Breast/Chestfeeding: How We Can Best Support Parents

/ Med-Peds Forum, General Med-Peds / By

Inclusive Language

People of all gender identities are birth parents and may choose to nurse their children. Recognizing this fact, we should mirror language that patients use for themselves.

Gendered language that centers on binary definitions of cisgender female identity can be a barrier to inclusive care. Care providers should communicate an understanding of gender dysphoria and transgender identities in order to build patient trust and provide competent care. 

Vocabulary:

  • Breastfeeding / Chestfeeding
  • Maternal / parental, mom / parent, etc.

Furthermore, a parent’s ideals for breastfeeding the imagined infant often differ from their experience feeding the real infant. There are bumps in the road and setbacks, which is where support should kick in. In supporting parents, we need to choose our words well. Consider the following strategies: 

  • Focus on the infant
  • Contextualize weight messages
  • Provide clear explanations
  • Reassure within clear boundaries

Key Guidelines!

AAP’s Recommendations on Breastfeeding Management for Healthy Term Infants: 

  1. Exclusive breastfeeding for about 6 mo
    • Breastfeeding preferred; alternatively expressed mother’s milk, or donor milk
    • To continue for at least the first year and beyond for as long as mutually desired by mother and child
    • Complementary foods rich in iron and other micronutrients should be introduced at about 6 mo of age
  2. Peripartum policies and practices that optimize breastfeeding initiation and maintenance should be compatible with the AAP and
    Academy of Breastfeeding Medicine Model Hospital Policy and include the following:

    • Direct skin-to-skin contact with mothers immediately after delivery until the first feeding is accomplished and encouraged throughout the postpartum period
    • Delay in routine procedures (weighing, measuring, bathing, blood tests, vaccines, and eye prophylaxis) until after the first feeding is completed
    • Delay in administration of intramuscular vitamin K until after the first feeding is completed but within 6 h of birth
    • Ensure 8 to 12 feedings at the breast every 24 h
    • Ensure formal evaluation and documentation of breastfeeding by trained caregivers (including position, latch, milk transfer, examination) at least for  each nursing shift
    • Give no supplements (water, glucose water, commercial infant formula, or other fluids) to breastfeeding newborn infants unless medically indicated using standard evidence-based guidelines for the management of hyperbilirubinemia and hypoglycemia
    • Avoid routine pacifier use in the postpartum period
    • Begin daily oral vitamin D drops (400 IU) at hospital discharge
  3. All breastfeeding newborn infants should be seen by a pediatrician at 3 to 5 d of age, which is within 48 to 72 h after discharge from the hospital
    • Evaluate hydration (elimination patterns)
    • Evaluate body wt gain (body wt loss no more than 7% from birth and no further wt loss by day 5: assess feeding and consider more frequent
      follow-up)
    • Discuss maternal/infant issues
    • Observe feeding
  4. Mother and infant should sleep in proximity to each other to facilitate breastfeeding
  5. Pacifier should be offered, while placing infant in back-to-sleep-position, no earlier than 3 to 4 wk of age and after breastfeeding has been established

AAP’s Recommendations on the Role of the Pediatrician: 

  1. Promote breastfeeding as the norm for infant feeding.
  2. Become knowledgeable in the principles and management of lactation and breastfeeding.
  3. Develop skills necessary for assessing the adequacy of breastfeeding.
  4. Support training and education for medical students, residents and postgraduate physicians in breastfeeding and lactation.
  5. Promote hospital policies that are compatible with the AAP and Academy of Breastfeeding Medicine Model Hospital Policy and the WHO/UNICEF “Ten Steps to Successful Breastfeeding.”
  6. Collaborate with the obstetric community to develop optimal breastfeeding support programs.
  7. Coordinate with community-based health care professionals and certified breastfeeding counselors to ensure uniform and comprehensive breastfeeding support.

Nursing can be challenging!

Questions to ask parents early on: 

  • First ask: How are you doing?
  • How is milk production going?
    • Colostrum first, then mature milk
    • Feeling of fullness before feeds then softening after feeds
  • How many times a day is the baby feeding?
    • Goal is to feed every 2-3 hours, or 8-12 times per 24 hours
  • Birth weight? Weight today and changes over time?
    • Most term babies will have reached maximum weight loss by day 5
  • Number of wet diapers?
    • Typically 6-8 voids per day after the first few days of life
  • Number of stool diapers (and consistency)?
    • Typically 4+ stools, which are often yellow and seedy in appearance

Questions parents will ask you: 

  • How to improve milk transfer?
    • A good latch!
  • How to increase milk production?
    • Demand drives supply!

Further support!

Local: 

National / International: 

Common medical concerns…

Medication safety

Mastitis

  • Facts from the Academy of Breastfeeding Medicine: 
    • Worldwide, the most common pathogen in infective mastitis is MRSA. Less commonly, the organism is a Streptococcus or Escherichia coli.
    • The preferred antibiotics are usually penicillinase-resistant penicillins, such as dicloxacillin. First-generation cephalosporins are also generally acceptable as first-line treatment, but may be less preferred because of their broader spectrum of coverage. Cephalexin is usually safe in women with suspected penicillin allergy, but clindamycin is suggested for cases of severe penicillin hypersensitivity.
    • Many authorities recommend a 10-14-day course of antibiotics; however this recommendation has not been subjected to controlled trials.
  • Diagnosis: clinical (swollen, wedge-shaped area of breast and fever or systemic illness)
  • Management:
    • Frequent and effective milk removal
    • Supportive care (warm/cool packs)
    • NSAIDs
    • Antibiotics if no improvement in 24 hours (or if patient is acutely ill)

Engorgement

  • Diagnosis: 
    • Breast fullness and firmness, accompanied by pain/tenderness
    • If the areola is engorged it can impair the baby’s ability to latch and worsen the engorgement
  • Management: 
    • Effective management hinges on adequate removal of the milk
    • Hand expression to soften areola and make feeds easier
    • Limited use of breast pump

Further resources!

Take-Home Points!

  • Feeding newborns with exclusive human milk is our medical recommendation
  • However, families should be supported in whatever choices make sense for them
  • Essentials= a good latch + demand drives supply + physical/mental health support for feeding parents
  • Consult your interdisciplinary colleagues and know your local resources!

Blog post based on Med-Peds Forum talk by Rebecca Raymond-Kolker, PGY1

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