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How Obstetricians Can Best Support Breastfeeding Dyads: Antepartum, Intrapartum and Postpartum Pearls August 10, 2016 Lauren Hanley, MD, IBCLC, FACOG Department of Obstetrics and Gynecology Massachusetts General Hospital No conflicts of interest to disclose. * I was formula fed. This was recommended as optimal way to feed by my pediatrician in 1971. Objectives To review how Obstetricians can support women to achieve their breastfeeding goals during the following timeframes: -Antepartum/Prenatal -Intrapartum -Postpartum To review how and why Skin to Skin supports normal newborn physiology and enhances breastfeeding To review medication usage during lactation and resources to check safety To review available Resources Breastfeeding is a public health issue. Even in developed countries, infants who are not breastfed face higher risks of infectious and chronic diseases, and mothers who do not breastfeed face higher risks of cancer and metabolic disease. ACOG Recommendations The American College of Obstetricians and Gynecologists strongly encourages women to breastfeed and supports each woman’s right to breastfeed. The College recommends exclusive breastfeeding for the first 6 months of life, with continued breastfeeding as complementary foods are introduced through the infant’s first year of life, or longer as mutually desired by the woman and her infant. Committee Opinion No. 658 Photo: Massachusetts Breastfeeding Coalition Mother’s breastfeeding goals Baby friendly maternity care Supportive family and friends Informed medical providers Adequate leave, workplace support Breastfeeding success! Your care directly affects a woman’s breastfeeding success. Both observational and randomized trials demonstrate that routine health care practices can enable mothers to meet their infant feeding goals – or derail breastfeeding and increase health risks for mother and child. What is Baby Friendly? Global initiative of the WHO and UNICEF Implemented in the USA by “BFUSA” (designating body) Based on “The Ten Steps to Successful Breastfeeding: The Special Role of Maternity Services” 1989 Adherence to the Ten Steps decreases racial, ethnic, and sociocultural disparities in Breastfeeding Rates in the US. HP 2020 goal (births in BF hospital): 8.1%, we are at 18%!! The Ten Steps 1. Have a written breastfeeding policy. 2. Train all health care staff. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within one hour of birth. 5. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breastmilk, unless medically indicated.* 7. Practice rooming in - that is, allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10.Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. Breastfeeding Disparities Ever Breastfed 83 Breastfed at 6 months Breastfed at 12 months 83.9 83.2 82.4 71.5 66.4 65.6 55.8 51.4 42.3 32.8 35.3 32.6 27.9 16.9 Non-Hispanic white Non-Hispanic black 14.4 Hispanic Non-Hispanic Asian Non-Hispanic Hawaiian/Pacific Islander 28.8 17.9 Non-Hispanic American Indian or Alaskan Native Maternity Facilities in zip codes with more Black residents are less likely to provide Ten Steps Care 60% 46% 39% 28% 26% 13% Early initiation Limited use of Rooming in supplements >12.2% Black residents ≤12.2% Black Residents Lind et al (2014). MMWR Morb Mortal Wkly Rep 63(33): 725-8. The World Health Organization’s “Ten Steps to Successful Breastfeeding” should be integrated into maternity care to increase the likelihood that a woman achieves her personal breastfeeding goals. Committee Opinion No. 658 Maternity care directly affects a woman’s breastfeeding success FIGURE 1 Among women who initiated breastfeeding and intended to breastfeed for >2 months, percentage who stopped breastfeeding before 6 weeks according to the number of Baby-Friendly Hospital Initiative practices they experienced DiGirolamo, A. M. et al. Pediatrics 2008;122:S43-S49 Patient-Centered Care 60% of women do not meet THEIR OWN breastfeeding goals. CDC/FDA Infant Feeding Practices Survey II, 2008 Antepartum Education:Why is it important? • 1997 JHL study found that 23% of expectant mothers received counseling from OB. • 1998 JHL study associated antenatal advice associated with intent to BF (61% vs 35%). • 2007 Cochrane review: professional support was effective in prolonging any breastfeeding. • 2011 BMJ review:breastfeeding promotion interventions increased exclusive and any BF @ 4-6 wks & 6 mos. Antepartum Education: Is it happening? • 12/2013 Demirci J, Bogan D,Holland C et al. • Breastfeeding discussion @ initial OB visit • 172 recorded encounters • BF discussion @ 29% of visits for mean 39 sec. • CNM more likely to initiate discussion than OB residents. When should we discuss breastfeeding during prenatal care? As soon as possible! Unless there is a question of miscarriage During the breast exam Open ended questions Decisions are often made prior to pregnancy or in first trimester Open ended questions that may facilitate a discussion about feeding: Have you ever thought about how you will feed your baby? Are you interested in learning about why breastfeeding is the healthiest option for you and your baby? Do you have any family members or friends that breastfed their baby? What are your plans regarding work outside of the home after the birth? History/Anticipatory Guidance Breastfeeding History Other relevant medical/surgical history Involving partner/other family /social supports Review resources Did she breastfeed in the past? How long? Why did she wean? Classes, Hospital Support (Lactation, nursing, OB/CNM/pedi) Community Support Review hospital practices that will support breastfeeding History of Breast Injury or Surgery Reduction Mammoplasty Augmentation Mammoplasty Lumpectomy or Biopsy Especially if significant ducts or nerves are severed/removed Greatest concern are periareolar incisions Previous Treatment for Breast CA Hx of Trauma, Burns, or Chest Tube (childhood) Nipple Piercings with Infection or Scarring Percent breastfeeding at 6 weeks 80 70 73 54 60 41 35 40 20 9 0 Favors breast No preference Favors Formula Health care provider opinion Physicians Hospital Staff Send a clear message to patients: ‘I recommend breastfeeding.’ DiGirolamo et al. Birth 2003;30:94-100 Summary of Antenatal Education Discuss breastfeeding early and often Review benefits for mother and child Review practices in the hospital that will enhance success Rooming In, Feeding on Demand, Skin to Skin Unnecessary supplementation, Avoid pacifiers Support groups and Community Resources Review how to combine working and breastfeeding/ pumping and how to work with employers. Breastfeeding Friendly Office Posters/Art depicting breastfeeding throughout the office, multicultural women and children NO formula marketing/coupons Sign to remind patients that breastfeeding is welcomed in the waiting room Mother’s room for patients and staff Patient and Staff Education Community Based Resources/Printed materials Prenatal Classes • • • Families should receive noncommercial, accurate, and unbiased information so that they can make informed decisions about their health care. Obstetric care providers should be aware that personal experiences with infant feeding may affect their counseling. In addition, pervasive direct-to-consumer marketing of infant formula adversely affects patient and health care provider perception of the risks and benefits of breastfeeding. Committee Opinion No. 658 Step 4: Help mothers initiate breastfeeding within 1 hour of birth Skin-to-skin supports normal physiology of breastfeeding Contact in first hour of life, when infant is awake and alert, is a “critical period” for nursing success Step 4: Initiate feeding within one hour What about Cesarean Delivery? AAP Guidelines 2005, revised 2012 Healthy infants should be placed and remain in direct skin-to-skin contact with their mothers immediately after delivery until the first feeding is accomplished. Skin-to-skin supports normal physiology of breastfeeding Contact in first hour of life, when infant is awake and alert, is a “critical period” for nursing success Remember: a gown, blanket, or bra between baby and mother is NOT skin to skin! Cochrane Database Study, 2007, Moore et al. 30 studies, 1925 dyads, 29 RCT, diverse populations Improved infant glucose levels Improved rates at 1 & 4 months and total duration of breastfeeding Rooming in also increased duration Skin to skin improved temp and CV stability Improved maternal attachment No adverse effects Skin to Skin MGH Cesarean Section: February, 2014 started as a PDSA Tracking rates and working on documentation Staff / patient satisfaction Safety: “Speak Up” model Anesthesia, OB, Pedi “buy in” Discuss in preop huddle and postop debrief Clear drape Baby to chest after 5 minute APGAR TEAM effort Skin to Skin buttons for staff Actual Size of a Term Newborn’s Stomach Teaching tool for learning to understand the new baby’s needs www.massbreastfeeding.org What we do really matters! What is the usual protocol in the L&D unit for skin to skin? Change takes time, but introducing the idea and working with staff to accomplish this goal has excellent science behind it and makes a difference! Patient(s) are more satisfied when baby not “taken away” for weight, exam, injection, eye ointment etc. (MOM and BABY) Postpartum Considerations Where Providers lack confidence Peds/OB providers polled about where deficiencies lie: Referral services Returning to work/Pumping Low Milk Supply Breast Pain Teaching Basic Skills/Evaluating Latch Know when, and to whom, to refer – make use of lactation consultants. Taveras, E. M., R. Li, et al. (2004). Pediatrics 113(4): e283-90. What do I tell my patients? • Skin to skin at delivery, early initiation of breastfeeding and not using supplementation without a medical indication can be helpful in improving breastfeeding success • What happens in the hospital matters to helping mother’s meet their intended breastfeeding goals. Hospital Practices Tips Facilitate skin to skin Initiate breastfeeding/pumping in delivery room Room in, demand feeding Avoid supplementation unless medically indicated Avoid early introduction of pacifiers (except for procedures) and bottle nipples Medications and Breastfeeding Pearls for making the best choices Golden Rules: Reaffirm mother’s goals Try to enable a scenario where mother is appropriately treated and no interruption of feeding occurs Only rare circumstances where breastfeeding needs to temporarily or permanently cease Consult your resources adequately/quickly Meds: Golden Rules: continued Mothers with depression symptoms should seek treatment. Most of these meds are safe or can choose one that is safe. Most drugs are safe in breastfeeding mothers If drug is not safe, can TEMPORARILY discontinue until the drug is metabolized. Not always necessary to stop altogether Choose drugs with short T1/2, high protein binding, low oral bioavailability or high molecular weight. Resources for Medication compatibility with breastfeeding Lactmed Medications and Mother’s Milk, Hale, 2014 Website App Infantrisk.org App AAP Committee on Drugs document (more general) PDR (NO!!) Compiles all packages inserts standard recs are NOT to take—Poorest source of information http://lactmed.nlm.nih.gov Or Google “LactMed” Lact Med FREE! Medications and Mothers’ Milk Tom Hale, PhD Hormonal Methods: General rule is to avoid estrogens if possible Combined OCP, Patch, Ring: all can decrease milk supply Progesterone methods have less impact on milk supply Progesterone Implant (3 year) Progesterone IUD (5 year) POP Medroxyprogesterone Injection (3 months) *Sometimes they can alter milk supply as well Progesterone Only Methods Theoretical risk of introducing too early may impact full supply being established Postdelivery decrease in progesterone part of the physiologic cascade to start lactogenesis II. Most experts recommend delay initiating these methods until full supply is established (4-6 weeks minimum) Rarely patients see a drop in supply even with Progesterone IUD. Progesterone Methods Failure Rates Depot Medroxyprogesterone (IM q 3 months) Typical failure rate: 0.3% Progesterone Only Pill: 8-10% (Typical use) Perfect use: 1% Implant (Etonorgestrel Rod) Typical use <1% Also helpful for medically complicated patients that are not estrogen candidates Postpartum Checkup: How can we help enhance breastfeeding duration and exclusivity? Have referral/resources for community support readily available with staff for phone calls and during appointments Remind patients to call the office with questions or problems relating to breast health at ANY time postpartum even after the PP exam Review transition of return to workforce and plans to highlight the law and offer support and advice re: expressing at work. ACA Supporting Breastfeeding and Lactation The Affordable Care Act (ACA) has two major provisions: Coverage of comprehensive lactation support and counseling Coverage of costs of renting or purchasing breastfeeding equipment for the duration of breastfeeding. Support of continuation through first year Offer to provide a letter for employer reviewing the medical and economic benefits for an employee to continue to breastfeed Better employee retention Less absenteeism due to sick child Financially advantageous to retain breastfeeding employees rather than hire new employee Better work satisfaction Resources/Links http://acog.org/breastfeeding Hypoglycemia Near-term infant Discharge Ankyloglossia Supplementation NICU graduate Mastitis Contraception Peripartum management The breastfeedingfriendly physician’s Cosleeping office Model Hospital Policy Anesthesia and Human milk storage analgesia Galactogogues The hypotonic infant Resources for Black Families ACOG/AAP/ABM Know Your Local Resources and the Law Lactation consultants – ILCA.org Community support – LLLI.org – WIC – Local hospital groups Frenotomy providers Breast specialists Breastfeeding in Public/Employment Laws Happy National Breastfeeding Month! Thank you Kathy Hartke, MD and Paul Hartke Cresta Jones, MD GE Questions?