Newborn Nursery at LPCH

Babies At Risk

  Not all babies in the newborn nursery have equal chance of breastfeeding success. Either maternal or infant factors can contribute to impaired milk transfer, so it is important for physicians to be aware of the risks and knowledgable about proactive management strategies. The "preventative management guidelines" presented here are intended for the mother and baby who are exclusively breastfeeding. They are designed to support breastfeeding for those pairs who are at risk of breastfeeding failure.

This material was developed by Jane Morton, MD and produced for educational purposes only.  Reproduction for commercial purposes is prohibited.  Utilization and copying of the materials to improve care of pregnant women and their newborns is encouraged with proper citation of source.

 

Introduction

C-section Mothers

Mothers with multiples

Infants who have not latched-on or nursed effectively for 12 hours

Mothers of NICU or PSCN infants

Infants supplemented more than once in 24 hours

Infants < 38 weeks or less than 6 pounds

Infant with loss of 10% birth weight

Mothers with breast surgery

Mothers with a history of breastfeeding failure

Antepartum mothers at risk of preterm delivery

 

Introduction

To promote exclusive breastfeeding, as recommended by the American Academy of Pediatrics (2005 Policy Statement) and the LPCH Breastfeeding Policy (2004), lactation support focuses on three critical determinants:  the establishment of a robust milk supply, effective attachment (latch-on and transfer of milk), and maternal confidence. These are the three most common issues, accounting for the largest drop off in breastfeeding, which occurs within the first several post-partum weeks. (Ertem, 2001; Taveras, 2003; Kuan 1999; Dewey, 2003)

Routine maternity care may not address the needs of patients at risk for breastfeeding failure. Proactive management guidelines are recommended for sub-groups of mother-infant pairs at highest risk for early discontinuation of breastfeeding.  Patients with unpreventable risk factors include mothers of preterm infants and/or multiples, those separated from their infants for medical reasons, and mothers with C-section deliveries, breast surgery, or a previous history of breastfeeding failure. Proactive management begins with the early identification of these at-risk mother-infant dyads and more aggressive measures to support milk production, attachment and maternal confidence than would be required by low-risk dyads.

Each shift, each mother-infant dyad will be assessed for risk factors, and a plan of care will be tailored to address their current, individual issues.  Those at higher risk will receive an escalated level of consultation from a team of lactation support providers.

Here we identify nine sub-groups, which are at risk for lactation failure.  For each sub-group, the first paragraph summarizes the rationale for the risk factors.  Following this, suggested proactive measures are listed, which should begin on the first day.  The last paragraph presents a suggested script to be used to inform the mother of the reason for these steps, while fostering a positive approach.  The Appendices provides readily available instructions and tools to implement the management guidelines.

In order to create a sustainable system, our goal is to maximize the knowledge and skills of frontline maternity nurses. For a patient with risk factors, who requires the attention of a more trained individual, the primary nurse will be required to review her plan of care and attend bedside consultations.

 

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C-Section Mothers


Rationale:

C-sectioned mothers are at higher risk for producing insufficient milk, having attachment difficulty and early termination of breastfeeding. (Dewey 2003) Peripartum events, including anesthesia, infant-mother separation, and delayed initiation of suckling contribute to these risks.  Initiate preventative measures within the first hours to reduce these risks. (AAP Policy 2005,  Kurinij, 1991)

Suggested measures:

  1. Reestablish the connection of the un-bathed infant with his/her mother within the first post-partum hour and offer hands-on assistance with the first breastfeeding, if needed.  Explain to the mother that scent and touch are the key imprinting senses for early feeds, and bathing can come later. (Schall, 2003,  K Mizuno, AAP Policy)
  2. Provide skin-to-skin contact, as much as possible, especially during the first day, and focus the teaching on attachment, effective suckling and increasing milk production (Hurst, 1997, Kirsten 2001)
  3. Teach the mothers to manually express colostrum into a teaspoon as often as possible (at least with each breastfeeding session) and feed this to her infant. (See Appendix G). 
  4. On day 2, add pumping if the infant is too sleepy to attach and nurse effectively. The frequency should be 8 times every 24 hours, with no more than a 5 hours interval at night. 

 

Suggested script:

Even though you have exactly the amount of colostrum your baby needs now, for these first couple of days, we have learned that babies born by C-section may require a little more help to learn how to latch on and nurse effectively.  By offering your baby frequent tastes of your colostrum, and stimulating your breasts by manual expression to “phone in your order for Day 3”, we can make sure that by the time you go home, your production will be higher.  This will make it easier for your baby to learn just how to breastfeed and get a full feeding.

 I know you are recovering from surgery right now, but it is important for your breasts to get the message to make lots of milk for your baby. Be sure to keep your baby with you all the time, and have your (husband, mother, partner) and the nurses help you with feedings both day and night.

 

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Multiples


Rationale:

The "supply and demand" production principle of lactation is a compensatory mechanism, which ensures the availability of adequate amounts of human milk, no matter how many infants are breastfeeding. A lack of time for the increased number of breastfeedings, physical and emotional difficulties associated with caring for more than one infant, and a lack of available professional support generally are greater hindrances than an inability on the part of the mother's body to produce milk for all infants. Multiples born prematurely are at greatest risk for under consumption. (Geraghty, 2004) The physiologic and behavioral differences of preterm infants mean that breastfeeding strategies commonly used for term, healthy infants, in particular, unmonitored "demand" feedings, may not be appropriate for preterm infants, because of the risk for dehydration and slow weight gain (Meier, 1996). Promoting adequate milk production for multiples, especially preterm infants, can be accomplished more reliably, if known stimulants to milk production are initiated early in the first postpartum day.  Protect mothers from unnecessary interruptions, and offer physical assistance with feedings on a regular basis.

 

Suggested measures:

  1. Explain to mothers the importance of protecting herself from unnecessary interruptions and investing her energies in these first few days in building up her milk supply.
  2. Avoid or minimize maternal-infants and infant-infant separations.
  3. Provide parents with a chart and teach them how to keep a daily record of milk intake, wet diapers, bowel movements, etc. (see Appendix C)
  4. Provide greater assistance with positioning and attachment, recommending feeding each infant separately, until both mother and infant have achieved some level of breastfeeding competency. (Some parents find it helpful to have a partner hand-express or pump the other breast, while one twin is nursing.  This volume can then be fed to the second twin. (see Appendix G) If twins nurse well, teach partner how to get the second infant attached after the first has started to feed.
  5. Alternate breasts between twins, to balance milk volumes.  One baby may have a more vigorous sucking style, promoting increased production on both sides, and making it easier for the less vigorous infant.
  6. Recommend back-to-back feedings, 10-12 /day in the first 3 days to accelerate the learning process and lactogenesis (increase in milk production).  This upfront investment will make it easier for a mother after discharge.  “Recovering”, by separating the mother and infants in the hospital, increases her post discharge workload, when less help may be available.
  7. For preterm babies, pump after each nursing to insure maximum emptying.
  8. Once babies learn how to breastfeed, around the third week, bottles of expressed milk can be introduced for convenience, without the same risk of interfering with breastfeeding.
  9. Test weighing may be useful, especially for mothers with preterm twins. (See Appendix D)

 

Suggested script:

The most important thing you can do these first few days is to signal your breasts to make enough milk for triplets instead of twins. The more milk you have, the easier your life will be at home with twins. So, ask for lots of help with positioning the babies and expressing milk.

Your babies’ different nursing styles can be used to your advantage. The more vigorous, wakeful baby should set the pace. Then you can wake up the sleepier baby after her (his) sib has finished or once the first baby is started nursing well.  Alternate breasts between twins, so both breasts get the loud and clear order for the “double latte”.

You can nurse both babies at the same time after each has learned how to latch on, and stay on, by him(her)self.  Or, once you get one baby started, (Dad, Grandma, etc.) can help the second baby get started. We want you eventually to be able to nurse them at the same time to save yourself a lot of time.

 Figure out all the things you do not absolutely have to do, and let your partner do them, like diapering or keeping the feeding record, or protecting you from unnecessary interruptions or phone calls.   Tuck your babies in on each side of you and learn how to say, “later, but not now…I’m in the middle of things.” Your job right now is just to feed the babies and take care of yourself.

 

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No LATCH in 12 Hours


Rationale:

Term infants normally lose about 7% of their birth weight before they begin to gain weight by day 4-5, and then regain birth weight by day 10. (AAP, 2005) This respite from high caloric/fluid requirements provides infants time to learn the process of effective suckling, when a mother’s breasts are soft. (A newborn with weight loss of 10% in the first several days is not equivalent to an infant who is 10% dehydrated.) Instead of intake, the appropriate focus should be on keeping infant and mother together, teaching techniques to assist with latch on, and promoting milk production by hand and/or pump expression. If and when supplementation is medically needed, attention should be given to appropriate volumes as well as modes of feeding that have been demonstrated to be least likely to interfere with ultimate breastfeeding. Compared to bottle-fed infants, well-fed, breastfed infants consume less than half as much in the first couple of days. (Dollberg, 2001, Riordan J. 2005. J Hum Lact. 2005 Nov;21(4):406-12. Indicators of effective breastfeeding and estimates of breast milk intake.) As supplementation and the use of artificial nipples has been shown to interfere with infants acquiring breastfeeding skills, (Dewey, 2003 and Howard, 2003) the use of spoon or cup-feeding is recommended here.


Suggested measures:

Guidelines for total feeding volumes per day for a term infant, unable to breastfeed. (see Appendix B)

Neonatal Feeding Amounts for the First Five Days Following Birth (Full-term Infants)

AGE
Birth - 24 hours
24 - 48 hours
48 - 72 hours
Infants 37 - 38 weeks AND 6 pounds or less 5 ml (1 tsp) every 2 - 3 hours, at least 8 times in 24 hours 5 ml (1 tsp) every 2 - 3 hours, at least 8 times in 24 hours 5 ml (1 tsp) every 2 - 3 hours, at least 8 times in 24 hours
Infants < 37 weeks OR < 6 pounds 5 ml (1 tsp) every 2 - 3 hours, at least 8 times in 24 hours 10 ml (2 tsp) every 2 - 3 hours, at least 8 times in 24 hours 15 ml (3 tsp) every 2 - 3 hours, at least 8 times in 24 hours
  1. If baby continues to have difficulty attaching to breast, and supplementation is determined to be necessary for medical reasons, begin feeding using “alternative feeding measures”, such as spoon, cup, syringe or finger-feeding.
  2. Breast expression: Begin hand expression at least 8 times per 24 hrs. (see Appendix G ) By 24 hours, add pumping if the infant is too sleepy to attach and nurse effectively. The frequency should be 8 times every 24 hours, with no more than a 5 hours interval at night.
  3. Practice skin-to-skin contact as much as possible, avoiding maternal-infant separation (see Appendix I).
  4. Other measures after 48-72 hours: (Dewey, 2003;Howard, 2003; Ferber, 2004)
    Apply nipple shield if the baby is unsuccessful latching, preferably not until milk volume is up. When possible, avoid use of pacifiers; use holding and skin-to-skin to sooth infant.

Suggested script:

Even the smartest babies in the world take a bit of time to figure out how to breastfeed. Lucky for us, there’s no urgency to get calories in, for the first couple of days. The “baby steps” of learning will come more naturally if we keep him (her) skin-to-skin with you and just practice breastfeeding. There are lots of things we can do to help him (her) learn. In the mean time, we also need to ‘phone in your order’ for lots of milk, because s(he’ll) need it after 3 days.

Most babies do a lot of sleeping in the first day.

Your baby is just recovering from the birth.

Your baby is just trying to figure out the world.

You are doing a great job.

Put on your light if your baby starts moving around or wakes up. I’ll come in and help you.

This is a learning time for both of you.

This is hard now, but it will get easier.

 

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Sick infant in NICU or PSCN


Rationale:

The short and long-term outcome of the sick and preterm infant depends heavily on the early post-partum management of the mother. Delaying (waiting more than 6 hours post-partum) the initiation of frequent (8 sessions/24 hours) and effective expression of milk (hand expression coupled with electric pumping) may permanently compromise future milk production potential. The most critical determinant of post-discharge breastfeeding, with all the associated health and developmental benefits, is the early establishment of a robust milk supply (>600 ml/day by 2 weeks). (Wooldridge, 2003; Bier, 2002; Hill, 1999; Flacking, 2003, Smith, 2003; Furman, 2002) A mother’s emotional recovery is enhanced by her contribution to her infant’s recovery. Pumping and suckling stimulate multi-hormonal effects which contribute to physical recovery. ( prolactin, oxytocin, up arrow insulin, up arrow glucagon, up arrow gastrin up arrow cholecystokinin, cortisol, with a down arrow in BP and a down arrow in anxiety.) With such high stakes, and because mothers feel so unprepared, overwhelmed and focused on the health of their infants, the maternity staff must assume responsibility for this intervention until she and her family can demonstrate a level of competency.

Suggested measures:

Seven “best practice” measures, described by the California Perinatal Quality of Care Collaborative, contribute to maximizing milk production.

  1. Inform the mother of the rational to pump early and pump often. (See Appendix F: For mothers of preterm infants, watch on closed circuit TV: A Premie Needs His Mother, First Steps to Breastfeeding Your Premature Baby)
  2. Providing equipment, staff and logistics to pump early (within 6 hours of birth), pump often (8 times/24 hours with no more than a 5 hour interval at night.
  3. Provide a diary log, and begin recording every pumping and hand expression session.
  4. Teach adjunctive manual stimulation: breast massage and hand expression 8 times/day. (See Appendix G)
  5. Facilitate early colostrum feeds.
  6. Provide skin-to-skin contact, whenever the mother is with her baby or as soon as the baby is stable enough to be transferred to and from his bed.
  7. Maternal discharge planning: (See Educational Check List, Appendix E)


Suggested information followed by script:

1. The urgency and importance of deciding to provide milk vs. whether to breastfeed:

“Maybe you did not have the chance to think much about breastfeeding, but would you be willing to provide your milk for your baby, at least during this hospitalization? Your baby needs something only you can provide.” (Not: “Have you decided to breastfeed?”)

2. Protective role of human milk for preterm infants:

“Milk is far more than food. It’s protection for your baby. Colostrum is more like a first vaccination.”

3. Uniqueness of her milk for her infant:

“Your milk is constantly CHANGING and specifically designed for your baby, with live cells, immunoglobulin, enzymes, and hormones .”

4. The importance of starting pumping ASAP after delivery and appropriate goals:

“Hand express your milk as often as a term baby would nurse, at least 8 times/day, beginning right from birth. Add pumping within 6 hours, 8 times per day, with no more than a 5 hour interval at night. This frequent breast stimulation is like ‘phoning in your order’, so by the end of the first week, you’ll reach your goal of 20 ounces per day. Today we will help you learn to express your milk for your baby. We expect just drops today. We’ll catch those and take them to your baby.”

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Infants supplemented more than once in 24 hours

Rationale:

• Infants given formula and/or pacifiers (including those who initially nursed well without supplementation in the first day) are 3 times more likely to develop breastfeeding problems by days 3 -7. (Dewey, 2003)
• Mothers who intend to combination feed vs. exclusively breastfeed are less likely to likely to reach their OWN breastfeeding goals. (Chezem 2003)
• Professionals who underestimate the importance of their advice or believe they do not have time to encourage exclusive breastfeeding are more likely to have patients who discontinue exclusive or any breastfeeding by 12 weeks. (Taveras, 2004; Taveras, Capra 2003)
• The sharpest drop off in breastfeeding rates is within the first couple of weeks, with the most commonly sited reasons being insufficient milk production and problems with attachment.(latch-on and milk transfer) (Taveras, 2003; National Immunization Survey, 2003)
• Preventative measures should be initiated as early as possible, certainly when it is anticipated the infant will need to be supplemented more than once.


Suggested Measures:

  1. Skin-to-skin contact as much as possible, to abbreviate the learning time to attachment and effective suckling and increase milk production
  2. Advise mothers to breastfeed at least 8-12 times/day
  3. If not nursing effectively by 12 hours, begin hand expression at least 8 times per 24 hrs. (See Appendix G)
  4. If not nursing effectively by 24 hours, begin pumping, in addition to hand expression, 8 times/24 hrs
  5. Use alternative feeding modes to decrease the risk suboptimal outcome (Dewey, 2003) See Appendix B for volumes per feed.


Suggested scripts:

Script for the mothers who have decided to combination feed:

We have learned that the very best thing for your baby (and for you, too!) is if you can give your baby nothing but your own milk as long as possible.

Good for you for providing your baby with your wonderful breastmilk. If you really think it will be necessary to give him other foods, it would be best if you wait as long as possible before you do that.

The doctors who care for your baby suggest you try to provide only breastmilk until your baby is about six months old. All the benefits of your milk are less if you add cow milk to his diet too soon.

Many mothers choose to both breast and bottle feed, and this is very doable, once your breasts produce lots of milk and your baby has become an “A” student at the breast. To reach your goal, first “turn on” your breasts by breastfeeding, hand expression or pumping. Teach your baby that the BEST nipples in town are yours, not a bottle; the BEST food in town is at “Mom’s, not from cow milk”. Once this is accomplished, back-up bottles are an easy next step. This way, you keep your plans to breast and bottle feed AND keep your options open.


Script for the mothers who are supplementing for medical reasons:

It is so important that you have decided to breastfeed. I know we talk about exclusive breastfeeding, and that is also important, but sometimes it is necessary to give breastfeeding babies formula. Think of this additional milk as “medicine” for your baby.

Even though we need to give your baby some additional food right now, the most important thing is to stimulate your breasts to produce much MORE than your baby needs. Just like riding a 2-wheeler, it’s easier to balance when you go fast. It’s easier for your baby to learn to breastfeed when milk flow is fast, so we need to help you make a great milk supply. By feeding often, expressing/pumping your milk frequently, you are "phoning in a double order (double latte)" by following these steps.

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Infants Born <38 Weeks Gestation or < 6 lbs.


Rationale:

Near term or SGA infants are at higher risk for hyperbilirubinemia, dehydration and hospital readmission than infants >38 weeks. (Sarici, 2004) The threshold for treatment (supplementation and/or phototherapy) should be lower, with a maximum of 8% weight loss or bilirubin levels of > 15 at 72 hours. (see AAP guidelines, Bhutani’s curve, for age-appropriate guidelines.) Early preventative measures should be initiated within 8 hours to reduce these risks.

Suggested Measures:

  1. Advise mothers to breastfeed at least 8-12 times/day. It may be necessary to wake the baby if he/she does not indicate hunger.
  2. Encourage 24 hour rooming-in. Practice skin-to-skin contact from birth and as much as possible, especially during the first days. Benefits of this simple practice include: abbreviation of the learning time to attachment and effective suckling, stimulation of milk production, decreased infant crying, and increased sleeping time. (Blaymore-Bier,1996; Kurinij, 1991; Hurst, 1997; Ferber, 2004;Quillin, 2004)
  3. Supplement in addition to breastfeed: (See Appendix K)
  4. Within the first 6 hours, teach mothers to manually express colostrum into a teaspoon (see Appendix G) and spoon feed this to the infant, after each breastfeeding, using these volumes: (See Appendix K)

Supplementation of SGA or Near Term Infants

After each breastfeed, spoon feed: colostrum, colostrum + formula, donor milk, or formula

AGE
Birth - 24 hours
24 - 48 hours
48 - 72 hours
Infants 37-38 weeks AND 6 lbs or more 5 ml (1 tsp) every 2 - 3 hours, at least 8 times in 24 hours 5 ml (1 tsp) every 2 - 3 hours, at least 8 times in 24 hours 5 ml (1 tsp) every 2 - 3 hours, at least 8 times in 24 hours
Infants <37 weeks OR <6 pounds 5 ml (1 tsp) every 2 - 3 hours, at least 8 times in 24 hours 10 ml (2 tsp) every 2 - 3 hours, at least 8 times in 24 hours 15 ml (3 tsp) every 2 - 3 hours, at least 8 times in 24 hours
  1. Add pumping by 24 hours, in addition to hand expression (8 times/24 hrs.) if the infant is too sleepy to attach and nurse effectively.
  2. Begin ad lib supplementation if weight loss exceeds 8%, while encouraging mother to hand express, pump, and breastfeed at least 8 times/24 hrs. Begin with expressed milk and add formula, if needed.
  3. For infants less than 37 weeks or less than 5 pounds, in-home measurement of at-breast intake by test-weighing should be considered, or at least once a day weights. (Meier, 1997) (See Appendix D).
  4. When phototherapy is indicated, consider use of in-room or at-home therapy with a bili-bed, when appropriate, to reduce maternal-infant separation.
  5. Follow-up appt. within 24-48 hours of discharge (See AAP, Management of hyperbilirubinemia, 2004).


Suggested script:

Even though you have exactly the amount of colostrum your baby needs now, for these first couple of days, we have learned that babies born a little early are, in some ways, “too good”. They don’t cry as much, fall asleep quickly, are not as vigorous at the breast, and may not stimulate your breasts to produce as much milk as your baby will need by the 3rd. day. For this reason, we’ve learned that this little “boost” is a very important way of “phoning in your order for Day 3."

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10 % Weight Loss

Rationale:

A term infant is born with a protective store of fluid, electrolytes and calories to protect him/her during the first several days of the establishment of copious milk production, which occurs around 72 hours post partum (somewhat earlier for a mother who has previously breastfed and later for the primiparous mother). It is normal for term infants to loose up to 7% of their birth weight before regaining it by day 10. Though not equivalent to “10% dehydration”, a 10% of birth weight loss warrants attention. For a near-term baby, measures should be taken earlier (See Infants Born <38 Weeks Gestation or < 6 lbs)

Suggested measures:

Until infant is consistently having several liquidy bright yellow stools per day:

  1. Breastfeed at least 8 times/day and limit to 30 minutes.
  2. Supplement liberally with expressed breastmilk and/or formula to satiety after each breastfeeding.
  3. Pump and hand express milk at least 8 times per day.
  4. Follow up daily. Alert parents that several bright, yellow stools per day should be expected.

Suggested script:

Some babies jump the gun and temporarily need a bit more fluid until your milk comes in. The best way to make sure everything eventually goes well is have three messengers (your baby, your hands and your pump) send signals to your breast to bring in your milk. At the same time, we will give your baby the advantage of a little extra fluid and calories, so she/he will be vigorous at the breast. Once your production is up, we won’t need to supplement.

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Breast Surgery

Rationale:

Reduction mammoplasty: Many women with breast reduction report they were not well informed about the risks of under-production, and therefore anticipate they will be able to exclusively breastfeed. They typically feel their milk “come in” and can easily express small volumes. Due to the disruption of the collecting system, it is the exceptional mother who can exclusively breastfeed. This may be a risk for any mother with peri-areolar incisions. Mothers should be encouraged and taught proactive measures to maximize production, and yet be provided realistic expectations, close follow-up and clear indications of inadequate milk intake. Compensatory glandular development is poorly understood in humans. In animal studies, post partum mammary proliferation peaks early (within the first 2 weeks), and correlates with subsequent lactation performance.(Fowler, 1990, Knight 1984) The brief window of time in the first few days may offer potential to maximize ultimate milk production.

Augmentation mammoplasty: While these mothers are more likely to be able to exclusively breastfeed than are mothers with breast reduction, they should be cautioned that implants may provoke engorgement and impair milk removal, and thereby compromise ultimate milk production. Preventative measures should focus on frequent breast emptying. The implants themselves pose no risk to the safety or quality of the milk. Again, these infants warrant close follow-up and mothers need to know clear indicators of suboptimal milk intake.

Suggested measures:

  1. For mothers with breast reduction, explain that the ultimate potential for exclusive breastfeeding can be increased by practicing both breastfeeding 8-12 times per day as well as hand and pump expression for the first 3-5 days. (See Appendix G) The frequency of milk expression during the first five days is more important than the duration of nursing or pumping in determining ultimate milk production capacity.
  2. For mothers with breast augmentation, teach hand expression and stress the importance of frequent, effective nursing and emptying, especially between the 3rd to 5th days.

Suggested script:

Mother with breast reduction: Some of the newer techniques for breast surgery enable some mothers to exclusively breastfeed, but this is not the rule. How we handle these first three days can make all the difference in how much milk your breast can ultimately produce. The best strategy is to increase the number of times we express small volumes of milk from the breast in the first 3 to 5 days, beginning on the first day. For example, every waking hour, hand express small volumes of milk from each breast (appendix G) for about 5 minutes. In addition to this, breastfeed frequently, 10-12 times per day, instead of the usual 8 times. You need to see your baby’s doctor if your baby is not having several liquidy, bright yellow bowel movements a day by the 4-5th day. In fact, it might be best to have your baby checked out when he’s about 3 days old. Have your doctor keep a close eye on your baby’s weight for the first two weeks.

Mother with breast augmentation: When your milk comes in, in larger volumes, around the 3rd or 4th day, you may experience more pressure. During this time, the implants can make it a little more difficult for the milk to flow freely. We need to practice hand expression now, so that when you start feeling full, you’ll be an expert at getting the milk to flow. The plan is to keep milk moving through the breast every few hours – day and night. Any time you start to feel fullness, hand express a bit of milk, waken the baby to feed and then hand express again. This will make it much easier for your baby to nurse and more comfortable for you.

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History of Breastfeeding Failure

Rationale:
Most mothers are not prepared to experience any difficulties or problems when breastfeeding their first baby, and they are alarmed by commonplace issues. (Colin, 2002) Yet mothers are more likely to blame themselves for lactation failure, rather than the hospital system that may have contributed to it. Primary organic causes for lactation failure are rare. The most common reasons for early abandonment of breastfeeding are 1) perceived insufficient milk production and/or 2) problems with attachment (latch-on or effective milk transfer), and 3) lack of maternal confidence. (Ertem, 2001; Taveras, 2003; Kuan 1999; Dewey, 2003) Most breastfeeding problems are secondary phenomena, commonly related to suboptimal practices in the early post-partum period leading to delayed, infrequent or ineffective breastfeeding. A lack of maternal confidence can undermine a mother’s experience with a subsequent baby.

Suggested measures:

  1. Discuss the issues associated with the mother’s first experience.
  2. Provide clear guidelines focused on the establishment of milk production and infant attachment (latch-on and milk transfer).
  3. Encourage participation in the group breastfeeding class.
  4. If there is concern for a primary organic cause, such as “insufficient mammary glandular development” (Neifert MR), request bedside Lactation Consultation. (See Appendix L)

Suggested script:

Most mothers believe that breastfeeding comes easily for everyone else. The problems you had last time are quite common. Breastfeeding is natural, but it does not come naturally for most babies…anymore so than walking. Usually, however, the earlier any problems are taken care of, the more likely you are to overcome them. Let’s see what we can do to give you and your baby extra help and extra practice. The more frequently you breastfeed in the first 3 days, the less likely problems will develop.

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Pregnant Mothers with Risk Factors for Premature Delivery on the Antenatal Unit


Rationale:

Mothers of preterm infants decide to provide milk for their infants for different reasons than those of healthy term infants, usually related to the infant’s vulnerable medical condition. (Sisk PM, 2006) Mothers who had not intended to breastfeed are not made to feel guilty, when asked to provide milk. In fact, they feel resentful if not fully informed of the advantages of their own milk for the infant. (Miracle DJ, 2002) Newly delivered mothers of preterm infants are typically unprepared and medically compromised for the task of pumping. Yet initiating pumping within the first 6 hours and maintaining a schedule of >5 sessions/day is critical for the establishment of lactation. (Furman, 2003) Therefore, the ideal time to approach any mother with risk factors for delivering prematurely is before delivery. The most successful approach involves all healthcare members taking an active supportive role. (Powers, 2003).

Suggested Measures:

  1. With chart and physician input, assess patient for risk of preterm delivery and desire to care for a viable infant (i.e. no plans to adopt or abort infant).
  2. Discuss importance of breastmilk for all babies, but especially preterm infants, who get out of the hospital sooner and healthier if they receive mother’s milk.
  3. Offer to have her watch the video, "A Premie Needs his Mother" on closed circuit TV, and encourage her to have her family take a copy home for viewing, as the family will need to understand the importance of providing breastmilk and how to help.
  4. Show her: a) what a breast pump looks like, b) what a 1cc syringe looks like (the normal amount to be given to the baby right after birth), and c) what a pumping diary looks like.
  5. Discuss how we make every effort to help her begin expression immediately after delivery, and how her colostrum will be used right away for his/her baby’s “first immunization”.


Suggested script:

We encourage all of our mothers who have even a small chance of delivering prematurely to learn about the life-saving importance of breastmilk for small and sick babies. Because there is so much to learn, would you be willing to watch an award winning educational video, which was filmed here at Stanford? Many of our staff and families participated in this video. If you do deliver prematurely, we would like to help you collect your babies “first immunization” (your colostrum) in the delivery room, just after your baby is born. Just as a healthy baby nurses right after birth, your colostrum can then be taken straight to the NICU for your baby. Once you’re back to your room, we’ll help you start pumping and recording each session in a diary.


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