PHILIPPINE SOCIETY OF NEWBORN MEDICINE

NRPh+
BREASTFEEDING MODULE (SCORPIO)

STATION NO. 1: How Milk Gets from the BREAST to BABY

Aim: To understand breastfeeding anatomy and lactation physiology and how this relates
to effective breastfeeding.

Objectives: At the end of Station 1, the participants are be able to:

1. Explain mechanism of effective breast milk production, let-down, and suckling
2. Identify major factors that promote and inhibit breast milk production

Teaching method:
- Interactive station that uses tell-show-do-feedback to ensure participation of participants

• Picture mat of brain & breast is laid out on the table

I. Identify parts of the brain, breast

Tell & Show: 5mins

- Participants are asked to label parts of the brain, breast, uterus

- Facilitator discusses the following:

A. Parts of the brain:

- Hypothalamus: prolactin inhibiting hormone (dopamine)
- Anterior pituitary gland: prolactin
- Posterior pituitary gland: oxytocin

b. Anatomy of the breast:

a. myoepithelial cells contract due to oxytocin
b. milk producing cells secrete milk because of prolactin
c. alveoli are the small sacs composed of milk secreting cells
d. lactiferous/milk ducts carry the milk to the outside
e. nipple is surrounded by areola has an average of 9 milk ducts passing to the outside,
and contains muscle nerves and fibres
f. areola houses the Montgomery’s glands from which an oily fluid is secreted. This
produces the mothers’ unique scent that attracts her baby to her breast
g. Fat & supporting tissue give the breast its size and shape
h. areola
i. nerve endings

c. Identify ovaries
- Progesterone
- Estrogen
II. HORMONAL CONTROL OF MILK PRODUCTION

Tell & Show: 5mins

- Interactive discussion between facilitator & participants (Using flashcards)

A. Pregnancy priming for milk production:
- hormones of pregnancy (estrogen & progesterone) helps breast to develop and grow in
size (Lactogenesis I)
- ductal growth is regulated by estrogen
- alveolar/acini development requires progesterone
- birth reduces level of estrogen & progesterone; Unang Yakap & early latching result to
prolactin surge & milk production

Use Diagram with newborn suckling mother’s breast (as flashcard)

- Effective suckling of the baby at the breast triggers the posterior lobe to secrete oxytocin for
milk let-down
- Positive thoughts, no doubt, no anxiety, positive support from husband, family members,
hospital staff & positive environment also trigger oxytocin release for milk let-down
- Once the breast is emptied, the anterior lobe of the pituitary will secrete prolactin for
production of milk for the next feeding

B. PROLACTIN
- blood levels increase during pregnancy, stimulating the growth and development of
breast tissue in preparation for milk production
- triggers the cells of the alveoli to secret milk
- hormone that makes the alveoli produce milk
- under the influence of prolactin, breasts start to make large quantities of milk
- usually takes 30-40 hours after birth before large volume of milk is produced
- colostrum present when baby is born
- infant attaches & stimulates nerve endings in areola, sends signal to hypothalamus to
reduce prolactin inhibiting factor, hence prolactin release
- suckling of baby at the breast increases and stimulates milk production by the alveoli
(“supply and demand” feedback mechanism)
- night time feedings are important because more prolactin is produced at night
- prolactin induces relaxation in mothers & promotes sleep

C. OXYTOCIN
- causes muscle cells around the alveoli to contract & makes milk flow down the ducts
(MILK EJECTION REFLEX/OXYTOCIN REFLEX/LET DOWN REFLEX)
- suckling of baby on mother’s breast stimulates the “let down reflex”
 - oxytocin also induces a state of calm and reduces stress

D. FEEDBACK INHIBITOR OF LACTATION (FIL)

- polypeptide contained in breastmilk that can reduce breastmilk production
- when one breast is not drained efficiently (e.g. delayed initiation of breastfeeding,
introduction of milk formula, timed feeding, breast milk not expressed every 2-3 hours when
baby is separated from mother) this causes build up of FIL and stops alveolar cells from
secreting more milk
- EMPHASIZE: empty one breast before offering the second; amount of milk produced
depends on how much is removed
- It is also important that the baby will get the hindmilk which has higher fat content

III. FACTORS THAT PROMOTE AND INHIBIT LACTATION

Tell, Show: 10 mins

- Participants are handed out metacards & categorize which of the factors PROMOTE or
INHIBIT milk production
- Facilitator provides reinforcement or correction to participants

A. FACTORS THAT PROMOTE MILK PRODUCTION

1. Antenatal education
Women before giving birth should be emotionally and psychologically prepared
because breastfeeding journey may be difficult for some. They need love,
support and understanding. In their prenatal check-up or in mothers’ class , they
need to receive adequate information about breastfeeding: the benefits of
breastfeeding, dangers of milk formula, the feeding reflexes, correct position and
attachment , how to collect and store breastmilk if baby will be separated from
mothers
2. Early skin to skin contact
Increase rate of breastfeeding success
3. Breastfeed in the first hour
this is the Unang Yakap , sensitive on feeding reflexes
4. Keep mother and baby together
The mother can immediately recognize the feeding reflexes and needs of her
baby
5. Show mother how to breastfeed
This should be hands-off technique, this boosts her confidence if she is doing it
on her own. We inform them when to feed their baby, what is the correct position
(in- line, closed, facing, supported), correct attachment – latching most of the areola,
chin touching the breast, no clicking sound, no pain, how to collect and store
breast milk.
6. Do not give supplement
No water (Breast milk is 88.1% water, the rest are nutrients), no milk formula
Supplements will cause overdistenstion of acini/alveoli and that
will stop milk supply
7. Breastfeed on demand
 Breastfeeding is an infant-led feeding , the baby is the one
who will dictate the frequency, if she/he is hungry and duration of feeding
8. Do not limit the duration of feeding
Unlimited feeding as long as with feeding cues; the baby will let go off the breast
once he/she is full
9. Partner support
Enhances positive environment , making the mother happy and
relax; help the oxytocin reflex work
10. If mother & baby separated
Express the breasts regularly every 2-3 hours, not at
their convenient time to avoid the distention of alveoli/acini that would stop the
milk secretion.
11. Empty the first breast before offering the second
The production of milk would matter on how much the milk is removed; the
baby needs to receive the hind milk which has higher fat
12. Progestin-only oral contraceptives
Does not affect breast milk production

B. FACTORS THAT INHIBIT MILK PRODUCTION

1. Poor attachment
the breast will not be emptied well , result to engorgement nipple
pain, soreness , bleeding. The baby is always crying , hungry, with slow weight
gain
2. Infection
If the baby is separated from the mother , mother need to express breast
milk every 2-3 hours and store in freezer. If the mother has infection like cough,
colds , fever, she needs to do strict handwashing ,and wear mask, she can take
medicines. Medicines that are absolute contraindicated to breastfeeding are anti-
malignancy and radioisotopes.
3.Pain
Ask if the mother is comfortable or experiencing any pain. Give pain reliever if
there is pain from incision site. If there is pain from the nipple, please check the
position and attachment
4. Timed feeds
This will cause overdistention of alveoli/acini and this would stop milk
secretion
5. Cesarean section
Because of sedation and anesthesia drugs;
Health care providers can still perform Unang Yakap and early latching even the
mother is sedated
6. Separation mother & infant
If the breast is not emptied , there will be secretion of
Feedback inhibition of lactation (FIL) and this will stop milk production
7. Supplementary feeds with formula
Can cause overdistention of alveoli/acini that will stop the milk supply
8. Prelacteal feeds
Same as with #7
 9. Drugs in labour & post partum
Sedation, anesthesia drugs
10. Estrogen -
Containing oral contraceptives – reduces breast milk production

Do: 10 minutes
- The participants will be asked to explain how milk gets from the breast to the baby, mention
the promoting and inhibiting factors for breast milk production

Feedback: 10 minutes

RESOURCES:
1. Facilitator
2. Anatomical and physiological model of breastfeeding (infant, breast and brain picture)
3. Labels for anatomy and hormones
4. Picture of hormone levels in pregnancy and lactation
5. Picture of mother and baby with prompts for the ‘let-down’ down reflex, and
6. Labels for promoting and inhibiting factors
STATION NO. 2: ESTABLISHING EARLY AND EFFECTIVE BREASTFEEDING

Aim: That all participants are able to facilitate and support early and effective
breastfeeding for mothers and newborns

Objectives: At the end of station 2, the participants are able to:

1. Discuss the importance of skin to skin contact between mother & baby
2. Implement skin to skin contact and first breastfeeding
3. Recognize good attachment, positioning, and effective milk transfer
4. Demonstrate different breastfeeding positions and the C-hold
5. Understand breastfeeding in the low birth weight infants

Teaching method: Interactive session incorporating the concepts of tell, show, do, feedback

I. Skin to Skin Contact

TELL & SHOW: 5mins

- Benefits of skin to skin contact discussed in video
- Facilitator discusses the following key points as shown in the video:
- Full skin to skin contact between mother & newborn
- Newborn unclothed but back is covered with clean linen for thermoregulation
- Newborn is placed on mother’s abdomen or between the mothers’ breasts and allowed to
crawl towards mother’s breast (breast crawl)
- Newborn is positioned to allow proper airway (head tilted to one side)
- Precaution on newborn safety while on skin to skin contact; mother may embrace newborn
- Breathing pattern, circulation is observed during skin to skin contact

II. Skin to skin contact to First Successful Breastfeeding

TELL & Show: 5mins

- Video of Breast Crawl is shown

- Facilitator emphasizes the different phases a newborn goes through before the first successful
breastfeeding as follows:
1. Birth cry - intense crying immediately after birth
2. Relaxation - no activity of head, arms or body
3. Awakening - small thrusts of head up & down, side to side
4. Active - moves head & limbs without moving body, rooting
5. Crawling - pushing which moves body
6. Resting - rests with some activity, such as sucking on hands
7. Familiarization - infant has reached areola/nipple with mouth
8. Sucking - infant starts to suckle
9. Sleeping - infants has closed its eyes - moves head & limbs without moving body, rooting
• Without knowledge of these steps, health care personnel may interrupt these innate
behaviour contributing to delay in first successful breastfeeding

III. OPTIMAL ATTACHMENT & POSITIONING

TELL, Show: (5 mins)

- Pictures will be shown of attachment & positioning

- Participants will be asked to identify signs of good attachment and positioning through the
use of metacards

- Facilitator uses breast model and hand to demonstrate the signs of good attachment as
follows:
- (1) mouth wide open
- (2) lower lip turned outwards with a furrow below it
- (3) chin touching or almost touching the breast
- (4) more of the areola visible above the baby’s top lip than below the lower lip
- Facilitator uses baby doll to demonstrate good positioning as follows:
- (1) baby’s body should be straight, not bent or twisted
- (2) the baby should face the breast
- (3) baby’s body should be close to the mother
- (4) entire body, not just the head and neck should be supported

- Participants will be asked to identify incorrect signs of attachment & positioning via pictures

IV. Effective Milk Transfer

Tell & Show: (5 mins)

- Video of effective milk transfer is shown
- Discuss signs of effective milk transfer as follows:
- (1) baby takes slow, deep sucks, sometimes with pauses for a short time
- (2) you can see or hear the baby swallowing
- (3) baby’s cheeks are full and not drawn inward during a feed

V. Breastfeeding Positions

Tell-Show-Do: (10 mins)

- Facilitator introduces and demonstrates the different breastfeeding positions through picture
slides.
(Cradle, Cross-cradle, Side-lying, Underarm positions)

- Facilitator demonstrates the C-hold using the breast model as follows:

- 1. Place breast in the palm of the hand
- 2. Put the thumb on to of the breast
 - 3. Cup the fingers around the bottom of the breast
- 4. The hand should look like it is in the shape of the letter C
- 5. Keep the thumb and fingers behind the areola so they do not get in the way of the baby’s
mouth

- Facilitator uses a breast model, baby doll and asks for a volunteer to demonstrate the actual
breastfeeding positions. Facilitator also emphasises the C-hold.

VI. Recognition of Breastfeeding Cues

Tell-Show: (5mins)
- Facilitator demonstrates the different feeding cues using pictures
- Increase alertness, movements of arms and legs
- Mouthing
- Licking
- Tonguing
- Hand to mouth

VII. Breastfeeding the Low Birth Weight

Tell-Show: (3 mins)
- Facilitator mentions that stable LBW infants can do direct breastfeeding
- Pictures of breastfeeding LBW infants are shown

Do & Feedback: 7 mins

- Role Play:

RESOURCES:
1. Facilitator
2. Slides
3. Videos
4. Breast model
5. Baby doll
6. Metacards for attachment & positioning