Armanian Amir Mohammad, MD Neonatologist Assistant Professor of IsfahanFaculty of Medicine

3. BREASTFEEDING Armanian Amir Mohammad, MD Neonatologist Assistant Professor of IsfahanFaculty of Medicine

4. It is equally important that all health care personnel involved in careing for mothers and infants possess basic breastfeeding knowledge so that they can provide accurate and consistent information . Adequate communication between obstetric and pediatric care professionals in the immediate postdelivery period will greatly facilitate helping the breastfeeding.

5. Before hospital discharge • Before discharge, anticipatory guidance regarding the breastfeeding process should be provided to the patient, her partner, and other supporting family members. • Follow-up visits should be arranged . • The patient should be given information on how to easily access further breastfeeding support if it in needed.

6. most mothers can produce an adequate quantity of milk and most infants can nurse effectively and consume an adequate volume, specific maternal and infant Risk factors can place an infant at risk for inadequate breastfeeding. • It is assumed that risk factors for breastfeeding problems are assessed as part of routine prenatal care, although some mothers may present with limited or no prenatal care.

7. Findingsof the prenatal maternal breast examination that may adversely affect adequacy of milk production (such as inverted nipples, severely asymmetrical or tubular breasts, and prior breast surgeries )should be forwarded to the pediatric care professional . • This information also should be discussed with the patient in a supportive and realistic fashion. • Particular, lack of breast growth during pregnancy is a red flag and should be communicated from the obstetric to the pediatric care professional.

8. inverted nipple tubular breasts

9. Maternal History • Appropriate maternal history includes: • Amount and timing of prenatal care and education • Medical complications • Obstetric complications • Medical history (especially breast surgeries , infertility, endocrine problems ,and past breastfeeding difficulties) • Family history (atopy, breastfeeding problems) • Psychosocial history (Substance abuse, mental illness, sexual abuse , family support of breastfeeding).

10. Infant History • Appropriate infant history includes: • Medical complications • Postnatal feeding and elimination patterns • Infant temperament and sleep patterns

11. Feeding Patterns • New mothers should be encouraged to: • Nurse at each breast at each feed • Starting with the breast offered last at the prior feeding (This will help her achieve an optimal milk supply) • However, it is perfectly normal for a newborn to fall asleep after the first breast and refuse the second. • It is preferable to allow an infant to drain the first breast wellbefore switching him to the other breast

12. Feeding Patterns • The mother should not interrupt a feeding just to switch to the second side • Typically, the infant will spontaneously release the first breast after sufficient draining • Timing each side is not necessary • Limiting the time at the breast has no effect on nipple soreness but correct latch and positioning are crucial

13. Hunger Cues • Many new parents expect their baby to cry when he is hungry • But need to be informed that crying is a late sign of hunger and can result in an infant who is difficult to calm and latch to the breast • Anticipatory guidance and rooming- in 24 hous a day allow the parents to notice early infant hunger cues such as Increased alertness Flexin of the extremities, Mouth and tongue movements, Cooing sounds, Rooting,bringing the fist toward the mouth, or sucking on fin

14. Feeding Frequency • In addition to information regarding latch –on and positioning of the infant , the mother should be instructed on expected breastfeeding routines which can vary widely • Typically, newborns will nurse 8 to 12 times or more/ day for 10 to 15 minutes per breast

15. Feeding Frequency • The interval between feedings is figured from the beginning of one nursing to the beginning of the next. Frequent breastfeeding in the first few days: Minimizes postnatal weight loss Decreases bilirubin levels Helps establish a good milk supply

16. Feeding Frequency • There is a great deal of variation from infant to infant and during a 24 –hour period , Although every 2 to 3 hours is the average Human milk empties from the stomach faster than formula

18. Feeding Frequency • Without anticipatory guidance, new mothers often compare their infants to bottle-fed infants and misinterpret the Normal Higher frequency of breastfeeding to mean they have insufficient milk. . • As infants get older: • They nurse more efficiently • The frequency and duration of feedings decrease

20. Nursing Styles • Infants have been classified by their feeding behaviors • The key to appropriate counseling is recognizing the difference in infants and responding to them

22. Neonate Behaviors • Sleepy Infant After the usual 1 to 2 hours of quiet alertness immediately after birth (The ideal time to initiate breastfeeding) many infants fall into deep sleep ,with only brief , partial arousals for several hours • This is a normal pattem and does not indicate a need for supplementation.

23. Neonate Behaviors • Sleepy Infant … • Sometimes Unwrapping ,gentle massage ,holding upright, motion, changing a diaper, talking ,or holding the infant skin-to-skin against the mothers chest may arouse the sleepy infant • Infants have short wakeful periods throughout the first 2 days that can be missed.

24. Neonate Behaviors • Sleepy Infant… • Rooming – in where the infant sleeps in close proximity to the mother, allows the mother to recognize subtle hunger cues • The newborn whose mother received a large quantity of narcotics or sedativesmay have longer periods of sleep and may need to be awakened after 4 hours to feed

25. Neonate Behaviors • Fussy/unsettled infants • infants may be fretful after a feed , especially before lactogenesis stage 2 is complete • An extra minute or 2 at the breast, or a diaper change will usually satisfy the infant • If the infant is consistently fussy after every feeding, even after the milk supply is established, the breastfeeding mother and infant should be carefully assessed with regard to milk supply , milk transfer , and infant weight gain

26. Neonate Behaviors • Fussy/unsettled infants • Breastfeeding should commence when the infant is in the quietalert state • If the infant is at an active alert or crying state, he may need to be consoled before he can be successfully breastfed • Crying has been interpreted through the years as a sign of vigor, “good lungs,”and general health

27. But Cryingresults in Increased work ,energy expenditure, and swallowing of air, which may precipitate vomiting Depletes metabolic reserves, which may precipitate hypoglycemia, and disrupts early breastfeeding behavior • Crying is a very late sign of hunger • Babies who cry for a long time may become exhausted and go to sleep without nursing, or before they have finished the entire feeding.

28. Frequent feeding will diminish crying episodes . . • Efforts should be made to minimize crying.

30. Assessment of the Breastfeeding Infant • Physical examination of the infant should include a general examination, vital signs, growth percentiles and percentage weight change from birth, and • a more detailed oral-motor examination (mandible size, frenulum, rooting, sucking) • Presence of congenital anomaly and overall tone should be noted

31. Assessment of the Breastfeeding Infant • Breastfeeding Observation. • It is helpful for the physician to observea feeding and evaluate positioning, latch ,milk letdown ,and milk transfer. • Also note maternal responses to the feeding (painful,pleasurable, anxious, relaxed) • The hospital staff should observe and document these breastfeeding observationsat least twice daily.

32. Assessment of the Breastfeeding Infant • Latch: • The infant’s mouth should be wide open with lips flanged outward (“fish lips”) encompassing the nipple and a significant part of the areola • Some of the factors that are Important in assessing latch include the ability of the infant to latch, quality of the latch ,presence of audible swallowing, characteristics of the anatomy and physiology of the nipple, maternal sensation, and … . Good attachment Poor attachment

33. “fish lips”

34. Assessment of the Breastfeeding Infant Weight Changes: • The most accurateappraisalof the adequacy of breastfeeding is the serial measurement of the infant’s naked weight

35. Assessment of the Breastfeeding Infant • Nearly all infants lose weight for the first 2 to 4 days after birth • A weight loss greater than 7% of birth weight may be excessive even if lactogenesis and milk transfer seem not to be proceeding normally. • Significant dehydration: • First 24 h : > 4 % weigth loss • 24 – 48 h : > 8 % weigth loss • > 72 h : > 10 % weigth loss

36. Assessment of the Breastfeeding Infant • Once lactogenesis stage 2 is completed, an infant who did not lose excessive weight and who is nursing effectively should obtain enough milk to begin gaining weight by day 4 or 5 at a rate of approximately 15 to 30 g per day • At this rate,most breastfed infants will exceed their birth weight by 10 to 14 days , and gain 150 - 210 g / week for the first 2 months

37. Assessment of the Breastfeeding Infant • A breastfed infant who weighs less than birth weight at 2 weeks requirescareful evaluationand intervention

38. Evaluation Patterns • Urine output usually exceeds fluid intake (U.O.> I) for the first 3 to4 days after birth, a physiologic response to contract the extracellular fluid space • Stoolling and voiding patterns after the first few days are good indicators of adequate milk intake

39. Evaluation Patterns • Urine Output: • By 5 to 7 daysthe breastfed newborn should be voiding colorless, dilute urine 6 or more times per day ( > = 6 / day)

40. Evaluation Patterns • Stool output and characteralso are particularly useful indicators of adequate milk intake • The normal green-black meconiumstool should change to transitional green , • thento soft, seedy yellow stool • by day 4 or 5 after birth .

41. Evaluation Patterns • Anticipatory guidance is essential • because normal human milk stools are quite loose and may be confused with diarrheaif parents are accustomed to seeing the firm brown stools typical of formula-fed infants • Insufficient milk intake in an infant older than 5 days ( > 5 day) may be signaled by the presence of meconium stools, green –brown transitional, stools, infrequent(<3per day) stools, or scant stools.

42. Evaluation Patterns • By 5 to 7 days of age, • well–nourshied breastfed infants usually pass a medium-sized yellow stool at least 3 - 4 times a day • Some infants stool after most feedings. • After the first month the volume of each stool increases but the frequency decreases