Breastfeeding Paeds Presentation PDF 2024

BREAST FEEDING R C S I 2 0 2 4 D R. C L A I R E M U R P H Y D R G E O R S A N C A R U T H P R O F N A O M I M C C A L L I O N LEARNING OUTCOMES The benefits of breast feeding – Describe the benefits to the baby and the mother...

BREAST FEEDING R C S I 2 0 2 4 D R. C L A I R E M U R P H Y D R G E O R S A N C A R U T H P R O F N A O M I M C C A L L I O N LEARNING OUTCOMES The benefits of breast feeding – Describe the benefits to the baby and the mother The anatomy and physiology of breast milk production – Describe the hormonal mechanisms involved in the production of breast milk Normal feeding patterns and assessment of intake – Describe normal patterns of infant feeding – Be able to perform an assessment of infant feeding Common problems and maternal questions – Describe some common breast feeding challenges and their management – Identify sources of information for breastfeeding mothers and their clinicians Case Vignette – Apply your knowledge to this clinical case WHY BREASTFEED? Benefits to Baby Benefits to Mother Nutritionally complete and composition changes over time Reduces the risk of in accordance with the baby’s needs – breast cancer Prevents NEC in preterm infants – ovarian cancer Reduces the risk of – type 2 diabetes – Sudden Infant Death Syndrome (cot death), – osteoporosis – Gastroenteritis, ear and respiratory infections, Increases calorie consumption and assists weight loss – Obesity Uterus returns to pre-pregnancy size more quickly – Allergies and eczema Relative infertility during lactation facilitates pregnancy – Cardiovascular disease in adulthood spacing in the developing world Facilitates maternal-infant bonding Financial Benefit – Free Benefits to the environment – No need for formula powder, bottles, sterilisers – No production, packaging, transport or waste disposal required  “EVER BREAST FED” RATES BY COUNTRY- UNICEF 2018 Sweden 98% Russia Canada 89% Ireland 92% France Ireland 55% Europe 63% USA China Ever attempted 74.4% 96.1% Breastfeeding Cubaon discharge Rwanda 96,2% Breastfeeding at 6 weeksGuinea 98.8% 98.1% Exclusive breastfeeding for 6 months Burundi 98.8% Argentina Australia 95.8% 92%  WHO RECOMMENDS EXCLUSIVE BREASTFEEDING FOR THE FIRST SIX MONTHS OF LIFE Worldwide – 41% of infants receive this Ireland (2016) Breastfeeding on discharge from hospital – 56.9% receive any breast milk – 46.3% exclusive breastfeeding Exclusive breastfeeding for 6 months – Only 15% of infants receive this L ACTATION  BREAST ANATOMY Breasts contain – Areola – Nipple – Ducts – Glandular tissue Alveoli are lined with lactocytes which produce milk – the milk is released into the alveolus Alveoli are surrounded by smooth muscle cells which contract in response to oxytocin, secreting milk into the lactiferous duct The lactiferous ducts flow into the lactiferous sinus which then opens on the nipple PHYSIOLOGY OF LACTOGENESIS Inhibitors Stimulators Progesterone Prolactin Influences the growth and size of alveoli and lobes Produced in the anterior pituitary Inhibits lactation during pregnancy- levels fall 1. Growth and differentiation of alveoli during quickly after delivery pregnancy 2. Stimulates mammary gland to produce milk Oestrogen (after delivery) Stimulates the development of the ductal system High levels inhibit lactation during pregnancy Oxytocin Secreted from the posterior pituitary Human placental lactogen 1. Promotes smooth muscle contraction and let down of milk into the ducts Produced in the placenta Prolactin-like effect on growth of the breast Both produced in response to suckling Inhibits milk production STAGES OF LACTOGENESIS Stage 1 – Colostrum is produced initially – small volumes, very high protein content – Production is hormone dependent Stage II – 500-600 mls/day of milk produced – Production is dependent on breast emptying to continue production Usually baby suckling May be mimicked by using breast pump to express milk WHAT’S IN BREAST MILK? WHAT’S IN BREAST MILK? Colostrum Mature milk Secreted in the first 48-72 hours Transitions from 72 hours of age Very small volumes Foremilk High in protein – Delivered at the start of a feed Lots of immunoglobulins – Watery – Contains lactose and protein – Important for hydration Hindmilk – Delivered at the end of a feed – Creamy & rich in fat – Important for satiety Note: Breast fed infants require IM vitamin K at birth and Vitamin D supplementation until one year of age DELAYS TO LACTATION Caesarean section – Milk production may be delayed by 24 hours Inhibitors of prolactin production – Postpartum haemorrhage – Retained placenta after delivery Maternal Risk Factors – Gestational diabetes mellitus – Polycystic ovarian syndrome – Breast reduction (removes glandular tissue)- most of the breast producing tissue is in the anterior third – Breast augmentation- depends on method of same- particularly if nipple disrupted Infant unable to suckle effectively – Unwell infant – Premature infant – Congenital malformation, e.g. cleft palate – Neurological problems EARLY NEONATAL FEEDING PATTERNS Latch within the first hour of life (or hand express if infant can’t feed) – Improves milk supply at one week – Infant will find breast based on smell and colour 1st 4-6 hours: infant is alert and has a strong suck Next 18-24 hours: sleepy Day 2-Day 3: infant cluster feeds overnight – Happens at night because mothers prolactin levels are higher to optimise milk production – Constantly feeds Important to keep mum and baby together where possible HOW TO TELL WHEN A BABY WANTS TO BE FED? HOW DO YOU KNOW IF A BABY IS GETTING ENOUGH BREAST MILK?  ASSESSMENT OF BREAST MILK INTAKE 1. Urine 2. Stool 3. Weight Should pass 1 wet nappy All babies should pass meconium All infants lose weight after in first 24 hours in the 1st 24 hours delivery 2 wet nappies on day 2 Pass meconium for first two days Up to 10% is normal Day3-5 : transitional stool 3 wet nappies on day 3 >10% needs assessment of End of first week: should have 4 wet nappies on day 4 transitioned to seedy stools feeding and may require >6-8 per day from day 5 Breast fed babies stooling pattern intervention can vary from passing stool a few Top ups with EBM/ times a day to every few days formula/ IV fluids if severe Colostrum has laxative effects Gut transit time 95% regain birth weight by 40 minutes for breast milk two weeks of age 120 minutes for artificial formula Conclusion: If a breast fed baby is passing normal amounts of urine and stool and is gaining weight appropriately, it is likely they are receiving adequate volumes Checking weight again may help to reassure parents BREAST FEEDING TOOLKIT UNICEF UK have designed tools for a mother/health care worker to assess if a baby is breast feeding well – Maternity Hospital – Neonatal Unit – Home Visit by public health nurse – Two week check https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/implementing-standards- resources/breastfeeding-assessment-tools/ UNICEF HOME VISIT ASSESSMENT TOOLKIT  SUPPORTING BREAST FEEDING BABY FRIENDLY HOSPITAL INITIATIVE Developed by UNICEF and WHO Launched to ensure all maternity hospitals become centres of breast-feeding support Criteria to become a Baby Friendly Hospital – Hospital does not accept free/low cost breast milk substitutes/ bottles/teats – Hospital has implemented 10 specific steps to support breast feeding TEN STEPS TO SUCCESSFUL BREASTFEEDING 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2.Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within one half-hour of birth. 5. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breastmilk, unless medically indicated. 7. Practice rooming in - that is, allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10.Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic The Rotunda Hospital is a “Baby Friendly Hospital” SUPPORT FOR BREASTFEEDING MOTHERS After Discharge Antenatal Partner Breast feeding information is provided during Public Health Nurse antenatal classes Community breast feeding groups Lactation Consultant In Hospital Maternity Hospital breast feeding support classes Midwife Doctor Other support links Lactation Consultant Baby friendly health initiative www.babyfriendly.ie Health Care Assistant Cuidiú – Irish childbirth trust www.cuidiu-ict.ie HSE breastfeeding support www.breastfeeding.ie La leche league Ireland www.lalecheleagueireland.com The breast way www.thebreastway.ie ENVIRONMENT Baby’s should room in with their mothers Limit visitors in the early postnatal period Reduce maternal stress Comfortable position- feeding pillows etc Skin to skin first if the infant is distressed CAN YOU HELP ME LATCH THE BABY TO FEED? Some pointers Bring the baby to the breast Position the baby’s stomach to mum’s stomach Baby’s nose to the nipple Baby’s ears, shoulders and hips in line Lead with chin Nipple at soft palate (deep latch)  HOW TO SUPPORT BREASTFEEDING IN THE NICU Skin to skin contact between mum and baby Expert advice from lactation consultants Regular expression of milk using breast pump – Every 3 hours including overnight Latching of infants as soon as they are well enough to do so Maternal support groups  COMMON CHALLENGES IN BREAST FEEDING  Nipple pain Nipple discomfort is common during the first few days of breast feeding Mastitis If it persists throughout feeding or lasts more than 1 week Inflammation of the breast, Assess for poor position or latch Most common while breastfeeding May be non-infective or infective Cracked nipples May be treated with lanolin cream Treatment: Exclude fungal infection Continue to breast feed/ pump The use of nipple shields is controversial. They may be useful in some cases such as Analgesia, heat, massage flat nipples but carry the risk of incomplete emptying or trauma to the nipple if used inappropriately Monitor for signs of maternal systemic infection which may require antibiotics Breastmilk Jaundice A cause of prolonged jaundice (jaundice which lasts > 2 weeks) Need to exclude pathological causes e.g. biliary atresia The cause of breastmilk jaundice is unknown- thought to be due to a substance in breast milk preventing bilirubin metabolism Unconjugated hyperbilirubinemia in an otherwise thriving infant Stool and urine colour normal Can last 3 to 12 weeks Treatment: Continue to breast feed The jaundice will resolve over time WHEN IS BREAST FEEDING CONTRA- INDICATED? Maternal HIV infection (Developed world) Galactosaemia Mother receiving chemotherapy WHEN MIGHT BREAST FEEDING BE SUPPLEMENTED? Low blood glucose in infant (IV fluids or formula supplementation) Poor weight gain if lactation support unsuccessful Severe neonatal jaundice (needing complex treatment) Insufficient maternal milk in high risk infant (may use donor expressed breast milk) DOCTOR, I’M TAKING MEDICATION X, CAN I BREAST FEED MY BABY? There are very few medications which are contra-indicated during lactation Most maternal medications can be taken while breast feeding Drug specific information can be found from the following sources – Hale’s Medications and Mothers’ Milk – Drugs and Lactation Database “Lactmed” – Hospital pharmacy department – Summary of Product Characteristics www.medicines.ie Risk category given Weigh up risks and benefits on an individual basis: no evidence does not always mean no feeding! DOCTOR, MY BABY HAS A TONGUE TIE, CAN I BREASTFEED THEM? Most babies with tongue tie can breast feed successfully Tongue tie or “ankyloglossia” refers to an anterior position of the lingual frenulum Lactation assessment if feeding difficulties – Assessing for tongue tie- assessment score A small number will require surgery to fix the tongue tie at around 2-3 weeks of age Indications for frenulotomy: Presence of a tongue tie AND – Maternal nipple pain/ ulceration – Mastitis – Infant can’t latch or maintain a latch RCPI GUIDELINE Expert Assessment Using guidelines and tools that are widely available Important to rule out other feeding problems, cleft palate etc. Important to seek lactation consultant advice on latching Frenulotomy Indicated in small number of infants with tongue tie Risks of frenulotomy Bleeding 1 in 300 Infection 1 in 10,000 Scar/reattachment 3-10% Salivary duct damage URL: https://www.hse.ie/eng/services/publications/clinical -strategy-and-programmes/paediatrics-tongue-tie-in- early-infancy.pdf CASE VIGNETTE Mary brings her baby back to the Rotunda for her Newborn Bloodspot Screen on day 5 – Johnny is her first baby and she is exclusively breast feeding him – She tells the midwife that she is worried Johnny isn’t getting enough milk because he’s feeding all the time and she’s exhausted What questions would you ask Mary about feeding? What tool can you use to assess his feeding? TAKE HOME MESSAGE The WHO recommends exclusive breast feeding for the first six months of life Breast feeding is beneficial to both mum and the baby All staff who work with newborns have a role in promoting and supporting breast feeding