Melanie R. Silverman MS, RD, IBCLC Pediatric Registered Dietitian Board Certified Lactation Consultant

1. Melanie R. Silverman MS, RD, IBCLC Pediatric Registered Dietitian Board Certified Lactation Consultant Breastfeeding Update: What Every Dietitian Should Know

2. Objectives List the health benefits of breastfeeding for the mother and baby Understand the barriers to breastfeeding Describe ways to support breastfeeding mothers and babies

3. American Academy of Pediatrics New breastfeeding policy Published February 27, 2012 Pediatrics: Breastfeeding and the Use of Human Milk How timely for us today!

4. Statement Specifics Breastfeeding and human milk are normative standards for feeding Exclusive breastfeeding for six months Continue breastfeeding as food introduced Breastfeed 1 year + if agreed upon

5. Breastfeeding Benefits

6. Moms’ Benefits Less blood loss Less depression Less weight…for some Less diabetes Less rheumatoid arthritis Less CVD Less ovarian CA Less breast CA

7. Babies Benefits Less ear, respiratory and GI infections Less asthma, dermatitis, eczema, allergies Less celiac disease (52%) Less IBD (31%) Less obesity (15-30%) Less diabetes (30%) Less SIDS (36%) Less leukemia/lymphoma (20%) Less dental caries

8. Other Benefits Economic If 90% of US mothers breastfed 6 months, there would be a savings of $13 billion per year —medical costs lower for fully breastfed infants then never breastfed infants….(less visits, prescriptions, hospitalizations) Cheap Warm Less environmental waste

9. Contraindications Infant diagnosed with galactosemia (enzyme to digest galactose is missing) Mother infected with HIV, taking antiretroviral medications untreated, active TB infected with human T-cell lymphotropic virus I or II using/dependence on illicit drug cancer chemotherapy radiation therapy Source: CDC on Breastfeeding with Diseases and Conditions

10. Barriers To Breastfeeding

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12. Barriers to Breastfeeding (Report from United States Breastfeeding Committee, 2008) Health Care System and Providers Social, Economic and Political Factors Media and Marketing Practices

13. Barriers to Breastfeeding Health Care System and Providers Lack of knowledge Unnecessary use of medical interventions Insufficient attention to immediate skin-to-skin contact at birth and other evidence based breastfeeding practices Insufficient numbers of providers skilled in both clinical/social support

14. Barriers to Breastfeeding Social, Economic, Political Limited awareness of public health impact and attention to action Misperceptions and fears due to lack of societal awareness and support Limited third party payment for sufficient support Rare public health programming in support outside of WIC and limitations within WIC Lack of paid maternity leave/brevity of any leave Lack of workplace support

15. Barriers to Breastfeeding Media and Marketing Practices Aggressive marketing of formula (samples, gifts, coupons) to mothers Public misperceptions secondary to aggressive marketing to the public Lack of media representation in television and cinema breastfeeding as normative behavior Source: United States Breastfeeding Committee, 2008

16. Baby Friendly Hospital Initiative (BFHI) Baby-Friendly USA, Inc. envisions an American culture that values the enduring benefits of breastfeeding and human milk for mothers, babies and society

17. What is the BFHI? Global program by WHO and UNICEF Encourage/recognize hospitals and birthing centers that offer optimal level of infant feeding care Assists hospitals to give mothers information, confidence and skills >19,000 international maternity facilities have received Baby-Friendly Award 125 US Baby-Friendly Hospitals/Birth Centers as of December 22, 2011

18. Baby Friendly Hospital Initiative (BFHI) Ten Steps Have a written breastfeeding policy that is communicated to all staff Train all health care staff in skills necessary to implement policy Inform all pregnant woman about benefits/management of breastfeeding Help mothers initiate breastfeeding within one hour of birth Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants

19. Baby Friendly Hospital Initiative (BFHI) Ten Steps Give newborn infants nothing other than breast milk, unless medically indicated Practice “rooming in”—allow mothers and infants to remain together 24 hours a day Encourage breastfeeding on demand Give no pacifiers or artificial nipples to breastfeeding infants Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic Source: BFHI Usa

20. Support Breastfeeding

21. How it Works Baby sucks?stimulates nerve endings in nipple/areola?sends signals to pituitary by hypothalamus?secretes prolactin and oxytocin into blood?oxytocin stimulates around alveoli to contract squeezing milk from all parts of breasts

25. Skin-to-Skin Contact (Kangaroo Care)

26. Skin-to-Skin Contact (Kangaroo Care) Source: March of Dimes BENEFITS Maintain temperature Regulate heart/breathing Gain weight Deep sleep Less crying time Successful breastfeeding->milk production increases

27. Our Breastfeeding Checklist Preparation Position Latch Nursing frequency Poops/Pees Weight Gain Nipple Care Nutrition Pumping Making Milk Medications Mastitis Yeast Breast Surgery Weaning

28. Preparation and Position Preparation Deep breaths…milk flows Breast massage…while breathing Relax Position Cradle, cross-cradle, football, side-lying, your choice Pillows and blankets “Tummy to tummy”

29. “Tummy to Tummy”

30. The LATCH Tickle baby’s bottom lip for wide latch Lower lip on breast and cover as much of breast with upper lip seal Areola doesn’t have to be covered… If latch shallow, painful after 10-15 seconds…RE-LATCH

31. Nursing Frequency 8-12 times per day (newborn) Hunger signs before baby cries (rooting, head turning, hands in mouth) Nurse both breasts every feeding to empty (foremilk and hind milk) Sessions vary…8-20 minutes each Can change. Will change. Be flexible.

32. “I don’t feel my baby is getting enough” Poop/Pee is the MOST important marker of adequate intake other than a scale Time is NOT a marker

33. Poops/Pees: How many? 3-4 scoopable poops per day (size of quarter) 6-8 soaked wet diapers 1st month is the minimum after milk in Pooping slows down after ~6 weeks

34. The Look of Poop Meconium (black, tarry-looking)? Green? Yellow Seedy

35. Weight Gain Initial weight loss Regain by 10 days to 2 weeks 3-4 months=6 ounces per week 4-6 months=4-5 ounces per week 6-12 months=2-4 ounces per week Follow the WHO growth charts

36. Nipple Care GET OUT OF THE BRA LADIES

37. Nipple Care Expose breasts to air Take approved pain reliever Elevate breasts (lie down) Express milk, rub, air dry Hand express to soften Lanolin cream for protection

38. Nutrition Eat Drink Be healthy…most of the time *Hydration does NOT make milk 450-500 calories per day Prenatal vitamin 200-300 mg Omega 3 DHA (1-2 portions of fish/week or supplement)

39. Pumping

40. Pumping What to know… Supply and demand The more you empty…the more you make Pumping NOT required in breastfeeding Baby is best pump

41. Pumping Hospital grade electric pumps Double electric pumps-higher prolactin surge Manual pumps

42. My Pumping Rules Fall in love with the pump Both breasts 10-15 minutes Frequency DO NOT WATCH

43. Making Milk Still have low milk production? Galactogogues Pharmaceutical: Domperidone, (Reglan), Glucophage Foods: almonds, coconut, sesame seeds, rice puddings, pumpkin, sunflower seeds, sesame seeds, chicken, seaweed soups, cooked papaya, millet, rice, fennel, dill, cumin, caraway, ginger, mushrooms, barley, oats, chickpeas, dandelion Herbals: Fenukgreek, goat’s rue, nettle, alfalfa, blessed thistle, dill, saw palmetto,

44. Medications Thomas Hale “Medications and Mother’s Milk” Your “GO TO GUY” on medications/breastfeeding ibreastfeeding.com OK: Anti-anxiety, depressants, psychotic What about? Caffeine, Alcohol, Birth Control Pill

45. Mastitis Definition: Any inflammation of the breast Symptoms: Cracked nipple with signs of infection Pus/blood in milk Red streaks Sudden and severe symptoms with no cause Treatment: 10-14 day course cloxacillin, dicloxacillin or cephalosporin Source: LLL Breastfeeding Book,2003

46. Plugged Ducts vs. Mastitis Plugged Ducts Mastitis Comes on suddenly Pain is intense, but localized Red, hot swollen breasts Mother has flu-like symptoms Temp is >101F

47. Yeast Candida Albicans Lives in dark, moist places (BRAS!) Symptoms: Intense pain Itchy, burning, shooting pain Cracked nipples, red, shiny TREAT MOM & BABY (nystatin, difulcan, gentian violet, clotrimazole)

48. Breast Surgery Breast Lift = usually no glandular tissue removed Breast Implants = depends on entry and placement. Incision around areola affects supply Breast Reduction = reduces supply because glandular tissue is removed PRODUCTION VARIES Give it a try…

49. Weaning Emotional Gradual is best Substitutes Cabbage leaves

50. Breastfeeding > 1 year Benefits Better oral development Immunity Good nutrition when sick Bonding

51. Questions You May Hear

52. FAQs Round I How long should I breastfeed? Can I get pregnant while breastfeeding? How long does breast milk stay in the refrigerator? Can I have wine/beer while breastfeeding? Do I have to stop breastfeeding with antibiotics? Is that yellow seedy poop diarrhea? Should I wear a bra to support my breasts? Should I eliminate all dairy while I breast feed? Can I give my baby a pacifier? What are cabbage leaves used for?

53. FAQ’s Round 2 How often should I feed my baby? Can I work and breastfeed? When should I introduce a bottle? How much weight should my baby gain? How do I lose the baby weight quickly? Will my milk make my baby fat? Do I need to supplement my baby with formula? Will I have enough milk for my twins/triplets? Why did my baby stop nursing? Why is there blood in my breast milk? Can I breastfeed my adopted baby?

54. Case Study #1 JRV is a 31 year old G1P1 mother…5 month old healthy male named Charlie. “I don’t think my baby is getting enough” “Wants to eat every 2 hours, use to be every 3-4 hours and is up at night all the time” “He needs formula”

55. Case Study #2 MRS is a 33 year old G2P2 with 21 month old small girl named Sydney. Nursing morning/night. Eats table foods well. “She is beginning to bite me and laugh” “I am in pain” “Should I keep breastfeeding? I’m worried because she is small”

56. Case Study #3 CHR is a 37 year old G1P1 with 6 week old breastfed Josh. She went back to work full time five days. She pumps at work. “I can only pump 4 times per day for 10 minutes” “I am only getting 1-2 ounces and I use to get 4 ounces” “I think my body cannot produce enough milk”

57. Resources Breastfeeding.com Womenshealth.gov Llli.org Kellymom.com Ilca.org

58. Take Home Messages… Benefits are numerous Barriers need to be broken Cheerleading is crucial Start with skin-to skin contact Supply and demand process No special diets for moms initially

59. Follow Me… Feeding Philosophy FeedPhilosophy

60. Thank you!  EMAIL: melanie@feedingphilosophies.com OFFICE: 949.607.8248 Melanie R. Silverman MS, RD, IBCLC Images in lecture from GOOGLE IMAGES, Microsoft Clip Art