Pointers for Professionals: Pointers for Professionals: The 5 ‘M’s” for Breastfeeding SuccessThe 5 ‘M’s” for Breastfeeding Success

1) Mammals 2) Milk Production3) Magic Numbers5) Matching counsel6) Money!! (last but not least)

by Deanne Francis, RNC, IBCLC, LCCE

We are Expected to be the ExpertsWe are Expected to be the Experts

“Have concerns?How the breast works?How much? How often? Is this normal? How to fix it? Does your counsel match mammalian physiology?Will it result in eventual successful breastfeeding or sabotage it? How to fit my lifestyle?

““M”M” #1: We are Mammals! #1: We are Mammals!

We are “carry” We are “carry” mammals-- like apes mammals-- like apes and kangaroos. and kangaroos. We are not “cache” We are not “cache” mammals or “follow” mammals or “follow” mammals or “nest” mammals or “nest” mammals. mammals.

““There is a reason behind There is a reason behind everything in nature.” everything in nature.” AristotleAristotle

Composition of Milk from Composition of Milk from Different Mammals Different Mammals

SpeciesSpecies Content of Milk (%)Content of Milk (%)

FatFat ProteinProtein LactoseLactose

Human 3.8 0.9 7.0

Horse 1.9 2.5 6.2

Goat 4.5 2.9 4.1

Cow 3.7 3.4 4.8

Growth Rate of Different Growth Rate of Different Mammals’ Offspring Mammals’ Offspring

SpeciesSpecies Number of days to Number of days to double birth wtdouble birth wt..

Human 180

Horse 60

Goat 19

Cow 47

Normal Mammalian Behavior Normal Mammalian Behavior after Birthafter Birth

Mom and baby stay together Humans should act like ‘carry’

mammals Lots of skin 2 skin contact Baby controls the feedings Non-essential intervention is

postponed Supplement ONLY if medically

necessary

Skin-to-Skin Contact is Skin-to-Skin Contact is AssociatedAssociated with: with:

•Babies who are skin with the mother for 1-2 hours after birth:

•Are more likely to latch on

•Are more likely to latch on well

•Will cry less

•Have higher blood sugars

•Have higher skin temperatures

•Will breastfeed longer and more exclusively

Seven Natural Laws for Seven Natural Laws for Nursing Mothers Nursing Mothers

1. Babies are hardwired to breastfeed.

2. Mother’s body is baby’s natural habitat.

3. Better feel and flow happen in the comfort zone.

4. More breastfeeding at first means more milk later.

5. Every breastfeeding couple has its own rhythm.

6. More milk out equals more milk made.

7. Children wean naturally. (Mohrbacher/Kendall-Tackett 05)

Recommended Reading: Recommended Reading:

Breastfeeding Made Simple: Seven Natural Laws for Nursing Mothers

By: Mohrbacher, N & Kendall-Tackett, K. New Harbinger Publications. 2005

“M”M” # 2: Milk Production # 2: Milk Production

What can each of What can each of these breasts these breasts actually DO?actually DO?

A new breast drawing

for the anatomy books. (Hartmann and Ramsay)

Old Anatomical Model Old Anatomical Model (Sir Astley Cooper 1840)

Dissection: ducts full of colored wax and Dissection: ducts full of colored wax and straightened out into lobesstraightened out into lobes

Lactiferous Sinuses (Reservoirs) Lactiferous Sinuses (Reservoirs) Do Not ExistDo Not Exist

Normal Milk VolumesNormal Milk Volumes

First 3 days = drops to 15 mls/feed

5 days PP = 500 mls/day 10 days PP = 750 mls/day 14 days PP = 750 – 1000 mls/day Average = 24 ozs/24 hrs Twins = 32 ozs/24 hrs

Supply SaboteursSupply Saboteurs

Poor or NO advice Some meds Some herbs Visitors Separation Delayed BF Pacifiers Hormones Alcohol Feeding by the clock

Abnormal breast configuration

Breast surgery Cigarettes (25% less

milk with 20% less fat) Infant oral

abnormalities OBD Poor supplementation

plan Late preterm-no pump

The Perfect Mouth and Nipple The Perfect Mouth and Nipple Match-upMatch-up

Chin Touches FirstChin Touches First

Importance of a Good Latch -MomImportance of a Good Latch -Mom

Importance of a Good Latch- BabyImportance of a Good Latch- Baby

Evaluate this LatchEvaluate this Latch

On the other hand…….On the other hand…….

““M” #3 : M” #3 : MagicMagic NumbersNumbers

Breasts are designed to PRODUCE milk, and ducts to TRANSPORT milk (both directions) but neither are designed to STORE milk for any length of time. Breasts must be drained before reaching “capacity” to maintain production.

Capacity of breasts is variable. Size is not the main issue. Overall production capacity has nothing to do

with “full” capacity Breasts produce milk fastest when DRAINED. Question: Should we really counsel all mothers

the same?

Defining Magic NumbersDefining Magic Numbers

Breast fulness: When storage capacity is reached in an individual mother’s breasts, milk production slows. NOTE: Drained breasts make milk fastest!

Breast storage capacity: Maximum volume of milk available to her baby when an individual mother’s breast is full. Capacity affects time it takes for breast to fill.

Counsel using AveragesCounsel using Averages

24 hour AVERAGE Production in gms/mls: Total = 572 – 1016/day (750 av.)

AVERAGE Capacity in gms/mls (when “full”) Total = 350 gms/mls (combined breasts)

Assuming two given babies each require 750 mls/day, what counsel would you give the mother whose capacity is 150 mls total vs the one whose capacity is 400 mls total?

Individualizing CounselIndividualizing Counsel

Two studies found that breast storage capacity in a range of mothers is 74 – 606 gms.

Largest capacity = 90% of baby’s daily needs at any one time in both breasts.

Smallest capacity = 20% of baby’s daily needs at any one time in both breasts.

Recommendations:Recommendations:

How to figure it out?BF mothers = pump test. Decide if problem is something MOM is doing or something BABY is doing. Pump-dependent mothers – 1/wk keep track of the 24 hr milk volumes with DOUBLE pumping. Mohrbacher, N (2011) “The Magic Number and Long-Term Milk Production.” Clinical Lactation. Vol 2-1. (USLCA jnl)(Online free at ClinicalLactation.org)

The “4-hour” test

How much milk is mom making?

Remove milk with a hosp-grade pump every hour for 4 hours.3rd + 4th pumping X2 = MP/hr MP/hr X 24 = Daily milk production (Hartmann, Hale and Lai)

Test WeightsTest Weights

How effective is the baby at milk extraction?

Using a gm scale, weigh the baby before the feeding.

Leave the scale on. Weigh immediately after the

feeding without changing anything. Increased gms = volume consumed

Recommendations cont. Recommendations cont. First morning pumping: Mothers who

expressed 10 oz of milk or more at the first morning pumping can maintain their milk production with as little as 5 expressions/d.

Employed mothers: think back to maternity leave. How many feedings/d did baby need? That number of expressions/d will keep milk production stable. How many is baby taking? How many pumpings to add?

Copy the baby!

Establish and Maintain Mother’s Establish and Maintain Mother’s Milk Supply until BF is PossibleMilk Supply until BF is Possible

Pump or express milk regularly with a hospital grade electric pump everyevery 3 hours3 hours, or anytime infant feeding is inadequate or absent. 8X/day minimum to begin. Start soon! Delay negatively impacts milk volumes at 6 wksDouble pumping is most effectiveHand-expression imperative

Hospital Grade Breast PumpHospital Grade Breast Pump

http://newborns.stanford.edu Go to Go to Breastfeeding then Hand expression. Breastfeeding then Hand expression.

The best way to assure that babies get enough milk in the first few days (especially colostrum), or are able to establish a milk supply with a pump, is to teach the mother’s to use their hands effectively.

This website has fabulous information for professionals

Frequency and Duration of Frequency and Duration of Expression – Beginning CounselExpression – Beginning Counsel

Should imitate a healthy newborn.Will affect volume changes.Frequency more important than duration.100 min/day minimum (average)15 minutes each time (average)8 expressions per day (average) Depends on mother’s “magic numbers”

Simultaneous pumping produces higher prolactin levels.

Does Pumping Work When Does Pumping Work When Breastfeeding Doesn’t?Breastfeeding Doesn’t?

“Mothers who express milk are more likely to breastfeed to 6 months….the appropriate use of expressed breast milk may be a means to help mothers to achieve six months of

full breastfeeding while giving more lifestyle options.” (Win, 2006 Int’l BF Jnl)

“2/3 of all women return to work after having a baby. “Company-sponsored lactation programs can enable employed mothers to provide breast milk for their infants as long as they wish, thus helping the nation attain the Healthy People 2010 goals of 50% of mothers

breastfeeding until their infants are 6 mos. old.” (Ortiz, 2004 Ped Nurs))

“Extraordinary efforts should be made to use mother’s own milk.” (Heiman & Schanler, 2006 Early Hum Dev.

Don’t all breast pumps do the Don’t all breast pumps do the same thing?same thing?

Make sure the pump flange is Make sure the pump flange is not a tourniquet!not a tourniquet!

Correct flange fit Too tight!

Develop a Milk-Management StrategyDevelop a Milk-Management Strategy

Rule 1 = Feed the baby! (well-fed babies breastfeed better)

Rule 2 = Protect the Milk Supply!

Rule 3 = Find and FIX the problem.

More Than One Way to Provide More Than One Way to Provide Medically Necessary SupplementMedically Necessary Supplement

““M” # 4: Matching Counsel to M” # 4: Matching Counsel to Natural Laws Natural Laws

1. Must agree with normal and individual mammalian physiology/behavior.

2. Must conform to natural laws.3. Interventions should be medically

indicated and appropriate.4. Interventions should be designed to result

in eventual successful BF.5. Professionals must see the value of both

breastfeeding and breast milk. Help mother match natural laws to her individual situation to succeed.

Keep mom and baby together! Keep mom and baby together! Rooming-InRooming-In

Mothers who room in and care for their babies 24 hours/day have babies that are better breastfeeders, are less disorganized, cry and startle less frequently, and feed more frequently than babies cared for in central nurseries.

Ten Steps to Ten Steps to Successful BreastfeedingSuccessful Breastfeeding

8. Encourage breastfeeding on demand. Whose demand?

Feeding CuesFeeding Cues

The baby may exhibit these cuescues

several times in 20 to 30 minutes. If no response may go back to sleep-If no response may go back to sleep-

which equals a missed feeding which equals a missed feeding opportunity opportunity

Infants who have had delayed feedsdelayed feeds due to missed feeding cues often have difficulty latchingdifficulty latching on subsequent feeds

Crying is a Crying is a late feeding cue late feeding cue

Early cues have been missed.Infant now in disorganized state. Tongue retracts with crying.Important to teach parent feeding cues as often they think crying is the feeding cueWhen do nurses notice feeding cues in the nursery?

Nipple Confusion vs PreferenceNipple Confusion vs Preference

Several theoriestheories on why some infants have difficulty with breastfeeding after bottles/pacifiers FlowFlow preference PalatalPalatal super/stimulation by nipple Confusion in tonguetongue movement Reduced milk supplymilk supply from pacifier vs

breast sucking. Difference between shapeshape of mom’s

nipple and bottle nipple.

Practice on the right piece of Practice on the right piece of equipmentequipment

Nutritive vs Non-Nutritive Nutritive vs Non-Nutritive Suckling.Suckling.

Non-nutritive (pretending)Non-nutritive (pretending) Rapid, choppy. Vertical motion

(chewing/munching) Little swallowing

Nutritive (drinking)Nutritive (drinking) Slow, rhythmic, Suck/pause Wide jaw angle Swallowing

You Can’t MAKE a Baby You Can’t MAKE a Baby Breastfeed. COAX!Breastfeed. COAX!

Promote flexion. Pay attention to cues/maturity. Oral stimulation – encourage rooting. Skin to skin. Rooming in. Minimize distractions. (JOGNN Nov/Dec ’06)

Stabilize both breast and head. Appropriate supplementation while

learning. Be patient. Don’t push or pull jaw

down.

““M” #M” #5: Money!!5: Money!!

If 90% of US families could comply with medical breastfeeding recommendations for 6 months, the US would save $13 billion/yr and prevent an excess of 911 deaths. $10.5 billion with 80% compliance.

Bartick, and Reinhold. 2010 The burden of suboptimal breastfeeding in the United States: A Pediatric Cost Analysis Pediatrics.

Human Milk is VALUABLE STUFFHuman Milk is VALUABLE STUFF

Laws are Becoming More BF FriendlyLaws are Becoming More BF Friendly

17-15-25.   Right to breast feed.     The county legislative body may not prohibit a woman's breast feeding in any location where she otherwise may rightfully be, irrespective of whether the breast is uncovered during or incidental to the breast feeding. Enacted by Chapter 131, 1995 General Session

76-10-1229.5.   Breast feeding is not violation of this part.     A woman's breast feeding, including breast feeding in any location where the woman otherwise may rightfully be, does not under any circumstance constitute a violation of this part, irrespective of whether or not the breast is covered during or incidental to feeding. Enacted by Chapter 131, 1995 General Session

Working MothersWorking Mothers

55% of women with children under 3 yrs are in the work force.

New U.S. Dept. of Labor requirements for BF mothers. Signed into law Mar, 2010.

New laws and recommendationsNew laws and recommendations

Employers with >50 employees must allow women 15 min 2X/d to pump and provide a private place to do so (not a bathroom)

Aug. 2012 Affordable Care Act. Health insurance reform: health plans cover and eliminate cost sharing for breastfeeding support, supplies and counseling.

(Guidelines at: www.hrsa.gov/womensguidlines) (Interim final rule at http://

www.ofr.gov.OFRUpload?OFRData/2011-19684 PI.pdf)

Health Care Provider InformationHealth Care Provider Information

Beginning Aug 2012 breastfeeding support by a board certified lactation consultant, will be a “billable” service with no copay as long you have billing privileges.

Breastfeeding support products, such as pumps, must also be covered.

Billing Codes are Time-RelatedBilling Codes are Time-Related

Example: Intermountain has Charge 1 – consult

from 1 – 15 min. Charge 2 – consult from 16 – 30 min. Up

to Charge 4 = 1 hr or longer. Only one charge/day is allowable. ICD-9 and CPT codes should be

understood by your billing professionals Insurance will cover IBCLC coming to

your office to provide service.

Example of billing codeExample of billing code

Primary medical reason and up to 2 – 3 descriptions:

779.3 Neonatal Feeding Difficulty(initial) 750.0 Ankyloglossia 676.54 Suppressed milk supply I.E. This baby is not nursing because is

tongue tied and the mother has little milk. Then, charge based on how much time was

spent face to face (cannot charge for phone consults).

Excellent ResourcesExcellent Resources

BOOKS Medications & Mothers’ Milk 2011 (Hale) Drugs in Pregnancy & Lactation (Briggs &

Freeman) Making More Milk (West & Marasco) Breastfeeding: a Guide for the Medical

Profession 7th Ed. (Lawrence & Lawrence) Breastfeeding Management for the

Clinician (Walker) Immunobiology of Human Milk (Hanson)

Excellent ResourcesExcellent Resources

WEBSITESwww.bfmed.org (ABM Protocols)

http://newborns.stanford.edu (hand expression, etc)

www.toxnet.nlm.nih.gov (go to LactMed)

www.healthcare.gov/news/factsheets/womensprevention Affordable Care Act

http://www.lowmilksupply.orgwww.nursingmothers.com/handexpressionwww.breastfeedingoutlook.com)

Nationally Recognized Nationally Recognized GuidelinesGuidelines

Academy of Breastfeeding Medicine www.bfmed.org

“International professional organization which unites physicians to protect and support breastfeeding and human lactation.”

Multidisciplinary International (25 countries) $150/yr for physician to join

Receive invaluable newsletters Yearly international conference

Journals and OrganizationsJournals and Organizations

JOURNALSBreastfeeding Medicine (ABM)Journal of Human Lactation (ILCA)

Clinical Lactation (USLCA)ORGANIZATIONSWIC (each county)LLLI La Leche League International

HMBANA – Human Milk Bank Assoc of N.A.

Final Final “M”“M” = Make it Happen! = Make it Happen!

Breastfeeding is a team Breastfeeding is a team sport.sport.

For mother, baby and all support people

involved in their care. YOUYOU can make a difference