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Improving the Quality of Maternity Care in

North Carolina:

Supporting Moms in Breastfeeding –


Achieving Breastfeeding Frequency

www.ncbfc.org
www.sph.unc.edu/breastfeeding
www.breastfeeding4health.com
Our Goal in Supporting Breastfeeding:
Healthy Mom, Healthy Newborn
• Evidence Base for Action
• Clinical Practice and Skills
• Achieving Change among All Staff
What to we wish to achieve?
• Homeostasis, and
• Avoidance of:
– Hypothermia
– Hypoglycemia
– Significant weight loss
– Hyperbilirubinemia
• Eventually, Growth and Development
When mom and baby achieve good EBF
feeding skills during the hospital stay,
we have succeeded
Correct sucking technique at discharge
100% Incorrect sucking technique at discharge
Percentage

50%

P<0.001 P<0.01 P<0.01 P<0.01

0%
EBF in hospital 1 month 2 months 3 months 4 months
Any breastfeeding
From: Righard L and Alade O. (1992) Sucking technique and its effect on success of breastfeeding Birth 19(4):185-189.
How do we achieve this?
• Frequent, effective breastfeeding
• Assessment - and support - through Observation
• Skills and Outcomes
1. Establishing Rapport
2. Comfort
3. Position
4. Latch
5. Effective Milk Transfer
6. Cue recognition
7. Hand expression
8. Frequency
Skills 1/2/3:
Rapport, Maternal Comfort, Positions
• Seek permission to observe and support
• Maternal Comfort
– suggest different positions
– use pillows or nursing stools only if positioning looks
uncomfortable or issues arise
• Position
– infant head, shoulders, and hips are in alignment
– infant faces the mother’s body. BELLY TO BELLY
– Infant brought to the breast, not the breast to the infant
– Avoid pushing the back of the infant’s head; the infant may
arch away from the breast
Cradle Hold and
Cross-Cradle Hold

Photo © Joan Meek, MD, FAAP


Football Hold and Side-lying Hold

Photo © Lori Feldman-Winter, MD, MPH, FAAP

Photo © Roni M. Chastain, RN


Skill 4: Supporting Good Latch-on
• Often helps to use C-hold/ sandwich
• 4 fingers underneath and away from areola:
parallel to jaw
• thumb on top of the breast and away from
areola: parallel to upper lip
• Rooting reflex
• Stimulate by touching to nipple
• Infant opens his mouth wide
• Mother quickly draws the infant to her breast
• Infant takes in an adequate amount of the
breast, not
just nipple
C OR R E C T
Proper Latch

INC OR R E C T
• Nipple protected by positioning far
back in infant’s mouth
• Breast tissue inferior to nipple
exposed to massaging action of
tongue and lower jaw.

Photos © Jane Morton, MD, FAAP


Job-aid for Latch: LANCET
– Latch –
• Infant grasps the entire nipple and as much of the areola
as possible, generally more below areola
• The nose and chin of the infant will touch the breast;
• Lips will be flanged out
– Audible - swallow may not be audible first day,
organizes
– Nipple – everted by baby
– Comfort
• Undulating motion
• act to reduce any discomfort on latch
• release suction
– Elimination – wet diapers, meconium –> seedy
stool
– Timing – as often as baby demands/cues
Skill 5 – Assessing Milk Transfer
• Suck and swallow:
– Audible swallowing
– Sucking that begins with rapid bursts to stimulate
milk let-down
– A rhythm of sucking, swallowing, and pauses
following establishment of milk flow
• Becomes slower and more rhythmic
• From a few to 1 suckle/swallow per second
– Undulating action — no stroking, friction, or in-and-
out motion of the tongue
– Debate: Milking vs Negative pressure
Skill 6:
Cue Recognition
• Rapid eye movements (fluttery eye movements
while eyes are closed)
• Muscle tension, such as flexed arms or closed fists
• Wriggling or fidgety body movements
• Vocalization
• Hand to mouth movement (even if eyes are closed,
may include sucking on own hand)
• Rooting (Mouth open wide!)
• You are Too Late if Crying
– In newborns crying is usually a late indicator of
hunger and may lead to difficulty with latching
on to the breast or feeding well.
Skill 7: Hand expression
• Follow the physiology:
– Relax and “milk” the source and the ducts
– Go for empty
– Disallow fullness
• Watch Breastfeeding Management,
Educational Tools for Physicians and Other
Professionals by Jane Morton, MD, FAAP, for
a live demonstration of how to observe and
assess breastfeeding.
http://newborns.stanford.edu/Breastfeeding/FifteenMinuteHelper.html
Outcome/Skill 8: Frequency 10-12+ per 24 hr
Breastfeeding frequency in 1st 24 hours and incidence
of hyperbilirubinemia on day 6
30% 28.1%
24.5%

20%
Incidence

15.2%
11.8%
10%

0.0%
0%
0-2 3-4 5-6 7-8 9-11
Frequency of breastfeeding/24 hours

From: Yamauchi Y and Yamanouchi I. Breast-feeding frequency during the first 24 hours after birth in
full-term neonates. Pediatrics, 1990, 86(2):171-175.
Next: Getting ready to “See one, do
In your team: one, teach one!”
• Consider which staff will be with the dyad at the time
when breastfeeding support is needed:
– Who is most likely to be with the mother at the time of the first
feeding?
– Who is most likely to be asked for support?
– List all the staff will need these skills
• Discuss the current level of each of these skills among
the staff
– 1) Rapport 2) Comfort 3) Position 4) Latch 5) Milk
Transfer 6) Cue recognition 7) Hand expression 8) Frequency
– Consider: What additional training is needed to ensure that all
staff in contact with the mother/baby dyad at these times can
carry out this basic support? Do we have staff skilled to do this
training? How soon can this be accomplished?
Reference

• AAP Breastfeeding Residency Curriculum: Prepared


with information from the AAP/ACOG Breastfeeding
Handbook for Physicians
• http://www.aap.org/breastfeeding/curriculum/

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