Certified Lactation Counselor

Predominant Breastfeeding

Babies who receive breastmilk and other liquids (e.g. water, minerals, vitamins, oral meds).

Breastfeeding

Baby receives human milk, as well as other foods or fluids, including formula.

Complementary Feeding

Process starts when BM alone or infant formula alone is no longer sufficient to meet nutritional requirements of infants, therefore other foods or liquids are introduced. Typically child is between 6-23 months

3 strategies for increasing BF initiation and duration

Promotion, Protection, Support

Promotion

Focuses on advantages of BF on a personal, community, country, or global level. BF to the community.

Protection

Focuses on government, manufacturer, and social responsibility to assure BF ability to compete with commercial interests.

Includes state, local, an national laws regarding BF.

International Code of Marketing of Breast-milk Subsitutes

Addresses improper marketing practices by formula companies. It is not currently a law in the US.

What does the International Code Prohibit?

Distributing free formula

Giving coupons for formula

What did the AAP resolution state in regards to the International Code?

No distributing formula, discharge bags, industry written handouts.

Support

Focuses on interaction of helpers with family, as well as program development and implementation.

10 steps to successful BF

1. Written BF policy. Skin to Skin immediately after birth.

2. Train healthcare staff

3. Inform pregnant women about benefits and management of BF

4. Help all mothers initiate BF within 1 hour after birth

5. Show mother's how to BF and maintain lactation

6. Exclusive breast milk only

7. Practice rooming in 24 hours a day

8. Encourage BF on demand

9. No artificial teats or pacifiers

10. Establishment of BF support groups

Healthcare staff responsibility for working with lactating mothers include what?

1. Training

2. Minimum of 20 hours of training

3. 3 hours of competency verification

What are the indications for providing supplementation other than breast milk?

1. Medical condition

2. Parents request after being informed of consequences

Protocol for calculating Baby's daily needs

Baby's weight x 2.5 (2.7 or 3.0 if Baby needs to catch up weight) = daily ounces. PCP decides what the multiplier is!!!

What should be assessed 3-5 days after birth by PCP?

Hydration (elimination patterns)

Body weight (no more than 7% loss)

Observe Feeding

Maternal or infant issues

What is a CLC?

Nationally recognized designation awarded by the ALPP. Practice parameters are designated by professional scope of practice.

How many stools per day should a breast fed newborn have?

4, some yellow by day 4.

When should a baby be back to birth weight?

12-14 days post birth

How much weight should a baby gain daily?

Approximately 1 ounce

Why do women supplement with formula when there is no medical need?

1. Lack of preparation for what the newborn period would be like.

2. Lack of timely interventions

Alveoli

Small glands in the breast that produce milk

At-Breast Supplementer

a device that allows a supplement to be given while a baby is actively nursing at the breast,

ex: Supplement Nursing System

Atopy

hypersensitive or allergic state involving an inherited predisposition

What is the BFHI Baby Friendly Hospital Initiative

Initiative by UNICEF and WHO (1991) to support breastfeeding in hospitals and maternity centers. "The 10 Steps".

Unicef. Baby-Friendly Hospital Initiative. Available online: http://www.unicef.org/programme/breastfeeding/baby.htm.

Bilirubin

an orange-yellow pigment formed in the liver by the breakdown of hemoglobin and excreted in bile.

CCK (cholecystokinin)

Hormone that regulates the emptying of the gallbladder and secretion of enzymes by the pancreas.

Colostrum

Thick, milky fluid secreted by the breast during pregnancy and during the first days after birth before lactation begins. Causes a laxative effect which helps the baby pass meconium.

Coryllos type

Classification system for anklyloglossia (tongue-tie)

Dancer Hand Position

Technique used to support Baby's chin and mother's breast. Use Thumb and index finger under chin, remaining 3 fingers to support breast.

Alveolar Cells

found in the walls of the alveoli, simple squamous epithelial cells, main sites of gas exchange

myoepithelial cells

contract in response to stimulation by sympathetic nervous system and squeeze milk up the duct

Montgomery glands

Bumps on breasts (Look like goosebumps)

Produce a unique blend of milk and sebum (skin oil)

Modern study of the structure of the breast reveals what?

-Fat is mixed throughout the breast

-Uneven spacing of the ducts

-3-5 functioning nipple pores (May have 5-9, but not all work)

-No lactiferous sinus

What are the 2 hormones pathways that control lactation?

Prolactin and Oxytocin

Prolactin (4 details related to milk production)

1. is triggered by touch (pregnant and non pregnant women). Higher levels when stimulating breast/nipples vs breast alone.

2. Lengthening time between feeding leads to lower baseline levels. (Weaning)

3. levels go down between nursings and rise during nursing.

4. Infrequent nursing leads to lowering of this hormone

Average number of feeds in a day?

8-12

What produces colostrum?

Progesterone in the receptor sites

What produces more mature milk?

Prolactin in the receptor sites

What happened when infants suckled in the first 2 hours of birth?

Ingested significantly more milk on day 4

What happened to mother of preemies who initiated milk expression within 1 hour of birth?

Had significantly more milk when measured on days 7 and 42. Better to stimulate breasts throughout the day right after birth to continue to stimulate production.

Oxytocin

A hormone released by the posterior pituitary that stimulates uterine contractions during childbirth and milk ejection during breastfeeding.

What 3 things can trigger Oxytocin?

1. Conditioned response

2. Nipple stretching

3. Hand massage

Conditioned Response from Milk Ejection (Let down)

-Example- Mother lets down when not near baby, but hears a baby cry.

-Conditioned over time

-Faster for women who have BF in the past

-To condition the response can use any sense-smell, touch, sound

Nipple stretching

Only happens with a proper latch

Hand massage: Baby

When we allow babies to be more hands on they can help control flow rate by how they massage the breast.

How many triggers does Oxytocin have? Can it be triggered by stress.

3 triggers. Yes.

What is hormone is triggered by stimulation?

Prolactin

What 3 emotional/behavioral function do the hormones of lactation have besides making milk?

1. Aggression

2. Protection

3. Bonding/trust

What is special about the composition of milk?

1. Mammal species with higher water content milk feed more frequently.

2. Prolactin triggers production of lactose in the mammary cells.

What are the different care patterns of mammalian mother's and their babies?

1. Nest (eg. puppies, cats) OR cache (deer, rabbit)

2. Carry (monkey), follow (giraffe, bison), or hibernate (bear)

What kind of milk has the highest lactose of all mammalian milk?

Human milk: high in water, low in protein and fat.

When does paracellular transport occur?

1. In the first few days after birth

2. Mother with low prolactin levels

When are cells not plump?

During paracellular transport

Transcelluar pathway

Substances must go through the milk cell to enter the milk.

Cells are plump and can no longer go around.

Why is colostrum easier to suck/swallow

Because it is thicker and takes longer to express from the breast.

What are the 3 stages of milk making?

1. Secretory Differentiation: Lactogenesis I

2. Secretory Activation: Lactogensis II

3. Lactation: Lactogenesis III

What happens during Secretory Activation? Lactogensis II

Rapid drop in progesterone, mature milk making is activated

What happens during Secretory Differentiation? Lactogenesis I

Cells grow and expand

When does breast milk composition change?

Can occur:

1. Within a feeding

2. Within a day

3. Over course of lactation

What happens during Lactation? Lactogensis III

Mature milk is being made. frequent expression of milk

Preterm milk composition is...

Higher in protein, fat, and electrolytes than mature milk

What is foremilk?

first milk excreted at the beginning of feeding. Does not always mean low fat.

What is hindmilk?

Milk at the end of the feed. Not always higher in fat.

When is fat transfer high?

When oxytocin levels are high.

Does a mother need to nurse both breasts in one feed?

No. Some babies do better on one breast per feeding.

Who regulates the fat intake when feeding?

The baby can regulate his fat intake quickly.

When is fat content higher?

When the flow is faster.

Can milk fat be different if the baby is male or female?

Yes.. Mother's seem to produce milk that is 25% higher in fat content for males.

galactorrhea

abnormal discharge of milk.

Ex: Men make milk, due to brain tumors or drug side effects (haldol, Thorazine).

Reasons why BF protects babies from diarrhea?

1. pH of the gut is lower. Bifidus factor promotes growth of friendly bacteria which maintains lower pH in the gut.

2. Low iron in the gut. Organisms need iron to survive! Lactoferrin deprives bacteria of iron.

3. Hormones and growth factors stimulate growth, development, and motility of the gut.

4. Antibodies (e.g. Secretory IgA [SIgA] which bind to microbes in the digestive tract and prevent them from being absorbed.

5. WBC kill microbes (e.g. B and T lymphocytes)

6. Cell wall disrupters that kill microbes by destroying the cell walls

7. B12 binding factor. Same result as iron.

8. Mucous also wall protectors which keep bacteria from attaching to the cell wall.

9. Microbes (bacteria from the mother's intestine) from the mother's skin transferred to baby.

10. Absense of exposure to contaminants (e.g. bottle, water, teat)

11. Exposure to mother's immunize system.

12. Cells from the babies mouth go into the mother's breast. Antibodies are made in the breast.

Does feeding a baby formula occasionally make a difference?

Yes, even just one bottle can impact the pH of the babies gut.

Gut of exclusive BF baby is lower (more acidic), while gut of formula fed baby is more neutral

What bacteria do formula fed babies have an over abundance of?

C Diff

Vagal nerves (parasympathetic)

Stimulates peristalsis and secretion not the GI tract

splanchnic nerves

Inhibits peristalsis and secretion. Adrenal gland increases secretion of adrenaline and noradrenaline.

Somatostatin

hormone that inhibits release of growth hormone and insulin

What promotes glucose induced insulin release and exert trophies effects of the gut?

Gastrin & CCK (cholecystokinin)

What increases gastrin and decreases somatostatin in babies?

1. Sucking

2. Own species milk

3. Decreased stress

4. Wellness

5. Touch

When do babies start to suck?

27 weeks.

What happens when babies suck?

Sucking activates cutaneous receptors in the babies mouth, causing the baby's parasympathetic nervous system to trigger release of gastrin and decreased somatostatin. This makes us feel sleepy and full.

Are mother's GI hormones impacted by sucking and skin contact?

Yes, it activates the parasympathetic nervous system. Increases in gastrin, CCK, and insulin have been observed.

How much weight loss is acceptable in a neonate after birth?

No greater than 7% from birth & no loss after day 5.

What would cause an increase lose of weight in the first postpartum days?

1. Labor meds used

2. Interpartum fluids used

3. No labor prior to cesarean

Hypernatremia

High concentration of sodium in the blood

Why would a baby develop hyperetremia or malnutrition

1. Not feeding frequently enough (e.g. q3-6 hours/day 5-10min/side=60-120 min/day)

2. Babies too sleepy (likely due to lack of nutrition)

3. Babies should be fed on demand, not qxxx hours.

What color is meconium stool?

Dark brown

What color is transitional stool?

Green

What color is mature breast milk stool?

Brown

What causes hyperinsulinemia?

Excess insulin in the blood, due to overproduction. This might cause the higher weight gain in formula fed babies. Could also be related to high fat and protein levels in bovine formula.

What is a significant protective factor against obesity in children?

BF

What does the White House Task Force on Childhood Obesity recommend?

Exclusive BF for 6 month, then BF with complementary foods for 1 year or more.

What are some BF myths?

1. Breast size matters.

2. She isn't drinking enough fluids

3. She is exercising too much, working too hard, not resting enough.

4. She is too stressed.

5. It's what she eats or doesn't eat.

How do we assure an adequate milk supply?

1. Understanding of how BF works

2. Early initiation and adequate BF

3. Appropriate BF assessment

4. Improved and early BF support

5. Appropriate HCP/LCP f/u in the postpartum

How much milk does a mother produce?

750-1000mLs/day

What are some negative influences on milk supply?

1. Long spaces between feedings

2. Long, slow feedings

3. Excessive pressure on the breast

4. Breast surgery/injury

5. Anatomical concerns

6. Altered physiology

7. Physical objects

What could cause pressure on the milk-making cells?

1. Vascular, lymphatic, and third-spacing forces

2. Secretory activation - Lactogenesis II

What are some characteristics of the normal breast?

-Soft

-Normal body temp

-Mother feels well

-Breasts may be hot

-Nipple graspable

What are some characteristics of the engorged breast?

-Hard

-Temp normal +

-Mother feels discomfort

-Breast hot, shiny

-Nipple is hard to grasp/latch

When do symptoms of engorgement occur?

-Between days 3-5

-Moms with a lot of IV fluids, may have swelling up to day 9

-Women who have had a c-section experience it 24-48 hours later.

What happens to the engorged breast?

- As pressure increases, milk production decreases.

What causes pressure in the breast (engorgement)? 4 things...

1. Milk left post feed

2. Missed feedings

3. Restrictive bras and clothing

4. Breast implants (storage capacity is less)