Breastfeeding Module for PostPartum Lesson 1

Student Objectives

Introduction

There are other serious players in this game. The World Health Organization and UNICEF recommend exclusive breastfeeding from birth for the first 4-6 months of life, and sustained breastfeeding together with adequate complementary foods up to 2 years of age or beyond. With all these recommendations from world renowned institutions, So why is it that the majority of mothers in most countries start giving their babies artificial feeds or drinks before 4 months, and many stop breastfeeding long before the child is 2 years old? We will explore the many barriers that make it difficult for mothers to continue breastfeeding.

It is shocking that nearly 1 in 4 new mothers in the US is back at work within just two weeks of having a new baby, according to a 2012 survey published in huffingtonpost. The U.S. is the only major developed country on the globe that offers no paid time off for new mothers, placing a terrible burden on these women, their families and the country at large. In the absence of paid time off, economic hardships forces new mothers out of their houses and back to the offices which is devastating for new mothers and their families — economically, emotionally and physically. Mothers who return to work so early are plagued with depression and less likely to breastfeed their children.

For successful breastfeeding, mothers and babies should be in close proximity where infants are allowed to nurse in an unrestricted fashion, and at their own time. This is called breastfeeding on demand; which simply means that the infant is able to nurse as often as he wants and as much as he wants, day and night around the clock. But in our fast-paced, highly mobile society, many new mothers have unrealistic expectations setting up breastfeeding schedules to conveniently fit into their structured routine. They quickly get frustrated due to the normal frequency and unpredictability of nursings and the fact that breastfeeding can not be delegated to anyone else.

The separation of mothers and babies due to employment poses a logistical obstacle to continued breastfeeding. Although many options exist for employed mothers to maintain lactation at the workplace ranging from on-site child care to expressing breast milk at the office, there’s no doubt that employment represents a societal barrier to successful and fulfilling breastfeeding experience.

Another barrier is self consciousness which is related to our society’s emphasis on the breast as a sensual organ rather than a source of infant nutrition. In American culture, breasts have often been regarded primarily as sexual objects, while their nurturing function has been downplayed. A study that analyzed data from a national public opinion survey conducted in 2001 found that only 43 percent of U.S. adults believed that women should have the right to breastfeed in public places. Embarrassment remains a formidable barrier to breastfeeding in the United States and is closely related to disapproval of breastfeeding in public. Many new nursing mothers are therefore hesitant to breastfeed in public because they are self conscious and also feel like they are making others feel uncomfortable. Breastfeeding mothers need to be confident enough and know how to nurse discreetly in public without feeling uncomfortable. Embarrassment about breastfeeding is not only limited to public settings, however. Women may find themselves excluded from social interactions when they are breastfeeding because others are reluctant to be in the same room while they breastfeed. For many women, the feeling of embarrassment restricts their activities and is cited as a reason for choosing to feed supplementary formula or to give up breastfeeding altogether.

Concern about insufficient milk supply is another frequently cited reason for early weaning of the infant. According to a national study on feeding practices, 50 percent of mothers cited insufficient milk supply as their reason for stopping breastfeeding. Having a poor milk supply can result from infrequent feeding or poor breastfeeding techniques, but lack of confidence in breastfeeding or not understanding the normal physiology of lactation can lead to the perception of an insufficient milk supply when in reality the quantity is enough to nurture the baby to good health. But most mothers have the perception that their breast milk is inadequate to provide the sole nutrition for their new baby. Mothers’ concerns about lactation and nutrition issues is one of the top reasons for stopping breastfeeding. Other reasons cited are “my baby began to bite” “my baby was waking up at night hungry” or “my baby lost interest in breast milk”.

There are other barriers as well; related to breast conditions and breast feeding difficulties which include sore nipples, engorged breasts, mastitis, leaking milk, pain, and failure to latch on by the infant. Women who encounter these problems early on are less likely to continue to breastfeed unless they get professional assistance. Research has found that mothers base their breastfeeding plans on previous experiences, and resolution of these problems may affect their future decisions about feeding.

Many maternity facilities throughout the world have adopted the “Baby Friendly” design which was initiated by the World Health Organization when it launched The International Code of Marketing of Breastmilk Substitutes in 1991. The WHO code seeks to protect breastfeeding by ensuring the ethical marketing of breast-milk substitutes by industry. One requirement for being “Baby Friendly” is that a facility shall not accept or distribute free samples of infant formula. This is geared to promote exclusive breastfeeding from the moment the infant is born. Despite all these efforts, even mothers who initiate breastfeeding satisfactorily, often start complementary feeds or stop breastfeeding within a few weeks after delivery. And that is why all health care workers including Nurse Assistants who care for women and children after the perinatal period have a key role to play in promoting and sustaining breastfeeding.

Many health workers lack the training required to deal effectively with breastfeeding issues. All healthcare workers who care for mothers and young children, in all countries, should therefore be trained in the skills needed to both support and protect breastfeeding.

Breast Engorgement

Normal breast fullness occurs when a mother’s breast milk first “comes in,” approximately 2 to 4 days after delivery. In addition to the breasts filling with milk, the breasts also experience significant venous and lymphatic congestion. The breasts fill with milk, increase in size, feel warm, and there is a feeling of pressure within the breasts. Milk flow is not affected. Normal fullness lasts for about 24 hours or so.

Engorgement is different from normal fullness. Breasts can become very hard, taut, and shiny, causing pain for the mother. Breast engorgement is often accompanied with a low-grade fever. Milk flow may be interrupted. When the breasts are so full, the baby has difficulty latching to the breast because the areola is hard and the nipple may be somewhat flattened. Breast engorgement will also suppress milk production. As a result, it is very important to prevent and/or relieve breast engorgement.

Breast Engorgement is caused by infrequent nursing, improper latch-on techniques, and ineffective sucking by the infant. Breast engorgement can occur when milk production increases, the alveoli are filled to capacity, and ineffective feedings fail to drain the breast. Pressure from the milk occludes the blood vessels surrounding the cells that secrete milk. Venous congestion results in edema which increases the pressure within the breast even more. The woman is predisposed to mastitis when this occurs because normal lymphatic drainage of toxins, cellular debris, and bacteria is interrupted. As a result of the pressure within the breast tissues, milk production is inhibited. Pressure on the lactiferous ductules and duct can prevent milk removal. Engorgement can occur in just the areola or body of the breast or may occur in both areas.

Engorgement is prevented by frequent, effective breast feeding determined by the baby’s need. The first breast should be drained before the second is offered. The baby should be allowed to nurse until satiated at each feeding.
If a mother is engorged and her baby is having difficulty latching on, then she should address the problem using different techniques. To reduce swelling, the mother can apply cold compresses on her breasts for 15 minutes every hour or so between feedings. She can apply gel packs, chilled cabbage leaves, or bags of ice cubes or frozen vegetables such as peas or corn covered with a washcloth or towel to both breasts. Just before the mother feeds her baby, she can take a warm shower or apply warm compresses to her breasts. Warmth may encourage leaking of milk. She can also massage the breasts before feedings, attempting to encourage the “let-down” of milk. This would allow her to express some milk before the feeding as well.

A breastfeeding mother can hand express or use a pump to help drain her breasts if they are engorged. If available, a breast pump works very well to relieve engorgement, and it is often more convenient than some other methods used to relieve engorgement. Removal of milk by these means will reduce the buildup of feedback inhibitor of lactation (FIL) that occurs when the breasts are engorged. It will also decrease pressure on the alveoli, ducts, lymph and blood vessels within the breast and help to relieve pain.

Frequent feeding, proper latching-on, and allowing the baby to drain one breast before moving to the next will help relieve engorgement. If at least one breast softens at each feeding, progress has been made. If the mother is experiencing a lot of pain, she should be encouraged to take an anti-inflammatory pain medication. Note that engorgement that occurs when the mother’s milk first comes in will resolve after a few days. Engorgement that occurs with missed feedings will resolve as feedings become more regular or as the breasts adjust their supply to the baby’s reduced milk demand. A visit by a lactation consultant is helpful to any breastfeeding mother, and is especially welcome when problems such as breast engorgement or flat, inverted, or sore nipples are present.

Sore Nipples 
Sore nipples caused by heightened sensitivity can occur from the 3rd to 6th postpartum days. They are usually relieved as the volume of milk increases and nipple flexibility improves. The pain may occur when the baby latches on and be relieved when let-down occurs and milk is ejected. Pain that occurs throughout a feeding can be caused by a poor latch, fissures or cracks, blisters, infection, or nipple vasospasm. Preventing sore nipples is the best intervention.  The most common cause of sore and cracked nipples is a poor latch. A good latch is one in which the baby’s mouth covers the nipple and part of the areola, with signs that a transfer of milk is occurring. The baby will be satisfied and the mother will most likely avoid sore nipples. If only the nipple is in the baby’s mouth, the nipple will become sore very quickly. Furthermore, the baby will receive a minimum amount of milk because he or she is not able to compress the ducts properly. If the latch is not corrected, the nipples can become cracked in a short time and bleeding can occur.

Both mother and baby should be comfortable and well supported while nursing. The baby’s head and body should be supported so that it doesn’t slide or fall and pull on the nipple and causing damage and pain. To promote a good latch, it is important that the mother holds her breast in a way that allows the baby to touch the breast with the chin first. The baby’s body should be supported in straight alignment with its shoulders and buttocks. In this way, the baby is encouraged to open the mouth widely to take in the nipple and part of the areola. It is normal for the latch-on to be asymmetrical with more areola in the lower jaw than the upper. However, a centered latch is also appropriate. The comfort of the mother and efficient milk transfer is the most important result. Even with a good latch, it is normal for the woman’s nipples to be a little sore at the beginning of a feeding when she first starts to breastfeed. This soreness should not last through the entire session of nursing and should resolve after about 1 week of breastfeeding.

Pain that continues throughout the feeding or goes beyond the first week of nursing, however, is not normal. When nipple pain is present, assess the latch to see if it is efficient. Correct the position of the mother, baby, and the way in which the mother holds her breast as needed. Silicone nipple shields or gel dressings may be helpful in some situations with the supervision of a lactation consultant. It is helpful to have the baby start breastfeeding on the nipple that is less sore, which promotes milk flow on the opposite breast at each feeding. Using a different nursing position for each feeding can also help alleviate soreness and promote healing.

Make sure that the mother is not using soap to clean her nipples. The use of soap removes the natural oils that lubricate the nipple. She can rinse the nipple with water after a feeding and then rub breast milk onto the areola and nipple. Breast milk is full of antibodies and promotes healing of the nipples. If nipples are cracked or bleeding, breast shells can be worn inside a bra to prevent the fabric from further irritating the nipple. Some women wear breast pads inside their bras to prevent leakage of milk through outside clothing. Plastic liners should not be used, and wet breast pads need to be changed frequently so that the moisture is not retained. Lanolin that is appropriate for breastfeeding mothers can also be rubbed onto the nipples and areola. The lanolin is soothing and promotes healing. Air-drying nipples after a feeding, especially after breast milk is rubbed onto them, is also helpful for promoting healing of sore nipples.

Plugged Milk Ducts
Although a plug usually involves only one duct, it can still be painful. A hard lump appears in the breast, and the lump is usually accompanied by pain at the site. The new mother who has a plugged milk duct, however, does not have the fever that is associated with breast engorgement. A white spot may be seen on the nipple of the affected breast. This is a bleb blocking a nipple pore, which must be opened with a sterile needle to unplug the duct. Plugged ducts are usually caused by the inadequate removal of milk due to pressure on the breast, ineffective suckling by the baby, or skipped feedings. Plugged ducts can occur at any time during the breastfeeding experience.

Plugged ducts need to be treated immediately to prevent mastitis. When the breastfeeding mother experiences a plugged duct, she should immediately apply warm compresses over the site before each feeding and have the baby nurse from the affected breast first. The purpose is to empty the breast, specifically the affected milk duct, and it usually takes a few feedings before she feels the lump begin to disappear. The mother needs to feed frequently and to massage her breast during the feeding. If the mother begins to develop a fever and flu-like symptoms or the baby refuses to nurse on the breast, she needs to contact her healthcare provider immediately because these are symptoms of mastitis. Plugged milk ducts do not always cause mastitis, but if they are not dealt with aggressively, the risk of mastitis increases.

MASTITIS

Mastitis is a breast infection caused by the bacteria Staphylococcus aureus and usually occurs in the first 3 to 4 weeks postpartum or after a sudden change in breastfeeding behavior. Bacteria can enter through cracked nipples caused by improper latch-on during breastfeeding. Mastitis can also develop due to blocked milk ducts and milk stasis in breastfeeding women. Blocked milk ducts and milk stasis occurs as a result of improper latching and inadequate breast emptying. The mother with mastitis will have a sudden onset of flu-like symptoms. Not only does mastitis cause localized pain and inflammation of a hard lump on the breast, it also causes:

• A fever of 100.4° F or higher
• Red streaks on the affected breast leading towards the axilla
• Body aches
• Higher sodium level in milk, baby may reject salty taste
• Chills

When a woman is breastfeeding, she needs to contact her healthcare provider as soon as she begins to experience these symptoms. The most common organism involved is Staphylococcus aureus. If antibiotics are started early with the onset of these symptoms, mastitis begins to resolve in 24 to 48 hours. The mother must take the entire dose of the antibiotics as prescribed, usually for 10 days. Noncompliance with antibiotic therapy for mastitis can contribute to the formation of a breast abscess. Mastitis usually resolves quickly as long as patients continue to breastfeed or pump regularly. To prevent mastitis, it is crucial that postpartum caregivers teach breastfeeding patients proper latch techniques.
In addition to antibiotic treatment, other important interventions for mastitis include:

• Getting appropriate bed rest
• Wearing a supportive bra
• Draining of milk from the affected breast
• Taking an analgesic/antipyretic such as acetaminophen
• Applying warm compresses
• Taking a nonsteroidal anti-inflammatory such as ibuprofen
• Increasing fluid intake

It is important to breastfeed every 2 to 3 hours on the affected breast to promote draining of the breast. If the breastfeeding is too painful for the mother, she needs to use a breast pump to drain the breast. In the past, women were often told to stop breastfeeding when they got mastitis, but this made the problem worse. The breasts would become engorged, and the mother would experience even more pain. The following factors can predispose a new mother to mastitis:

• Nipple trauma involving cracked and/or bleeding nipples
• Poor hand washing by the mother
• Breast engorgement
• Plugged milk ducts
• Wearing underwire bras
• Inadequate draining of the breasts
• Missed feedings

The breastfeeding mother should be aware of ways to avoid all of these factors so that she can prevent mastitis. Mastitis can make the mother very ill and can lead to breast abscesses. The breastfeeding mother should be taught about the symptoms of mastitis before she is discharged from the hospital. She must report symptoms to a healthcare professional as soon as possible to prevent further complications.

Flat and Inverted Nipples

A small percentage of women have flat or inverted nipples. Both flat and inverted nipples are a concern for women who want to breastfeed. In the past, women were encouraged to prepare their nipples during pregnancy to promote eversion of the flat and/or inverted nipples. Research has demonstrated that these practices do not help and may put too much emphasis on whether the woman can breastfeed successfully.  There are various techniques that can help the nipple become more prominent prior to breastfeeding. A lactation consultant should evaluate the mother’s nipples and suggest the best technique to use. Immediately prior to breastfeeding her baby, a mother with flat nipples can apply a cold washcloth to her nipple. A mother can also roll her nipples between her fingertips to help her nipples become more prominent before trying to put her baby to the breast. Gentle pressure with the hand can be used to evert the nipple. Mothers should place their thumb on top of the areola, about a 1 1/2 to 2 inches behind the nipple. Fingers should be placed the same distance underneath the areola. The mother should then gently push back into her chest, which will hopefully cause the nipple to become more prominent. The most important factor for a proper latch with any type of nipple is to be sure that the baby has grasped the proper amount of areola along with the nipple. Then, when suckling starts, the nipple can be drawn forward during the feeding, and the resting length of the nipple is doubled.

A breast pump can be used before a feeding to help pull out the nipple. Once the nipple is pulled outward, the breast pump is detached, and the baby is put to breast immediately. Leakage of colostrum or milk on the nipple from use of the breast pump usually increases the baby’s interest in latching onto the areola. Breast shells may be helpful to promote eversion. They can be worn prenatally or in the postpartum period. Mothers should be instructed to put breast shells in their bras 30 minutes prior to breastfeeding, or they can wear them in their bras all day in between feedings. Breast shells need to be taken out at night or while napping so that they do not cause obstruction of any lactiferous ducts. The breast shells need to be washed with soap and water and kept dry and clean. It is also important that the woman’s nipples fit through the hole in the base of the shell and that the shell is not too tight over the areola. There are syringe-like devises available to apply suction to the nipple. The mother applies suction to her level of comfort to evert the nipple prior to feeding and several times a day. At this time there is no available research on these devices and their effectiveness or potential harm. Nipple confusion can especially be a problem for women with inverted nipples.

Milk Supply

Even though a breastfeeding mother has an adequate milk supply to feed her baby, she may be concerned that this is not the case. A breastfeeding mother cannot actually see how much milk her newborn or infant is drinking. It may appear that her baby is not gaining enough weight if she compares her baby to one who is bottle-fed. The baby, however, is most likely getting enough milk if:

• The baby has a good latch when nursing
• Audible swallowing is heard
• The baby is allowed to feed to satiety on demand

The baby’s elimination pattern is also one of the most important indicators of whether he or she is getting enough milk.

Indicators of Sufficient Intake are
Age    Voids    Stools
1 day        1         1 black meconium
2 days    2-3      1-2 greenish black
3 days    3-4      3-4 greenish-yellow
4 days    4-10    4-10 yellow seedy

Nurses and Nurse Assistants should observe how the mother positions the baby and whether the baby latches onto the breast correctly and if audible swallowing can be heard with the feeding. It is also important to assess how often a mother feeds her baby. Mothers should breastfeed 8 to 12 times in a 24 hour period to promote an adequate milk supply until the milk supply is well established. Prior to discharge from the hospital, it is essential that the breastfeeding mother know how to assess if her baby is getting enough milk. Healthcare providers should provide information about the normal amount of wet and soiled diapers as an indicator of adequate milk supply and should discuss symptoms of dehydration. Ideally, the breastfeeding mother will be seen a few days after discharge. If she is having problems, a lactation consultant should assess her breastfeeding technique.

In conclusion; breast engorgement is a problem that can be helped by expression of milk, regular breastfeeding, and adequate drainage of each breast. Prevention of sore nipples is most important and can be accomplished with the baby latching onto the nipple correctly. Mothers can promote the eversion of flat or inverted nipples with several techniques, including applying a cold washcloth or suction to the nipple or rolling the nipple between the fingertips. Any mother with a problem associated with breastfeeding can benefit from evaluation by a lactation consultant.