2. Welcome Back! • Crossword Puzzle (Review of Session 3) • Review answers as a large group • See “Crossword Puzzle Key” (Handout #5) • Preview of Session 4 • Silently read the topics for Session 4 • What are you most interested in learning about?

3. Helping Mothers with Special Challenges

4. Breastfeeding Challenges • Twins • Premature baby • Premature twins • Sick baby • Baby with other medical problems • Sick mother / diabetes

5. How to Help • Listen – let her talk about her feelings • Refer to a lactation specialist if they… • Have trouble breastfeeding • Are told to stop breastfeeding • Ask health care provider ways to treat problem • Your support can make a difference!

6. Discussion: Twins • Did any of you breastfeed twins or know a mother who has breastfed twins?

7. Twins • Most women make PLENTY of milk for twins • Nature made it possible to feed 2 babies • Breastfeeding can be easier and take less time than preparing bottles and formula for two babies

8. Suggestions • Start by feeding one baby at a time • Comfortable - try feeding babies same time • Baby with strongest suck start on different breast each time • Milk removed from both breasts • Reduces engorgement • Helps maintain good milk supply

9. More Suggestions • Let babies sleep in same crib • Get help shopping, cooking, cleaning, etc. • Keep snacks nearby • Rest when possible • Join a twin or multiple support group

10. Discussion: Twins • What positions do you think would be helpful for a mother breastfeeding two babies at the same time? • Compare your list to page 96

11. Activity: Twins • Activity • Find a partner • Practice teaching breastfeeding babies at same time • Use dolls/stuffed animals • Take turns being mother and peer counselor

12. Discussion: Premature Babies • Has anyone had or known someone who has had a premature baby? • What was it like for the mother? • What helped her? • What would have been helpful?

13. Premature Babies • 37 weeks or earlier • May be tiny and weak or healthy • Some cannot breastfeed in beginning • May need to pump until baby can breastfeed • Mother of premature baby makes special milk that meets baby’s needs

14. Doctors Recommend Breastmilk • Often prescribe breastmilk - premature babies • Some add extra calories, vitamins and minerals • Premature babies fed breastmilk: • Higher IQ - helps brain develop • Sick less often • Protects against necrotizing enterocolitis

15. How to Help • Let the mother know: • Giving breastmilk – something only she can do • Breastfeeding gets easier as baby grows • Focus on breastfeeding/pumping - caring for baby • Help her get a breast pump from WIC • Instructions - pumping/storing/labeling breastmilk • Provide extra help and support • Be a good listener!

16. Discussion: Sick Baby • Who has known a breastfeeding mother whose baby was sick or in the hospital? • How did breastfeeding go? • What happened? • What could you have done to help?

17. Babies Who are Sick • Most get better faster with breastmilk • Breastfeed to prevent dehydration • Breastfeed more for comfort • Some only want to breastfeed when sick • Some too weak to breastfeed or do not want to • Talk about pumping to keep up milk supply • REFER her to baby’s health care provider or a lactation specialist

18. Babies in the Hospital • Encourage mother spend time with baby • Breastfeed soon after any test or surgery • Talk with health care provider • If the baby can’t breastfeed… • Pump as often as she would breastfeed • Help get pump from WIC

19. Mothers with Diabetes • Hard time controlling sugar in blood • Eat right, exercise and take medications • Can get heart disease, kidney disease or become blind

20. Mothers with Diabetes • CAN breastfeed • Breastfeeding: • Improves the mother’s health • May reduce how much medication needed • May protect baby from getting diabetes later • Most medications are OK with breastfeeding • Suggest she talk to health care provider BEFORE baby is born

21. Discussion • Divide into small groups - answer these: • If you were sick (colds, flu, etc.) while you were breastfeeding, what did you do? • What did others tell you to do? • How could you help a mother who is sick keep breastfeeding? • Share with the group

22. Mothers with Minor Illnesses • Most of the time - can continue breastfeeding • Colds and flu do not pass through breastmilk • By the time mother knows - baby already exposed • Mothers give antibodies to their babies • May keep the baby from getting sick • Baby will get better faster • Everyone should wash their hands before touching baby!

23. Mothersin the Hospital • Talk to her about: • Can baby stay with her in the hospital? • Hospital let someone bring baby to breastfeed? • Will hospital let her use their electric pump? • If she can’t pump on her own, can someone help? • Where can she store milk in the hospital? • Can she pump & store breastmilk before going to hospital?

24. Mothers Who are Sick • Mother told not to breastfeed due to illness or treatment, talk to her about… • Pump & throw away breastmilk - keep up supply • Has she talked to a lactation specialist? Different medication that will work with breastfeeding. • Get breastmilk from the human milk bank

25. Activity • What questions do you have about helping a mother who is sick or in the hospital continue to breastfeed?

26. Tuberculosis (TB) • Lung disease treated with medication • Close contact with person with active TB • A mother with active TB can breastfeed after: • Taking medication for 2 weeks, and • Health care provider tells her it’s OK • Questions? REFER her to health care provider or a lactation specialist

27. Hepatitis • Liver infection • Hepatitis A • CAN breastfeed - protects the baby • Hepatitis B • Babies now get vaccines • CAN breastfeed • Hepatitis C • CAN breastfeed - if doesn’t have HIV

28. Sexually Transmitted Infections (STI) • Most mothers can breastfeed • Most medications are safe • Herpes or syphilis - can breastfeed (unless has open sores on her breasts) • Can pump on that side until healed • Any part of pump kit touches sore - throw out milk • Refer to lactation specialist or health care provider - if open sore on breast

29. Should NOT Breastfeed • HIV - (Formula is a safe alternative) • Human T-Cell Leukemia Virus • Chemotherapy

30. Activity • Divide into groups of 3 • Complete item G on page 102 • Make sure each person is the “counselor”, “mother” and “observer” • After each role-play, discuss questions on page 103 within your group of 3 • Share how your “counseling” went with the large group

31. Helping a Grieving Mother

32. Helping with Grief • Difficult challenge • Mothers experience… • Extreme sadness • Some will not want to talk • Others want to talk / need a shoulder to cry on • Some will be angry / depressed • Others will be in denial • Some need more time to adjust • No right or wrong way to grieve

33. How to Help • Be a good listener & understanding • Let the mother talk about her feelings • Remember her grief is her own • Listening & being supportive - BEST way to help • When appropriate, recommend a support group • Let lactation specialist know if mother needs help with breastfeeding/weaning

34. Activity: Grieving Mother • In small groups… • Make a list of reasons a pregnant woman or someone who has recently given birth may be experiencing grief. (Compare to list on page 106) • Discuss how your family & friends helped you cope with a loss… • How did they make the situation a little easier? • What would you avoid saying? • Share with the large group

35. Expressing Milk

36. Expressing Milk • Helps mother to start making milk • Helps keep her milk supply up • Mothers express breastmilk when: • Babies cannot breastfeed • They are away from their babies

37. Ways to Express Milk • Hand expression • Manual pumps • Battery operated pumps • Semi-automatic pumps • Personal use electric pumps • Hospital grade electric pumps • Lactation specialist can help choose best pump (for situation)

38. Discussion • In small groups, share your experience with expressing milk • How did you express milk? • What was your reason for expressing milk? • How did it work out?

39. Expressing Milk By Hand • Easy way for some mothers to express milk • Some like this method better than using a pump • Facilitator will demonstrate one method of hand expression (using a breast model) • See steps on page 108 • Optional activity – practice hand expression using a water balloon

40. Pumps

41. Manual Pumps • Not expensive • Used by mothers who will not be pumping very often • 3 types of manual pumps: • Cylinder pumps (e.g. Medela manual pump) • Trigger pumps • Rubber bulb pumps (bicycle horn)

42. Battery Operated Pumps • Suction controlled • Mothers who only pump a few times per week • Batteries need to be changed often • Used pumps may not work well • Mothers should NEVER share a manual orbattery operated pump with other mothers!

43. Electric Pumps • For mothers who need to express milk many times during the day • Pump both breasts at same time • 3 types of pumps • Semiautomatic • Personal Use • Hospital Grade

44. Putting Together Pump Kit • Watch facilitator put together a pump kit & connect it to an electric pump • Divide into groups • Practice putting pump kit together

45. Helpful Tips for Pumping • Let mother know… • Normal for one breast to give more milk • Normal for milk to change color • Continue pumping after 1st Milk Ejection Reflex • Milk flow will slow or stop • Another MER will occur - more milk will flow

46. Handle & Store Breastmilk

47. Activity • Find and review Handout #6 “Collecting and Storing Breastmilk When You’re Away” • How would handout help a mother returning to work/school? • Share in the large group • What questions do you have about handling, storing and using breastmilk?

48. Weaning

49. Weaning • Baby fed anything other than breastmilk • Most of us think of weaning - stop breastfeeding • In the U.S. – often begins in the hospital • Once mothers start giving formula - breastfeed less & stop sooner

50. Weaning • Around world most mothers breastfeed - 3 yrs. old • In the U.S. – most mothers wean by 4 months • If mother decides to wean before 1st birthday Give formula - NOT cow’s milk! • Some babies wean themselves