Bailey’s Golden Start Breastfeeding Curriculum for Nursing Students
Section Six: Objectives 13-16
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Bailey’s Golden Start Breastfeeding Curriculum for Nursing Students
Section Six: Objectives 13-16
8/5/2013
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Bailey’s Golden Start Breastfeeding Curriculum for Nursing Students
Section Six: Objectives 13-16
8/5/2013
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Bailey’s Golden Start Breastfeeding Curriculum for Nursing Students
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◦Image used with permission from Justine MacArthur on 7/24/12. Photo taken in June 2012.
◦Tricks to wake baby
Place baby in a sitting position in your lap
Talk to baby
Change diaper
Wipe bottom with a washcloth/wipe
Massage back and bottoms of feet
Massage mom’s breast to express milk and remind baby why they are there.
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Other breastfeeding attachment issues discussed in the literature include
the physiologic problems of ankyloglossia (Berg, 1990; Notestine, 1990;
Wiessinger & Miller, 1995), short labial frena (Wiessinger & Miller, 1995),
bubble palate (Snyder, 1997), and the presence or absence of the extrusion
reflex (Stephens & Kotowski, 1994) in the newborn.
In addition, exposure to artificial nipples, pacifiers, or dummies within the
child’s environment is believed to contribute to breastfeeding problems
and early weaning (Neifert, Lawrence, & Seacat, 1995; Righard, 1998;
Righard & Alade, 1997; Victora, Tomasi, Olinto, & Barros, 1993).
According to Newman (1990), the early introduction of bottles may render
infant sucking less effective or may result in breast refusal, resulting in failure
to thrive, hyperbilirubinemia, colic and crying, prolonged and frequent
feedings, sore and cracked nipples for the mother, and mastitis.
Difficulty with Latch (Microsystem and
Mesosystem). One of the major factors leading to
lactation termination is difficulty with latch. In
order to breastfeed successfully, infants must learn
to attach and suckle at the breast properly
(Righard, 1996; Righard & Alade, 1992).
Protractility of nipple tissue is required for proper
latch and efficient suckling; therefore, mothers
with inelastic tissue, or flat and inverted nipples
may encounter breastfeeding difficulties
(Biancuzzo, 1999; Fisher, 1994; Walker, 1989;
Woolridge, 1986).
Section Six: Objectives 13-16
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Baby knows there is more milk on one side vs. the other
Baby may have developed a preference due to pain / senses
Baby has a broken clavicle (pain)
Baby has head bruising from delivery, vacuum extraction (pain)
Baby has a auditory or visual deficit (sensory)
Babies can sense if mother has breast cancer before it is even
diagnosed and will refuse to breastfeed on affect breast.
Interventions
• Try to diagnose problem, is it pain or sensory related?
• Be creative with your positioning to minimize pain and maximize baby’s
senses.
• Preference related only: start feeding session on favorite side and
switch to refusal side after first couple minutes.
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•Some think nipple shield use is controversial r/t decreasing stimulation to mother.
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◦Image from Medela Pump & Style.
◦Encourage external stimulation:
massage, looking at infants picture, tape recorder of infants noises / crying, sitting
with infant blanket
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Often used for:
low milk supply, delayed lactogenesis, adoption, supplementing with alternative formula (dietary
requirement)
Need to educate parents on risks of using at home
Risks: managing milk flow, make sure flow is low enough that infant can manage with swallowing
Positives: Baby associates feeding with breast, Mother gets nipples stimulated for milk production
Negatives: Mother has to assemble, disassemble, wash
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Tandem feeding is advantageous due to the time saving aspect
Twins
• Mothers of twins will typically ask how to tandem feed
• Tandem Feeding: feeding both infants simultaneously.
• Best way to successfully tandem feed is to establish latching with each infant
separately, and then attempt tandem.
• Once both infants can latch well: Start by latching poorest latcher first. Once
latched, get second infant latched to breast. Will need another pair of hands to
manage both infants.
• Mother can designate each infant a breast or switch each time.
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Bailey’s Golden Start Breastfeeding Curriculum for Nursing Students
Go back to maternal lactation
history.
• Are there any red flags?
Horne (2001) reported that regular
formula feeds were commonly started
because the mother assumed that
the infant required more food than
she was able to provide.
Discuss supply and demand with
mother.
• Is mom’s frequency
appropriate?
• Is mom breastfeeding or
pumping long enough?
Supply and demand: Any time a
mother goes longer than 4-6 hours
without expressing the milk from
her breasts her body is going to
start to think she doesn’t want milk
produced anymore.
If the breast is not drained of
about 75-85% of the milk, most of
the time, the rate of milk synthesis
will slow down to match the
demand.
Additional Risk factors for low milk
supply:
Delay of Lactogenesis II: retained
placental fragments, c-sx, high
stress on mom and baby at birth,
premature delivery, insulin
dependent diabetes mellitus,
obesity, endocrine disturbances,
primiparity, long labor, elevated
cord blood glucose
concentrations (infant has higher
blood sugar = less hungry).
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Perception of Insufficient Milk Supply
(Microsystem). Perceived insufficient milk
supply is the most common reason cited in
the U.S. for the early supplementation
and/or discontinuation of breastfeeding
across cultural, socioeconomic, rural, and
urban settings (Arora, McJunkin, Wehrer, & Kuhn,
2000; Blyth et al., 2002, 2004; Hill & Humenick, 1989, 1996;
Marandi, Afzali, & Hossaini, 1993; Martines, Ashworth, &
Solids, however, were initiated when a
mother believed that her infant had
reached an appropriate age. In
Quandt’s (1984) study, solids had no
negative consequence on
breastfeeding duration for infants
introduced to solids at four months or
later, yet for infants introduced to
solids before four months of age, a
decrease in breastfeeding frequency
was demonstrated after solids were
initiated. In contrast, Hornell (2001)
reported no association between the
decline of breastfeeding and the
introduction of solids, nor did Jackson
(1992) in her study in Thailand, where
rice is traditionally introduced early
into a newborn’s diet and where
lactation is long.
Kirkwood, 1989; McCann & Bender, 2006).
Concern over milk supply can lead to early
weaning (Binns & Scott, 2002; McCann et al., 2007).
Conversely, perception of adequate milk
supply boosts maternal confidence (Hill &
Humenick, 1996).
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What is it: the breasts response to increased swelling (r/t pregnancy) and increased milk volume in ducts. As swelling increases
milk leaks into tissue causing inflammation & pain.
When to expect it: most typically seen in first 7 days of milk production. Can be seen at any time during lactation if milk has been
restricted from expression.
S/sx: swollen shiny breast, warm to touch, c/o pain
Treatment: warm compress X 15 minutes prior to pumping, stand in shower with chest toward shower head to soften breast tissue,
pumping may be necessary to relieve pressure enough for baby to latch on, massage down while pumping.
Latching example with balloon that is to full, can’t tie till some of the air is let out. If breast become to swollen baby is physically
not able to latch until swelling is relieved.
Treatment: Other thoughts in literature: cabbage leaves, cold compress, anti-inflammatory drugs, ultrasound
Which of the following is MOST likely to cause engorgement after lactogenesis II?
• Baby is breastfeeding very frequently on Day 2 before the onset of lactogenesis II.
• A staff member feels baby is not getting enough milk and, with mother's approval, gives baby infant formula.
• Baby slept for 6 hours that night. Mother also slept well.
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◦Second most common complaint of breastfeeding women. Usually occurs in the first week, peaking
day 3-6, and resolving by itself. Persisting beyond the first week is abnormal.
◦Cause: improper latch, improperly breaking latch, poorly fitting breast pump, infection, allergy,
sensitivity
◦Treatment: diagnose and fix underlying problem! Warm moist compress, application of human milk,
lanolin, cleansing and air drying, hydrogel products, breast shells, topical antibiotics / steroids.
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Risk factors for milk stasis: plugged duct, engorgement, trauma, tight fitting bra/top,
decreased BF/pumping, stress, fatigue, cracked / fissured nipple, decrease in feeding
frequency, large milk volumes, breast trauma, sleeping position, poor maternal
nutrition, vigorous exercise of upper arms and chest
Treatment: If left untreated or mother discontinues milk expression an abscess can
form.
To continue BF or pump and dump: Term babies: continue to BF but pump after BF
attempt to remove ALL milk from breasts. Sick or premature babies: mother needs to
pump and dump milk from affected breast.
A mom presents complaining of having flu-like symptoms. You can see an inflamed,
wedge-shaped area developing on the upper, outer quadrant of her breast. Which of
the following actions has been associated with worsening of the symptoms described?
• Rest the affected breast, breastfeeding from the unaffected side only
Mastitis: an event that causes milk stasis, leading to
infection. Most commonly occurs in the first weeks post
partum.
S/sx: swelling, breast pain, redness extending from
nipple to chest wall, headache, flu like body aches,
fever, fatigue, tachycardia, breast appears reddened,
hot, and tender. Unilateral sx.
Treatment: refer to provider for antibiotics,
acetaminophen for body aches and fever, cold packs
to breasts for pain relief, breastfeeding / pumping to
express milk, breast massage. Promote hand hygiene
with each pumping to prevent future infections.
Pain and Mastitis (Microsystem: Biological). Termination of breastfeeding
in the first six months postpartum is frequently caused by individual microsystemrelated biological problems of the breast, such as pain, sore and cracked nipples, and
mastitis and/or breast infection (Abou-Dakn, Schafer-Graf, & Wockel, 2009).
Classification of these physiological problems is essential for treatment and ongoing
support. Assessing for the presence or absence of erythema, edema, engorgement,
mastitis, and abscess formation is an important function of healthcare providers when
working with postpartum women (Centuori et al., 1999).
Centuori et al. (1999) examined nipple care, sore nipples, and breastfeeding duration;
they found that between the control group, who used no nipple ointment, and the
intervention group, who used an ointment, there was no difference in the incidence of
sore and cracked nipples and in breastfeeding duration. However, the use of a
pacifier and a bottle in the hospital were both associated with sore nipples at
discharge (p = 0.02 and p = 0.03). In this population, full breastfeeding up to four
months postpartum was significantly associated with breastfeeding on demand,
rooming-in at least 20 hours/day, non-use of formula and pacifiers, and no pre and
post-feeding weight checks at each breastfeed (Centuori et al., 1999).
Abou-Dakn et al. (2009) evaluated the relationship between psychological stress and
the occurrence of breastfeeding disorders in the U.S., and reported a significant
relationship between maternal stress and breast disease. In contrast, women with
diminished levels of psychological stress reported less breast-associated disorders. The
majority of women who reported breast problems terminated lactation sooner than
those who did not.
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In order to allay and prevent nipple pain, several assessment tools have been developed to evaluate the ability of the baby to
suckle. Some of the more commonly used tools are the Infant Breastfeeding Assessment Tool (IBFAT) (Matthews, 1993), the MotherBaby Assessment Tool (MBA) (Mulford, 1992), and the LATCH Scoring System (Jensen, Wallace, & Kelsay, 1994). Each letter of the
acronym denotes a category, where “L” represents latch, “A” represents audible swallow, “T” represents mother’s nipple type, “C”
represents mother’s degree of breast or nipple discomfort, and “H” evaluates the amount of help the mother needs to position her
baby at the breast.
Riordan, Bibb, Miller, and Rawlins (2001) researched the validity of the LATCH breastfeeding assessment tool on 133 dyads and
found that women who were breastfeeding at six weeks postpartum had higher total LATCH scores than those who had weaned.
All means for LATCH measures were higher in the group still breastfeeding at six weeks, with one exception; the women who
weaned before six weeks reported greater breast or nipple discomfort than those who were still breastfeeding (p < .05).
Finally, Rempel (2004) researched factors that influenced breastfeeding decisions of long-term breastfeeders (n = 80) in a
longitudinal infant feeding study where “long-term” was defined as any mother who had breastfed from 9 to 12 months
postpartum. Rempel (2004) found that reasons for weaning in this population were infants’ perceived readiness to wean; mothers
felt they had breastfed long enough to give their infants the benefits of breastfeeding; infant biting, leading to nipple soreness and
pain; insufficient milk supply; and mothers’ desire to engage in behavior believed to be incompatible with breastfeeding, such as
losing weight, smoking, or taking certain medications.
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Antibodies!
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Image taken by Jennifer DeJong, Summer 2012.
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Is donor milk available?
Nutramigen causes less harm to infant gut but very expensive.
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Take 2 – 3 minutes now, to write 1-2 priority nursing diagnoses for this client.
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Image used with permission from Marissa Funkhouser, “Freezer Stash”, July 2012.
Health-Seeking Behavior related to the preparation and storing of breastmilk for return to work as
evidenced by (or as manifested by) mother’s comment “I’d like to learn more about preparing and
storing milk for when I go back to work.”
Fear related to the need for return to work in 3 weeks without a sufficient knowledge base as
evidenced by mother’s comment “I just really don’t know what I’m doing. I’m afraid I’m going to do
it wrong, and that I’m not going to find time to do it.”
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What is the MOST effective way to increase the duration of exclusive
breastfeeding to 6 months and any breastfeeding to 12 months and
beyond?
Referral to and attendance at peer support groups.
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During an assessment/evaluation of a breastfeed which of the following would you point out to
the mother to observe for so that she can feel confident her baby is receiving breastmilk?
The change in sucking pattern that occurs when she has a milk ejection.
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New Question:
What subjective and objective data do you need from the client?
Write out your instructions for her, and discuss anticipatory guidance.
Case Study or Role Play #2: Safely Preparing And Storing Expressed Breast Milk: Students can either get into groups and answer the
Case Study questions, or you can assign roles to each team (1 nurse needed, 1 mother needed per team).
Instructions:
Be sure to wash your hands before expressing or handling breast milk.
When collecting milk, be sure to store it in clean containers, such as screw cap bottles, hard plastic cups with tight caps, or heavyduty bags that fit directly into nursery bottles.
Avoid using ordinary plastic storage bags or formula bottle bags, as these could easily leak or spill.
If delivering breast milk to a child care provider, clearly label the container with the child's name and date.
Clearly label the milk with the date it was expressed to facilitate using the oldest milk first.
Do not add fresh milk to already frozen milk within a storage container. It is best not to mix the two.
Do not save milk from a used bottle for use at another feeding.
Safely Thawing Breast Milk
As time permits, thaw frozen breast milk by transferring it to the refrigerator for thawing or by swirling it in a bowl of warm water.
Avoid using a microwave oven to thaw or heat bottles of breast milk Microwave ovens do not heat liquids evenly.
Uneven heating could easily scald a baby or damage the milk
Bottles may explode if left in the microwave too long.
Excess heat can destroy the nutrient quality of the expressed milk.
Do not re-freeze breast milk once it has been thawed.
Source: American Academy of Pediatrics.
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Reference: Academy of Breastfeeding Medicine. (2004)
Clinical Protocol Number #8: Human Milk Storage Information for Home Use for Healthy Full
Term Infants [PDF-125k]. Princeton Junction, New Jersey: Academy of Breastfeeding
Medicine. Available
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• The flavor of breastmilk is affected by foods in the maternal diet.
• This daily variation can help the infant to become used to the tastes of the family foods
and ease the transition to these foods after six months of age.
• Artificial infant formula tastes the same for every feed.
• The taste of formula is not related to any foods the baby will eat when older.
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