Key Messages for Parents Cues are simplistic and NOT specific ◦ Parents may need to “play detective” to figure out what their babies are trying to tell them For most healthy term babies, feeding cues are obvious 51
What are your questions? 52
Baby Basics Crying CRYING IS A VITAL “TALENT” USED BY INFANTS TO INDICATE DISTRESS. 53
Crying: Babies’ “Superpower” Crying results in a sound that affects the nervous system in most adults ◦ Drives adult activity! Must be loud to rouse sleeping caregivers ◦ Prompt response to cues can reduce crying Hiscock H. The Crying Baby. Australian Family Physician 2006; 35: 680-4. 54
Understanding Crying All babies cry for many reasons Hungry babies use hunger cues Occurs more often when needs are not addressed ◦ Cues not clear? ◦ Inappropriate response? ◦ Overstimulation? 55
Day 1 vs Day 2 56
Calming Crying Babies Address the issue – look for cues! Reduce varied stimulation Introduce repetitive, sustained stimulation (repetition to soothe) 57
Why Bottles “Work” Bottle = quiet baby ◦ Crying baby must swallow- can’t make noise ◦ “sweet fluid” on tongue triggers the sucking reflex This can be explained to parents 58
Be a Baby Behavior DETECTIVE! Baby Luz is 28 hours old She was fed an hour ago, and now she is being passed around and held by relatives visiting the hospital. She begins to cry. Thinking she is hungry, her mother tries to breastfeed her. But Luz seems to get only more upset, crying, turning her head away and arching her back. 59
Key Messages for Parents Crying doesn’t always mean hunger – look for hunger cues (feed every time they see them) Respond to other cues as best they can Reduce stimulation if possible Use repetition to soothe as needed 60
Baby Basics Sleep BABIES DO NOT SLEEP LIKE ADULTS 61
Infant Sleep States Active sleep (REM) is light sleep Qui Quiet s sleep eep i is deep deep s sleep eep o Babies dream and blood flow o No dreaming increases to the brain bringing o Little or no movement nutrients to active o Important for the brain cells brain to rest and o Images stimulate brain recover development o Growth hormones o Easy to wake o Difficult to wake Infants “cycle” through active sleep, quiet sleep, and waking. Peirano et al. J Pediatr 2003; 143: 70-9. 62
Newborn Sleep/Wake Cycle Newborns start sleep in Active Sleep (AS) (dreaming for 20-30 mins) and move to Quiet Sleep (QS). Wake frequently 63
Sleep patterns change predictably with infant age… 64
Key Messages for Parents Dreaming/light sleep are good for baby’s development and safety Newborn may wake when laid down while dreaming As they get older, babies sleep longer and more at night 65
What are your questions? 66
Supporting Exclusive Breastfeeding 67
Newborn Behavior and Breastfeeding Disengagement cues are confusing Crying on day 2 is often misinterpreted Waking frequently is misinterpreted 68
The Breastfeeding Transition Latch takes time ◦ Baby will signal distress ◦ Baby will attempt feeds frequently Expect quick improvement Can be a roller coaster at first Learning to BF is a “journey, not a moment…” 69
The breastfeeding transition : The only certainty is variation 70
Preparing parents for visit with “the expert” (lactation consultant) 71
Key Messages for Parents about Early Breastfeeding On day 2, baby will wake and demand feeds Babies use cues – get better with response Latching takes practice – expect quick improvement Moms feel changes in breasts after discharge 72
Prepare for strong emotions ◦ Use body language and baby behavior knowledge to reassure Explain and demonstrate how to obtain best level of alertness for feeding Supporting ◦ Variety to awaken, repetition to soothe Lactation Demonstrate steps for latch attempts ◦ Pre-interpret or reinterpret “rejection” of the breast Explain feeding reflex not volume drives satisfaction with feeds – can’t rush process 73
What are your questions? 74
Tools: Teaching Parents about Baby Behavior 75
The Cornerstones of Baby Behavior 1.Engage the caregiver by explaining baby behaviors parents see and hear (use the baby’s name) 2.Share information. Stay with the basics related to caregiver questions/needs 3.Empower parents to help them fix or cope with the issue Simplification of NBO and NCAST interventions 76
Engage Show caregivers that you understand their baby (use the baby’s name) “I can see that Lila is upset. Before I came in, did she……? And then did she …..” 77
Share Information “Lila may cry for many reasons.” “Latching does take practice.” “It’s hard but crying more on day 2 shows us Erin is doing well.” “When her face twitches, Keisha is dreaming and sleeping lightly.” 78
Empower “Once you and Lila know each other better, you’ll be able to understand her cues better than anyone.” “Keisha will fall asleep in light sleep first and she’ll be easy to wake. You could hold her in the same position until she stops twitching or you could have someone else hold her until she falls into a deeper sleep. What do you think will work for you?” 79
Self Assessment Find the Words 80
A mother calls you shortly after her 6 morning visitors leave. Baby Luz is 28-hours-old, quietly fussy and arching away from her mother who says “she hates breastfeeding, she’s rejecting the breast. We need a bottle.” What might you say first? a. All we need to do is calm her down, I’ll show you how. b. Before she started to cry, did Luz close her eyes and try to turn her head away when you tried to feed her? c. Babies need time to learn to latch. 81
Baby Lilly is 36 hours old. Her mother, Monica, is eagerly anticipating a consultation with the lactation consultant. She tells you, “I’ll be so relieved once they fix her latch problem and I can be sure she’s getting what she needs.” What might you say first? a. Holly will help us both see Lilly’s progress and if there is anything slowing you guys down as you get closer to a consistent latch. It always takes a few days. b. Holly is the best LC there is. She’ll be able to help you. c. Don’t get your hopes up, sometimes babies take several days to latch consistently. 82
Parents get overwhelmed if you make baby behavior too complicated Identify cues/signs that the baby is already exhibiting or that parents are most likely to see and use the baby’s name Simplify Promote and support interaction rather than focus on infant development Consistent messaging is important 83
What are your questions? 84
Thank you for all the wonderful work you do! UC Davis Human Lactation Center lactation.ucdavis.edu 85
Addressing Racial Disparities in In-Hospital Formula Feeding INCREASING EXCLUSIVITY WITH PRENATAL EDUCATION ON BREASTFEEDING GOALS SEPTEMBER 3, 2020
Marcia Burton McCoy, MPH, IBCLC marcia.mccoy@state.mn.us Stacey Welman, WIC peer counselor Stacey.Welman@hennepin.us Rocio Ancasi, WIC peer counselor Rocio.Ancasi@hennepin.us
Poll
Exclusive compared to partial breastfeeding Even brief exposure to formula carries risks Even brief exposure to formula alters the infant microbiome. Among infants who were exclusively breastfed post-discharge but received formula as neonates, this brief supplementation was detectable at 3 to 4 months of age, with lower abundance of Bifidobacteriaceae and higher abundance of Enterobacteriaceae. (Forbes) Avoiding cow’s milk formula for at least the first three days of life was protective against allergy at 2 years of age. (Urashima) Formula supplementation in the hospital often leads to continued supplementation after discharge. (Pérez-Escamilla; Wilde)
Exclusive compared to partial breastfeeding (post-discharge) Exclusively breastfed infants had lower rates of respiratory and gastrointestinal tract infections compared to partially breastfed infants. (Duijts 2010) Exclusive breastfeeding minimizes the risk of sudden infant death (SIDS), compared to partial and full formula feeding (Hauck 2011) ◦ odds ratio for breast+formula feeding: 0.40 (95% CI: 0.35–0.44) ◦ odds ratio for exclusive breastfeeding: 0.27 (95% CI: 0.24–0.31)
Among MN WIC participants: McCoy, M. B., & Heggie, P. (2020). In- hospital formula feeding and breastfeeding duration. The risk of early weaning was Pediatrics , 146 (1) e20192946; DOI: https://doi.org/10.1542/peds.2019-2946 significantly greater for breastfed infants when they were given formula in the hospital (Hazard ratio for weaning 2.5 to Commentary: 6.1 times greater for supplemented In-Hospital Formula Feeding and Breastfeeding Duration Lori Feldman-Winter and Ann Kellams babies across the first year). Pediatrics July 2020, 146 (1) e20201221; DOI: https://doi.org/10.1542/peds.2020-1221
Rates of In-Hospital Formula Feeding (IHFF) and median days breastfed for breastfed infants born in 2016 and enrolled in the Minnesota WIC program, by cultural identity infants in percentage median days Interquartile original sample breastfed range IHFF American Indian 273 41.8 73 19-254 Hmong 714 82.4 53 8-143 non-Hmong Asian 600 58.3 174 52-381 U.S.-born Black 1284 52.5 61 15-174 foreign-born Black 1899 72.6 271 147-382 White 2295 32.6 119 31-313 Hispanic (all races) 1658 44.3 191 51-381 McCoy, M. B., & Heggie, P. (2020). In-hospital formula feeding and breastfeeding duration. Pediatrics , 146 (1) e20192946; DOI: https://doi.org/10.1542/peds.2019-2946
Evidence-based strategies to increase exclusivity Implementation of Baby-Friendly Hospital Initiative (BFHI) 10 Steps Culturally appropriate prenatal education Peer counseling Staff and physician education Giving supplementation only when medically indicated Early skin-to-skin contact. Team -based care including lactation specialists integrated into routine patient care helps to reduce IHFF and supports the infant feeding goals of mothers and families
Poll When do you see families?
What mothers are telling us about supplementing in the hospital Just to Lack of confidence/nervousness/pressure be safe It’s o.k. if ‘permission’ to give formula you need to supplement Doing the mom a favor Mom needs No permission asked before giving formula to rest
Prenatal goal setting Onus is on the care provider, not the family Provider endorsement very influential Racial/cultural gap in prenatal education
Breastfeeding goal sheet
I want to initiate breastfeeding/chestfeeding within the first hour. I would like to give the baby an opportunity to self- attach, and I do not want the baby forced into the first feeding. I would like all newborn procedures delayed until after the first feeding with my baby lying on me or held by me. I want my baby to stay in my room with me, and I want to hold my baby skin to skin as much as possible during our stay.
I would like help in establishing a comfortable and effective latch and learn different positions for nursing my baby. I would also like assistance in learning hand expression, how to recognize my baby is swallowing, and what to expect in the days following discharge from the hospital. If I encounter any breastfeeding problems, I would like help from an International Board Certified Lactation Consultant or other staff trained to assist breastfeeding mothers.
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