Nothing but Breastmilk: Building Rates of Exclusive Breastfeeding

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Nothing but Breastmilk Building Rates of
Exclusive Breastfeeding

• Cathy Carothers, BLA, IBCLC, RLC
• EVERY MOTHER, INC.

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Learning Objectives

• Name at least three reasons breastfeeding mothers
  begin early supplementation.
• Demonstrate how the breast makes milk
• Identify at least three strategies for
  encouraging women to exclusively breastfeed their
  babies.

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Exclusive Breastfeeding

• Definition An infant receiving only breast
  milk and no other liquids or solids except for
  drops or syrups consisting of vitamins, minerals,
  or medications (Centers for Disease Control)
• Health impact of exclusive breastfeeding

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Exclusive Breastfeeding to 6 Months means

• Optimal infant growth, development and health
  outcomes
• Lower obesity risk
• Delayed fertility
• Longer duration

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Longer Duration Means

• Lower risk of infections, obesity, childhood
  cancer, diabetes for infants
• Better growth and development outcomes for
  infants and children
• Lower risk of breast cancer for moms
• Lower rate of child abuse and neglect

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Consider

• Exclusive breastfeeding during the 1st month
  postpartum is associated with breastfeeding
  duration of gt6 months
• The strongest determinant of breastfeeding
  duration at 1 year is exclusive breastfeeding
  during months 4-6
• Piper S Parks L. 2001. Use of an intensity
  ratio to describe
• breastfeeding exclusivity in a national sample.
  J Hum Lact, 17227-232.

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National Breastfeeding Goals
Centers for Disease Control and Prevention,
National Immunization Registry, 2005.
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Exclusive Breastfeeding Goals
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When Does Exclusive BF Decline?

• 21 of infants receive formula or water
  supplements in the hospital
• Dewey KG, et al. Risk factors for suboptimal
  infant breastfeeding
• behavior, delayed onset of lactation, and excess
  neonatal weight
• loss. Pediatrics, 2003. 112607-619.
• 50 of babies born at public or community
  hospitals were supplemented compared with 15
  born at a university hospital
• Kurinij N, SHiono PH. Early formula
  supplementation of
• breastfeeding. Pediatrics, 1991 88745-750.

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When Mothers BeginFormula Supplements

• 52 of babies are being supplemented with infant
  formula in the hospital
• 61 of new mothers regularly give formula y 3
  months
• Half of new mothers have already started solid
  foods by 4 months (Grummer-Strawn 2008)

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Why Mothers Offer Formula

• Lack of confidence in their milk production
• Lack of awareness of newborn behaviors
• Cannot see what the baby is taking
• Received formula from the hospital
• Used a breast pump and got very little milk
• True physical issues impacting production

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Reasons Hospital Staff Offer Supplements

• 1 help the mother rest
• 2 mother is ill or unable to feed
• 3 the mother does
• not have enough milk
• Kurinij 1991

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Maternal Factors
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How the Breast Makes Milks

• Glandular and ductal tissue development
• Lactogenesis transition from pregnancy to
  lactation
• Lactogenesis I colostrum present at 16 weeks
• Areola darkens, Montgomery glands appear

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Lactogenesis II

• Lactogenesis II copious secretions of milk
  beginning _at_ days 2-3 until day 8.
• Affected by
• Rapid drop of progesterone after placenta
  delivered
• Release of prolactin from anterior pituitary
• Release of oxytocin from posterior pituitary

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Lactogenesis II is FRAGILE

• Lactogenesis II affected by
• Placental retention
• C-section birth
• Traumatic or stressful labor/delivery
• Hypothyroidism
• Diabetes
• Obesity

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Impact of Obesity

• Adipose (fat) tissue may retain progesterone
• Higher rates of diabetes (less insulin available
  for producing milk)
• Other metabolic or steroid alterations
• Lessened prolactin response to infant suckling

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Endocrine Switches to Autocrine

• Prolactin receptors formed in early days
• Frequent milk removal
• Multiple milk ejection reflexes will release more
  milk to baby
• Affected by stress, fear, PAIN
• Unresolved engorgement leads to involution

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Lactogenesis III

• Depends on what happens in the early days!
• Amount made at 5 days depends on what happens on
  day 2
• Amount made at 1 month depends on what happened
  by day 7

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Recommendations are Simple

• Direct skin to skin contact until the first BF
  occurs
• 8-12 breastfeeds
• Appropriate latch
• Feeding cues
• Efficient milk transfer
• No supplements unless medically indicated
• SUPPORT!

American Academy of Pediatrics, Pediatrics,
2005. Vol. 115(2)496- 506
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How We Mess it Up

• Lack of prenatal education
• Formula company messages during pregnancy and
  hospital period
• Routine separation of mothers and babies
• Supplementation
• Unresolved breast problems
• Maternal lack of confidence
• Full-time employment

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When WIC Women begin Supplementing

• By 5 days¼ of infants given formula
• By 16 days½ of infants given formula
• By 1 month
• Only 13 are exclusively breastfeeding
• 2/3 are already weaned to formula

WIC Infant Feeding Practices Study (1997)
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Common Reasons Mothers and Family Members
Supplement

• Real or perceived low milk supply
• Fussy, unsettled baby
• Normal newborn behaviors
• Inefficient breastmilk transfer
• Growth spurts
• Perception that supplementing will help baby
  sleep better at night
• Return to work/school, busy life

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Whats the Harm in JUST ONE BOTTLE?
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One bottle

• Significantly affects infants gut flora
• Can provoke sensitivity and allergy to cows milk
  protein (Zeiger 2003)
• Can be the environmental trigger in the
  development of diabetes
• Lowers duration rate of breastfeeding

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Continued Supplementation

• Leads to insufficient milk supply
• Leads to ultimate decline in breastfeeding

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The CDC Guide to Breastfeeding Interventions

• www.cdc.gov/breastfeeding

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I. Maternity Care Practices

• Take place during the intrapartum hospital stay
• Include the WHO/UNICEF Ten Steps to Successful
  Breastfeeding
• Include birthing practices

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What Research Says

• Institutional changes in maternity care practices
  increase bf initiation and duration
• Source Fairbank et al., 2000
• Number of Baby Friendly steps in place predict bf
  duration
• Source DiGirolamo et al., 2001
• Use of pacifiers in hospital supplemental feeds
  in hospital negatively impact infant health bf
  outcomes
• Source Howard et al., 1999, Blomquist et al.,
  1994

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Action Steps

• Provide an 18-hour training for hospital staff
• Link maternity facilities and community networks
• Implement ONE evidence-based practice in
  hospitals and clinics
• Implement a BAN THE BAGS campaign in your
  community!

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II. Professional Support

• Counseling behavior interventions to improve BF
  outcomes
• Lack of professional support a major barrier to
  BF

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What Research Says

• Professional support improves BF outcomes
• Is most effective combined with education
• In-person more effective than phone
• Source Guise, et al, 2003

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Action Steps

• Work on reimbursement with state Medicaid and
  insurance commissioners
• Increase of WIC staff who are IBCLCs
• Develop disseminate
• resource directory of
• lactation support services
  

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III. Educating Mothers

• Programs taught by experts in lactation
  management
• To increase BF knowledge and skills
• To influence attitudes towards breastfeeding

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What Research Says

• Maternal education is the most effective single
  intervention for increasing initiation and short
  term duration rates

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Action Steps

• Incorporate information about how the breast
  makes milk into all prenatal education programs
• Incorporate visual, skills-building teaching
  opportunities
• Learn how to CONNECT through effective counseling
  skills

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IV. Peer Support

• Encouragement supportmother to mother!
• Cost-effective, individually tailored approach
  
• Source Chapman et al., 2004

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What Research Says

• Peer counseling is effective by itself in
  increasing BF rates
• Especially effective w/
• middle income moms
• lower income Latinas and African Americans
• Moms who plan to BF
• Moms with uncertain breastfeeding goals

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Action Steps

• Establish hospital or community based
  mother-to-mother support programs
• Improve referral network for peer support
• Expand coverage of WIC peer programs
• Look for other creative ways to incorporate
  mother-to-mother support

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V. Workplace Support

• Benefits and services that support continued
  lactation while mothers are employed

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What Research Says

• 70 of employed mothers with children lt3 yrs old
  work full time
• 1/3 work within 3 months
• 2/3 work within 6 months
• Low-income work earlier
• Source US Department of Labor, 1999

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Action Steps

• Returning options
• Tailor a breastfeeding and work schedule
• Advocate for corporate lactation programs
• Provide pumps!
• Teach her how to maintain milk supply

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Action Steps

• Provide information to employers about workplace
  support local resources
• Establish model program for state employees
• Promote legislation to support worksite lactation
  programs
• Recognize work sites and employers who
• support breastfeeding employees

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VI. Media Social Marketing

• Media
• Social Marketing Comprehensive, multifaceted
  approaches for a variety of audiences

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Media Social Marketing-ACTION

• Identify local experts who can pitch stories to
  the media that highlight breastfeeding
• Provide Loving Support materials to interested
  local physicians, schools, clinics, hospitals,
  and child care centers
• Conduct World Breastfeeding
  Week activities
  

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EVERY MOTHER, INC. TRAINERSCathy
Carotherscathy_at_everymother.org