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Flashcards in Lactation and Breastfeeding Deck (60):

Why was the 1981 International Code of Marketing of Breast-Milk substitutes established?

The aim of the Code is “to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, and by ensuring the proper use of breast-milk substitutes, when those are necessary, on the basis of adequate information and through appropriate marketing and distribution.”


1989 WHO/UNICEF’s statement included the “Ten Steps to Successful Breastfeeding” which led into the Baby-Friendly Initiative as well as the Innocenti Declaration. On the National level, goals were set to improve initiation, continue bf until___ and for at least __

6 months

12 months.


What are the 10 steps to successful breastfeeding?

1. Have a written BF policy that is routinely communicated to all health care staff.
2. Train all health care staff in the skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of BF.
4. Help mothers initiate BF w/in 1 hour of birth.
5. Show mothers how to BF and how to maintain lactation, even if they are separated from their infants.
6. Give infants no food or drink other than breast-milk, unless medically indicated.
7. Practice rooming in - allow mothers and infants to remain together 24 hours a day.
8. Encourage BF on demand.
9. Give no pacifiers or artificial nipples to breastfeeding infants.
10. Foster the establishment of BF support groups and refer mothers to them on d/c from the hospital or birth center.


this document is an excellent guide for public health professionals to select strategies to support breastfeeding mothers and increase breastfeeding rates.

2013 CDC Guide to Strategies to Support Breastfeeding Mothers and Babies


How do we measure the success of BF in states

1. % of BF (ever, 6 mo, 12mo, exclusive bf at 3 mo)
2. rooming in
3. skin-to-skin
4. % of baby friendly facilities
5. % of of breastfed infants receiving formula before 2 days of age,
6. number of La Leche League leaders per 1,000 births and
7. State’s regulation supports onsite breastfeeding.


What are the 5 hospital maternity care practices that will help with successful breastfeeding

1. Infants are breastfed in the first hour after birth.
2. Infants stay in the same room as their mothers.
3. Infants are fed only breast milk and receive no supplementation.    
4. No pacifier is used. 
5. Staff gives mothers a telephone number to call for help with breastfeeding.  


Per WHO, CDC, UNICEF, AAP, ACOG, ABFM and others, the current recommendation for breastfeeding is:

Infants should be exclusively breastfed for 6 months and continue breastfeeding, with the introduction of appropriate complimentary foods, through the second year of life and beyond.


The ___ in human milk provide its major source of calories.


*Human milk contains more than 200 ingredients


Human milk contains more than 200 ingredients. They work in harmony to enhance ___, while other nutrients promote ___

the immune system

optimal brain development.


Be aware of marketing strategies that suggest a particular formula is “closest to mother’s milk.” Formula is a distant second choice for nutritional/growth components, as it has no ___ to provide immunological protection

living cells


Compare human milk vs substitutes (formulas):
Anti-infective properties:
Growth Factors:
Digestive enzymes:

Minerals: correct amount in HM., vit added in formula

Anti-infective properties: present in HM, absent in formula

Growth Factors: present in HM, absent in formula

Digestive enzymes: present in HM, absent in formula

Hormones: present in HM, absent in formula

Vitamins:present in HM, absent in formula


Compare fats in human milk vs substitutes

human milk: Appropriate quality/quantity of essential fatty acids, lipase present which helps digest fat.

sub: lipase absent

*Human milk is low in protein, high in lactose.


Compare protein in human milk vs substitutes

human milk: Appropriate (species specific), easier to digest

Sub: Corrected in quantity but not in quality (not species specific)

*Human milk is low in protein, high in lactose.


Certain hormones that are present in human milk such as __ and __ are linked with satiety and may be key to long term prevention of obesity.

Leptin and ghrelin







Studies show that breastfeeding reduces the risk of:

2. diabetes and obesity in childhood
3. reduced risk of childhood leukemia
4. IBD
5. eczema, allergies, asthma
6. protects babies against ear infections and diarrhea
7. premature infants less likley to develop NEC


Maternal benefits of breastfeeding

1. maternal infant bonding, social interaction
2. reduced blood loss
3. delayed menstruation
4. reduced risk of breast and ovarian CA
5. wt loss after birth
6. convenience
7. monetary savings
8. welcome calming breaks w/ release of mothering hormones prolactin and oxytocin


Describe the 3 possible barriers related to breastfeeding

1. Individual:
2. Interpersonal:
3. System:


What are individual barriers to breastfeeding

1. early negative impressions of breasts or breastfeeding,
2. deciding on a feeding method after the first trimester of pregnancy,
3. having developmental or social issues influenced by cultural norms (such as body-image, sexuality, independence, social acceptance.)


What are interpersonal barriers to breastfeeding

1. unmarried,
2. lacking family support,
3. partner who is negative about breastfeeding,
4. relatives who have not breastfed or are negative.


What are system barriers to breastfeeding

1. little or no access to help with breastfeeding either peer or professional,
2. living or working in a community that does not support breastfeeding,
3. hospital birth that has restrictive breastfeeding practices and
4. misinformation from peers or professionals.


What is breastfeeding contraindicated?

1. Galactosemia
2. PKU proceed w/ caution
3. CF need supplemental pancreatic enzyme

Temporary medical reasons for supplementation:
4. infant born less than 1500g
5. or less than 32 weeks gestation
6. risk for severe hypoglycemia
7. mother is too ill postpartum


Describe the breastfeeding recommendations for certain ID infections
1. HIV
2. TB

1. HIV: can be transmitted through BM. don't in US
2. TB: don't if mother has active TB and not on meds for 2 weeks (infant and mother must be separated due to risk to infant of airborne transmission). May pump and store breast milk for first 2 weeks of treatment since TB is not transmitted through the milk.


Why should mothers w/ active TB not breast feed

(infant and mother must be separated due to risk to infant of airborne transmission). May pump and store breast milk for first 2 weeks of treatment since TB is not transmitted through the milk. Mother should be closely monitored and should be followed to confirm that she is no longer considered infectious with negative smears and cultures within 2-4 weeks of starting TB therapy.

*. The AAP recommends INH prophylaxis for all infants whose mothers have been diagnosed with active pulmonary TB in the postpartum period. In many parts of the world, separation of the mother and infant after therapy has been started on the mother and prophylaxis begun for the infant, the infant and mother are no longer separated.


describe the recommendations of caffeine, alcohol, and marijuana while breastfeeding

*Caffeine and alcohol do pass though the breast milk.
-Limit caffeine to less than 3 cups/day.
-Occasional single alcoholic beverage is ok if mother is feeling unaffected. Best to bf first, then wait for 2 hours after having the drink to bf again. If affected by alcohol, then it is recommended to pump and dump the milk.

*dont use marijuana but we don't have the evidence to date

(don't smoke either)


describe the 2 stages of lactogensis

stage 1: starts about the 20th week of pregnancy, colostrum is present in the breast, colostrum is available for the first few days of life until the milk comes in.

Stage 2: starts a few days postpartum. Milk production is baby driven


Breast milk is easily digested so needs to eat every ____ though may cluster feed at a certain time/day.

q2-3 hours


what drives milk production?

*baby driven!- reflexes and hormones that drive milk supply

1. Baby suckles
2. releases milk production hormone Prolactin from the Anterior pituitary AND milk ejection hormone Oxytocin from the Posterior pituitary
3. let-down sensation
4. rhythmic sounds of baby swallowing during a feed


If a mother wants a good milk supply, then it is important to breastfeed __ in the first weeks which is a challenge for the “los dos” population in Denver area .

often and exclusively


describe the composition of milk at the beginning and end of a feed

milk present at beginning of feed is the foremilk (1.5-2% fat), milk at the end of feed is the hindmilk (5-6% fat).


Breastfeeding on demand without time limits allows baby to get more of the ___ which provides calories to gain weight and be satiated between feedings. ___ the breast frequently sets up a good milk supply in most cases




Basics of Breastfeeding: helping the mother and baby get started

1. Skin to skin or kangaroo care
2. positioning: cradle, modified cradle, football, laid-back or biological nurturing
3. attachment
4. Early hunger cues
5. the perfect latch


why is skin to skin care important

many physiologic and psychological benefits to mothers and babies. It has no disadvantage and costs nothing. It appears also to increase milk volumes in mothers of preterm infants.


What are signs of correct attachment

1. Lips are flanged out, nose touching breast
2. Mouth is wide open
3. Chin is against the breast
4. Asymmetrical latch- more of the areola is visible above the upper lip and below the lower lip.


What are early infant hunger cues?

1, rooting
2. hands to mouth
3. mouthing movements
4. waking up
5. fists clenched


Nutritional Parameters (easy to remember rules of 5’s and 10’s)

1. weight loss (up to 10% )
2. Regain birth weight by DOL 10, gaining approx. 20-30 grams/day
3. Colostrum: A teaspoon (5ml) at a good feed. On DOL 1-2, about 40-50 ml in the first 24 hours.
4. Yellow stools by Day 5


Describe colostrum

1. thick yellowish fluid present in the breast during pregnancy (lactogenesis 1) and for about the first 2-4 days after birth.
2. It is the perfect newborn nutrition to help assure transition from the sterile intra-uterine environment to the real world!
3. It contains more protein(mainly IGA) and much less fat than mature milk and is rich in beta-carotine and white cells.
4. It also contains lactose which prevents hypoglycemia and is a natural laxative (helps the passage of meconium!)


Milk generally “comes in” (lactogenesis 2 Between DOL ___. Mother notes that her breasts feel full and baby’s swallowing pattern becomes more distinct.



By day 14, women produce about ____ mls of milk/day. Lactation not really established until ___ days postpartum.

750-800 mls

28-30 days


use the __ growth charts not the __ charts.

-BF babies gain more rapidly during the first ___ of life and slow down in the ___

*The WHO curves indicate how healthy breastfed babies should grow!

3 to 4 months
latter half of the first year.


7 helpful screening questions to assess how breastfeeding is going

1. How is breastfeeding going? (may to see in office next day if not going well)
2. How many stools has your baby had today?
3. How many times have you breastfed? (10-12 times in 24 hours is realistic, minimum of 8x’s in 24 hours)
4. Do your breasts feel full before feedings and softer afterwards? (This is a sign of effective milk removal in the early weeks, also “let down sensation or milk dripping)
5. How many times have you supplemented with formula?
6. What color are the baby’s stools?
7. How long is the baby awake and actively suckling and swallowing at the breast?


describe the stooling pattern of a breastfed infant

-One per day of life up until day 4=4

-Yellow seedy not black or green transition stools


Supplementing BF with forumula ____ times can effect milk supply

More than 2x in 24 hours can effect milk supply


How long should the baby be awake and actively suckling and swallowing at the breast?

At least for 10 minutes per breast, baby is content between feedings as well as sounds of baby swallowing during a feed.


What are common concerns/breastfeeding problems?

#1 maternal concern that she doesn’t have enough milk (main reason why women stop breastfeeding their infant.)
#2 sore/cracked nipples
#3 engorgement
#4 mastitis: infection of the breast not the milk

*Take home message: the continuation of breastfeeding with lots of support usually will help remedy the problem!


What is the most common cause of inadequate milk supply

1. ineffective or infrequent sucking
2. Mothers lack of understanding of basic lactation physiology leads them to think that their supply is inadequate.

*main reason why women stop breastfeeding their infant.


What is the treatment plan for mothers who are concerned they don't have enough milk?

1. parents responding quickly to early hunger cues,
2. check for effective latch and suckle,
3. increase feeding frequency,
4. apply moist heat before feeding,
5. pump,
6. limit formula feedings,
7. pre-post feed weights to evaluate transfer of milk,
8. reassurance and close follow up,
9. identify sources of support


What is the main reason why women stop breastfeeding their infant

maternal concern that she doesn’t have enough milk


Common Causes of non-transient nipple pain include:

1. Incorrect latch or removal of the infant,
2. misuse of pump or other equipment such as shields or topical treatments,
3. anatomic variations of infant such as short frenulum (tongue tied) or the mother such as inverted nipples and
4. candidiasis of mother and baby.

*up to 96% of women report sore nipples, it pain is not resolved and uncorrected, the pain will progress into nipple damage


Treatment for sore/cracked nipples

1. Enhance milk let down reflex first,
2. Assist with positioning and attachment,
3. continue breastfeeding with close follow up,
4. treat both mother and baby for thrush,
5. assist with wound treatment strategies,
6. vary positions at breast (football hold vs. side-lying, etc.),
7. support.


what are common causes of engorgement?

1. insufficient frequency of feeds at breast,
2. insufficient emptying of breast,
3. poor positioning or
4. poor attachment to the breast.

*sign of milk production, varies from woman to woman if and when it occurs, usually resolves by first week.


Treatment for engorgment

1. shower and massage before feeding,
2. express milk by hand or pump to soften breast,
3. breastfeed more often,
4. assess infant’s position and latch,
5. breastfeed more often,
6. apply cabbage leaves for 20 mins,
7. may take Ibuprofen prn.
8. support


When does mastitis commonly occur

occurs in up to 23% of women with highest incidence occurs around 6 weeks of life.


Causes of mastitis

1. milk stasis and
2. nipple trauma as both predispose the ductal system to bacterial invasion


Treatment of mastitis

1. . Prevention of stress and fatigue,
2. treat nipple abrasions/assess for effective suckling/good latch,
3. nurse more frequently ,
4. moist heat prior to feeding,
5. antibiotics,
6. rest for first 24 hours,
7. increase fluids.


if __ and __ can be treated early, most likely mastitis will be prevented!

engorgement and plugged ducts


How can you prevent mastitis

1. tx enorgement and plugged ducts
2. REST,
3. frequent nursing,
4. alternating positions to drain all ducts,
5. hand expression and
6. warm/moist heat.

*Mastitis often leads to early weaning however this can worsen the situation. Remember it is an infection of the breast and not the milk so baby can continue to drink this milk.


Compare the onset and site of engorgment, plugged duct and mastitis

Engorgement: gradual onset, immediately post patrum

Plugged duct: gradual onset, after feedings

Mastitis: sudden onset, after 10 days,
-usually unilateral


Compare the swelling and heat, pian, body temp and general sx of engorgment, plugged duct and mastitis

Engorgement: generalized swelling/heat
-generalized pain
-normal body temp
-feels well

Plugged duct: no heat, may have swelling
-mild but localized pain
-normal body temp
-fells well

Mastitis: localized red, hot and swollen
-intense but localized pain
-temp over 38.4C
-flulike sx


Resources for BF mothers

1. lactation consult (prenatal, after delivery, and 1st week of life)
2. WIC (women, infant, children) offer education, breast pumps, food packages
3. La Leche League Groups offer free breastfeeding help and information via phone or monthly meetings.
4. Mother's milk banks