Managing the
Breastfeeding Woman
2007 University of Pennsylvania School of Medicine
Objectives
• To understand the benefits of breastfeeding for both the
mother and the child.
• To understand breastfeeding mechanics and proper
technique.
• To recognize the additional energy, vitamin and mineral
requirements for women during lactation.
• To understand potential obstacles and contraindications to
breastfeeding.
2007 University of Pennsylvania School of Medicine
Obstacles to Initiating and
Continuing Breastfeeding
• Physician apathy and misinformation
• Insufficient pre-natal breastfeeding education
• Distribution and promotion of infant formula
• Disruptive hospital policies
• Inappropriate interruptions of breastfeeding
• Early hospital discharge
• Lack of social support
2007 University of Pennsylvania School of Medicine
Role of the Physician
• Establish positive attitudes in pregnancy
• Address medical issues/ physical obstacles
• Encourage nursing immediately after delivery
• Provide post-partum support
• Explain nutritional needs
• Assess substance use
• Discuss employment concerns
2007 University of Pennsylvania School of Medicine
Establish Positive Attitudes
• Endorse and encourage breastfeeding because
it is best for mother and baby.
• Ask about previous experience
• Provide positive statements about breastfeeding
• Offer confirmatory words from all office staff
• Distribute appropriate education materials
• Be supportive no matter what the woman plans
2007 University of Pennsylvania School of Medicine
General Benefits
of Breastfeeding
• Maternal-infant bonding
• Inexpensive
• Convenient (no preparation)
• Perfect temperature
• Easily digested
• Immunological protection
• Allergy prophylaxis
2007 University of Pennsylvania School of Medicine
Breastfeeding
Advantages for Mothers
• May delay return of ovulation.
• Reduction in postpartum blood loss due to
increased oxytocin levels.
• Reduction in pre-menopausal breast cancer
and reduced risk of ovarian cancer.
• Improved bone remineralization postpartum.
2007 University of Pennsylvania School of Medicine
Immunological Contents
of Breast Milk
• Immunoglobulins
IgA, IgG, IgM, leukocytes, cytokines
• Host resistance factors
Complement macrophages, lymphocytes, lactoferrin
• Anti-inflammatory components
Enzymes: catalase, histaminase, lysozymes, lactoperoxidase
Antioxidants: acsorbic acid, alpha-tocopherol
Prostoglandins
• Interleukin-6
Stimulates an increase in mononuclear cells in breast milk.
2007 University of Pennsylvania School of Medicine
Breastfeeding
Advantages for Baby
• Decreased incidence and/or severity of otitis media,
diarrhea, lower respiratory infections, bacteremia,
bacterial meningitis, botulism, urinary tract infections,
and necrotizing enterocolitis.
• Less hospitalization in first 6 months.
• Possible protective effect against sudden infant death
syndrome, type 1 diabetes, Crohn’s disease, ulcerative
colitis, lymphoma, allergies, and chronic digestive
diseases.
2007 University of Pennsylvania School of Medicine
Evaluating the
Pregnant Woman
• Consider physical obstacles
Physical examination of breasts and nipples.
Inverted or flat nipples.
Use breast shells for 6-8 weeks before delivery.
Breast cancer-avoid pregnancy and lactation for
5 years.
• Encourage communication and support
Misinformation, fears, self assurance.
Father’s and family’s attitudes.
Prenatal referral to lactation
consultants/educators.
2007 University of Pennsylvania School of Medicine
Physiology of Lactation
• Suckling stimulates nipple
--->pituitary gland secretes Hypothalamus
oxytocin--->let down reflex
Pituitary Gland
results in milk ejecting cells
contract forcing milk from
Oxytocin
milk cells into milk ducts. Prolactin
• Milk pools in lactiferous Uterus
sinuses under the areola.
Suckling stimulates milk to Myoepithelial
Cell
come from the nipple.
Lacteal
2007 University of Pennsylvania School of Medicine
When to Breastfeed
• Initiate feeding as soon as possible after delivery.
• Signs of hunger include:
Alertness, increased activity, mouthing and rooting
• Feed on demand at least every 4 hours.
10 minutes per breast for first few weeks.
Breast milk empties from stomach in 1.5 hours.
Not unusual to breast feed every 2 to 3 hours or
8 to 12 times in a 24 hour period.
• Do not give glucose water to infant.
2007 University of Pennsylvania School of Medicine
Proper Positioning
of the Infant
• Cradle position
• Football hold
• Lying down
2007 University of Pennsylvania School of Medicine
Latching on Properly
• Hold the breast in the opposite hand.
• Stroke the baby’s cheek or lips with the
nipple to get him to open his mouth (rooting
reflex).
• Once his mouth is open, pull the baby
towards the breast, making sure that his
head is facing the breast and mother and
baby are stomach to stomach.
• Get as much of the nipple and areola into
the baby’s mouth as possible.
2007 University of Pennsylvania School of Medicine
Care of the Breasts
and Nipples
• Demonstrate proper latch on and positioning.
• Cleanliness and attention to fissures.
• Use Lansinoh (pure lanolin) for cracked nipples.
• Avoid soaps and other ointments.
• Insert nipple shield into bra for irritated nipples.
• Use breast pads for leakage and change often.
2007 University of Pennsylvania School of Medicine
Assessing Breastfeeding
• Mom feels tugging on nipple without pain.
• Infant weight gain pattern consistent (4-7 oz/wk).
• Voiding: 6-8 wet diapers/day.
• Stooling: generally more stools than formula.
• Feeding pattern-generally every 2-3 hours.
• Duration of feedings-generally 10-20 minutes/side.
• Activity and vigor of infant.
2007 University of Pennsylvania School of Medicine
Composition of Breast Milk
• Colostrum: small amount during days 3 to 5
High in protein, immunoglobulins and minerals,
Low in lactose and fat
• Transitional milk: produced during days 6 to10
High in fat, lactose
Lower in protein and minerals
• Mature milk: available by 2 weeks post-partum
Average secretion: 750 ml/d
Provides 20-22 kcal/ounce
60-80% whey protein, 40% lactose, 50% fat
Growth factor
Low in vitamin D
2007 University of Pennsylvania School of Medicine
Nutritional Requirements
During Lactation
• Breastfeeding is an anabolic state, resulting in increased
energy and nutrient needs:
500 kcal/day (birth to 6 mo)
400 kcal/day (7 - 9 mo)
• Protein, zinc, niacin, vitamins A, E, C requirements increase
above those in pregnancy.
Protein = 71 g/day
• Chronically low maternal iron, vitamin B, C, D, thiamin, and
folate intake leads to low content in breast milk.
2007 University of Pennsylvania School of Medicine
Insufficient Lactation
Infant Failure-to-Thrive
• Maternal causes
Poor milk production: diet, illness, fatigue
Poor let down: psychological, drugs, smoking
Inverted nipples
• Infant problems
Poor intake: poor suck, infrequent feedings, Cleft palate
Low intake: vomiting, diarrhea, malabsorption
High energy needs: CNS impairment, premie, SGA, CHD
2007 University of Pennsylvania School of Medicine
Breastfeeding
Recommendations
• “Exclusive breastfeeding is the ideal nutrition source
and sufficient to support optimal growth and
development for the first six months of life.”
• The American Academy of Pediatrics recommends
breastfeeding continue for at least the first 12
months.
(American Academy of Pediatrics Position Statement. Breast Feeding and the Use of
Human Milk. Pediatrics 1997;100:1035-1039.)
2007 University of Pennsylvania School of Medicine
Introducing a Bottle
• Breastfeeding does not have to be all or
nothing.
• Try to wait at least 6 weeks to introduce the
bottle.
• Pumping breast milk is an ideal option.
• Give bottle when infant is not extremely hungry.
• Start at the mid-day feeding.
• Let spouse, relative or care-giver offer the bottle
initially.
2007 University of Pennsylvania School of Medicine
Employment Issues
• Rent an electric breast pump.
• Discuss milk storage facilities.
Use breast milk within 24 to 48
hours or freeze
• Consider traveling issues.
• Set an example and breast
feed your children.
2007 University of Pennsylvania School of Medicine
Sarah Barts, RD, LDN
OB/GYN Registered Dietitian
Hospital of the University of Pennsylvania
1 West Gates, Helen O. Dickens Center
Philadelphia, PA. 19104
215-615-5389
[email protected] 2007 University of Pennsylvania School of Medicine
