the length of time they continue to
breastfeed is not increasing. Mothers tell us that they are not getting the
support and information they need to feel confident about continuing to nurse
their infants. Much of breastfeeding success comes from mother’s confidence in
her ability to nourish her child. That confidence must come from encouragement,
help, and support from those around her.
Because this support must also come from the medical community, physicians,
midwives, hospital staff and public health nurses are encouraged to update their
knowledge and skills to support lactating women and their babies. WIC Program
Breastfeeding Specialists and board-certified lactation consultants can help
your staff better assist mothers with breastfeeding questions. Your patients
expect and deserve the most accurate and supportive advice you can provide.
If you and your staff would like samples of new breastfeeding education
materials or educational videos for loan, contact the West Virginia Office of
Nutrition Services/WIC Program at 304-558-0030.
Remember, "Your Support Makes Breastfeeding Work" for your patients.
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- by Connie Neuner, IBCLC, Breastfeeding Education
Coordinator, WV Bureau for Public Health/Office of Nutrition Services/WIC
If your patient expresses concern about breastfeeding in public, here are
some tips you can give her:
Where to Go: Find a place to sit. Try a quiet corner in a fast food or other
restaurant or store; Department stores often have women’s lounges with chairs or
fitting rooms; Park benches; Create privacy by turning away from the crowd even
slightly.
What to Wear: Wear loose fitting, untucked shirts or front button tops; long,
full tops work well; Wear layers--cardigan sweaters, jackets, or scarves are
good.
How to Position Baby: If wearing a loose shirt, hold baby close to you and
lift your shirt from the bottom over the baby’s head, just high enough for baby
to find the breast. Shirt should drape over baby’s head. If wearing a buttoned
shirt, unbutton from the bottom (waist) to just below the breast and slip baby
in to nurse. Throw a baby blanket, sweater, jacket, or scarf over your shoulder
and baby.
Body Language: Body language can attract attention or divert it. If you’re
watching your hand unbutton your shirt, others will follow your gaze. Minimize
the attention you give your clothing. Meet people’s eyes and smile, or create
your own privacy zone by reading a book or focusing on something else.
Practice: Try feeding in front of a mirror so you can see if anything is
exposed, and practice adjusting your clothes.
Be proud of what you are doing for your child.
Act comfortable and natural and it will become easy.
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The Role of Obstetricians, Family Practice Physicians and
Midwives in Breastfeeding Success
- by Connie Neuner, IBCLC, Breastfeeding Education
Coordinator, WV Bureau for Public Health/Office of Nutrition Services/WIC
As an obstetrician, family practice physician or a midwife, you play an
important role in breastfeeding success. Your patients look to you for
information and guidance on how to nurture themselves and their unborn baby
during pregnancy. The prenatal care that you and your staff provide is vital to
a positive pregnancy outcome.
The choice your expectant mothers make on how they will feed their newborns
is an important step in laying a solid foundation for their baby’s growth and
development. We’d like to enlist your help in informing your patients on the
benefits of breastfeeding. The West Virginia Bureau for Public Health, Office of
Nutrition Services/WIC Program has been working to increase awareness of the
value of breastfeeding to expectant mothers, their families, employers, and
communities across West Virginia. However, we know that your support and
assistance is a key to our effort.
If you would like help with staff training in lactation management or
resource materials such as pamphlets or videotapes, please contact Connie Neuner,
IBCLC, WV WIC Program, at 304-558-0030.
Ways You and Your Staff Can Help Your Patients:
*Discuss the benefits of breastfeeding with your patients.
*Display up-to-date brochures, posters, or videotapes with breastfeeding
information.
*Make sure your staff is knowledgeable on breastfeeding issues and obstacles.
Know how to work through obstacles for a positive breastfeeding experience.
*Encourage your local hospital to appraise its breastfeeding support
practices so that nursing mothers receive appropriate information and
assistance. (Model hospital policies and protocols on breastfeeding support are
available from the WV WIC Program.)
*Provide a list of support services such as lactation consultants, a local La
Leche League, local WIC Program Breastfeeding Specialists, or WIC Program
Breastfeeding Peer Counselors.
Help Us Support the Healthiest Feeding Practice for Mother and
Infant---Breastfeeding.
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Suggested Consistent Management Messages for Mothers
These messages were developed with the input of the Health Care
Professional subcommittee of the Breastfeeding Promotion Consortium and the
National Breastfeeding Leadership Roundtable.
With consistent messages in the community for the early
post-partum period (until baby’s first check-up), we hope that the duration of
breastfeeding will begin to increase. Further management messages can continue
to be age-appropriate as baby grows and breastfeeding questions change.
The following messages are offered as a suggestion for
distribution among health care professionals, and for use by breastfeeding task
forces.
Mothers Remember: Making Milk is Easy. Here’s How---
1. Breastfeed soon and often
•As soon as possible after birth is best--within 1st
hour;
•8-12 times each day in the early weeks is usual to build milk supply.
2. Be sure you and baby are both comfortable
•Help baby latch on correctly with wide open mouth as he
latches on; and lips flanged out;
•Hold baby close; chest to chest; use pillows to lift baby to breast level.
3. Avoid bottles and pacifiers during the first 2 weeks
•They can confuse baby’s sucking and reduce milk supply;
•Breastmilk alone is all most babies need.
4. Notice signs of plenty of milk
•Swallowing sounds when baby suckles;
•Wet diapers (6-8 each day after day five; 3-4 heavy disposables);
•2-3 stools each day, turning yellow & soft by day four;
•Usually happy baby (all babies cry some);
•Normal weight gain (7-10% weight loss at first, then 1/2-1 oz. gain per day
after day 6.
5. Call when you have questions--Request competent
information from physician, mid-wife, WIC Program, hospital staff.
•We all need help when learning something new;
•Express questions & concerns early, before problems develop;
•Competent advice will support breastfeeding while finding solutions to
problems.
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Physician Guide to Assessing Early Breastfeeding
by Marianne Neifert, MD
Dr. Neifert is the medical consultant to the Health One
Lactation Program in Denver and a member of the AAP Work Group on
Breastfeeding. Adapted from the Academy of Breastfeeding Medicine News &Views
Vol. I. Fall, 1995.
As physicians and other health care providers are being called
upon to evaluate newborns within the first few days after discharge, they need
specific criteria to accurately assess whether breastfeeding is off to a
successful start or whether intervention is necessary to correct early
difficulties which may lead to more serious problems later.
Infant Weight Criteria
A naked infant weight and the calculated percent weight loss
from birth are the most accurate measures of the baby's nutritional status and
the adequacy of breastfeeding. Peak weight loss occurs just prior to milk
"coming in," usually on the 3rd day of life. The period of weight loss after
birth is short-lived. If breastfeeding is going well, babies will not continue
to lose weight after abundant milk production begins. Physicians traditionally
have been trained to accept up to 10% loss from birth weight as being normal.
Yet, very few breastfeeding infants will lose this much unless breastfeeding
problems are present. Tolerating 10% weight loss and calling it normal only
serves to delay intervention when infants could benefit from early modifications
in breastfeeding frequency or techniques.
Shortly after milk comes in abundantly, thriving breastfed
infants will gain approximately an ounce per day during the early weeks of life.
Steady weight gain should commence by 5 days of age and most breastfed babies
will surpass their birth weight by 10-14 days unless the baby fails to obtain
sufficient milk. "Faltering" infant weight in the early weeks of breastfeeding
should not be considered a normal pattern. It is suggestive of inadequate milk
intake by the infant, which shortly will lead to diminished milk production. For
this reason, early intervention to improve milk delivery to the baby is
essential. This does not mean to simply discontinue breastfeeding, but to
improve breastfeeding effectiveness or to supplement, if necessary.
Infant Elimination
An infant's elimination pattern is one of the most sensitive
indicators of the adequacy of milk intake.
Shortly after mother's milk has became abundant, a thriving
breastfed newborn should void colorless urine at east 6 times daily. With
inadequate infant intake, mothers often report a "brick dust" appearance in the
diaper due to precipitated urate crystals (not uncommon in the first 2 days of
life, but considered abnormal later.)
At about the 4th or 5th day of life, well-nourished breastfed
infants typically begin to pass sizable (not a small stain) loose, yellow "milk
stools," resembling cottage sheese and mustard after most feedings. Between 4
days and 4 weeks of age, a thriving breastfed baby typically will pass at least
4 such "milk stools" each day. Dark transition stools, infrequent movements, or
scant volume of stools in the young breastfed infant are common indicators of
insufficient milk intake. A weight check is in order when an infequent stooling
pattern is present after the mother's milk has "come in". By one month of age,
stooling frequency gradually diminishes in breastfed infants.
Frequency of Feedings
Inadequate feeding frequency is a common, preventable cause of
insufficient milk. A mother must be prepared to nurse her new baby whenever the
infant fusses, roots, sucks the hands, just acts hungry or of course cries.
Crying is the late sign of hunger, however.
Newborns should nurse approximately 8 to 12 times in 24 hours,
usually taking both breast at each feeding. Mother should nurse her baby every 1
2 to 3 hours during the early postpartum weeks to maximize her milk supply and
assure adequate infant intake. A single longer night interval of about 4 hours
is common. A mother should be instructed to awaken a non-demanding baby to nurse
at least every 3 hours during the daytime. She should slternate the side on
which feedings are started because the infant suckles more vigorously at the
first breast. Pacifiers should be withheld until a consistent pattern of
acceptable weight gain has been estalished.
Duration of feedings should be approximately 15 minutes per
breast, during which the infant's swallowing can be seen and heard by mother.
Infants are unlikely to obtain sufficient milk by suckling less than 10 minutes
per breast in the early weeks of life, while feedings that last more than 50
minuted usually signal ineffective nursing.
Infant Behavior
Once milk has "come in," a mother should hear her baby swallow
regularly during feedings and see evidence of milk in the baby's mouth. This
observation is subjective, however, and does not always correlate with objective
measures of intake.
Generally, a breastfed baby should appear satisfied after
nursing and sleep between feedings. Excessive crying, continual sucking on
fists, or constant need for a pacifier sometimes signify persistent hunger.
Exaggerated physiologic jaundice in a breastfed infant may be a
marker for inadequate breastfeeding, it must be distinguished from breast milk
jaundice which usually becomes noticeable at the end of the first week of life
and peaks during the second or third weeks of life. Jaundice should raise the
physician's suspicions and trigger a more detailed evaluation of brestfeeding
behavior. The physician should be reassured that:
* Baby was put to breast within 1 hour after delivery;
* Baby has been nursed every 1 and 1/2 - 3 hours, both in hospital and at
home;
* Mother observes Baby swallowing;
* Baby has received no supplemental foods by artificial nipple, unless
medically neccessary;
Maternal Breast Evaluation
Lactogenesis, or the onset of copious milk secretion, usually
occurs 2-4 days postpartum. Primary failure of lactogenesis occurs rarely.
Assessment of maternal breasts by prenatel care providers can reveal inverted
nipples or a surgical scar. Surgery may severed laciferous ducts, impairing milk
drainage. Abnormal breast development and lack of pregnancy-induced changes may
be associated with insufficient lactation.
The leading preventable cause of insufficient milk is failure to
accomplish regular, effective milk emptying once postpartum breast engorgment
occurs. When an infant is unable to empty the brests effectively, prescribing an
electric breast pump can preserve milk supply while efforts are being made to
improve baby's breastfeeding technique.
Most women experience slight nipple discomfort at the beginning
of feedings during the first few days of nursing. However, severe nipple pain,
pain lasting throughout feedings, or pain persisting beyond one week postpartum
is atypical and suggest that the baby is not positioned correctly at the breast.
It is important that hospital OB, postpartum, and newborn nursing staff be
trained in teaching and assessing proper infant latch-on. Improper infant
latch-on not only causes sore nipples, but also impairs milk flow and leads to
diminished milk supply and inadequate infant intake.
Early assessment allows for the timely detection and treatment
of breastfeeding problems that can jeopardize success.
By collaborating with community breastfeeding referral services,
care providers can help most women overcome early difficulties. Even when
breastfeeding appears to be going well, remember that new mothers require our
affirmation, encouragement, and ongoing support to assure the continuation of
breastfeeding.
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Offering Breastfeeding Options to Your Patients.
by Michelle Cissel, IBCLC
Ms. Cissell is a Board Certified Lactation Consultant, with the Shenandoah
Valley Medical System/WIC Program.
Many women return to work or school after the birth of their child, some
within a few weeks of delivery. For this reason, many women choose not to
breastfeed. If they could be informed of the many options breastfeeding offers,
more might decide to breastfeed, even if only for a while. Increasing her infant
feeding options can enable the new mother to feel more confident about balancing
family and work schedules- and reap the health rewards that come with
breastfeeding.
Lets look at some of these breastfeeding options and the necessary planning
that goes with them. A breastfeeding woman who plans to return to work or school
has the following choices in regards to breastfeeding: a)wean before returning
to work or school, b) have the baby’s care giver use formula while the mother
breastfeeds when at home, or c) express her milk for the baby’s care giver to
use in bottles and breastfeed when at home.
Weaning before returning to work:
This option provides the baby with the benefits of short term breastfeeding:
1. Colostrum provides abundant amounts of antibodies and immunoglobulins
that enhance baby’s immune system. The health protective potentials of human
milk are related to the amount of human milk an infant receives. Short term
nursing gives short term health benefits that are not available from
commercial formulas.
2. Breastfeeding during the early weeks reduces postpartum bleeding and
stimulates the mother’s uterus to return to pre-pregnancy size faster.
3. Short term breastfeeding provides priceless bonding between mother and
infant. The health benefits of breastfeeding for only a few weeks may be
temporary, but effective breastfeeding gives mother and baby both satisfaction
and a healthier start in life. The mother will need to be given weaning
information to ensure her comfort and reduce her risk of complications due to
improper weaning. Gradual weaning will also be more acceptable to baby.
Using commercial formula while at work/school:
More and more businesses offer supportive breastfeeding policies. They are
learning how breastfeeding can make a difference in the health, satisfaction,
and medical costs of their employees. However, some women are uncomfortable with
the idea of expressing milk at work or they are unable to pump at work due to
the nature of their job or the lack of a private, clean place to express milk.
Providing commercial formula for the day care giver to feed baby while mother is
at work/school and breastfeeding while she is at home is an acceptable
alternative. It is better than no breastmilk at all. Mother should be encouraged
to breastfeed exclusively for at least 3-4 weeks post partum before introducing
a bottle.(If early supplementation is medically necessary, methods other than
bottles may be used to deliver milk to the baby.) Two weeks before returning to
work or school, the mother can gradually start weaning to a commercial formula
for the 2-3 feedings when she would normally be at work, and breastfeed when she
would normally be home. If she does this gradually over the two weeks before
returning to work or school, she will prevent any discomfort. If mother weans to
formula more suddenly, she needs to know that her breasts will get full and
possibly uncomfortable while at work due to the missed feedings. She should be
prepared for leakage and should be given information on hand expression to make
herself comfortable. The feeling of fullness will decrease as the weeks
progress. Frequent nursing on her days off will help maintain her milk supply.
While the health benefits of breastfeeding are reduced with the introduction
of formula, combination feeding is better than formula alone. Breastfeeding is
the easiest way to reconnect with her baby when mother gets back home.
Expressing milk at work or school for use by day care provider:
By choosing to express her milk, a mother knows she is giving her baby the
best nourishment possible. She also saves her family money and improves the
health of her baby. A healthier baby leads to less missed work days due to
caring for a sick child. Again, mother should be encouraged to breastfeed
exclusively for 3-4 weeks post partum before introducing a bottle. About 2 weeks
before returning to work/school she should begin expressing and storing her
milk. She will need a good electric breastpump for repeated long term pumping.
The electric breastpumps available at drug and discount stores are only meant
for an occasional missed feeding. They may not stimulate and empty the breasts
well enough for an extended period of time to maintain a good milk supply. The
cost of renting an efficient electric pump is much less than the cost of the
formula she would otherwise need. (Medela, Inc. even has a foot pump that works
well and can be purchased at a reasonable price–No electricity or batteries
needed!). There is always the option of hand expression. Some women can hand
express as successfully as others can pump.
By giving women options, we enable them to make an educated decision about
whether or not to breastfeed their baby. No matter which option she chooses, she
will need support. Help is available to breastfeeding women from La Leche
League, board-certified lactation consultants, the WIC Program, breastfeeding
support groups, and friends or family with breastfeeding experience. Good
breastfeeding information and local support enable a smooth transition to work
with added comfort and satisfaction.
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One Physician’s Way of Providing Breastfeeding Information
In August the American Academy of Pediatrics/American College of
Obstetrics/Gynecology national offices sponsored the second breastfeeding
training conference for physicians at AAP national offices in Oakbrook,
Illinois. Dr. Michal Young, neonatologist, D.C. General Hospital, Washington,
DC, was a speaker at the conference. In Dr.Young’s neonatology practice all new
mothers are given the following information about the difference between
breastmilk and commercial formulas. The information conveys this physician’s
belief that breastmilk is the preferred infant food choice for all infants.
Mothers in this urban, inner-city practice are given this material and advised
to make their own choice. Dr. Young does not believe that "guilt" comes into
play when a patient is given accurate information about optimum health
practices. Dr. Young gives permission to share the following material with other
physicians:
Mothers who choose to formula feed please be aware of the following:
1. Formula is an inferior substitute for breast milk.
2. Unlike breast milk, formula does not contain substances that will fight
colds, ear infections, diarrhea, and pneumonia in your baby.
3. Unlike breast milk, formula does not contain substances that improve
brain function - i.e. breast-fed infants have higher IQ’s later in life than
formula fed infants.
4. Breastfeeding helps you lose weight–you burn extra calories daily while
breastfeeding.
5. It costs $1000 per year to formula feed. Even if you are receiving WIC
formula, remember, it is a supplement. The formula will run out before the
month does. WIC supplies more food for a mother to eat when she is
breastfeeding.
6. Formulas try to imitate breast milk - why give your child second best
when they can have the real thing!
7. Unlike breast milk, formula cannot help protect your baby from diabetes
and cancer.
Breast milk is the best milk for your baby. Unless you have the AIDS virus,
or are taking drugs that will cause harm to the baby you should breastfeed.
Anything less is less than the best for your baby. Its your choice. Please
choose wisely.
Michal A. Young, MD, FAAP
Division of Neonatology, Dept.Pediatrics
D.C. General Hospital
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