Breastfeeding Initiation Risk Factors – TRANSCRIPTION

Evi Dewhurst / May 2019

Last month, we posted a link to Dr. Diane Spatz’ (PhD, RN-BC, FAAN) previously recorded Facebook Live event on “Breastfeeding Initiation Risk Factors.” She took the opportunity to present research and information to clinicians and hospital staff about proper breast milk initiation, the value of human milk, and maternal risk factors that may impede coming to volume.

But what if you prefer to read research and information? We’ve heard your requests! Below you will find a complete transcription of Dr. Diane Spatz’ presentation.

(If you missed our post on the video recording and prefer to watch rather than read, you can find the recording here.)

Breastfeeding Initiation Risk Factors, presented by Dr. Diane L. Spatz, PhD, RN-BC, FAAN

Hi, thanks so much for joining us this evening. My name is Dr. Diane Spatz. I am a professor of perinatal nursing at the University of Pennsylvania School of Nursing, as well as a nurse researcher, and director of the lactation program at Children’s Hospital of Philadelphia. I have been working as a nurse scientist in this field for, hard to believe, about twenty-five years now. I don’t know how that happened!

I’m quite passionate about this idea of “How do we help mothers meet their personal breastfeeding goals?” and this idea of initiation. And really looking at what risk mothers bring to the equation is so important, because what we know is that in the United States we have more women breastfeeding than ever, but we have women who start breastfeeding and who aren’t able to reach their personal breastfeeding goals.

Data from the Centers for Disease Control and Prevention show us that well over 80% of women are starting to breastfeed. But when you look at the exclusive breastfeeding rate at six months, we still have less than 25% of infants being exclusively breastfed. So clearly, we have to be doing something different, so that more women are able to provide exclusive human milk for their babies for the first six months.

The first question that actually came in for this Facebook Live event was a really great question about “How do we improve prenatal education?” What do we do so that women get the right messaging? And this is actually one of my favorite topics, because I would actually love to see prenatal education for women be totally changed.

When we think about pregnancy, the breasts are prepared to make milk from sixteen weeks of pregnancy on. And I recently, in my class at the University of Pennsylvania, had a panel of seven breastfeeding mothers speak to my students. And one of my students asked the mothers, “How many of you were informed by your healthcare provider that you were making milk in your second trimester?” And zero out of seven women said that they learned anything about that. So we really have to have mothers understand that they are poised to make milk for their baby. Every single mother, as long as she has breasts (she hasn’t had a mastectomy) every single mother has the ability to make milk.

Even moms that have abnormal breast conditions, like glandular hypoplasia or insufficient glandular tissue, or they’ve had breast surgery, they will all make milk. It’s a question of “What amount of milk do we get them to?” You know, how much milk can we maximize then?

So, when we think about this concept of milk, we have to think about the vital role of colostrum. I have one of my favorite teaching tools here that I use for families to have them understand that a newborn baby really consumes very little colostrum when he is first born. This picture of colostrum represents an entire day’s worth of feedings for a newborn baby. So when a baby eats at any individual feed, he may be only getting 0.4 mL, a few drops of colostrum. And so our messaging to our mothers before they deliver needs to be, “Mom, you’re going to make milk, everyone is going to make milk. And the first milk that you make is a very vital milk for your baby that’s going to be present in small amounts.”

But then after that, what we really need to help mothers understand is that most women in America who are having babies come with some risks that set them up for either a delay in milk-making capacity or coming to volume as we would expect. And so, just being a first-time mother puts a mom at risk for a delay in developing her complete milk supply. If you think about what percentage of your patients are first-time mothers, it’s probably half of your practice, right? So we look at the first time mom, and how do we help her understand that “You’re going to come to volume, but we’re going to want to watch your milk supply very closely during the first three to five days.”

When you think about mothers having babies, we know that a large portion of women are overweight when they come to the child-bearing age. We also know that many women gain excessive weight during pregnancy. Obesity is a known risk factor for milk supply. And I’ve actually done research on this topic with some of my midwifery colleagues down at the University of South Florida at Tampa General Hospital. And we found that the heaviest women were at the highest risk for a delay in lactogenesis II, and also at highest risk for breastfeeding cessation. So does that mean that obese women should be counseled not to breastfeed? No, of course not! What it means is maybe we need to manage these mothers differently, and really help them know ahead of time that they come with this risk, and that we as healthcare providers need to help them effectively establish a milk supply.

So if a baby is effective at breastfeeding, the baby is the very best person to stimulate that mother’s milk production. And that baby needs to feed immediately, within the first hour, and that baby needs to feed really frequently.

Now unfortunately, in the United States, a lot of women have a lot of interventions that occur during the labor and delivery process. So a mother often gets IV fluids during labor and delivery, she may get Pitocin to induce her labor, she’s likely to have epidural anesthesia, and all of these things can influence the baby’s breastfeeding behaviors.

In addition to all the interventions we do to moms in labor and delivery, we also know that our cesarean section rate is about a third of women. And I’ve seen some hospitals that have had even higher cesarean rates. So we have a question from Kim, who says, “How can I help my mothers with cesarean births?” And so with the mother who has a cesarean birth, we really need to have a sense of urgency about milk supply. So, at Children’s Hospital of Philadelphia, we have really vulnerable babies and they’re mostly all born critically ill and sick. So if we have a baby who is healthy enough to breastfeed, which is not most of our babies because we don’t care for normal babies (in our unit), we put the baby to breast in the operating room. But, if we have a mother whose baby can’t go to breast, or doesn’t feed efficiently, we’re going to start her pumping. And so we actually are having the mom express milk, pump with a Symphony pump with Initiation Technology™. We do that right on the operating room table.

And so having this sense of urgency for cesarean mothers and their milk supply… I’m not entirely convinced it’s the cesarean that is impacting the milk supply. I think it’s the behaviors that happen after the cesarean. Because oftentimes with a cesarean birth, mom and baby get separated for a longer period of time, baby may go to the nursery while mom is recovering, the mom might have a hard time getting comfortable with positioning because of the cesarean. The nursing staff might be concerned that the mom will fall asleep and they’re worried about her holding the baby if no one else is in the room with her… And so, we do all these things that prevent the baby from having frequent breastfeeding opportunities. And so you know, when we think about our cesarean moms, we really have to help them ensure that their baby is feeding effectively every one to three hours or eight or more in twenty-four, but if the baby is not feeding effectively, we then really want to introduce that pumping, okay? We want to use that Initiation Technology for these mothers who are at risk. So, our first-time moms. Our mothers who are overweight, our mothers who have had cesarean deliveries.

So, how we message to mothers I think is also very important. Earlier, I was talking about the importance of prenatal education, and moms’ understanding that they’re making milk before they ever deliver their baby. And, it’s a small amount of milk, but it’s a perfect amount of milk. But then, we have to understand that we have a critical window of opportunity to develop a complete milk supply. We have research that really shows us what happens in the first three to five days sets the stage for the rest of the mother’s lactation experience. And if the mother doesn’t reach a threshold of 500 mL per day by the end of week two, she is going to be at high risk for not being a long-term breastfeeding mom.

And so, one of my favorite things to really emphasize to families (and I do this before they ever deliver) is this concept of “Your only job after you have a baby, is to eat, sleep, and breastfeed your baby.” And it’s really important to emphasize all of those things. Because if the mom isn’t eating, she’s going to be cranky, and she’s not going to be excited about breastfeeding her baby. And if she’s not sleeping, she’s going to be cranky! And she’s not going to be excited about breastfeeding her baby. Now, sleeping doesn’t mean that she sleeps all night long, and someone else feeds the baby – because the baby’s going to be up during the night and feeding. So we have to prepare the mother, in advance, that she needs to sleep or nap when the baby’s napping, and she needs to be prepared that around the clock, her most important job is to eat, sleep, and breastfeed her baby. We want to tell mom, “That’s your only job. The rest of your family is really responsible for doing everything else for you.”

So – a question came in from Mara. And she wants to know, “What are the best ways to support or promote breastfeeding when mom and baby are separated?” So that could be an acutely ill mother, or that could be a baby who comes to the NICU or requires intensive care. While many of you who have ever heard me speak know that this is my favorite topic area, and so that is the 10-step model that I developed for human milk and breastfeeding in vulnerable babies. The number one priority when moms and babies are separated, is we first have to make sure that the mother and her family understand that human milk is a medical intervention. The research is clear, for both healthy babies and sick babies, that human milk is vital, that human milk improves health outcomes, that human milk improves developmental outcomes.

We want to make sure, in the case of maternal/infant separation, that even if the mother did not have the goal prenatally to breastfeed, that we help her understand that human milk is vital. Once we have the mother and her family understand why human milk is vital, and how human milk is effective in helping their baby, then we want to make sure that mom is set up to have an abundant milk supply.

So we want to make sure that moms are pumping within the first hour with Initiation Technology, we want them pumping early and often. And we have a really great quality improvement project that we have published from the Children’s Hospital of Philadelphia, called “Pump Early, Pump Often,” that shares our journey with really bringing our pumping initiation times down. And this has also been replicated at Tampa General Hospital in an article that they published, where they were able, by implementing my 10-step model, to significantly bring down the time to first pump, which means more babies got human milk at their first feed, and their human milk rates actually tripled at discharge, just by paying attention to that early, frequent pumping. So that’s really critical.

If the mother also goes to an intensive care unit, then we have to assign someone the job of making sure that mom is pumping. So the mom is in a medical ICU, she’s not going to be able to express the milk herself – so is there a family member that can be involved? It could be a grandmother, it could be a father, it could be a sister, it could be a cousin… or, it could be the bedside nurse.

It’s really critical that all nurses have education about human milk and breastfeeding, and the evidence about human milk and breastfeeding, and why there is this critical window of opportunity to establish milk supply. So that should be for any nurse, no matter what department they work in. So we want to make sure that message gets conveyed on importance.

A question came in from Sonya, about the frustration with handling visitors for newborns. I feel your pain! I feel your pain. One of the biggest pieces of advice I think we can do to prepare mothers, before they deliver their babies, is to help them understand that they should take that time in the hospital, that short length of stay (24-hours, 48-hours, 72-hours) and look at that time as being a priceless time to establish the new family unit. That it’s great that everyone wants to come and see the baby. But really, during the birth/hospital stay, we don’t need the visitors at that point in time. And if we can delay them until later, and we can really protect that time for that mother, as a new mom.

One of the things I also really like to talk about in this space is the importance of skin-to-skin contact. And with the Baby Friendly Hospital Initiative, we see that many hospitals are working on skin-to-skin, but often what you see is that we do skin-to-skin in the labor and delivery room. The baby may be at skin-to-skin for fifteen minutes, or an hour, maybe a little bit more, but then the mom and baby are often separated. And then, after the mom and baby get to the postpartum unit, even if mom and baby stay together in the same room, often the baby is wrapped up in the baby blanket like a little baby burrito, and the baby’s over here in the crib, and he’s no longer skin-to-skin with his mom. And so I encourage the mother to kind of think about how you want that baby to be skin-to-skin on your chest, not just for one hour, but for as much of that stay when you’re in the hospital. And that’s another reason to kind of keep the visitors at bay. Keep them away so that mom can just have that time to keep her baby skin-to-skin.

And in fact, even after the mother goes home, let’s talk about what we want her to do at home. Can we encourage the mother to keep her baby skin-to-skin for that first two weeks? If we can have that mom have the sense of idea that maybe she should just plan to be topless, that she should find some comfortable space in her house, where she can really just spend as many hours of the day with her baby on her chest, skin-to-skin. Because when she does that, she is activating all the secretory cells, even if the baby isn’t attached, she’s activating her milk supply, and that baby is so very smart. He migrates himself, or she migrates herself, right to the breast to eat as soon as they’re hungry.

You know, one of the things I think is very interesting, at least about our U.S. culture, is as soon as a family is pregnant, they get all excited about, you know, getting a room, building a nursery, buying all types of supplies for the nursery, decorating the nursery, and creating this space for the baby. But we don’t want the baby in the nursery, away from the mom. We want the baby next to the mom’s bedside so that that baby is easily accessible 24-hours a day, 7-days a week. So if the mom and baby create a space that they can be together at home, and really just focus on that skin-to-skin and that breastfeeding contact.

So, this is one of my favorite sayings: It takes a village. And you’ve all heard this. It takes a village to raise a child. When you’re a new mother, breastfeeding, you shouldn’t be doing that in isolation. You really need to have that family support. You need to be able to identify one person, who’s going to be your go-to person, who’s going to be unwavering in your support for breastfeeding.

It can be really hard in some families if the mother is the first person in her family to think about breastfeeding. If her mama didn’t breastfeed, and her aunties didn’t breastfeed, and her sister didn’t breastfeed, and she’s the first person to think about breastfeeding, that can be a really hard journey. So before the mom ever delivers, really helping her to identify who are those support people going to be, to help you in your journey.

Remember that in the United States, most women are not delivering their babies without risk. We have older mothers, having their babies for the first time over 30, we have mothers who are overweight at the time of delivery, we have mothers who deliver by cesarean birth. So, we have moms who bring risk factors, and so women, just by nature of how they’re giving birth in the United States, with medicalized birth, Pitocin, epidurals – their babies are immediately going to be at risk for less-than-ideal breastfeeding outcomes. What we want to really do is create a sense of urgency about milk supply. We want to feel that milk supply is the most important part of the equation. Because if a mother doesn’t effectively convert from lactogenisis I to lactogenesis II, and develop that milk supply during that first week… If you try to do it five weeks out, it’s not going to happen. So we really need to have this sense of urgency about milk supply.

There’s a great website called Initiate, Build, Maintain, where you’ll be able to go for information this topic. There are some amazing infographics, and resources with references for you as the health professional. Also there is the opportunity to enter your email to learn about upcoming podcasts and webinars. In March, I will actually be hosting a podcast, as well as a webinar, on this topic of risk for lactation. What we really want to be able to do, is delve further into the science, and the physiology of lactation, because our goal – my goal, your goal as a healthcare provider – is to really ensure that all women can meet their personal breastfeeding goals. We want mothers to be able to reach that goal that they set, so that we have healthier mothers, healthier babies, and a healthier society. There is a free promotion code for being able to log on to the online education. So if you use this code (XS6TSP), you will be able to access the education for this program.

I want to thank you all again for logging on tonight for this event. This was my first Facebook Live event, so I’m very excited that I had the opportunity to share this with you. It’s a topic that I am really passionate about because I think it’s so important for us, as health professionals, to give moms the tools they need to be able to reach their personal breastfeeding goals. And if I’ve convinced you of one thing tonight, it’s that I really hope that you understand that we have to have a sense of urgency about milk supply.

About the Author

Diane L. Spatz, PhD, RN-BC, FAAN is a Professor of Perinatal Nursing & the Helen M. Shearer Professor of Nutrition at the University of Pennsylvania School of Nursing sharing a joint appointment as a nurse researcher and director of the lactation program at the Children’s Hospital of Philadelphia (CHOP) and the clinical coordinator of the CHOP Mothers’ Milk Bank. Learn more about her here.