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Transitioning Baby to the Breast
©2012 Nancy Mohrbacher, IBCLC,
FILCA 1
Transitioning Baby to the Breast
Nancy Mohrbacher, IBCLC, FILCA
Transitioning from…
• Bottle
• Sipping or lapping methods– Cup
– Bowl
– Spoon
– Syringe
• Tube feeding Preterm/ill baby
• Nipple Shield
Does It Really Matter
How Baby Gets the Milk?
Rasmussen & Geraghty. Am J
Public Health 2011; 101(8):1356-59
Long-term
pumping can be a hardship
• Stressful: “Triple
duty” compared to breastfeeding
• Hormonal levels
differ from less body contact
Affects breastfeeding duration
• 4 months after preterm birth:
– 72% still breastfeeding
– 10% still pumping Smith, et al. Pediatrics 2003; 111(6 Pt 1):1337-42
• Earlier formula use increases risk of
negative health outcomes Ip, et al. Evid Rep Technol Assess (Full Rep) 2007; (153):1-186
Affects milk quality
– After expression, vitamin, antioxidant,
immunological levels decrease
– Freezing kills live
cells
– Contamination risk
– Leaching from container & effect
on components
Transitioning Baby to the Breast
©2012 Nancy Mohrbacher, IBCLC,
FILCA 2
Affects baby’s oral development • Breastfeeding
promotes normal oral development
• Bottle-feeding increases risk of oral malformations
– Cross-bite
– Maxillary atresiaCarrascoza, et al. J Pediatria
2006; 82:395-397. Kobayashi, et al. Am J Orthod Dentofacial Orthop2010; 137:54-58.
May Contribute
to Overfeeding & Obesity
• Consistent flow =
more milk faster
• Overrides appetite
control mechanism
DiSantis, et al. Int J Behavi Nutr 2011; 8:89; Li, R, et al. Pediatrics 2009;
DOI: 10.1542.2009-2549; Li, et al. Pediatrics 2008;122 Suppl 2: S77-84; Taveras, et al. Pediatrics 2006;118(6): 41-48
Bottle-feeding stresses preemies
– Fast milk flow disrupts organization of suck-swallow-breathing
– Greater incidence of oxygen desaturation, apnea, bradycardia
Photo: The Breastfeeding Atlas
Meier. Nurs Res 1988; 37(1), 36-41 Meier & Anderson. MCN Am J Matern Child Nurs 1987; 12(2), 97-105
At what age should we
lose hope that baby will breastfeed?
• Breast-seeking behaviors observed among Australian adopted children, from 8 mo to school ageGribble. Journal of Prenatal & Perinatal Psychology & Health 2005; 19(3):217-235
• Despite age and long use of other feeding methods, older babies and toddlers transition to breast
Babies Are Hardwired to Breastfeed
Our Primary Job: Ooze Confidence
in Breastfeeding
Transitioning Baby to the Breast
©2012 Nancy Mohrbacher, IBCLC,
FILCA 3
With Any
Transition
Start with
the Basics• Share positive
time together there– Talk
– Smile
– Play
• Don’t let it become a battleground
Keep the breast a pleasant place
Keep the breast a pleasant place
Baby’s feet touching mother or something
soft nearby
Reflex TriggersBaby’s front resting on
mother’s body
Use Skin-to-Skin and Body ContactChiu, et al. Breastfeed Med 2008; 3(4):231-37
• Without pressure to take breast
• If baby becomes unhappy,
move away
No Need to Wake BabyColson, MIDIRS Midwifery Digest 2003; 13(1):92-97
Photo: Melanie Ham
Cuddle drowsy,
sleeping baby in
laid-back
positions
• Triggers
feeding reflexes
• Blunts reflex
response &
frustration
Use Sleep
Lowers baby’s resistance to the breast
• Breastfeed while baby sleeps
• Hold baby at breast during sleepSmillie in Genna, Supporting Sucking Skills in Breastfeeding Infants, 2008
Transitioning Baby to the Breast
©2012 Nancy Mohrbacher, IBCLC,
FILCA 4
Baby’s feet touching mother or something
soft nearby
Reflex TriggersBaby’s front resting on
mother’s body
“Breast sandwich”Photo: The Breastfeeding Atlas
“Nipple-Tilting”Photo: Rebecca Glover, RM, IBCLC
Use Breast Support and ShapingKeep baby at breast
level, so less to juggle
Basics Checklist
� Is gravity working for or against breastfeeding?
� If laid-back, tried varying lies & angles of recline?
� Are baby’s feet touching mother’s body
or something soft nearby?
� Did baby first lie on mother’s body in a position
he chose and go to breast in his own time?
� Is baby crying?
� Tried breast support or shaping?
� Tried breastfeeding when baby’s drowsy & asleep?
• If awake, feed a little
first so baby is not ravenously hungry
• Baby will be more open
to trying something new
Photo: Kirsten Hedberg Nyqvist, RN, PhD
IF BABY STILL BALKS AT THE
BREAST, CONSIDER THE 4 Fs
• FEEL• FLOW
• FAMILIARITY• FITNESS to
breastfeed
Target Strategies to the Cause
Glover and Wiessinger in
Genna, Supporting Sucking Skills in Breastfeeding
Infants, 2013
Transitioning Baby to the Breast
©2012 Nancy Mohrbacher, IBCLC,
FILCA 5
FEEL?• Has baby been
exposed to artificial nipples?
• Were baby’s feeding reflexes triggered first?
• Are there positioning issues?
• Does baby need to feel the breast deeper?
Photo: The Breastfeeding Atlas
FEEL Issues
• Use
positioning, body contact &
sleep to release
feeding reflexes
• Help baby achieve a
deeper latch to
trigger more active suckling
Tools can be
used to firm mother’s
nipple (FEEL):
• Inverted syringe
• Nipple everter
• Breast pump
• Nipple shield Kesaree, et al. J Hum Lact 1993; 9(1):27-29
FLOW?• Is baby used to instant, consistent flow?
• Is mother’s milk production low?
FLOW Issues
• To increase flow, boost
mother’s milk production
−Milk expression
−Galactogogues
• Deliver instant flow at breast
−Spoon
−Eyedropper
−Syringe
−At-breast supplementer
FAMILIARITY?
• Previous bad experiences?
– Rough aspiration
– Pushing, fighting
• Hair-trigger temperament or resistant to change?
• Used to another feeding method?
Photo: The Breastfeeding Atlas
Transitioning Baby to the Breast
©2012 Nancy Mohrbacher, IBCLC,
FILCA 6
FAMILIARITY Issues
When transitioning
from another
feeding method,
take baby steps
Sipping/Lapping Methods
Muscles used more similar to breastfeeding than the bottleGomes, et al. Dev Med Child Neurol 2009; 51(12): 936-942Gomes, et al. Jornal de Pediatria 2006; 82(2):103-109
May lead to easier transition to the breastAbouelfettoh, et al. Int
Breastfeed J 2008; 3:27
Lang, et al. Arch Disease Child 1994; 71(4):365-369
Photo: Kirsten Hedberg Nyqvist, RN, PhD
Baby Steps from the Bottle
Make bottle-
feeding more like
breastfeedingKassing. J Hum Lact
2002; 18(1):56-60
Photos: Karl B. Walker
Bottle-feed at breast
• Rest baby’s cheek against exposed
breast
• Wrap bottle in cloth so baby can’t touch it
Photo credit: The Breastfeeding Atlas
“Bait & Switch”• Start bottle-feeding
against exposed breast
• As baby sucks and swallows, quickly remove bottle and insert breast
Transitioning Baby to the Breast
©2012 Nancy Mohrbacher, IBCLC,
FILCA 7
FITNESS to breastfeed
• Is baby in pain?
• Is there a physical or health issue affecting breastfeeding?
Possible Fitness Issues
Genna, Supporting Sucking Skills,
2013
Baby
• Unusual palate or oral anatomy ?
• Pain or birth injuries?
• Respiratory issues?
• Born early?
• Health problems?
• Neurological or tone
issues? Photo: The Breastfeeding Atlas
Possible Fitness Issues Genna, Supporting Sucking Skills, 2013
Mother• Large breasts?
• Taut breast tissue?
• Unusual nipple placement?
• Unusual nipple anatomy?
Do What Works.Don’t Do What Doesn’t Work.
One Mother’s Story
0
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0 1 2 3 4 5 6 7 8 9 10
ml
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Daily average of supplement given to baby
ave MyS
ave F
Transitioning Preterm Babies to the Breast
Transitioning Baby to the Breast
©2012 Nancy Mohrbacher, IBCLC,
FILCA 8
When to Start Breastfeeding
Rather than
“readiness,” think
of breastfeeding as a normal behavior
to be facilitated,
like walking and talking
71 healthy babies born at 26-35 wk– Breastfeeding
began when the babies could breathe without ventilator or CPAP
– Earliest breastfeeding: 28 wk gestation
Nyqvist, et al. Early Hum
Dev 1999; 55(3):247-264
Photo: Kirsten Hedberg Nyqvist, RN, PhD
How to Start BreastfeedingNyqvist, et al. Early Hum Dev 1999;55(3):247-264
Starting preemies
on an “emptied breast” is based on
bottle-feeding
research—not necessary
Photo: The Breastfeeding Atlas
Skin-to-Skin and Body ContactColson, et al. MIDIRS Midwifery Digest 2003; 13(1): 92-97
• Triggers inborn feeding behaviors
• Late-preterm newborns actively breastfed 2.5 hrduring first 24 hr
• Keep baby under mom’s clothes so she learns when baby’s ready to breastfeed from movements, changes in breathing
Photo: Kerstin Hedberg Nyqvist, RN, PhD
Keep environmental
stimulation
• Lights
• Sound
• Touch
to a minimum
Nyqvist, et al. Early Hum Dev 1999;
55(3):247-264
If baby has
breathing or heartbeat
irregularities
– At first, HCP monitors baby
during feedings
– If baby stays
stable, mother can monitor breathing & color
Nyqvist, et al. Early Hum Dev
1999; 55(3):247-264
Transitioning Baby to the Breast
©2012 Nancy Mohrbacher, IBCLC,
FILCA 9
Baby SignsNyqvist, In Supporting Sucking Skills in Breastfeeding Infants 2013
Keep Breastfeeding Stop Breastfeeding
Baby SignsNyqvist, In Supporting Sucking Skills in Breastfeeding Infants 2013
Keep Breastfeeding Stop BreastfeedingChanges in Physiology
Regular heartbeat and breathing
Skin color unchanged
Fast, slow heartbeat or breathing
Color changes (pale, flushed)
Movements
Stable muscle tone
Tucks himself closer to breast
Low muscle tone
Maintains flexed arms or legs
State
Stable sleep or alertness
States easy to distinguish
Drowsy, moves with closed eyes
Fast shifting between states
Interactions
Orients to mother’s face, voice
Mimics facial expressions, coos
Looks away
Eyes “float” side to side or roll
Preterm Breastfeeding StagesNyqvist, In Supporting Sucking Skills in Breastfeeding Infants 2013
1. Tube-feeding, skin-to-skin contact, and frequent
milk expression
2. Breastfeeding begins—Rooting, licking, mouthing
3. Single sucks, short bursts, long pauses, some
milk intake
4. Longer suckling bursts, feedings, more milk
more often, supplements gradually reduced
5. Milk intake increases, occasional larger volumes
6. Milk intake varies, immature suckling pattern,
can fully breastfeed with semi-demand feeding
7. Vigorous, mature suckling, long bursts,
breastfeeds on demand
Photos: Kirsten Hedberg Nyqvist, RN, PhD
Older or healthier babies may start at a later stage
Semi-Demand Feeding
• Stage 6 of 7
• When most
Swedish
preemies are discharged
• Can work well with late
preterm babies
Photo: Kirsten Hedberg Nyqvist, RN, PhD
Semi-Demand Feeding
• Mother does not rely on
baby’s cues alone
• Initiates feedings often
(every 1-2 hr during waking hours)
• Used until about term corrected age
Photos: Kirsten Hedberg Nyqvist, RN, PhD
Practice at the BreastNyqvist, In Supporting Sucking Skills in Breastfeeding Infants 2013
• Feeding every 1-2 hr during the
day eases transition to full breastfeeding
• Closer to typical breastfeeding
rhythm
• Normal behavior to be facilitated
Photo: Kerstin Hedberg Nyqvist, RN, PhD
Transitioning Baby to the Breast
©2012 Nancy Mohrbacher, IBCLC,
FILCA 10
Feeding More Often Improves Feeding Tolerance
• VLBW fed every 2 hrreach full feedings
2.7 days sooner than those fed every 3 hr
• VLBW fed every 3 hrmore likely to:
– Receive ≥28 days of parenteral nutrition
– Have feeds held for ≥7 days
DeMauro, et al. J Perinatol 2011;
31:481-486; N=354
Odor of Mother’s Milk Speeds Transition to Oral Feedings
Preterm babies stimulated by the
odor of mother’s milk while gavage fed transitioned to
oral feedings 3 days earlier than control group
Yildiz, et al. J Nurs Scholarsh
2011; 43(3):265-73; N=80
Cue-Based & Paced Bottle Feeding
• Feed when baby cues
• Hold baby upright
• Start with bottle
horizontal
• Slow-flow teat
• Rest nipple across baby’s lips
• Pause often
• Let baby set pace
Video: Paced Bottle-Feeding by Wilson-Clay, IBCLC, FILCA & Hoover,
MEd, IBCLC, FILCA; Available from ww.breastfeedingmaterials.com
Feeding practice a
better predictor of
effectiveness than
gestational ageCunha, et al. Early Hum Dev
2009; 85(2):125-130
Pickler, et al. J Perinatol 2006;26:693-699
Practice at the BreastNyqvist, et al. Acta Paediatr 2008; 97(6): 776-781
Nyqvist, et al. Early Hum Dev 1999; 55(3): 247-264
• Average gestational age babies began taking milk
from the breast: 30 6/7 wk
• With regular practice at breast,
by 36 weeks 57 of 67 or (85%) exclusively breastfeeding, some as
young as 32 wk
• Median age of exclusive breastfeeding: 35 wk
Photo: Kerstin Hedberg Nyqvist, RN, PhD
Transitioning Baby to the Breast
©2012 Nancy Mohrbacher, IBCLC,
FILCA 11
Emotional Barriers
• What will mother gain? (more time, less work)
• Discuss the value of breastfeeding (not just the milk)
• Start in the hospital (it’s more than nutrition)Pineda. J Perinatol 2011; 31: 540-45
– 0 of 785 Swedish study mothers were pumping and bottle-feeding at dischargeAkerstrom, et al. ActaPaediatr 2007; 96:1450-54
• Signs of milk intake– Swallowing sounds
– See milk around mouth
• Weight checks
• Test weights (to 2g) – Reliable for measuring
milk intake at breastMeier, et al. J Hum Lact 1994; 10:163-68
– Even reliable with leadsHaase, et al. Breastfeed Med 2009; 4:151-56
Nipple Shields?Meier, et al. J Hum Lact 2000; 16:106-14
• Useful tool if preemie:– Slips off nipple when pauses
– Falls asleep quickly
• Preemies on shield took mean 14.4 mL more milk
• No association between length of shield use and duration of breastfeeding
Photos: Catherine Watson Genna, BS, IBCLC
Transitioning from a Nipple Shield
• Nipple shields once considered verboten by many, but
pendulum has swung backJ Hum Lact 1996;12(4)
•95% of LCs & 80% of other HCPs use
nipple shields in their practice
Eglash, et al. Breastfeed Med2010; 5(4):147-51
Reasons Nipple Shields Are UsedChertok. J Clin Nurs 2009;18:2949-55; N=54
Mother-related: 63%
– Flat or inverted nipples
– Nipple pain
– Nipple trauma
– Engorgement
Baby-related: 39%
– Poor or weak latch
– Ineffective suck
Transitioning Baby to the Breast
©2012 Nancy Mohrbacher, IBCLC,
FILCA 12
Thick, rubber shields reduced milk intake by 22% Woolridge. Early Hum Dev 1980;4(4):357-64
– Do mothers need to pump to maintain milk production?
– Study babies had breastfed well & were using shield for first time
• No difference in
weight gain among babies using thin,
silicone nipple shield
vs those not using shield Chertok. J Clin Nurs 2009;
18:2949-55
• No need to pump
afterwards if baby is
feeding well
• Signs of milk transfer:– Milk seen in the
shield after feedings
– Swallowing sounds
– Breast feels less full, heavy
• Weight checks
• Test-weighing
Photos: The Breastfeeding Atlas
Weaning from a Nipple Shield
• Start with shield on
• When swallowing,
slip off shield,
slip in breast
• If not, try again at a
relaxed time
• Not every day
Weaning from a Nipple Shield
• Cutting the shield
no longer recommended
• Was safe with latex shields
• With silicone shields, creates
sharp edges
• 67% eventually weaned from shield
• 33% used it throughout breastfeeding
– 11% could have nursed without it
– Continued using it for greater comfortPowers, et al. J Hum Lact 2004;20(3):327-34; N=202
Weaning from a Nipple Shield
Transitioning Baby to the Breast
©2012 Nancy Mohrbacher, IBCLC,
FILCA 13
Babies are
hardwired to
breastfeed
Conclusion
Mothers are
hardwired to help
When the basics
don’t work,
think “Four Fs”
– Is there a fitness issue?
– Use feel, flow & familiarity
to help baby
accept the breast
Target tools
and strategies
to the
problem’s
cause
Questions? E-mail: [email protected]
Reporting on breastfeeding trends at: www.NancyMohrbacher.com
www.BreastfeedingMadeSimple.com
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