What Overview Mothers Need to breastfeeding (EBF)? …...Hoddinott, et al. Matern Child Nutr 2010;...

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



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



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



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



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.”



“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



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



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



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




During pregnancy,

most focused on educating

about “benefits” of breastfeeding


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



• ↑ 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



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



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



[email protected]

www.NancyMohrbacher.com Facebook.com/NancyMohrbacherIBCLC

Pinterest.com/nancymohrbacher@BFReporter

www.YouTube.com/NancyMohrbacher

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What Overview Mothers Need to breastfeeding (EBF)? …...Hoddinott, et al. Matern Child Nutr 2010;...

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