October 2012 Issue

Breast-Feeding Success
By Juliann Schaeffer
Today’s Dietitian
Vol. 14 No. 10 P. 52

Experts offer solutions to five common problems to help RDs counsel working mothers.

The evidence of breast-feeding’s many health benefits—for both mothers and babies—is plentiful and has stood as the backbone of current recommendations from the American Academy of Pediatrics, the American Academy of Family Physicians, and even the Academy of Nutrition and Dietetics.

These organizations espouse the importance of breast-feeding exclusively for the first six months of life and then in concert with complementary foods for at least 12 months.

Today’s Dietitian interviewed experts on the subject of breast-feeding. They discuss the myriad health benefits it provides, the obstacles women face in carrying it out successfully, and the solutions nutrition professionals can share with clients and patients to help them meet their goals.

Health Benefits Abound
“Breast-feeding provides many well-documented health benefits for the child and the mother,” explains Karthi Streb, MPH, director of programs at the National Initiative for Children’s Healthcare Quality and program director for its Best Fed Beginnings project, which aims to improve maternity care practices in US hospitals to better support breast-feeding. “For infants, it decreases the incidence and severity of many infectious diseases, helps in neurodevelopment, and reduces mortality. It also decreases an infant’s risk of becoming obese later in childhood. For moms, breast-feeding decreases the risk of ovarian and breast cancers, cardiovascular diseases, diabetes, and rheumatoid arthritis. For both mother and child, there are benefits to the emotional bonding as well, including those associated with skin-to-skin contact.” She also notes there are cost considerations to bear in mind when choosing breast-feeding over using formula.

What’s more, breast-feeding reduces an infant’s risk of developing type 1 diabetes due to breast milk’s high insulin levels. It also reduces the risk of ear infections, allergies, and sudden infant death syndrome. Plus it reduces the risk of postpartum bleeding and postpartum depression in mothers, according to Gay Bearzi, RN, IBCLC, a lactation consultant at Sinai Hospital of Baltimore.

“These are just a few of the many benefits for mother and child,” Bearzi says, adding that all the specifics of breast-feeding’s benefits are still being teased out with new research. “Every component of breast milk has a specific role, and we’re still learning how the different elements contribute to the child’s overall health.”

According to a recent study published in the July issue of Pediatrics showing that 85% of new mothers planned to exclusively breast-feed for the first three months of their child’s life, the knowledge of breast milk’s benefits seems to be reaching most women. However, in a telling and disconcerting statistic, the same study found that only 32.4% of these women actually met their breast-feeding goals.

“Breast-feeding may be the healthful choice, but it’s certainly not the easy choice,” Streb says. “The fact that 85% of new mothers intend to exclusively breast-feed for the first three months is great, although it could be higher. But the number of moms who actually meet that goal is more concerning.

“Breast-feeding isn’t the right, or even feasible, choice for everyone for a myriad of reasons,” she adds. “But for those mothers who do choose breast-feeding, we need to make this choice an easy choice by setting up the system to support them. This includes the hospital, the community, and employers for those moms who return back to work.” 

Streb is involved with one initiative aimed at making breast-feeding the easy choice from day 1—at hospitals. Hospitals that complete the National Initiative for Children’s Healthcare Quality’s Best Fed Beginnings program are designated “Baby-Friendly,” which is “a global designation indicating that the hospital employs best maternity care practices to support breast-feeding mothers, as outlined by the World Health Organization’s Ten Steps to Successful Breastfeeding,” Streb says. “But it’s important to remember that the hospital is just one part of a complex system. We also need better supports in the community and the workplace.”

Lactation consultant Michelle Branco, IBCLC, RLC, agrees: “We’ve focused a great deal of the public health effort on getting education [about breast-feeding’s benefits] to parents, and I think that’s worked. However, what hasn’t happened is the effect that we’re seeing now: mothers who have the goal of breast-feeding and can’t meet that goal. That has everything to do with the hard part for us as healthcare providers: support for those mothers in how we practice and how we advocate for them and their babies.”

Although motivated by the knowledge of its benefits and an instinct to do what’s best for the new baby, many women still struggle with breast-feeding. Whether struggling with the physical difficulties of insufficient latching and pain during the first few days or weeks of a baby’s life or even the lifestyle hindrances that come when mothers return to work, Gina Ciagne, CLC, a certified lactation counselor and senior director of breast-feeding relations at Lansinoh Laboratories, says most women who encounter obstacles during breast-feeding can overcome them with the necessary knowledge, strategies, and support to ensure they meet the goals they set for themselves and their babies.

“If and when problems arise, there are many solutions and these can help a mom to continue,” she says. “It’s when a challenge isn’t addressed that the problem can intensify and it can be harder to remedy. Once moms and their babies get the hang of nursing, within the first few days and weeks, it does get easier and mom tends to feel more confident in herself and her breast-feeding.”

The following are the top five obstacles that often hinder a woman’s plans to breast-feed and solutions to remedy the problems.

Common Breast-Feeding Obstacles

Insufficient Milk Supply
Bearzi says new mothers attempting to breast-feed most frequency ask whether they have enough breast milk to feed the baby, noting that many women fear they can’t provide enough milk to sustain the child.

However, she says providing proper education can help ease this common anxiety. “As medical professionals, we need to explain to the mother and family that ‘yes, you do have enough breast milk,’” she says. “An infant’s stomach is only as big as a marble the first couple of days of life. A breast-fed baby feeds every two to three hours. An infant’s stomach is made to absorb breast milk faster than formula.”

“Providing parents with teaching about normal newborn behaviors and feeding patterns is critical,” Branco says. “The idea that baby isn’t getting enough is a very normal concern for parents. They need appropriate teaching about colostrum and milk ‘coming in.’” Also remind moms that the more the baby latches (or mom pumps), the more milk will be produced, Streb says. “It’s also important for mom to eat well and drink lots of water.”

Ciagne, who’s a La Leche League International-trained breast-feeding peer counselor, says getting the professional opinion of a breast-feeding expert can help immensely in handling any issues that could be contributing to low milk transfer, adding that provisions in the Patient Protection and Affordable Care Act now allow lactation consultant services (by those certified as IBCLCs) to be covered under many health insurance plans.

“Assessment of a mother’s lifestyle also can address underlying issues such as being exhausted and unable to get sufficient rest; postpartum depression, which can lead to a mother skipping feedings; or a mother being on medications or herbal supplements, which can sometimes impact milk supply,” she says.

Pain
New mothers frequently experience pain and nipple injury, especially upon breast-feeding initiation. In this case, Branco says reassurance and referrals to appropriate lactation staff is critical, as pain can be a major deterrent to continuing breast-feeding, especially after mothers return home and lose the support of the hospital environment.

“If pain is a factor, mothers often will soldier on through a couple of weeks, then be unable to continue,” Branco says. “Providing guidance about how pain and nipple [injury] aren’t normal—though very common—and referrals to appropriate resources help not only to fix the problem at hand but also prevent the mother from feeling hopeless about breast-feeding the next time.”

If a new mom is experiencing pain or soreness when nursing, Ciagne says incorrect latching is more than likely the culprit. “An in-person assessment by an international board-certified lactation consultant or trained breast-feeding counselor is important so the provider can assess the latch, the baby’s milk transfer, and anything that could be causing the poor latch—tight frenulum, mouth anatomy, etc,” she says, and then teach the mother how to correctly latch the baby to the breast.

Isolation and Lack of Support
Streb says being a new mom at home with a newborn can be incredibly isolating—and she speaks from personal experience. “On top of that, I decided to nurse my baby so there wasn’t much for dad to do,” she remembers. “He was supportive, changing diapers, and soothing our daughter, but when my daughter was hungry, it was up to me and in the beginning, that was all the time. Knowing that I was making the first healthful choice for my family and providing her with natural nourishment kept me going, which really boils down to education and support from my family.”

But not all family members support mothers in their quest to breast-feed, and some well-meaning members may be all too quick to offer to feed a formula-filled bottle so “mother can rest.”

“However, skipping a feeding can alter milk supply, so learning how to nurse lying down so she and the baby can get rest can be a great option,” Ciagne says. “Keeping baby in the room with you within arm’s reach in a bassinet or cradle near to the bed also can help lessen the time it takes to go into another room when baby wakes at night. As they grow and get older, the time periods between feedings gets longer, so it’s not always going to be the case that she’s so tired. Uninterrupted sleep will return eventually.”

In addition to hard-copy educational materials, provide mothers with info for local breast-feeding support services as well; they can be a lifeline, Branco says. “Making sure mothers are connected with support in the community upon discharge is critical, whether it’s an outpatient hospital clinic, community public health clinic, or private lactation consultant,” she says. “Mother-to-mother support like La Leche League, Breastfeeding USA, or other community support groups have been shown to contribute positively to both duration and maternal satisfaction with breast-feeding.”

Sometimes, the seemingly small act of listening and finding a way to establish a rapport with the mother can do wonders, Bearzi says. “Listen carefully to show that you’re really interested in helping her,” she says. “Offer information, make suggestions, and discuss options. Put your own feelings and experiences in the background and make the mother the main focus.”

Returning to Work
As if juggling the mountain of new baby responsibilities isn’t enough, returning to work can add pumping- and work-related challenges to the mix, causing many mothers to reconsider just how much they can handle at one time.

“I commute an hour each way to work in New England, and it’s not fun dragging around your laptop, your pump, and a cooler to store all that breast milk—whether it was in the rain, snow, or sunshine,” Streb recalls. “It’s also not easy to carve out time in a busy day to pump.”

“Returning to work often is cited as a time when mom weans early as she worries about balancing breast-feeding and pumping and her job-related duties,” says Ciagne, who recommends mothers have an up-front conversation with their employers about the specifics of pumping in the workplace.

“Talking with her employer ahead of time about where she can pump privately and practicing with her pump ahead of time can ease many of these worries,” she adds. “As with anything, with practice, she’ll get more used to it. While it’s sometimes a labor of love to pump and leave milk behind while also nursing her baby when they’re together, it’s manageable to balance breast-feeding with working.”

Provisions in the Patient Protection and Affordable Care Act are meant to ease this stressful time for working mothers by ensuring they have break time and a private place to pump while at work. However, these provisions don’t apply to all employers, and they don’t erase all workplace obstacles.

“The problem is that the employee still has to take the time to pump on her own time, meaning lunch and breaks,” Bearzi says. “Some mothers who return back to work before three months have difficulty with their milk production. Even going back to work after three months can cause a milk production challenge.”

To ease these troubles, Bearzi suggests new moms take as much time off work as is feasible and recommends having five days’ worth of bottles in the freezer before returning to work.

The right breast pump also can make life easier for those who choose to return to work postbaby, so make sure they know what options are available. “It’s important that a mom that’s returning to work who will be away from her breast-fed baby for a sustained period of time invest in a quality double electric breast pump so she can keep up her supply and leave milk behind for a caregiver to feed the baby,” says Ciagne, adding that the cost of breast pumps and supplies are now covered under many health insurance policies, courtesy of the Patient Protection and Affordable Care Act.

Free Formula Samples
Until recently, it was the norm for most hospitals to send new parents home with a baby goody bag filled with free formula samples. And even though a hospital may openly support breast-feeding and give classes on the topic, giving this free formula is an implied endorsement, Ciagne says.

Even for those planning to exclusively breast-feed, the convenience of at-hand formula can be ever-so-tempting for mothers struggling with temporary breast-feeding obstacles, and studies have shown that this free formula can lead more women to stop breast-feeding sooner.

“Studies have shown that when mothers are discharged with formula samples, rates of exclusive breast-feeding are reduced at all time points: one week, one month, three months, six months, etc,” Bearzi says. “Free formula samples are convenient, but if they’re given to the baby, they undermine the mother’s ability to produce enough breast milk.”

However, hospitals and healthcare providers seem to be catching on to the correlation between handing out these free samples and its negative impact on breast-feeding. More healthcare systems are declining to offer samples to all moms, and some cities and states are refusing to do so as well. Recently, Massachusetts became the second state (after Rhode Island) in which hospitals voluntarily banned the practice.

What You Can Do
Besides sharing these tips to remedy breast-feeding problems women may encounter, Streb says dietitians can play a critical role in explaining and validating the benefits of breast-feeding to new mothers. “They also can play an essential role in supporting healthful eating for new moms that will pave the way for modeling healthful eating [patterns] as babies grow.”

And while breast-feeding offers benefits even when mothers’ diets aren’t optimal, Streb says a healthful diet is essential to optimizing breast-feeding. “Breast milk production is supported by a variety of diets, but optimizing nutrition is very important to give a baby all the nutrition she or he needs,” she says. “Important factors to consider are adequate intake of calcium, healthful fat, fiber, fruits, vegetables, and water. This conversation should begin as early as possible in pregnancy and continue through the postpartum period to ensure the best possible nutrition for both mom and baby.”

Dietitians also can help breast-feeding moms by providing handouts and referral information. “Simple handouts are very good tools to use, as mom can bring them home and assess them if she has a question or an issue arises,” Ciagne says. “Referrals to lactation consultants and other breast-feeding educators in the dietitian’s area also can be instrumental, as they’re trained in the intricacies of breast-feeding and often can supplement the dietitian’s guidance when helping a breast-feeding mom. The International Lactation Consultant Association has a great searchable database [www.ilca.org] in which a dietitian can find local professionals for referrals.”

Whether it’s providing prenatal or postnatal education, specific tips, or a hug of support, provide clients with what they need to overcome breast-feeding’s most common bumps in the road. Indeed, offering this assistance often can mean the difference between a disappointed, guilt-ridden, or miserable mama who gives up breast-feeding and one who can confidently overcome the obstacles to breast-feeding success.

— Juliann Schaeffer is an associate editor at Great Valley Publishing Company and a frequent contributor to Today’s Dietitian.