Breastfeeding Tutorial

Question 1

When should we initiate breastfeeding? When should women breastfeed until?

Answer 1

• Within 1 hour of birth

Question 2

Why should mother breastfeed exclusively for the first 6 months?

Answer 2

• Breastfeed exclusively for the first 6 months (infant gut is quite permeable, if they ingest cow milk’s protein, the protein will tend to pass through the gut and go to the blood circulation, triggering non-IgE mediated allergy responses [eczema or asthma])
• Give nutrition and safe complimentary food after 6 months (iron and other nutrients will not be enough in breast milk after 6 months)
• Breastfeed up to 2 years

Question 3

What are the policies implemented in HA to increase breast feeding rate?

Answer 3

1. Have a written Infant Feeding Policy that is routinely communicated to all healthcare staff in the hospital
2. Provide orientation and training on the implementation of this policy to healthcare staff in accordance to their roles (i.e. cup feeding = prevent reliance on artificial teats = but baby may forget now to suckle)
3. Inform all pregnant women about the benefits and management of breastfeeding (1st AN visit, 20-29 wks, 30-38 wks)
4. Help mothers initiate an uninterrupted skin-to-skin contact with their infants for at least one hour soon after birth
5. Show mothers how to breastfeed and maintain lactation even if they should be separated from their infants (teach mother breast milk expression)
6. Encourage exclusive breastfeeding by not giving newborn food or drink other than breast milk unless medically indicated
7. Practice 24H rooming-in (learn to respond to baby’s needs)
8. Promote ‘baby-led feeding’ / ‘demand feeding’ (previously, recommendations were to feed baby every 3 hours, but now, it is recommended to recognise the baby’s feeding cues [increased activity, alert, try to suckle their own fingers]
9. Do not give artificial teats or pacifiers to breastfeeding infants (imprinting memory = easy to express milk [baby may clench their jaw and bite artificial teats])
10. Refer mothers to community breastfeeding support groups on discharge from hospital or clinic (mothers usually only stay in hospital for 48H after birth)
11. Respect and support mothers who made an informed choice not to breastfeed (teach them skills, i.e. if you lie the baby flat and feed by bottle, milk may travel to Eustachian tube = risk of developing otitis media)
12. Promote and support mother friendly care (promote natural birth, non-pharmacological pain-relief method) [pethidine, fentanyl may cause uncoordinated suckling of baby, worsened hand-to-mouth coordination, reflexes)
13. Encourage and facilitate staff members to continue breastfeeding when returning to work
14. Comply with International Code of Marketing of Breastmilk Substitutes of the World Health Organisation (no advertising of all breastmilk substitutes to the public)
15. Support mothers to breastfeed their infants in public areas of the hospital and provide baby care room when necessary

Question 4

What is the benefit of early skin-to-skin contact?

Answer 4

• Keep baby warm & calm (vasodilatory effect of oxytocin on mother’s chest = warm)
• Promote bonding
• Enhance immunity of baby (colonisation of maternal flora onto baby’s skin = better immunity = protect baby from hospital bacteria)
• Facilitate breastfeeding

Question 5

What are some non-pharmacological pain relief methods?

Answer 5

Transcutaneous electrical nerve stimulation (TENS)
- Inputs impulse, low voltage currents to stimulate endorphins production in mother during early-phase of labour
- Birth ball (encourage descent of foetal head through birth canal)
- Birth massage (teach husband)

Question 6

Describe the anatomy of the breast

Answer 6

Alveolar cell in charge of milk production. Surrounded by myoepithelial cell which is controlled by oxytocin stimulating contraction. Milk goes down lactiferous duct and stored in large lactiferous duct.

Question 7

What is the hormonal effect on sucking stimulation on breast?

Answer 7

If mother feels pain in her lower abdomen as baby is breastfeeding, let her know this may be good as her uterus is contracting, thus she loses less blood

Question 8

What is feedback inhibitor of lactation (FIL)?

Answer 8

Protein substance ‘FIL’ in breast milk inhibits milk production.

If milk is not removed and the breast is full, inhibitor decreases milk production.

1. To ensure plentiful milk production, make sure milk is removed from the breast efficiently
2. Baby’s suckling controls the prolactin production

MORE BREAST MILK REMOVAL + MORE SUCKLING = MORE MILK

Question 9

Why is colostrum important for a normal healthy full-term baby?

Answer 9

• Baby cannot tolerate large volume of milk
• Small colostrum feeding are appropriate for the small size of newborns stomach and are sufficient to prevent hypoglycemia
• Colostrum is thick and viscous
• Easy to manage while newborn learns to coordinate sucking, swallowing and breathing

Quantity of colostrum/milk increases

Question 10

Why is baby’s body weight not a good indicator to assess baby’s feeding during the first 10 days? What are other reliable signs?

Answer 10

• Baby’s body carries extra fluid & nutrients at birth
• Baby loses ~5-7% of their birth weight in the first few days (pass meconium & remove extra body fluid)
• Therefore, baby’s body weight is not a very good indicator to assess baby’s feeding during the first 10 days
• Reliable signs for adequate intake is to observe urine and stool (if baby’s poop is still meconium, dark green stool, the baby may not be fed enough, by day 5 should turn yellow)
• Optimal breastfeed babies regain birth weight at around 10 days

Question 11

How to encourage breastfeeding early?

Answer 11

• Start skin to skin contact right after birth
• Recognise baby’s early feeding cues
• Start feeding ASAP
• Responsive feeding
• 8-12 feeds/24 hours

Question 12

What are the key points of good position in breastfeeding the baby?

Answer 12

• Baby’s head and body in line
• Baby held close to mother’s body
• Baby’s whole body supported
• Baby able to tilt head back
• Nipple pointing to baby’s nose (ensure that baby is looking up)

Question 13

What are ways to ensure good attachment of baby’s mouth to the mother’s breast?

Answer 13

• Baby’s mouth is wide open
• Chin indenting the breast
• Lower lips turned outwards
• Rounded cheek
• Bottom lip touches breast well away from the base of nipple
• No pain for the mother

Question 14

What are some breast-related problems associated with breast-feeding?

Answer 14

1. Breast engorgement
2. Plugged ducts
3. Mastitis
4. Breast abscess

Question 15

Comparison of S/S of engorgement, plugged duct & mastitis

Answer 15

Question 16

What is the pathology?

Answer 16

Breast engorgement
- Shiny
- Inelastic
- Nipple is shortened due to engorgement
- Baby cannot take nipple well

Question 17

Management of breast engorgement

Answer 17

1. Proper positioning and latch on
2. Frequent feeding
3. Don’t skip feed, esp. in night time
4. Apply hot compress before feeding (only for a few minutes to bring oxytocin to alveolar cells)
5. Express milk to soften the areola before feeding
6. Take pain-killer
7. If engorgement persists after feeding, apply cold compress
8. Wear supportive bra

Question 18

What is the cause of plugged ducts? What are predisposing factors?

Answer 18

Cause:
1. Abundant milk supply
2. Breasts are not adequately drained

Predisposing factors:
1. Incomplete draining - skipped feeding, constrictive bra
2. Stress

Question 19

What is seen here?

Answer 19

Plugged ducts: there may be pain over the alveolus

Question 20

Symptoms of blocked duct and mastitis

Answer 20

Question 21

How are plugged ducts managed? What may happen if they are ignored or untreated?

Answer 21

Management:
1. Antibiotics not needed
2. Self-care measures: continue feeding, moist heat, massage, change position
3. Effective removal of milk

If ignored or untreated, may lead to mastitis

Question 22

What is mastitis? When does it most commonly occur? What may mastitis be accompanied by?

Answer 22

Question 23

What are predisposing factors of mastitis? What are the two principle causes?

Answer 23

Question 24

• What are the common infecting organisms involved in mastitis?
• What organisms are sometimes implicated?
• What may cause fungal mastitis?

Answer 24

• Commonest: Staph aureus & Staph albus
• Sometimes: E. coli & Streptococcus
• Fungal: Candida & Cryptococcus

Question 25

What is the pathology?

Answer 25

Mastitis - Reddish skin - Crust on nipple

Question 26

What is the management of mastitis?

Answer 26

1. **Supportive counselling**: Continue feeding, listen & support, clear guidance given 2. **Effective milk removal** - most essential part of treatment: by continuing breastfeeding or by expression / moist heat, massage, change position 3. **Antibiotic therapy needed when**: Sx are severe from the beginning / nipple fissure is visible / Sx do not improve after 12-24H or improved milk removal / cell & bacterial colony counts: culture indicates infection 4. **Symptomatic treatment**: Loose constrictive clothing, analgesic e.g. paracetamol, resting in bed with the infant is a useful way to increase the frequency of BF, thus improve milk removal / drink sufficient fluid

Question 27

Breast abscess: - When is it most common? - What is it a complication of?

Answer 27

- Breast abscess is commonest in the first 6 weeks postpartum, but may occur later - Complication of mastitis

Question 28

What is seen here?

Answer 28

Breast abscess: - Mass - Border of mass/lump can be felt - Shiny skin

Question 29

What is the management of breast abscess?

Answer 29

1. Drainage: - Small abscess = aspirate with needle under USG guided - Large abscess = I&D, let it heal from inside 2. Antibiotics 3. Self-care measure

Question 30

Route of drugs from mother to baby via breastmilk

Answer 30

Question 31

Suggested approach for prescribing to breast-feeding mothers

Answer 31

* Use medication only when indicated * Medication that is used for infants is safe during breastfeeding * It is not necessarily true that medication that is considered safe during pregnancy is safe during lactation

Question 32

- What % of maternal dose of drug reaches the baby in BF? - What substances should be avoided for BF mother?

Answer 32

Question 33

Choice of medication - Use drugs with

Answer 33