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Improving
Breastfeeding
Practices
Nancy
Mohrbacher,
IBCLC, FILCA
~
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Overview
• Why exclusive
breastfeeding
matters
• Barriers
• One hospital’s
successful
efforts to
improve
breastfeeding
practices
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Exclusive Breastfeeding
• No water, formula,
other liquids or solids
• Recommended for
6 months as
best practice by
– WHO, AAP, other
organizations
– Exception: “if a
medical indication exists”
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CDC’s Biannual mPINC SurveyMaternity Practices in Infant Nutrition & Care
Scores US birthing
facilities by adherence
to evidence-based
best practices
Compared by
size, state, nation
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1 of 5 national
performance measures
required in facilities with
>1100 births/year
# of non-NICU babies
without a breastfeeding
contraindication who are
exclusively breast milk fed
The Joint CommissionPerinatal Care Core Measure on
Exclusive Breast Milk Feeding
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Baby FriendlyImplemented in >150 countries by WHO & UNICEF to improve hospital breastfeeding practices
Ten Steps to Successful Breastfeeding
361 US hospitals now Baby-Friendly certified (18% of US births annually)
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Ten Steps to
Successful Breastfeeding (BF)
1. Written BF policy routinely communicated to staff
2. Train all staff in skills needed to implement policy
3. Inform pregnant women of benefits & management of BF
4. Help mothers initiate BF ≤ 1 hour of birth
5. Show mothers how to BF & maintain lactation, even if separated
6. Give infants no food or drink other than breast-milk, unless medically indicated
7. Practice rooming in 24 hours a day
8. Encourage BF on demand
9. No pacifiers or artificial nipples
10. Foster BF support groups & refer mothers to them on discharge
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Why
Exclusive
Breastfeeding
Matters
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Exclusive Breastfeeding & Health OutcomesIp, S. (AHRQ) Evidence Report/Technology Assessment. 2007; (153):1-186
Bartick, M. & Reinhold, A. Pediatrics 2010; DOI:10.1542/;eds.2009-1616
Recent evidence
confirms
lifelong effects
of breastfeeding
on maternal & child health
If 90% of US women
exclusively breastfed for 6 mo,
annual healthcare savings
estimated at $13 billion
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2011 Surgeon General’s Call to Actionhttp://www.surgeongeneral.gov/library/calls/breastfeeding/index.html
Table 2. Excess Risk Associated with Not Breastfeeding
Outcome Excess Risk
Among full-term, healthy babies
Gastrointestinal infection 178%
Hospitalization for lower respiratory tract
disease during first year
257%
Childhood obesity 32%
Sudden Infant Death Syndrome 56%
Among preterm infants
Necrotizing enterocolitis (NEC) 138%
Among mothers
Breast cancer 4%
Ovarian cancer 27%
AHRQ: http://www.ncbi.nlm.nih.gov/books/NBK38337/
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Newborns’ gut junctions open at birth
• While open, proteins & pathogens can pass through
• ↑ risk of infection, NEC & allergy sensitization
• Take weeks to close
Le Huëron-Lurou, et al. Nutr Res Rev 2010; 23:23-36
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Colostrum
• Grows baby’s gut
• Helps it mature
• Protects from
pathogens
Le Huërou-Luron, et al. Nutr Res Rev 2010; 23:23-36
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One formula feed
changes gut flora
•↑ gut permeability
& keeps junctions
open weeks longer
•↑ risk of allergy
sensitization
•↑ risk of inflammation
& infection
•↑ risk of insulin
resistance & obesity
O’Sullivan, et al. Nutr Metab Insights 2015; 8(S1):1-9
Guaraldi & Salvatori. Front Cell Infect Microbiol 2012; 2 Art 94:1-4
Moodley-Govender, et al. Breastfeed Med 2015;10(10):488-92
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Barriers to
Exclusive
Breastfeeding
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Perrine, et al. Pediatrics 2012; 130(1):54-60
2/3 of US mothers
who intend to
breastfeed
exclusively
for ≥3 mo
do not reach
their goals
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http://www.surgeongeneral.gov/library/calls/breastfeeding/index.html
Surgeon General’s
2011 Call to Action
to Support
Breastfeeding
Identified
7 breastfeeding
barriers
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Personal Breastfeeding Barriershttp://www.surgeongeneral.gov/library/calls/breastfeeding/index.html
Lack of knowledge
Social norms based
on bottle-feeding
Poor family &
social support
Embarrassment
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Systemic Breastfeeding Barriershttp://www.surgeongeneral.gov/library/calls/breastfeeding/index.html
Problems with
health-care services
Lactation challenges
Employment &
child care
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One Hospital’s
Successful
Efforts to
Improve
Breastfeeding
Practices
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Increase Exclusive Breastfeeding at
Hospital Discharge
• Chicago suburban
hospital, 3500
births/year
• 8 board-certified
lactation
consultants on
staff
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Outpatient lactation clinic The Nurturing Nook opened
November 2014—a huge income
generator
Allowed for further expansion of lactation staff
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Results So Far
BF initiation Exclusive BF
@ d/c
Before Initiative
93% 60%
1 year later 93% 67%
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3 MDs, NPs, Midwives
2 Nurses
(Mother-Baby, L&D, NICU)
1 Lactation
Staff
Strategy 1st Things 1st
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Step 1: Get LCs on the Same Page
• Shadowed everyone
• Reviewed research
on conflicting
information as a team
• Developed handouts
for patients and staff
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Step 2: Get RNs on the Same Page
Five 30-minute live breastfeeding in-services
• Each offered 20-30 times around the clock near unit
• Offered nurses contact hours
• Mandatory—if missed, must watch recording, turn in assignment
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In-Service Topics
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1. Pumping & Medications Basics
Learner Objective
• Describe
optimal
pumping
strategies after
birth among
exclusively
pumping
mothers and
how they vary
over time
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Milk Volumes (mL) Day 1 to 6 Weeks
Parker, et al. J Perinatol 2012; 32:205-09; N=20 VLBW
Parker, et al. Breastfeed Med 2015; (10)2: 84-91; N=40 VLBW
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IN JULY, 82% OF PUMPING WAS INITIATED IN L&D
15.1
7.5
3.793.11
2.28
0
2
4
6
8
10
12
14
16
Baseline Feb/Mar n=32 April n= 20 May n= 17 June n= 10 July n=22
Average hours to initiate breast pumping for NICU babies
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2. Early Breastfeeding Positioning
Learner Objective
• Explain how
feeding positions
affect newborns’
innate feeding
behaviors and
the amount of
effort mothers
must expend
during
breastfeeding
•
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1. Birth cry: Lungs expand
2. Relaxation: Relaxed hands, no mouthing
3. Awakening: Small head & shoulder movements
4. Activity: More head & shoulder movements
5. Rest: May occur between any stages
6. Crawling: Movement to the breast
7. Familiarization: Licks nipple, touches breast
8. Suckling: Latches & suckles
9. Sleep: Falls into restful sleep
Breast Crawl: 9 Instinctive Stages after Birth
Widstrom, A-M, et al. Acta Pediatr 2011; 100:79-85; N=28
Girish, et al. J Perinatol 2013; 33(4):288-91; N=100
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• Videotaped feedings of
40 mother-baby pairs
• Identified 20 primitive
neonatal reflexes (PNRs)
• PNRs work for or against
breastfeeding,
depending on position
Colson, et al. Early Hum Dev 2008; 84(7):441-49
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20 Primitive Neonatal Reflexes
Include:• Rooting• Suck• Swallow• Hand to mouth• Mouth gaping• Tongue licking• Jaw jerk• Arm & leg cycling• Head lifting• Head bobbing• Stepping, crawling
More PNRs led to
breastfeeding when
mothers lean back with
baby on top (p=<0.0005)
Colson, et al. Early Hum Dev 2008; 84(7):441-49
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Sitting up,
PNRs
made
latching
more
difficult
Pull of
gravity
caused
gaps,
head-
butting,
arching
away
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Yet What Positions Are Often Taught?
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Learning to Breastfeed
36
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38-min. video: www.NaturalBreastfeeding.com
Short clips: www.YouTube.com/NancyMohrbacher
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3. Early Breastfeeding Adequacy
Learner Objective
• Discuss the key
information
parents of
breastfeeding
newborns need
about feeding
intervals,
length, and
number of
feeds per day
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Focus: 8-12 feeds/day
• Common patterns
– Clustering feeds
– More feeds at night
• Can feed in light sleep
No need to focus on:
• Intervals between feeds
• Feeding length,
except if at latch
baby appears asleep
• Diaper output (any OK)
• Weight loss ≤10%
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4. Supplementing the Breastfed BabyLearner Objectives
• List recommended supplements for breastfeeding newborns in order of priority
• Define biologically appropriate newborn feeding volumes by age
Photo: The Breastfeeding Atlas
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Photo: The Breastfeeding Atlas
Supplement
What
In order of priority
1. Expressed
mother’s own milk
2. Infant formula
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Protocol to supplement healthy, term babies
Volume per feed
1st 24 hr: 2-10 mL
24-48 hr: 5-15 mL
48-72 hr: 15-30 mL
72-96 hr: 30-60 mL
ABM. Breastfeed Med 2009; 4(3):175-82
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5. Nipples and Nipple Shields
Learner
Objective
• Describe 3
types of
nipples and
what to tell
mothers
about their
impact on
breastfeeding
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http://globalhealthmedia.org/portfolio-items/breastfeeding-
in-the-first-hours-after-birth/?portfolioID=5623
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Messages to Mothers
“Your nipples
are great
for nursing.”
(NEVER blame a
slow start on
mother’s anatomy!)
“Often breastfeeding
takes time and
practice to learn.”
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Planned Future Topics for RNs• Safe Sleep, Skin-to-Skin Contact & Breastfeeding
• Breastfeeding the Late Preterm Baby
• Counseling Skills
• Cultural Literacy
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Step 3: Get MDs on the Same Page
Invite Dr. Jen to talk to
the peds about
• Why a breastfeeding
friendly practice is
more successful
• Best breastfeeding
practices
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More Plans
• Expansion of
outpatient clinic
• Adding lactation
support
– Night shift
– Labor and delivery
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Overview
• Why exclusive
breastfeeding
matters
• Barriers
• One hospital’s
successful
efforts to
improve
breastfeeding
practices
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Questions?
www.NancyMohrbacher.com
Facebook.com/NancyMohrbacherIBCLC
Pinterest.com/nancymohrbacher
@BFReporter
www.YouTube.com/NancyMohrbacher
~