Support mothers to initiate and maintain breastfeeding
Describe at least 6 essential issues that every breastfeeding mother should know or demonstrate.
Importance of exclusive breastfeeding for the first 6 months.
Mother-infant eye-to-eye and body contact while feeding.
Feeding cues and signs of an adequate latch, swallowing, milk transfer and infant satisfaction and how to recognize all of them.
Average feeding frequency (at least 8 times per 24h) with some infants needing more frequent feedings.
How to breastfeed in a comfortable position and without pain.
Infants should be fed in response to feeding cues, offered both breasts per feeding and fed until they seem satisfied.
How to ensure/enhance milk production and let down.
Why and how to hand express colostrum/breast milk.
How to correctly use and care for her breast pump (for a mother who needs to pump).
Effects of pacifiers/ artificial teats on breastfeeding and why to avoid them until lactation is established.
Very few medications or mother’s illnesses contraindicated during breastfeeding.
Accurate information resources.
Reasons for a breastfeeding mother to avoid tobacco, alcohol and other drugs.
Guidance for creating a safe sleep environment for breastfeeding.
Recognize signs of undernourishment or dehydration in the infant and warning signs for calling a health professional management of most common breastfeeding difficulties.
Demonstrate to a mother how to hand express breast milk, noting 8 points.
1. Creating a comfortable environment to facilitate the let-down reflex
2. Washing hands.
3. Having a clean bowl/container to catch the milk.
4. Massaging the whole breast gently.
5. Shaping a “C” around the breast with fingers, push back toward the chest wall away from the areola.
6. Pushing fingers towards the chest and squeeze fingers together rhythmically, then pause.
7. Expressing milk from both breasts.
8. Expecting that a session will last 10-20 minutes as milk flow decreases
3 reasons why effective exclusive breastfeeding is important for baby.
Baby will learn to breastfeed more quickly.
Baby will learn how to self-regulate.
Provides all the nutrients needed for physical and neurological growth and development.
The effects of breastfeeding are greater when breastfeeding is exclusive.
Colostrum is rich in protective factors.
The microbiota (intestinal flora) of non-exclusively breastfed infants is different from exclusively breastfed ones.
Even one dose of formula changes the microbiota.
Describe 2 newborn indications for supplementation following skilled assessment and management.
Hypoglycaemia.
Signs or symptoms that may indicate inadequate milk intake (significant dehydration, weight loss or delayed bowel movements).
Hyperbilirubinemia associated with poor breast milk intake despite appropriate intervention.
Some inborn errors of metabolism.
List at least 2 potential contraindications to breastfeeding for a baby and 2 for a mother
Maternal contraindications.
HIV
Ebola virus.
Herpes simplex virus type 1 - active and on breast.
Specific maternal medications, substances and illnesses (see WHO “Acceptable medical reasons…”).
Infant contraindications.
Galactosemia.
Congenital lactase deficiency.
Some inborn errors of metabolism may require supplementation (phenylketonuria, maple syrup disease).
2 elements related to infant feeding patterns in the first 36 hours of life.
Minimum feeding frequency is 8 times per 24 hours.
Cluster feeding (many cue-based feedings close together in time) is common and normal in the first 24-36 hours and is not an indication of inadequate supply.
Help a mother achieve a comfortable and safe position for breastfeeding with her preterm, late preterm, or weak infant at the breast, noting at least 4 points.
First observe a mother breastfeeding before recommending changes.
Preterm, late preterm, or some weaker infants will require more time, more patience as they may not open mouth upon stimulation or may not open their mouths wide enough.
Guide a mother to bring baby to the breast and not breast to baby.
Help a mother identify the most useful positions for weaker babies.
Show how to do breast compression which may be useful with preterm, low tone or babies with a weak suck.
Show a mother how to express milk into the baby’s mouth.
Help a mother identify how and when to release a latch that is painful or shallow (more frequent with preterm infants) without hurting herself.
3 reasons why effective exclusive breastfeeding is important for mom.
Frequent, exclusive breastfeeding helps build up a mother’s milk supply.
Less risk of engorgement.
Breasts will feel more comfortable due to regular emptying.
Describe 2 maternal indications for supplementation following skilled assessment and management.
Delayed lactogenesis resulting in inadequate intake by the infant).
Insufficient milk production related to insufficient gland tissue.
Breast pathology or prior breast surgery resulting in poor milk production.
Temporary mother-infant separation and no expressed milk available.
Temporary suspension of breastfeeding.
Intolerable pain during feedings.
Demonstrate at least 3 important items of safe preparation of infant formula to a mother who needs that information.
AAP Guidelines
Wash your hands
Scrub feeding items in hot, soapy water, then rinse [dishwasher with heated water, hot drying cycle]
Wash, rinse, dry the top of formula can and equipment
Water must be from a safe source as defined by state/local health department
If uncertain about safety of tap water, use bottled water or bring cold tap water to rolling boil for 1 minute (no longer), then cool water for no more than 30 minutes.
Mix water as directed by the manufacturer.
Prepared formula must be discarded within 1 hour after serving an infant
Prepared formula that has been given to an infant may be stored in the refrigerator for 24 hours to prevent bacterial contamination.
Open containers of ready-to-feed formula or concentrated formula, should be covered, refrigerated, and discarded after 46 hours if not used.
Describe to a mother at least 4 signs of adequate transfer of milk in the first few days.
Baby sucks regularly, rhythmically at the breast with occasional pauses.
Rhythmic swallowing is seen or heard.
No clicking sounds when feeding.
Breasts can feel softer after feeds and regain fullness in-between feeds.
Urine output is progressively increasing to at least 4 heavy diapers/nappies per day and is pale yellow.
Number of stools is progressively increasing after the first day.
Stools changing from meconium (dark) to yellow.
Baby appears satisfied, not crying.
Weight stabilizes by day 4.
Engage in a conversation with a mother of a preterm, late preterm, or low-birth-weight infant not sucking effectively at the breast, including at least 5 points.
Facilitate prolonged skin-to-skin (Kangaroo Mother Care) to improve stabilization of temperature, breathing and heart rate.
Engage in a conversation with a mother about why it may be necessary to wake up the baby within 3-4 hours if he doesn’t demonstrate cues.
Observe the baby latch + suck + swallow.
Monitor closely for frequently encountered problems such as hypoglycemia, poor feeding, hyperbilirubinemia.
Engage in a conversation with a mother about how to avoid excessive neonatal weight loss (more than 7% on day 3) and adjust feeding plan accordingly.
Suggest frequent hand expression and compression of the breast to a mother.
Explain how to hand express milk (see below).
Explain/demonstrate how to cup feed the expressed breast milk.
Explain the negative effects of pacifiers and teats while breastfeeding is being established.
Describe medications that can affect breastfeeding.
Explain safe sleeping.
Explain the signs of undernourishment or dehydration in the infant.
Explain appropriate storage and handling of expressed breast milk.
Describe maintenance of lactation during separation or illness of mother or baby.
Explain 3 aspects of appropriate storage of breast milk
Labeling and dating of the expressed milk.
Container options for storage (bags, plastic or glass bottles).
Hygienic storage.
Temperature and duration of storage.
Signs of improper storage and spoilage.
Describe at least 3 risks of giving a breastfed newborn any food or fluids other than breast milk, in the absence of medical indication.
It may interfere with the establishment of milk production.
It decreases the infant’s suckling at breast, potentially creating a cycle of insufficient milk and supplementation.
Even one dose of formula significantly alters the intestinal microbiota.
It increases the risks of diseases and allergies.
Prelacteal feeds reduce importance of colostrum.
Identify 3 high-risk infant populations that may warrant extra precautions to protect against severe infections associated with powdered infant formula.
Infants 3 months of age and younger
Infants born prematurely
Infants with illnesses or medical treatments, such as chemotherapy for cancer.
Evaluate a full breastfeeding session name at least 5 points you are looking for.
Infant is able to latch and transfer milk.
Infant has rhythmic bursts of suckling with brief pauses.
Infant releases the breast at the end of feed in obvious satiation.
Infant shows similar behaviors if he takes the second breast.
Mother’s hand supports the baby's neck and shoulders, without pushing the baby’s head onto the breast.
Mother ensures the baby's postural stability.
Mother’s breasts and nipples are comfortable and intact after the feed.
Mother admits no breast or nipple pain.
Signs/symptoms that could require further evaluation and monitoring as assessed.
Engage in a conversation with a mother regarding at least 4 different ways to facilitate breastfeeding in order to prevent or resolve most common conditions of the lactating breasts (sore nipples, engorgement, mother who thinks she doesn’t have enough milk, infants who have difficulty sucking).
Frequent skin-to-skin.
24h rooming-in.
Importance of skin-to-skin and rooming-in for both parents.
Infant’s cues, signs of a good latch and milk transfer, infant swallowing, and how to remove a baby from the breast if in pain.
Baby can remain at her breast for as long as he desires.
Unrestricted frequency and responsive feeding.
Avoidance of pacifiers and/or bottles during the first weeks.
Typical feeding patterns: day and night for the first weeks and at least 8 times per 24h, expecting more often during the first week.
Mother’s perception of adequate milk supply (also versus colostrum).
How the mother can confirm reliable and adequate milk production by observing specific signs in the baby.
Breastfeeding takes practice, patience, and persistence.
Explain at least 3 aspects of handling of expressed breast milk
Order of milk use:
1. Fresh before stored.
2. If using stored/frozen milk, use oldest stored milk first.
Thawing and heating techniques.
Handling of previously frozen and thawed human milk (do not refreeze).
When to discard any remaining milk.
For those few health situations where infants cannot, or should not, be fed at the breast, describe, in order of preference, the alternatives to use.
1. Mother’s own expressed milk.
2. Donor human milk.
3. Infant formula.
Formula considerations for high-risk infants
Liquid infant formula is made to be sterile
Powdered infant formula is not sterile. Follow WHO formula prep.
Cleaning and sterilizing feeding and preparation equipment.
Use of boiled water.
Add powdered formula while water is above 70 degrees C.
Exact amount of formula as instructed on the label.
Cool the feed quickly to feeding temperature.
Check temperature of formula before feeding.
Discard formula not used within 2 hours.
For using liquid formula concentrate: follow manufacturer’s instructions.
Demonstrate at least 3 aspects of how to help a mother achieve a comfortable and safe position for breastfeeding within the first 6 hours after birth and later as needed during the hospital stay.
Make sure the mother understands why it’s important to adopt a comfortable and safe position.
Explain why to remove blankets or clothes that are in-between mother and infant.
Help the mother identify how to hold her baby to best facilitate the baby’s innate reflexes and latching.
Explain principles of position or holding baby (baby faces breast, close to mother, whole body supported).
Use a hands-off (or hands-on-hands) approach to promote a mother’s empowerment. Hands-on is only used after asking permission and when additional help is necessary.
Offer additional help to a mother who had a cesarean to attain a comfortable position.
Help the mother identify useful positions for a weaker baby
Describe at least 2 maternal a with delayed lactogenesis II.
Age over 30, Primiparity
Breast problems: Insufficient glandular tissue, flat or inverted nipples tissue, history of breast surgery.
Delivery problems: Cesarean delivery (especially if unplanned), complicated delivery, significant hemorrhage, prolonged labor, preterm delivery (<37 weeks), retained placenta.
Postpartum depression.
Metabolic problems: Diabetes (gestational, types 1 or 2), hypertension, preeclampsia, polycystic ovary syndrome, obesity (pre-pregnancy BMI >30), high cortisol levels, hypothyroidism, extreme tiredness, fatigue or stress.
Previous low supply.
Tobacco use and some drugs and medications may cause low milk supply.
Separation of mother and infant at birth
Delayed breastfeeding and/or milk expression
Describe at least 1 professional medical reference or resource for identifying medications that are safe/compatible for use during lactation.
LactMed (National Library of Medicine [LMN])
Hale’s Medications & Mothers’ Mik, current edition
InfantRisk
MotherToBaby
The Breastfeeding and Human Lactation Study Center, Division of Neonatology, University of Rochester
Selected Protocols from the Academy of Breastfeeding Medicine
Engage in a conversation with a breastfeeding mother who intends to feed her baby formula, noting at least 3 actions to take.
Elicit information about why she intends to mixed feed.
Assess a breastfeed to evaluate the presence of medical indications for supplementation.
Manage common breastfeeding difficulties.
Respond to the individual mother’s and family’s needs, concerns, preferences and values related to mixed feeding.
Encourage mother to continue exclusive breastfeeding in the first 6 months.
Demonstrate how to help a mother achieve an effective and comfortable latch, noting at least 5 points.
First observe mother breastfeeding before recommending changes.
Make sure the mother brings the baby to the breast and not the breast to the baby.
Infant’s mouth is wide open.
Infant’s chin is touching the breast.
More areola visible above the baby's mouth than below.
Lower lip is everted.
Infant’s cheeks are full, and no dimpling is evident.
Nipples are intact and not pinched after the feeding.
Absence of maternal pain.
Explain/demonstrate to mother how to release a latch that is painful or shallow without hurting herself.
Inform the mother to release or remove the baby from the breast when the latch is painful or shallow.
Describe at least 2 infant factors a with delayed lactogenesis II.
Infant Apgar <8.
High birth weight >3600 g.
Low birth weight (<2500g).
Poor or painful latch / restricted feedings.
Prelacteal feeds.
Prematurity (<37 weeks).
Infant condition impairing ability to suck including but not limited to oral anomalies, lethargy, effects of labor medication
Delayed skin-to-skin contact with mother
Respiratory or cardiac compromise