Post on 04-Aug-2021
What Mothers Need to Exclusively Breastfeed
©2016 Nancy Mohrbacher, IBCLC, FILCA 1
What Mothers Need to
Exclusively Breastfeed
Nancy
Mohrbacher, IBCLC, FILCA
~
Overview• Why exclusive
breastfeeding (EBF)?
• Reasons mothers give formula
• Impact of breastfeeding self-efficacy
• Strategies that ↑rates of EBF
Exclusive Breastfeeding
• No water, formula, other liquids or solids
• Recommended for 6 months as best practice by
– WHO, other organizations
– Exception: “if a medical indication exists”
Exclusive Breastfeeding & Health OutcomesIp, S. (AHRQ) Evidence Report/Technology Assessment. 2007; (153):1-186Bartick, M. & Reinhold, A. Pediatrics 2010; DOI:10.1542/;eds.2009-1616
Recent evidence confirms lifelong effects of breastfeeding on maternal & child health
If 90% of US women exclusively breastfed for 6 mo, annual healthcare savings estimated at $13 billion
2011 Surgeon General’s Call to Actionhttp://www.surgeongeneral.gov/library/calls/breastfeeding/index.html
Table 2. Excess Risk Associated with Not Breastfeeding
Outcome Excess Risk
Among full-term, healthy babies
Gastrointestinal infection 178%
Hospitalization for lower respiratory tract
disease during first year
257%
Childhood obesity 32%
Sudden Infant Death Syndrome 56%
Among preterm infants
Necrotizing enterocolitis (NEC) 138%
Among mothers
Breast cancer 4%
Ovarian cancer 27%
AHRQ: http://www.ncbi.nlm.nih.gov/books/NBK38337/
Why Exclusive Breastfeeding?
Newborns’ gut junctions open at birth
• While open, proteins & pathogens can pass through
• ↑ risk of infection, NEC & allergy sensitization
• Take weeks to close
Le Huëron-Lurou, et al. Nutr Res Rev 2010; 23:23-36
What Mothers Need to Exclusively Breastfeed
©2016 Nancy Mohrbacher, IBCLC, FILCA 2
Colostrum
• Grows baby’s gut
• Helps it mature
• Protects from pathogens
One formula feed
• Changes gut flora
• ↑ gut permeability & keeps junctions open longer
• Increases gut inflammation
Le Huërou-Luron, et al. Nutr Res Rev 2010; 23:23-36Moodley-Govender, et al. Breastfeed Med 2015;10(10):488-92
Why 6 Months?
Dose-response relationship
− EBF for 4-6 mo had
4x ↑risk of pneumonia
than EBF ≥6 mo
Exposure to foreign proteins
− EBF for ≥3 mo had 30%
↓risk of Type-1 diabetes
AHRQ: http://www.ncbi.nlm.nih.gov/books/NBK38337/AAP. Pediatrics 2012; 129(3):e827-41
Kramer & Kakuma. Cochrane Database of Systematic Reviews, 2012; 8. Art No. CD003517.DOI: 0.1002/14651858.CD003517.pub2
With 6 months EBF:
• Mothers lose more weight
• Longer infertility
Perrine, et al. Pediatrics 2012; 130(1):54-60
2/3 of US mothers who intend to breastfeed exclusively for ≥3 modo not reach their goals
http://www.surgeongeneral.gov/library/calls/breastfeeding/index.html
Surgeon General’s 2011 Call to Action to Support Breastfeeding
Identified 7 breastfeeding barriers
Systemic Breastfeeding Barriershttp://www.surgeongeneral.gov/library/calls/breastfeeding/index.html
Problems with health-care services
Lactation challenges
Employment & child care
What Mothers Need to Exclusively Breastfeed
©2016 Nancy Mohrbacher, IBCLC, FILCA 3
Irish Government, Ministry of Health & Agencies, Foundations, Manufacturers,
Assoc. of Lactation Consultants in Ireland
Credentialing Boards, County & Local Governments
Health Care Systems, Breastfeeding, Civic & Faith Organizations, County Public Health Departments
Offices, Clinics, Hospitals, Community Sites, Schools, Worksites, Childcare Sites
Employers, Child Care Providers, Clinicians, Other Health Professionals
Friends, Family, Co-workers, Other
Mothers (peers)
Mother & Baby
Initiatives to Reduce Systemic Breastfeeding Barriers
Photo: Marilyn Nolt
Baby FriendlyImplemented in >150 countries by WHO & UNICEF to improve hospital breastfeeding practices
9 hospitals in Ireland baby-friendly certified 9 working toward certifcation
Ten Steps to Successful Breastfeeding
Ten Steps to Successful Breastfeeding
1. Written BF policy routinely communicated to staff
2. Train all staff in skills needed to implement policy
3. Inform pregnant women of benefits & management of BF
4. Help mothers initiate BF ≤ 1 hour of birth
5. Show mothers how to BF & maintain lactation, even if separated
6. Give infants no food or drink other than breast-milk, unless medically indicated
7. Practice rooming in 24 hours a day
8. Encourage BF on demand
9. No pacifiers or artificial nipples
10. Foster BF support groups & refer mothers to them
1 of 5 national performance measures
required in facilities with >1100 births/year
# of non-NICU babies without a breastfeeding
contraindication who are exclusively breast milk fed
The Joint CommissionPerinatal Care Core Measure on Exclusive Breast Milk Feeding
Affordable Care Acthttp://www.hhs.gov/news/
press/2011pres/08/20110
801b.html
Covers preventative services, including
• Breastfeeding support
• Breastfeeding supplies
• Breastfeeding counseling
What Mothers Need to Exclusively Breastfeed
©2016 Nancy Mohrbacher, IBCLC, FILCA 4
Photo: Mary Jane Chase, RNC, MN, CCE, IBCLC
Addressing Systemic BarriersWhat Happens Next?
Australian breastfeeding initiation rates rose over 10 years from 84% to 94%
At 84%, age, education & income predicted breastfeeding rates
At 94% they did not
Scott, et al. Birth 2006; 33(1):37-45
Scott, et al. Birth 2006; 33(1):37-45
As systemic barriers fall & breastfeeding rates near universality, socioeconomic disparities disappear
What remains are the
personal barriers
Irish Government, Ministry of Health & Agencies, Foundations, Manufacturers,
Assoc. of Lactation Consultants in Ireland
Credentialing Boards, County & Local Governments
Health Care Systems, Breastfeeding, Civic & Faith Organizations, County Public Health Departments
Offices, Clinics, Hospitals, Community Sites, Schools, Worksites, Childcare Sites
Employers, Child Care Providers, Clinicians, Other Health Professionals
Friends, Family, Co-workers, Other
Mothers (peers)
Mother & Baby
Personal Breastfeeding Barriershttp://www.surgeongeneral.gov/library/calls/breastfeeding/index.html
Lack of knowledge
Social norms based on bottle-feeding
Poor family & social support
Embarrassment
What Mothers Need to Exclusively Breastfeed
©2016 Nancy Mohrbacher, IBCLC, FILCA 5
WHY DO MOTHERS GIVE FORMULA?
Hospital Formula Requests
~80% gave formula
– 87% not medically necessary (ABM)
Formula use 5x more likely if no breastfeeding class
Tender, et al. J Hum Lact 2009; 25(1):11-17; N=150 low-income moms
Tender, et al. J Hum Lact 2009; 25(1):11-17; N=150 low-income moms
39% wanted baby to get formula
17% milk not yet “in” (write-in)
14% unsure why gave formula
12% mom felt not enough milk
12% mom wanted to rest
10% baby ill
9% MD, RN (66% justified)
8% c-sec & medications
3% latch issues
~ 13% medically indicated~
Delving Deeper
12 focus groups to better understand decision-making process
Key: lack of preparation for newborn care & breastfeeding
Formula the “solution” to perceived “problems”
DaMota, et al. J Hum Lact 2012; 28(4):476-82; N=97 low-income
Hunger: the only reason for newborn waking & crying
Formula makes babies sleep more, so moms can rest
No clue that formula affects milk production
DaMota, et al. J Hum Lact 2012; 28(4):476-82 DaMota, et al. J Hum Lact 2012; 28(4):476-82
“I really wanted to breastfeed him, but
like I said, he was hungry all the time; he wasn’t sleeping as much
because of it, so I had to switch over.”
What Mothers Need to Exclusively Breastfeed
©2016 Nancy Mohrbacher, IBCLC, FILCA 6
“I felt like maybe I didn’t fill him,
because it was every 2 hr…but now sometimes it’s still every 2 hr”
DaMota, et al. J Hum Lact 2012; 29(4):476-82 DaMota, et al. J Hum Lact 2012; 28(4):476-82
1st request for formula triggered by:
–Typical newborn behaviors
–Unmet expectations
–Staff did not support their breastfeeding
–Belief formula the solution to problems
Nielsen, et al. Pediatrics 2011; 128(4):e907-14
Are concerns about milk supply valid?
First-Feed study measured milk intake at 15 & 25 wk
When WHO recommendations followed, no evidence of insufficient milk
What Can Be Done?
Impact ofBreastfeeding Self-Efficacy
(BSE)
A mother’s belief in her ability to breastfeed
Measuring BSE
• 1999 33-item instrument validated
• 2003 pared it down to 14 items
• Validated in many languages internationally
What Mothers Need to Exclusively Breastfeed
©2016 Nancy Mohrbacher, IBCLC, FILCA 7
Baby getting Baby getting Baby getting Baby getting
enough?enough?enough?enough?
Formula used?Formula used?Formula used?Formula used?
Coping well Coping well Coping well Coping well
with BF?with BF?with BF?with BF?
Latching baby Latching baby Latching baby Latching baby
well?well?well?well?
Satisfied how Satisfied how Satisfied how Satisfied how
managing BF?managing BF?managing BF?managing BF?
BF even if baby BF even if baby BF even if baby BF even if baby
is crying?is crying?is crying?is crying?
Want to Want to Want to Want to
keep BF?keep BF?keep BF?keep BF?
BF with family BF with family BF with family BF with family
around?around?around?around?
Satisfied with Satisfied with Satisfied with Satisfied with
BF experience?BF experience?BF experience?BF experience?
OK if BF is timeOK if BF is timeOK if BF is timeOK if BF is time----
consuming?consuming?consuming?consuming?
Finish 1Finish 1Finish 1Finish 1stststst
breast 1breast 1breast 1breast 1stststst????
BF @ every BF @ every BF @ every BF @ every
feeding?feeding?feeding?feeding?
Know when Know when Know when Know when
baby’s done?baby’s done?baby’s done?baby’s done?
Keep up with Keep up with Keep up with Keep up with
BF demands?BF demands?BF demands?BF demands?
BSES Short FormDennis. JOGNN 2003;
32(6):734-44BSE predicts:
• Decision to breastfeed
• How much effort mother expends
• Her self-talk
• Her decisions
• How long she persists if faced with problems
BSE significantly impacts breastfeeding initiation & duration
Skouteris, et al. Breastfeed Med 2014; 9(3):1-15
Stronger predictor than supplements
or perceived support Dunn, et al. JOGNN 2006;
35(1):87-96
BSE & Perceived Insufficient Milk (PIM)
<40% wanting to exclusively breastfeed did so @4 wkOtsuka, et al. JOGNN 2008; 37(5):546-55; N=262 Japanese mothers
• 73%: PIM main reason
• PIM significantly related to ↓BSE before discharge
More links found between PIM & ↓BSEMannion & Mansell. Obstet & Gynecol Int2012; doi:10.1155/2012/562704
BSE determined by: Whether a mother interprets her personal experience as success or failure
Task Mastery
What Mothers Need to Exclusively Breastfeed
©2016 Nancy Mohrbacher, IBCLC, FILCA 8
BSE determined by: What a mother has read, seen, heard from others
– Most effective role models are more competent peers who can break it down into easy steps
– Those closest to her have the greatest impact
Vicarious Experience
BSE determined by: What others tell a mother about herself
Verbal Persuasion
BSE determined by: How a mother feels physically & emotionally while breastfeeding
Photo:
Melanie HamPhysiological & Affective States
BSE:
A Variable,
Not a
Constant
To Boost BSE
• Gain experience, master skills
• Learn from other mothers’ successes
• Be persuaded by others
• Enhance physical comfort & positive emotions
Mastery starts with small victories
• Latching• Latch
comfort• Calming
fussy baby
• Feeding norms
Success boosts BSE
Repeated failures diminish BSE
What Mothers Need to Exclusively Breastfeed
©2016 Nancy Mohrbacher, IBCLC, FILCA 9
BFHI Step Ten:
Foster the establishment of
breastfeeding
support groups & refer mothers
to them
on discharge from the hospital or clinic.
Learn from Other Mothers’ Successes Be Persuaded by Others
• Maximize time with supporters
• Minimize time with critics
Criticism decreases BSE more than encouragement boosts it
More women start breastfeeding when during pregnancy they see
other women breastfeed in a positive context
Hoddinott, et al. Matern Child Nutr 2010; 6(2):134-46 Photo: The Breastfeeding Atlas
Strategies That Increase Rates of Exclusive Breastfeeding
Systematic Review of Interventions in High-Income Countries
• Peer-reviewed, randomized trials
• 7 of 18 successful
• Most successful interventions occurred after birth over a long period
• Support-based strategies more effective than education
Skouteris, et al. Breastfeed Med 2014; 9(3):1-15
What Mothers Need to Exclusively Breastfeed
©2016 Nancy Mohrbacher, IBCLC, FILCA 10
During pregnancy,
most focused on educating
about “benefits” of breastfeeding
Skouteris, et al. Breastfeed Med 2014; 9(3):1-15
5 of 8 successful programs were in the mothers’ homesSkouteris, et al. Breastfeed Med 2014; 9(3):1-15
Any home visits after birth ↑breastfeeding durationKronborg, et al. Public Health Nurs
2012; 29(4):289-301 Photo credit: Mary Jane Chase, RNC, MN, CCE, IBCLC
Boost BSE During Pregnancy
Completing 9-page workbook ↑BSE:
• Confidence building
• Breastfeeding testimonials
• Strategies for handling stress, problem-solving, asking for support & staying motivated
Nichols, et al. Health Educ Behav 2009; 36(2):250-59 Nichols, et al. Health Educ Behav 2009; 36(2):250-59
Nichols, et al. Health Educ Behav 2009; 36(2):250-59
Workbook only ↑BSE if birthing hospital was
Baby Friendly
Otsuka, et al. Matern Child Health J 2014; 18:296-306
What Mothers Need to Exclusively Breastfeed
©2016 Nancy Mohrbacher, IBCLC, FILCA 11
• ↑ BSE in 1st-time moms – Questionnaire
– Comfort
– Hands-on with dolls
– PowerPoint & videos
• Covered – Baby’s cues when hungry
& satisfied
– Positioning
– How to know baby got enough milk
– Coping tips
Noel-Weiss, et al. JOGNN 2006; 35(5):616-24Noel-Weiss, et al. JOGNN 2006; 35(3):349-57
WorkshopMilky Way Program
Goal: To ↑BSE & any breastfeeding at 6 months
• Group sessions
• Take-home learning activities (DVDs, written materials)
• Phone support after birth at 10 days & 3 mo
Meedya, et al. Midwifery 2013; 30:e137-44
Those in the Milky Way group
had a 33% higher rate
of any breastfeeding at 6 months
54% vs 31%
Meedya, et al. Midwifery 2013; 30:e137-44 Aghdas, et al. Women Birth 2013; doi: 10.1016.wombi.2013.09.004
For at least the 1st 2 hours
after birth ↑BSE
Effective Strategies After Birth
Skin-to-Skin
Contact
Systematic Review:
MTM support ↑rates of exclusive
breastfeeding if support is
continuous in pregnancy, birth & after
Kaunonen et al. J Clin Nurs 2012; 21: 1943-54; 30 studies, 4 reviews
MTM Support ↑BSE Because It Provides:
• Help in mastering skills
• A place to watch breastfeeding & hear stories
• Persuasion that she can succeed
• A safe haven where she can discuss her worries
What Mothers Need to Exclusively Breastfeed
©2016 Nancy Mohrbacher, IBCLC, FILCA 12
La Leche League Ireland
Cuidiú
Friends of Breastfeeding
• Charitable network of breastfeeding drop-in centres– 1x/wk, no appointment– Pregnant, breastfeeding
moms & partners welcome
• Baby Café run by HCPs, Baby Café Local by HCP or volunteer counselors – Relaxed atmosphere– Church halls, community
rooms, children’s centres
www.thebabycafe.org
Drop-in Centers
Group setting, IBCLC present
Weekly, biweekly
Often held in high-end baby stores
Mothers pay nominal fee
Mothers’ Coffees
Breastfeeding Peer Counselors
Di Meglio, et al. Breastfeed Med 2010; 5(1):41-47 N=78 teen moms
Teen moms called by peer counselor on Day 2, 3, 4, 7 & Week 2, 3, 4, 5 ↑EBF rates compared with control group
What Mothers Need to Exclusively Breastfeed
©2016 Nancy Mohrbacher, IBCLC, FILCA 13
MTM Support ↓Risk of PPD in high-risk mothers
≥4 phone calls from peers after birth
Prevented PPD in high-risk women by ↓feelings of isolation & ↑feelings of support
Dennis, BMJ 2009; 338:a3064 doi:10.1136/bmja3064; N=701
Secrets of Baby BehaviorJane Heinig’s team at UC Davis
Promotes exclusive breastfeeding by sharing norms for baby’s
– Sleep
– Cues
– Crying
www.SecretsofBabyBehavior.com
Taught at many US public health agencies
Free resources:
– Training materials: http://www.cdph.ca.gov/progra
ms/wicworks/Pages/WICCalifor
nia BabyBehaviorCampaign.aspx
– YouTube video: https://www.youtube.com/watch?v=eX2ijdLnIJU
Getting to Know Your Babyhttp://www.cdph.ca.gov/programs/wicworks/Documents/BabyBehavior/WIC-BB-GettingToKnowYourBabyBooklet.pdf
Offer ongoing access to successful peers
Address root causes
• Physical comfort
• Emotional issues
• Lack of knowledge & misconceptions
Effective Strategies Effective Strategies
Take place over time
Provide education & support
Build a mother’s confidence in herself
What Mothers Need to Exclusively Breastfeed
©2016 Nancy Mohrbacher, IBCLC, FILCA 14
Questions?nancy@nancymohrbacher.com
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