Normal Breastfeeding
Objectives • Describe what to expect the first week with normal breastfeeding • Identify how breastfeeding can change over the first month
Normal Breastfeeding A Summary Jan Barger, RN, MA, IBCLC, FILCA
Free Powerpoint Templates
Free Powerpoint Templates
Page 1
What to Expect - Feeds
Page 2
What to Expect - Feeds
• In hospital
• Imperative:
– Good first feed in L&D – Relatively poor feedings rest of first day •One sided •Short •May have difficulty latching
– Second day feeds improve in frequency and duration
Free Powerpoint Templates
Page 3
What to Expect – Feeds
Page 4
What to Expect - Feeds – 8 to12 minimum/24 hours • Slogan: “8 or more in 24!” • May not happen Day 1 • The more mothers and babies are kept skin to skin the more frequently babies will feed
– Babies need to be READY to nurse – When babies breastfeed, they are “in charge” •When babies are bottle fed, the caregiver is in charge
– Keep skin to skin so babies will wake and nurse when they are ready – Watch for baby’s feeding cues!
© 2015/Lactation Education Consultants
Free Powerpoint Templates
• Number of Feeds
• Waking babies to feed them is generally an exercise in futility
Free Powerpoint Templates
– Keep mother and baby together skin to skin as much as possible to facilitate feeds – Encourage skin to skin whenever mom is not eating, sleeping, using the bathroom or showering.
Page 5
• Intervals between feeds – Whatever the baby determines • Wait for baby readiness
– May cluster some feeds, may have longish intervals between others Free Powerpoint Templates
Page 6
Normal Breastfeeding
What to Expect - Feeds
Breastfeeding
• Length of Feeds – Length of feed bears no relationship to amount of milk consumed • (Ramsay, Kent et al, 2004)
– Baby will determine – Watch type of suckling baby is doing • Nutritive – wide jaw movements • Non-nutritive (hanging out) – This is not breastFEEDING – U se breast compression then switch sides – Poking the baby less effective than compression
Free Powerpoint Templates
– If nutritive sucking, then generally audible swallowing is present – teach mom to identify – Often only occasional audible swallows the first 24 - 48 hours – Frequency increases over next day or two – May sound like soft sigh or “ca” sound – Can be fooled by gulping or swallowing sounds
Page 9
Indicators of Effective Feeds
Page 8
• GULPING – May indicate baby taking in air from mom spraying with OAMER but may not actually take in a lot of milk
• How much does a baby take with one swallow? – No one really knows – which is one of the reasons listening for swallow sounds is not an effective way of assessing milk intake
Free Powerpoint Templates
Page 10
Colostrum
• Rooting • Wide mouth latch • Wide jaw movements • Mom reports
• First feed immediately after birth, bolus* of colostrum – Related to oxytocin influence of labor – What does this mean for pumping immediately after birth if baby is transferred to NICU?
– Sleepiness – Thirstiness – Uterine cramping
– *bolus may be related to type of labor/birth mom had
•More significant with multipara
© 2015/Lactation Education Consultants
Free Powerpoint Templates
Being Fooled by Swallows
• Audible swallows?
Free Powerpoint Templates
– Long, drawing sucks – Rhythmic suckling – Suck/swallow/breathe or suck/suck/swallow/breathe – The lower the milk supply, the more sucks before a swallow – Several sucking bouts then a pause
Page 7
Listen
Free Powerpoint Templates
• Will begin with short sucks then move to
Page 11
Free Powerpoint Templates
Page 12
Normal Breastfeeding
Transitional Milk
Indicators of Effective Feeds
• Mothers sense the sensation of fullness (suddenly or gradually) – 2-3 days for multip, 3days for primip
• By end of first week, after volume of milk increases
– Milk “coming in” after 72 hours is delayed lactogenesis II
• Mature milk days 10-14 • ~ 500 ml by days 5-6. • Gradually increases over the next several weeks to reach peak of about 800 ml/24 hours (25-28 ounces) Free Powerpoint Templates
– Baby feeds with eyes open at beginning of nursing – Falls asleep toward end of feed and STAYS asleep for a period of time •May nap for 10 to 20 minutes between breasts
Free Powerpoint Templates
Page 13
Indicators of Effective Feeds
Page 14
If Baby Not Feeding Effectively…
• Can go 1 ½ to 2 hours between MOST feeds • Baby should be taking around 500 ml (about 17 ounces) each 24 hours, increasing gradually over the next couple of weeks
• Have mom do hand expression after every feed into a spoon and give baby colostrum obtained • Helpful for lactation specialist and mom’s nurse to make brief bedside rounds daily to discuss any issues that may be of concern – Morton, 2014
Free Powerpoint Templates
Free Powerpoint Templates
Page 15
What to Expect - Stools
What to Expect - Voids
• Stools – – – –
Page 16
• Voids
Meconium first 2-3 days Transitional days 3-4 Yellow seedy by day 5 By day 4 – at least 3 “scoopable poops/day”
– – – –
1 wet diaper the first 24 hours 2 wet diapers the second 24 hours 3 wet diapers the third 24 hours 5 to 6 heavy wet diapers after milk is “in” •No uric acid crystals after milk in
Free Powerpoint Templates
© 2015/Lactation Education Consultants
Page 17
Free Powerpoint Templates
Page 18
Normal Breastfeeding
Research on Voids & Stools
What to Expect – Weight Loss
• Using only voids and stools as indicator of breastfeeding adequacy resulted in many false positives • Fewer than three good stools or adequate wet diapers by day four, especially coupled with delayed onset of lactation warrants immediate checking
• All babies lose some weight – Physiologic diuresis of extracellular fluid – Normal maximal weight loss is 5.5-6.6% of birth weight •Occurs between days 2-3
• Optimally, breastfed infants regain birth weight on average by 8.3 days
• Nommsen-Rivers, 2008 Free Powerpoint Templates
Page 19
What to Expect – Weight Loss • Infants with weight loss ≥ 4.5% by 24 hours had an twofold increased risk of weight loss ≥ 10% in the hospital – Flaherman, 2010
• However, intrapartum fluid overload not
taken into consideration
Free Powerpoint Templates
Page 20
What to Expect – Weight Loss • Women receiving >1200 ml fluid during labor – Average weight loss in babies at 60 hours 6.93% – Diuresis takes place first 24 hours to normalize body fluids in infant – Recommended that baseline weight at 24 hours rather than at birth •Noel-Weiss, 2011
Free Powerpoint Templates
Page 21
What to Expect – Weight Loss • Before jumping to supplementing these babies, need to determine maternal fluid intake during labor and amount of output of infant – If >10% weight loss and baby has voided or stooled a lot, don’t worry – If >10% weight loss and baby has minimal voids and stools, worry
Free Powerpoint Templates
© 2015/Lactation Education Consultants
Page 23
Free Powerpoint Templates
Page 22
By End of First Month • Most babies take in an average of 24 to 28 ounces/24 hours • Stools often decrease to less than one a day • As baby gets older & more efficient the feeds often get shorter • Up until two to three months, most feeds will end in baby sleeping Free Powerpoint Templates
Page 24
Normal Breastfeeding
Maternal Concerns
Interesting Facts…
• Concerns at days 3 & 7 – 532 moms • ≥ 1 concern at day 3 – Difficulty w/ breastfeeding (52%) – Breastfeeding pain (44%) – Milk quantity (40%)
• Significantly associated with increased risk of stopping breastfeeding and formula use especially if concerns continued to day 7 – Wagner, 2013
Free Powerpoint Templates
Page 25
• Cholecystekinin (CCK) is a GI hormone that enhances digestion, causes sedation & a feeling of well being. Vagal stimulation causes CCK release to both mother & infant within 10 to 30 minutes of the end of the feed – Hence, babies are DESIGNED to fall asleep at the breast after nursing Free Powerpoint Templates
Page 26
Bottom Line •If baby is gaining weight and mom’s nipples do not hurt, then breastfeeding is going well •Also known as “Pain-free weight gain.” Free Powerpoint Templates
Page 27
Amount of Colostrum…
Free Powerpoint Templates
Page 28
• Excess weight loss (>10% birth weight)
– Average gain per feeding was 1.5 ± 1.1 g – Total amount consumed in the first 24 hours – 15 ±11 g •Santoro, 2010 • (Do not know when the very first feed took place)
© 2015/Lactation Education Consultants
INTERESTING STUDIES
What to Expect – Weight Loss
• …consumed during the first 24 hours evaluated in 307 feedings
Free Powerpoint Templates
For your reading pleasure:
Page 29
– Occurred in 18% of exclusively breastfed •In mothers who received >200 mL/hour fluid during intrapartum period – Theorize that intrapartum fluid administration can cause fetal volume expansion and greater fluid loss after birth » Weight loss not always related to poor feeds – Chantry, 2011
Free Powerpoint Templates
Page 30
Normal Breastfeeding
What to Expect – Weight Loss
What to Expect – Weight Loss
– With 24 hour baseline 2.3 lost 7 to 10% and none in excess of 10%
– Use of newborn weight loss nomograms may assist with early identification of greater weight loss pattern – Cohort study – Kaiser Permanente hospitals:
•90% regained baseline weight by Day 9
– With birthweight baseline 33% lost 710% and 7.3% lost more than 10% •64% regained birth weight by Day 9 •By Day 14, 12% had not regained birthweight, but 99% had regained 24 hour baseline weight – Noel-Weiss, 2011
•Vaginal delivery – At 48 hours almost 5% lost > 10% of birth weight •Cesarean – At 48 hours over 10% lost > 10% – At 72 hours > 25% lost > 10%
•Weight gain typically began at 48 – 72 hours – Flaherman et al, 2015
Free Powerpoint Templates
Page 31
What to Expect – Weight Loss Nomograms have normalized weight loss in breastfed newborns • Can be used for reassurance to mom: – Instead of “down 7% at 48 hours” rephrase as “normal.”
• Nomograms are a new concept and more research is needed.
Free Powerpoint Templates
Page 32
Effects of IV Hydration • Nearly 50% of babies whose mothers received IV fluids lost >7% of birth weight. – Question – do we really think that this many babies are having problems breastfeeding, or is this number unrealistic?
• Twice as many infants lost >10% whose mothers received >2500 mL IV fluid than those whose mothers received around 1200 mL • Watson, 2012
• Taylor, 2015
–
Free Powerpoint Templates
Page 33
By End of First Month
Free Powerpoint Templates
Page 34
Numbers of Feeds • Babies from 4-26 weeks
• Milk Synthesis – Study done with 20 mothers (4-6 months pp) found that the average hourly volumes of milk produced were 18.0 ±3.1 and 14.0 ±4.8 mL/hour for the right and left breasts respectively •Averages about 32 mL/hour (high 40, low 24 mL) total which is in line with other studies
– Ranged from 6 to 18 feeds/24 hours – Average volume consumed: 76.0 ± 12.6 g
•NOTICE: This average is 2.5 ounces in babies from one month to six months of age
– 64% of babies woke 1-3 times at night to feed – at 6 months of age, 53% of babies were still waking at least 1 time
– Lai Ching Tat, 2010 Free Powerpoint Templates
© 2015/Lactation Education Consultants
Page 35
Free Powerpoint Templates
Page 36
Normal Breastfeeding
Numbers of Feeds
Feed Intervals
• Three factors influence frequency of feeds – Storage capacity of breast – Infant’s stomach capacity – Infant’s gastric emptying time •(Kent, 2006)
Free Powerpoint Templates
Page 37
Feed Intervals • “Some infants would breastfeed again within 1 hour after feeds of up to 175 g, (5.8 ounces) and others would not bf for >8 hours after a bf of as little as 35 g. In fact, the interval after the largest meal of 350 g (11.6 ounces!!!) was only 3 hours 35 minutes.” – Kent, et al., 2006
Free Powerpoint Templates
© 2015/Lactation Education Consultants
Page 39
• Intervals between “meals” was independent of the volume of the previous meal. • Interval was also independent of the average fat content of the milk consumed in the previous meal
Free Powerpoint Templates
Page 38
