Copyright 2022 Maya Bunik, MD, MPH, FABM, FAAP APPENDIX A 123 (continued on next page) Breastfeeding Touchpoint Parental Concern Main Obstacles Provider Advice Prenatal “I want to breastfeed, but since I am going to work, I need to be able to give formula too.” Lack of information about combining breastfeeding and working Lack of information about milk expression Strongly encourage attendance at a prenatal breastfeeding class (deserves equal time to birthing class education). Consider a longer maternity leave, if possible. Prepare to simplify life during the transition to parenting. “My husband and other family members will want to help feed the baby. Won’t they feel excluded if I only breastfeed?” Family members wanting to feed the baby Enlist partner’s/father’s help in supporting his nursing partner. Partners/fathers can interact with their infant by holding baby skin- to-skin or taking baby out while mother sleeps. After breastfeeding is well established, others can feed expressed milk by bottle. “I want to do combination feeding, or Los Dos.” Desire for “the best of both worlds” by combination feeding Lack of knowledge about the importance of frequent and exclusive breastfeeding during the early postpartum weeks for establishing mother’s milk supply “Puro pecho,” or only mother’s own milk, provides greater health benefits and helps maintain an abundant milk supply. If eligible, enrollment in WIC offers breastfeeding mothers a substantial food package, counseling, breast pumps, and peer counselors. Birth “My friend says it is a good idea to ask the nurses to care for my baby at night, so I can get some sleep.” Unrealistic expectations for the post- birth hospital stay Lack of prenatal education Frequent interruptions and excessive visitors deplete new mothers. Increased risk of formula supplements for nighttime births from 9 PM to 6 AM Promote immediate skin-to-skin contact after birth to facilitate initiation of breastfeeding within the first hour. Teach mother to interpret her infant’s feeding cues and breastfeed as often as baby wants. Advocate for no routine formula use in the system of care. Advise mother to request help in the hospital with breastfeeding to promote task mastery. Encourage continuous rooming-in, where mother can practice being with her baby in a controlled setting and learn to latch baby comfortably and effectively. “The yellow milk does not look like much. A little formula won’t hurt, will it?” Belief that the small amount of colostrum is insufficient until “milk comes in” Explain the potency and adequacy of colostrum and the rapid increase in milk production from 36 to 96 h. 3-5 d “Now that we are home, the baby seems to be feeding every hour. She or he doesn’t seem satisfied.” Lack of knowledge about normal frequency of feedings for breastfed newborns Infants typically begin feeding more frequently the second night after birth, when baby is at home. Concern about whether the infant is getting enough milk, due to mother’s inability to see what the infant takes at the breast Sleepy infant Explain that 8–12 feedings in 24 h are typical and necessary to establish an abundant milk supply. Provide a hand-pump, or teach hand expression, so mother can see that she has milk. Explain normal infant elimination patterns once mother’s milk comes in (3–5 voids and 3–4 stools per day by 3–5 d onset of yellow, seedy milk stools by 4–5 d). Perform infant test weights (before and after feeding) to reassure mother about baby’s milk intake at a feeding. Teach mother the difference between infant “flutter sucking” or “nibbling” that results in only a trickle of milk at breast versus “drinking” milk, with active sucking and regular swallowing. Tickling under axilla or holding hand up can help keep baby on task at breast. Or, compressing the breast when the baby stops slow, deep sucking can deliver a spray of milk to entice him or her to start drinking again. Anticipate infant appetite spurt at about 10–14 d of age. “My nipples are sore and cracked. Can I take a break and give my baby a little formula?” Sore nipples usually are attributable to incorrect latch-on technique and are a common reason that mothers discontinue breastfeeding early or start supplements. Observe a nursing session to evaluate latch. Consider referring mother to a lactation consultant for one-on-one assistance with latch. 2 wk “My breasts do not feel very full anymore. I’m afraid my milk went away.” As postpartum breast engorgement resolves, and the breasts adjust to making and releasing milk, mothers may perceive they have insufficient milk. Expect infant to be above birth weight by 10–14 d and reassure mother about infant’s rate of weight gain since the 3–5-d visit. Although mother’s breasts are less swollen than during postpartum engorgement, they should feel fuller before feedings and softer afterward. “How can I know my baby is getting enough?” The 10–14-d appetite spurt can cause mother to doubt the adequacy of her milk supply. Consider performing test weights (before and after feeding) to reassure mother about her infant’s intake. Anticipate another appetite spurt at about 3 wk of age. APPENDIX A Breastfeeding Touchpoints for Overcoming Obstacles to Exclusivity
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