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Transitioning from… Transitioning Baby
Transitioning Baby to the Breast Transitioning from… Transitioning Baby to the Breast • Bottle • Sipping or lapping methods – Cup – Bowl – Spoon – Syringe ~ • Tube feeding Preterm/ill baby • Nipple shield Nancy Mohrbacher, IBCLC, FILCA Does It Really Matter How Baby Gets the Milk? Rasmussen & Geraghty. Am J Public Health 2011; 101(8):1356-59 Long-term pumping can be a hardship • Stressful: “Triple duty” compared to breastfeeding • Hormonal levels differ from less body contact Affects milk quality Affects breastfeeding duration • 4 months after preterm birth: – 72% still breastfeeding – 10% still pumping Smith, et al. Pediatrics 2003; 111(6 Pt 1):1337-42 • Earlier formula use increases risk of negative health outcomes • After expression, vitamin, antioxidant, immunological levels decrease • Freezing kills live cells • Contamination risk • Leaching from container & effect on components Ip, et al. Evid Rep Technol Assess 2007; (153):1-186 ©2015 Nancy Mohrbacher, IBCLC, FILCA 1 Transitioning Baby to the Breast Affects baby’s oral development • Breastfeeding promotes normal development • Bottle-feeding increases risk of oral malformations – Cross-bite – Maxillary atresia oral Carrascoza, et al. J Pediatria 2006; 82:395-97 . Kobayashi, et al. Am J Orthod Dentofacial Orthop 2010; 137:54-58 Galán-Gónzalez, et al. Breastfeed Med 2014; 9(1):24-28 Affects feeding volumes, weight gain & obesity risk • Consistent flow = more milk faster • Overrides appetite control mechanism Li, et al. Arch Pediatr Adolesc Med 2012; 166(5):431-36 Affects stress levels in preemies • Fast milk flow of bottle disrupts organization of suck-swallowbreathing • Greater incidence of oxygen desaturation, apnea, bradycardia At what age should we lose hope that baby will breastfeed? Photo: The Breastfeeding Atlas Meier. Nurs Res 1988; 37(1):36-41 Meier & Anderson. MCN Am J Matern Child Nurs 1987; 12(2):97-105 Babies are hardwired to breastfeed Breast-seeking behaviors seen 8 mo to school age Despite age & other feeding methods, older babies & toddlers do transition to breast Gribble. Journal of Prenatal & Perinatal Psychology & Health 2005; 19(3):217-35 ©2015 Nancy Mohrbacher, IBCLC, FILCA Priorities 1. Feed the baby 2. Protect mother’s milk production 3. Support baby’s transition to breast 2 Transitioning Baby to the Breast With Any Transition Start with the Basics Our Primary Job: Ooze Confidence in Breastfeeding Let Gravity Help Keep the Breast a Pleasant Place Mother leans back & baby rests hands free, tummy down on her body • Share positive time together there – Talk – Smile – Play • Don’t let it become a battleground Identified 20 Primitive Neonatal Reflexes • Videotaped 40 mothers/baby pairs • 20 primitive neonatal reflexes (PNRs) • PNRs work for or against breastfeeding, depending on positioning Colson, et al. Early Hum Dev 2008; 84(7):441-9 ©2015 Nancy Mohrbacher, IBCLC, FILCA Colson, et al. Early Hum Dev 2008; 84(7):441-49 Include: • • • • • • • • • • Photo: Melanie Ham Rooting Suck Swallow Hand to mouth Mouth gaping Tongue licking Arm & leg cycling Head lifting Head bobbing Stepping, crawling Found more PNRs led to breastfeeding when mothers lean back with baby on top (p=<0.0005) 3 Transitioning Baby to the Breast Sitting up, PNRs made latching more difficult Pull of gravity caused gaps, head-butting, arching away A newborn’s curved spine makes her flail like a turtle on its back Photo: Melanie Ham Turn baby over & she has much more body control Start with Positions Easier for Baby Adjust Body, Baby, Breast www.YouTube.com/NancyMohrbacher ©2015 Nancy Mohrbacher, IBCLC, FILCA 4 Transitioning Baby to the Breast Adjust Your Baby Baby Heads Up Think Clock Adjust Your Breast, Think Sandwich • Compress breast into an oval • Fingers parallel to baby’s lips • Like hamburger, not taco Breast Shaping Keep baby at breast level, less to juggle “Breast sandwich” Photo: The Breastfeeding Atlas “Nipple-Tilting” Wiessinger. J Hum Lact 1998; 14(1):51-56 Photo: Rebecca Glover, RM, IBCLC Use Sleep Lowers baby’s resistance to the breast Cuddle drowsy, sleeping baby in natural feeding positions • Breastfeed while baby sleeps • Hold baby at breast during sleep • Triggers inborn reflexes • Blunts reflex response & frustration Smillie in Genna, Supporting Sucking Skills in Breastfeeding Infants, 2013 ©2015 Nancy Mohrbacher, IBCLC, FILCA Colson. MIDIRS Midwifery Digest 2003; 13(1):92-97 Photo: Melanie Ham 5 Transitioning Baby to the Breast Basics Checklist Skin-to-Skin and Body Contact Without pressure to take breast If mother lifts her arms, does baby stay in place? Is mother fully relaxed & partly reclined, not upright or completely flat? Is baby tummy down (frog legs) & heads up (head higher than bottom)? Tried varying baby’s lie (clock)? Baby’s feet touching mother or something else? Tried breast shaping (hamburger not taco)? Is baby upset, need to be calmed (arousal state)? With Severe Latch Problems If baby becomes unhappy, move away Chiu, et al. Breastfeed Med 2008; 3(4):231-37 Feed a Little First • Half were skinto-skin during breastfeeding tries, half weren’t • Same % overcame problems • In STS group, happened twice as fast Svensson, et al. Int Breastfeed J 2013; 8:1; 103 babies 1-16 wk old If awake, feed a little so baby’s not ravenously hungry Will be more open to trying something new Photo: Kirsten Hedberg Nyqvist, RN, PhD Target Strategies to the Cause IF BABY STILL BALKS AT THE BREAST, CONSIDER THE 4 Fs • • • • FEEL FLOW FAMILIARITY FITNESS to breastfeed Glover & Wiessinger. In Supporting Sucking Skills in Breastfeeding Infants, 2nd ed. by C.W. Genna, 2013, p. 105-48 ©2015 Nancy Mohrbacher, IBCLC, FILCA 6 Transitioning Baby to the Breast FEEL Issues • Use positioning, body contact, & sleep to release feeding reflexes • Adjust for a deeper latch FEEL? • Expectations altered by artificial nipples? • Positioned to trigger feeding behaviors? • Latched deeply enough to trigger active sucking? Use tools to evert or firm mother’s nipple (FEEL): • • • • • Inverted syringe Nipple everter Apply cold Breast pump Nipple shield Kesaree, et al. J Hum Lact 1993; 9(1):27-29 FLOW? • Baby used to instant, consistent flow? • Mother’s milk production low? FAMILIARITY? To increase flow • Boost low milk production • Deliver instant flow at breast − Spoon − Eyedropper − Syringe − At-breast supplementer ©2015 Nancy Mohrbacher, IBCLC, FILCA • Negative oral experiences? • Hair-trigger temperament? • Used to another feeding method? 7 Transitioning Baby to the Breast FAMILIARITY Issues Sipping/Lapping Methods Muscles used more similar to breastfeeding than bottlefeeding When transitioning from another feeding method, take baby steps Franca, et al. BMC Pregnancy Childbirth 2014; 14:154 May lead to easier transition to the breast Yilmaz, et al. J Hum Lact 2014; 30(2):174-79 Photo: Kirsten Hedberg Nyqvist, RN, PhD Baby Steps from the Bottle Make bottlefeeding more like breastfeeding Kassing. J Hum Lact 2002; 18(1):56-60 Photos: Karl B. Walker ’Bait & Switch’ Start bottle-feeding against exposed breast Bottle-feed at breast • Rest baby’s cheek against exposed breast • Wrap bottle in cloth so baby can’t touch it As baby sucks and swallows, quickly remove bottle and insert breast Photo: The Breastfeeding Atlas Photo: The Breastfeeding Atlas ©2015 Nancy Mohrbacher, IBCLC, FILCA 8 Transitioning Baby to the Breast FITNESS to breastfeed Fitness Issues Baby Genna, Supporting Sucking Skills, 2013 • Unusual oral anatomy? • Pain or birth injuries? • Respiratory issues? • Preterm? • Health issues? • Neurological or tone issues? Is baby in pain? Is there a physical or health issue affecting breastfeeding? Photo: The Breastfeeding Atlas Mother • Large breasts? • Taut breast tissue? • Unusual nipple placement? • Unusual nipple anatomy? One Mother’s Story Do What Works. Don’t Do What Doesn’t Work. Transitioning Preterm Babies to the Breast Daily average of supplement given to baby 900 800 700 ml 600 500 ave MyS 400 ave F 300 200 100 0 0 1 2 3 4 5 6 7 8 9 10 weeks ©2015 Nancy Mohrbacher, IBCLC, FILCA 9 Transitioning Baby to the Breast When to Start Breastfeeding 71 healthy babies born at 26-35 wk – Breastfeeding began when babies breathe without ventilator or CPAP – Earliest breastfeeding: 28 wk gestation Rather than “readiness,” think of breastfeeding as a normal behavior like walking & talking Nyqvist, et al. Early Hum Dev 1999; 55(3):247-64 Photo: Kirsten Hedberg Nyqvist, RN, PhD If baby has breathing or heartbeat irregularities Keep environmental stimulation • Lights • Sound • Touch to a minimum – At first, HCP monitors baby during feedings – If baby stays stable, mother can monitor breathing & color Nyqvist, et al. Early Hum Dev 1999; 55(3):247-64 Nyqvist, et al. Early Hum Dev 1999; 55(3):247-64 Baby Signs Baby Signs Nyqvist, in Supporting Sucking Skills in Breastfeeding Infants 2013 Nyqvist, in Supporting Sucking Skills in Breastfeeding Infants 2013 Keep Breastfeeding Stop Breastfeeding ©2015 Nancy Mohrbacher, IBCLC, FILCA 10 Transitioning Baby to the Breast Preterm Breastfeeding Stages Semi-Demand Feeding Nyqvist, In Supporting Sucking Skills in Breastfeeding Infants 2013 Older or healthier babies may start at a later stage 1. Tube-feeding, skin-to-skin contact, and frequent milk expression Stage 6 of 7 2. Breastfeeding begins—Rooting, licking, mouthing 3. Single sucks, short bursts, long pauses, some milk intake When most Swedish preemies are discharged 4. Longer suckling bursts, stays fixed longer, more milk more often, supplements gradually reduced 5. Milk intake increases, occasional larger volumes Effective with late preterm babies 6. Milk intake varies, immature suckling pattern, can fully breastfeed with semi-demand feeding 7. Vigorous, mature suckling, long bursts, breastfeeds on demand Photos: Kirsten Hedberg Nyqvist, RN, PhD Photo: Kirsten Hedberg Nyqvist, RN, PhD Semi-Demand Feeding Don’t rely on baby’s cues alone Initiate feedings every 1-2 hr during waking hours Used until about term corrected age Photos: Kirsten Hedberg Nyqvist, RN, PhD To Qualify for NICU Semi-Demand Feeding Baby 32-36 wk, gaining well Mother producing ≥200 mL/day, wants to BF & is available ≥6 hr stretches Davanzo, et al. J Hum Lact 2014; 30(4):405-09 ©2015 Nancy Mohrbacher, IBCLC, FILCA Feeding every 1-2 hr during the day eases transition to full breastfeeding Closer to typical breastfeeding rhythm Photo: Kerstin Hedberg Nyqvist, RN, PhD Semi-Demand Feeding Protocol • Morning wt & daily milk volume set • Test wt at feedings • Feed on cue • Wake after 3 hr • Gavage supplement • Fully semi-demand, no supplements Davanzo, et al. J Hum Lact 2014; 30(4):405-09 11 Transitioning Baby to the Breast Feeding More Often Improves Feeding Tolerance Odor of Mother’s Milk Speeds Transition to Oral Feedings VLBW fed 2 hr reach full feedings 2.7 days sooner than fed 3 hr Preemies who smelled mother’s milk while gavage fed transitioned to oral feedings 3 days earlier than controls VLBW fed 3 hr more likely to: – ≥28 days of parenteral nutrition – Have feeds held for ≥7 days DeMauro, et al. J Perinatol 2011; 31:481-86; N=354 Yildiz, et al. J Nurs Scholarsh 2011; 43(3):265-73 Cue-Based & Paced Bottle Feeding Video: Paced Bottle-Feeding by Wilson-Clay, IBCLC, FILCA & Hoover, MEd, IBCLC, FILCA; Available from ww.breastfeedingmaterials.com Feed when baby cues Use paced bottle feeding See handout For the Caregiver of a Breastfed Baby Practice Makes Perfect Feeding practice better predictor of effectiveness than gestational age On average babies began taking milk at breast: 30 6/7 wk With regular practice, by 36 wk 57 of 67 (85%) exclusively breastfeeding, some at 32 wk Median age of exclusive breastfeeding: 35 wk Cunha, et al. Early Hum Dev 2009; 85(2):125-30 Pickler, et al. J Perinatol 2006; 26:693-99 ©2015 Nancy Mohrbacher, IBCLC, FILCA Nyqvist, et al. Acta Paediatr 2008; 97(6): 776-81 Nyqvist, et al. Early Hum Dev 1999; 55(3): 247-64 12 Transitioning Baby to the Breast Emotional Barriers Mother’s gain? (↑time, ↓work) Value of breastfeeding (not just the milk) Start in the hospital (>nutrition) Pineda. J Perinatol 2011; 31:540-45 Signs of milk intake – Swallowing sounds – See milk around mouth Wt check Test wt 0 of 785 Swedish mothers pump/bottle-feed at d/c – Reliable for measuring milk intake at breast Akerstrom, et al. Acta Paediatr 2007; 96:1450-54 – Even reliable with leads Meier, et al. J Hum Lact 1994; 10:163-68 Haase, et al. Breastfeed Med 2009; 4:151-56 Nipple Shields? Useful tool if preemie: – Slips off nipple at pauses – Falls asleep quickly Preemies on shield took mean 14.4 mL more milk Nipple Shields No association between length of shield use & breastfeeding duration Meier, et al. J Hum Lact 2000; 16:106-14 Nipple shields once considered verboten by many, but pendulum has swung back J Hum Lact 1996;12(4) 95% of LCs & 80% of other HCPs use nipple shields in their practice Reasons Nipple Shields Used Mother-related: 63% – Flat or inverted nipples – Nipple pain – Nipple trauma – Engorgement Baby-related: 39% – Poor or weak latch – Ineffective suck Eglash, et al. Breastfeed Med 2010; 5(4):147-51 Chertok. J Clin Nurs 2009;18:2949-55; N=54 ©2015 Nancy Mohrbacher, IBCLC, FILCA 13 Transitioning Baby to the Breast Reasons Nipple Shields Used Nipple Shield Application Reasons at 3 days Nipple shield use • Latch problems (62%) • Nipple trauma (29%) • Pain (7%) • 3 days: 18% • 3 mo: 10% • 9 mo: 1% Women who used shields at 3 days had higher BMIs at start of pregnancy than those who didn’t use shields Ekström, et al. Breastfeed Med 2014; 9(9):458-66; N=540, 81 shields • Signs of milk transfer: Deep latch key to milk transfer Shield tip should not be visible during breastfeeding Photo: The Breastfeeding Atlas – Milk seen in the shield after feedings – Swallowing sounds – Breast feels less full, heavy • Weight checks • Test-weighing Photos: Catherine Watson Genna, BS, IBCLC Thick, rubber shields reduced milk intake by 22% – Do mothers need to pump to maintain milk production? – Study babies had breastfed well & were using shield for 1st time Woolridge. Early Hum Dev 1980;4(4):357-64 ©2015 Nancy Mohrbacher, IBCLC, FILCA No difference in weight gain in babies using thin, silicone nipple shield vs not using shield Chertok. J Clin Nurs 2009; 18:2949-55 Lower weight gain in shield group that got less support Ekström, et al. Breastfeed Med 2014; 9(9):458-66 14 Transitioning Baby to the Breast Weaning from a Nipple Shield • Start with shield on • When swallowing, slip off shield, slip in breast • If not, try again at a relaxed time • Not every day Cutting the shield no longer recommended Was safe with latex shields With silicone shields, creates sharp edges Priorities • 67% eventually weaned from shield • 33% used it throughout 1. Feed the baby 2. Protect mother’s milk production 3. Support baby’s transition to breast – 11% could have nursed without it – Continued using it for greater comfort Powers, et al. J Hum Lact 2004;20(3):327-34; N=202 When the basics don’t work, think “Four Fs” • Is it a fitness issue? • Use feel, flow & familiarity to help baby take the breast ©2015 Nancy Mohrbacher, IBCLC, FILCA Target tools & strategies to the problem’s cause 15 Transitioning Baby to the Breast Babies are hardwired to breastfeed Choose strategies that make the most of baby’s hardwiring ©2015 Nancy Mohrbacher, IBCLC, FILCA Questions? [email protected] ~ www.NancyMohrbacher.com Facebook.com/NancyMohrbacherIBCLC Pinterest.com/nancymohrbacher @BFReporter www.YouTube.com/NancyMohrbacher 16
