National University of Rwanda Family and Community Medicine

Breastfeeding Counseling
KABERA Ren, MD PGY IV Resident Family and Community Medicine National University of Rwanda

Plan
Anatomy Physiology BF advantages and disadvantages Principles and techniques of BF BF and Birth control Unhealthy environment BF challenges Weaning References

Anatomy

Anatomy
1. Breast Size

Depends on amount of fat in breast Not related to making milk One breast often different than the other

2. During Pregnancy

Breasts get larger Veins show more Area around the nipple darkens

Anatomy
Areola Darker skin around nipple Visual target for baby Size & color differ for every woman Larger & darker during pregnancy

Anatomy
Montgomery Glands

Small bumps on areola Protects nipple from dryness Scent helps baby find breast

Anatomy
Milk Ducts

Carry milk from the alveoli through the nipple

Alveoli

Grape-like clusters where milk is made

Anatomy
Nipples Muscles & nerves 4-18 openings Change during pregnancy & after childbirth Size/shape No need to prepare nipples

Types of nipples
Everted: Sticks out at rest, and more when touched

Types of nipples
Flat nipple : Flat at rest and when touched

Types of nipples
Inverted Nipple: Drawn inward dimpled at rest and when touched

Types of nipples
Wide or non-stretchable May not reach back of babys mouth Hard for a newborn to latch-on May need a breast pump to express milk

Physiology
The mammary glands :Their role is to provide nourishment for the newborn and to transfer antibodies from mother to infant. At the end of gestation, each breast will have gained approximately 400 g.

Milk production
Three important breastfeeding hormones are: Progesterone Prolactin Oxytocin

Physiology
Estrogen is responsible for the growth of ductular tissue and alveolar budding. Progesterone is required for optimal maturation of the alveolar glands. Glandular stem cells undergo differentiation into secretory and myoepithelial cells under the influence of prolactin, growth hormone, insulin, cortisol, and an epithelial growth factor.

Physiology
Prolactin is an necessary hormone for milk production, but lactogenesis also requires a low estrogen environment. Prolactin levels continue to rise as pregnancy advances, placental sex steroids block prolactin-induced secretory activity of the glandular epithelium. Sex steroids and prolactin are synergistic in mammogenesis but antagonistic in galactopoiesis. Lactation is not initiated until plasma estrogens, progesterone, and human placental lactogen (hPL) fall after delivery. Oxytocin Makes milk flow out of breast (Milk Ejection Reflex)

Physiology
1. An intact hypothalamic-pituitary axis is essential to the initiation and maintenance of lactation. 2. Lactation can be divided into 3 stages: mammogenesis, or mammary growth and development lactogenesis, or initiation of milk secretion galactopoiesis, or maintenance of established milk secretion

Physiology
Size of a womans breasts does not affect overall milk production Colostrum is a Thick, yellow milk produced in Last 3 months of pregnancy & after deliver First Immunization Colostrum changes to mature milk 2nd to 5th day after birth Transitional milk (takes about 1-2 weeks) Mature milk at beginning : Bluish and watery High in milk sugar (lactose) Low in fat Sometimes called foremilk

Physiology
Towards the end of the feeding, breastmilk is: Thicker, like cream Higher in fat, lower in milk sugar Higher in calories (energy) Sometimes called hindmilk Needed for growth

Foremilk and hindmilk

BF Advantages
For the Mother Breastfeeding is convenient, economical, and emotionally satisfying to most women. It helps to contract the uterus and accelerates the process of uterine involution in the postpartum period, including decreased maternal blood loss. It promotes mother-infant bonding and self-confidence and improves maternal tolerance to stress through an oxytocinassociated antifight/fight response. Maternal gastrointestinal motility and absorption are enhanced. Ovulatory cycles are delayed with nonsupplemented breastfeeding. According to epidemiologic studies, breastfeeding may help to protect against premenopausal cancer and ovarian cancer.

BF disadvantages
Regular nursing restricts activities and may be perceived by some mothers as an inconvenience. Twins can be nursed successfully, but few women are prepared for the first weeks of almost continual feeding. Difficulties such as nipple tenderness and mastitis may develop. Compared with nonlactating women, breastfeeding women have a significant decrease (mean, 6.5%) in bone mineral content at 6 months postpartum, but there is "catch-up" remineralization after weaning.

BF advantages
For the Infant 1. Breast milk is digestible, of ideal composition, available at the right temperature and the right time, and free of bacterial contamination. 2. decreased incidence : diarrhea, lower respiratory tract infection, otitis media, pneumonia, urinary tract infections, necrotizing enterocolitis, invasive bacterial infection, and sudden infant death.

BF advantages
Breastfed infants may also have a decreased risk of developing insulin-dependent diabetes, Crohn's disease, ulcerative colitis, lymphoma, and allergic diseases later in life. Breastfed infants are also less likely to become obese as neonates and adolescents. Suckling promotes infant-mother bonding. Cognitive development and intelligence may be improved.

BF Disadvantages and CI
Absolute contraindications to breastfeeding street drugs or excess alcohol human T-cell leukemia virus type 1 breast cancer active herpes simplex infection of the breast active pulmonary tuberculosis in the mother galactosemia in the infant maternal intake of cancer chemotherapeutic agents or certain other drugs.

BF disadvantages and CI
Breastfeeding is not usually possible for weak, ill, or very premature infants or for infants with cleft palate, choanal atresia, or phenylketonuria Human immunodeficiency virus (HIV) infection in the is not a contraindication in Rwanda to breastfeeding. Breastfeeding is a mode of HIV transmission. 15%

Principles & Techniques Of BF

Infants and mothers who are able to initiate breastfeeding within 1-2 hours of delivery are more successful than those whose initial interactions are delayed for several hours The initial feeding should last 5 minutes at each breast in order to condition the let-down reflex. At first, the frequency of feedings may be very irregular (810 times a day), but after 1-2 weeks a fairly regular 4- to 6-hour pattern will emerge

Ct
The baby should nurse at both breasts at each feeding, because overfilling of the breasts is the main deterrent to the maintenance of milk secretion increase discomfort due to engorgement Mother to be taught to empty the breasts after each feeding The use of supplementary formula or other food during the first 6-8 weeks of breastfeeding can interfere with lactation and should be avoided except when absolutely necessary.

Ct
The introduction of an artificial nipple, which requires a different sucking mechanism, will weaken the sucking reflex required for breastfeeding. Other fluids may be given by spoon or dropper rather than by bottle.

Ct
In preparing to nurse, the mother should wash her hands with soap and water, clean her nipples and breasts with water, and assume a comfortable position, preferably in a rocking or upright chair with the infant and mother chest-to-chest With time, mom and baby will find the position that is best for them

Position
Cross-Cradle Hold
Side-lying hold In early weeks When babys neck needs more support When mother needs to support her breast Can move to cradle hold after baby has latched on

Position
Clutch Hold(football)
After c-section Premature infants Mothers with large breasts Mothers can see babys mouth open wide & help with latch

Position
Cradle Hold
Good position for older babies after breastfeeding is going well.

Position
Side-lying hold
When mother needs rest Avoid in waterbeds or fluffy blankets/comforters Can start in cradle hold & slowly lower to side-lying position

BF procedure
Allow the normal newborn to nurse at each breast on demand or approximately every 3-4 hours, for 5 minutes per breast per feeding the first day. Over the next few days, gradually increase feeding time to initiate the let-down reflex, but do not exceed 10-15 minutes per breast. Suckling for longer than 15 minutes may cause maceration and cracking of the nipples and thus lead to mastitis.

BF procedure
Stimulating the cheek or lateral angle of the baby's mouth should precipitate a reflex turn to the nipple and opening of the mouth. The infant is brought firmly to the breast and the nipple and areola are placed into the mouth as far as the nipple-areola line. Slight negative pressure holds the teat in place and milk is obtained with a peristaltic motion of the tongue. Compressing the periareolar area and expressing a small amount of colostrum or milk for the baby to taste may stimulate the baby to nurse.

BF procedure
Try to keep the baby awake by moving or patting, but do not snap its feet, work its jaw, push its head, or press its cheeks. Before removing the infant from the breast, gently open its mouth by lifting the outer border of the upper lip to break the suction. After nursing, gently wipe the nipples with water and dry them.

BF procedure
Nipple Feeding versus Breastfeeding Lack of constant pain Chin touching breast Cheeks rounded Nipple may come out longer, not pinched or discolored Lips curled outward Nostrils barely touch breast (if at all) Babys swallows can be heard Breasts are softer & feel lighter after feeding

Signs Breastfeeding is Going Well

Weight gain Babies lose at first - regain by 10-14 days

Gain 1.3 - 3 lbs over birth wt by 1 month Gain 6-12 ozs per week during second month, and more slowly after that Babies usually double their birth weight by 6 months & triple by 1 year

Ct
Growth Spurts Increase in the number of times to breastfeed Adequate output

BF and Birth control

Non hormonal methods:
Barrier Methods Spermicides IUDs (intrauterine device) Sterilization LAM (Lactational Amenorrhea Method) <6 mo Natural Family Planning

BF and birth control

Hormonal methods Progestin
Started before baby is six weeks old Dose is too high Mother does not have a good milk supply (The Mini-pill ,Depo-Provera ,Progestin IUDs ,The Morning After Pill)

BF and birth control

Estrogen DO NOT use until baby is at least 6 months old Estrogen often reduces milk supply (The Pill ,The Patch, Vaginal Contraceptive Ring)

Unhealthy environments
Alcohol :
Equal amounts in breastmilk as in mothers blood No more than 1 drink per day: 148 cc of wine, 355 cc of beer, 44 cc ounces of liquor

Unhealthy environment
Smoking

Colds Ear infections Asthma Higher risk of Sudden Infant Death Syndrome (SIDS)

If not stopped Smoke after breastfeeding and outside , Change/Remove clothes after smoking

Unhealthy environment
Illegal drugs : Cocaine

BF challenges

Twins Premature baby Premature twins Sick baby Baby with other medical problems Mother with diabetes Mother who is sick

Methods of expressing milk

Hand expression Manual pumps Battery operated pumps Semi-automatic pumps Personal use electric pumps Hospital grade electric pumps

Weaning
The process of substituting other liquids or food for the mother's milk When fully weaned, a child no longer receives any breastmilk Begins when baby is fed anything other than breastmilk Most think of weaning as stopping breastfeeding Once mothers start giving formula They breastfeed less & stop sooner

Weaning
Around world mothers breastfeed up to 3 yrs. In Rwanda most mothers wean by 6 months, often begins at home Some babies wean themselves If mother decides to wean before 1st birthday should give formula

References
Current Obstetric & Gynecologic Diagnosis & Treatment - 9th Ed. (2003).The Normal Puerperium - Kim Lipscomb, MD, & Miles J. Novy, MD California WIC breastfeeding peer counseling program. Ten steps to successful breastfeeding,WHO/UNICEF joint statement 1989 Breastfeeding as a Public Health Issue: Planning Promotional Campaigns. Ted Greiner La Leche League

The end

Thank you