Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics.
My name is Emily Fronk and I am a 4th year medical student at the University of Virginia. This episode was developed along with Dr. Ann Kellams, Professor of Pediatrics and Director of Breastfeeding Medicine at the University of Virginia.
This podcast episode is a follow-up to our introductory episode entitled “Before Your First Time Working with a Breastfeeding Mother” and we recommend that you listen to that podcast first. Today, we’ll be reviewing additional details about breastfeeding that can help you to answer some of the most common questions that come up for families and, thus, make a positive impact on families during your pediatrics rotation. In this episode, we will talk about strategies to improve milk production, newborn stomach volumes, how to know if baby is getting enough milk, what to do if baby isn’t getting enough milk, and breastfeeding complications.
First, let’s talk about strategies that help lead to successful lactogenesis or milk production. These include skin-to-skin contact, frequent “on-demand” nursing, rooming-in, high quality latch, and hand expression. We’ll go through each of these topics to help you understand them.
Skin to skin contact is exactly what it sounds like. It’s when the naked baby (with just a diaper) is placed on the bare chest of an adult- usually one of the parents. Research has shown that when a full-term newborn is placed skin-to-skin on the mother immediately after birth, the newborn starts to seek the breast, which helps to strengthen the rooting reflex. As a result, it’s recommended after the baby has been delivered and dried, to lay the baby directly on the parent’s bare chest at least 60 minutes of uninterrupted skin-to-skin. This increases breastfeeding initiation and exclusive breastfeeding, while reducing formula supplementation. Interestingly, this skin-to-skin contact after birth also has other advantages, such as lowering maternal stress levels and improving newborn thermoregulation. Of course, depending on the health of the birthing parent and the baby, this is not always possible; however, we try to encourage it when able.
An important concept in breastfeeding is “feeding on demand”, also referred to as “feeding on cue” or “responsive feeding”. This means that the baby’s hunger cues- or signs that the baby is getting hungry- dictate when the baby breastfeeds, rather than adhering to a strict feeding schedule. This is why we want babies to room-in with their parents while in the hospital, as it gives the parents a chance to learn what their baby’s hunger cues are. Early hunger cues include smacking or licking the lips, sucking on objects, clothes, or hands, and opening and closing the mouth. Late hunger cues include crying, falling asleep from exhaustion, and moving the head back and forth. It’s more important to tell parents to count the number of times that baby successfully goes to breast over 24 hours with a goal of 8-12 in a 24-hour period, rather than telling them that baby needs to feed “every x hours”. Additionally, baby’s effort at the breast is more important than the number of minutes spent at the breast. You can assess baby’s effort by looking to see if they sustain a sucking pattern and listening for audible swallowing sounds.
Hand expression or manual expression means using your hand to squeeze the milk out of the breast into the baby’s mouth or a plastic spoon to be given directly to baby after a feed. We often recommend this if the baby is sleepy at the breast, and it may even be more effective at removing colostrum than having the baby suckle on the breast. It is a great way to ensure intake for the baby and signaling for the breasts to produce more milk, as the first few days are important for laying this groundwork for the development of milk production.
Latching is one of, if not the, most important concept in breastfeeding. To assess latch quality, it’s important to see if both the breastfeeding parent and baby are comfortable. The parent should not have any pain, compression, or rubbing of the nipple and surrounding tissue. We call it breastfeeding, not nipple feeding! It might seem like a straightforward concept, but latching is actually a highly detailed process and it’s essential to understand it. It is not as simple as putting the nipple directly into the baby’s mouth- instead, an effective latch is “asymmetrical” with more of the areola below the nipple in the baby’s mouth than the areola above. This means that you should be able to see the tip of the baby’s nose and the baby’s chin should be deeply buried in the breast. This puts the nipple in the right place along the baby’s soft palate. Tucking the baby’s chest snuggly into the birthing parent’s body, such that the baby is “looking up” at the breast and the nipple is pointing up to the baby’s forehead when they attach is helpful. If you’re having trouble visualizing this, look at the “Initiation of Breastfeeding” topic in UpToDate. I’ve included the link in the show notes. Signs of an ineffective latch include when it is painful for the mother or if there is nipple trauma, blanching, or compression such as when the nipple appears misshapen after a feeding, looking like a ski slope or flattened like a pancake, with audible swallows that sound like soft “clicks” during feeding. It’s important to remember that nipple pain is most often a latch problem and that small changes in repositioning can significantly relieve pain. Parents can use their pinky finger to gently release the suction and remove baby from the breast to allow for repositioning. It is better to reposition and/or hand express than to allow the baby to continue a painful latch, as the small ducts in the nipple can become occluded and inhibit milk flow.
Now, let’s discuss how much milk one needs to produce to adequately feed baby in the initial newborn period.
To understand this, it can be useful to know newborn stomach volumes. Parents are often surprised at how little breast milk a baby needs to be drinking in the first few days! It can therefore be very reassuring to share this information with them, as one of the biggest concerns that parents have is that they are not making enough milk for their baby. On day 1 of life, the newborn stomach is the size of a cherry and can hold about 5-7 milliliters or 1-1.4 teaspoons. On days 2-4 of life, the newborn stomach increases to the size of a walnut and can hold about 22-27 milliliters or 3/4 to 1 ounce. By one week of life, it is the size of an apricot and can hold 45-60 milliliters or 1.5-2 ounces. By 1 month of life, the newborn stomach has now increased to the size of an egg and can hold 80-150mL or 2.5-5 ounces.
Now that you know how much milk baby needs, how can we determine if the baby is getting enough milk?
First, it’s helpful to watch and listen for a “suck and swallow” rhythm as baby eats. In the first few days while colostrum is being produced, the pattern will typically be “suck, suck, suck, swallow”, while after milk production has increased, the pattern will become repeated cycles of bursts of “suck, swallow; suck, swallow” with each let-down reflex. Wet diapers can also be a good indicator that the baby is getting enough milk; there should be at least one wet diaper for every day of life until day 6, then more than 6 per day after day 6. Similarly to wet diapers, bowel movements can provide clues on if baby is feeding appropriately. Meconium is the first stool after birth and is thick, black, and tarry in consistency. Stools then turn green/brown within 2-3 days- these are called transition stools. Stools then become yellow/seedy by 4-5 days. If this progression in stools is not happening, that should be a red flag that feeding may not be going well. Baby’s weight can be helpful to track as well. In the first few days, most babies will lose weight. They can lose as much as 10% of their initial body weight in the first 3-4 days. Once they start gaining weight, they should gain 15-30 grams per day. Around 95% of babies regain their birth weight by 2 weeks and the remaining should by 3 weeks. The “Newborn Weight Loss Tool”, nicknamed the NEWT curve can be a useful online tool for ensuring that baby’s weight is appropriate for delivery type and feeding method during the first month. It can be particularly helpful to show the NEWT curve to parents who may be alarmed that their baby is losing weight to know that this is normal. We’ve included a link to the NEWT curve in the show notes.
If there is concern that the baby is not getting enough milk, you’ll want to make sure that there are no signs of dehydration on physical exam. Next, check how the baby is latching and ensure that the birthing parent is fully emptying their breasts 8-12 times per 24 hours. The breasts should feel softer after emptying. Additionally, you can recommend that the parent express milk after feeds, either by hand expression or with a breast pump, and then feed that to the baby. Some parents will be ok with giving this expressed breast milk in a bottle, while others may prefer to use a spoon or syringe. If bottle feeding, parents can use paced feeds to mimic the flow of breastmilk. Paced bottle feeding is a technique in which the baby has to root around and open wide before the bottle is placed in the mouth. The bottle is then held horizontally to the ground so that only the baby’s suckling, and not gravity, determines milk flow. Most babies do not require supplementation with anything other than their parent’s breast milk; however, in the small percentage that do need more, pasteurized donor milk, if available, may be a better option than commercial infant formula.
Parents that are having difficulty or concerns about breastfeeding can be referred to lactation professionals who are trained to help with these issues. At most hospitals, a referral can be placed so that a lactation professional can see the family before they go home from the hospital. Some hospitals may also have an outpatient Breastfeeding Medicine or Lactation Clinic that can be helpful for families. At these appointments, they can also check the baby’s weight, review the baby’s urine and stool output, and perform feeding evaluations.
Manual expression and pumping are important in certain situations, to ensure that the milk supply comes in and that baby gets enough milk. For example, if supplementation with anything other than the parent’s breast milk is needed, hand expression or pumping is necessary to provide extra signaling and encourage increase milk production. These options should be explored if the mother and baby have to be separated, for example, if the baby goes to the NICU or if the lactating parent returns to work. Some parents may feel guilty about needing to supplement for a medical reason; it’s important to reassure them that they are doing everything they can to keep their baby healthy and that we’ll do everything that we can to get them back to exclusive breastfeeding, if that’s their goal.
Finally, let’s talk about the most common complications of breastfeeding so that you know how to treat them. Breast engorgement is common when milk first comes in and can also occur when feeds are delayed or skipped. Treatment includes NSAIDs, massage of the breast, hand expression or pumping, and cold compresses. Blocked ducts occur when there is poor drainage of milk from one or more of the ducts of the breast, resulting in localized tenderness, redness, a lump without systemic symptoms, or a white bleb. This can be treated with gentle massage of the blocked duct towards the axilla while the mother is lying down on her back to encourage lymphatic drainage. Frequent emptying of the breast also helps. Finally, mastitis is an infection of the breast in which there are flu-like symptoms, such as fever, aches, and chills, and marked redness and warmth of the breast skin. Mastitis requires antibiotics and increased fluid intake for treatment. None of these conditions are contraindications to breastfeeding and continued breastfeeding should be encouraged. Mothers who are prescribed antibiotics should be reassured that it is safe to continue breastfeeding even while they are taking the antibiotic.
These are the most common questions that you will likely encounter from families who are breastfeeding. Knowing this information will help you to tailor your conversation and adjust your approach to fit each family’s needs. Having these discussions in an open and judgment-free manner can allow you to provide meaningful education and support that can have lifelong positive effects for your patients.
OUTRO:
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