Supporting Lactation in Primary Care

DFMCH Faculty Development Day

Michele Malloy MD || 4.11.2024

www.pollev.com/michelem014 or text michelem014 to 22333

The American Academy of Family Physicians (AAFP) has long supported breastfeeding. All family physicians, whether they provide maternity care or not, have a unique role in the promotion of breastfeeding.

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They understand the advantages of family-centered care and are well positioned to provide breastfeeding support in that context. Because they provide comprehensive care to the whole family, family physicians have an opportunity to provide breastfeeding education and support throughout the course of life to all members of the family.

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However, despite growing evidence of the health risks of not breastfeeding, physicians—including family physicians—do not receive adequate training about supporting breastfeeding.

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AAFP Position Paper. Breastfeeding, Family Physicians Supporting

https://www.aafp.org/about/policies/all/breastfeeding-position-paper.html

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Action 9. Provide education and training in breastfeeding for all health professionals who care for women and children.

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Action 10. Include basic support for breastfeeding as a standard of care for midwives, obstetricians, family physicians, nurse practitioners, and pediatricians.

2011 Surgeon General’s Call to Action to Support Breastfeeding

https://www.cdc.gov/breastfeeding/resources/calltoaction.htm

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Goals

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Identify specific actions family medicine clinicians can take to support lactation

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Name different evidence-based resources clinicians can use for lactation questions

Cite additional learning opportunities for clinicians to expand their lactation expertise

Current state

Credit: Mehmet Turgut Kirkgoz

https://health.gov/healthypeople

Any BF at 1 year

Exclusive BF to 6 mo

2015

2015

2020

2020

2030

2030

2009

2030

2009

Tools

Credit: Dominika Roseclay

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Three principles of support

Know the basics

Triple feeding is temporary

Engage support

Case: Delayed lactation

Case: Non-latching baby

Three principles of support

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Protect the milk supply

Feed the baby (preferably human milk)

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Work toward / meet parent’s goal(s)

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3

Feed the baby

Indications for supplementation:

Infant hypoglycemia not responsive to BFing

Separation of infant from BFing parent

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Insufficient milk supply*

Delay in lactation*

Excessive infant weight loss*

Infant illness causing ineffective BFing*

Most situations

Feed the baby

Protect the supply

4 hour max overnight

2-4 weeks

Meet the goals

Credit: Serdi Nam

Know the basics

2

breasts & pumps

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Not all sucking will cause milk transfer

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At-breast feeds are different than bottle feeds

Weight checks are crucial

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3

Non-nutritive sucking

Active drinking

Breast basics

Aim for 2 clear periods of frequent swallows

May be separated by several minutes

Breast basics

Milk transfer

Post-feed wt - pre-feed wt (in grams)

Breast basics

www.newbornweight.org

Weight basics

Flange

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Motor

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Settings

Graphic: Ariel Christie

Pump basics

Triple feeding is temporary

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Credit: Sarah Chai

Credit:Tamilles Esposito

 Credit: iStock.com / blanscape

Supply clues

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Transfer clues

Paced feeding

Engage support

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Know your local partners

Get staff trained

Use evidence-based resources

eConsults

Formal consults

Know your local partners

Dot phrase .picommunityresources

County

Pregnancy & newborn

https://lacted.org/providers-world-lactation-map/

https://ibclc-commission.org/public-registry/

Searchable database of current IBCLCs

Searchable database of lactation providers

Get staff trained

Use evidence-based resources

Outpatient Breastfeeding Champion course (IABLE)

eCourse (available for up to 1 yr) or live (8 weekly sessions)

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Little Green Book of Breastfeeding Management

Pocket-sized guide to clinical lactation / BF management

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LactMed

Database of information about effects of medications on lactation / babies

Slow infant weight gain

Transfer

Production

eConsults

Michele Malloy MD

Odana

Miena Hall MD

Verona

Anne Eglash MD

Odana, Sun Prairie

Amy Bauman DO

Yahara

Case: Delayed lactation

Case: Delayed lactation

7 d.o. baby girl

Exclusively at-breast feeding

12 gram weight increase in past 3 days

How do you proceed?

1. Recommend 1 oz supplement at each feed
2. Reassure parent that milk volume should increase soon
3. Tell the parent to stop nursing as their milk doesn’t have enough calories

Credit:Daisy Laparra

Case: Delayed lactation

7 d.o. baby girl

Exclusively at-breast feeding

12 gram weight increase in past 3 days

How do you proceed?

1. Recommend 1 oz supplement at each feed
2. Reassure parent that milk volume should increase soon
3. Tell the parent to stop nursing as their milk doesn’t have enough calories

Principle #1: Feed the baby

<

Credit:Daisy Laparra

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Case: Delayed lactation

7 d.o. baby girl

Exclusively at-breast feeding

12 gram weight increase in past 3 days

How do you proceed?

1. Recommend 1 oz supplement at each feed
2. Reassure parent that milk volume should increase soon
3. Tell the parent to stop nursing as their milk doesn’t have enough calories

Baby’s interval growth is inadequate

Weight nadir day 2-4

15-30 gram / d increase after nadir

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Credit:Daisy Laparra

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Case: Delayed lactation

7 d.o. baby girl

Exclusively at-breast feeding

12 gram weight increase in past 3 days

How do you proceed?

1. Recommend 1 oz supplement at each feed
2. Reassure parent that milk volume should increase soon
3. Tell the parent to stop nursing as their milk doesn’t have enough calories

Character of milk being produced is adequate

Volume is inadequate

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Credit:Daisy Laparra

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Case: Delayed lactation

7 d.o. baby girl

Exclusively at-breast feeding

12 gram weight increase in past 3 days

What else do you suggest?

1. Stop trying to nurse - it’s not worth it if the milk volume hasn’t increased by now
2. Pump every 3-4 hours, offer the breast up to 1-2x/d
3. Keep offering the breast at every feed and pump when you have time / energy

Credit:Daisy Laparra

Case: Delayed lactation

7 d.o. baby girl

Exclusively at-breast feeding

12 gram weight increase in past 3 days

What else do you suggest?

1. Stop trying to nurse - it’s not worth it if the milk volume hasn’t increased by now
2. Pump every 3-4 hours, offer the breast up to 1-2x/d
3. Keep offering the breast at every feed and pump when you have time / energy

Primip: Day 3-5

Multip: Day 1-3

Missed breast drainage early may shift timeline

First 2-4 weeks offer ongoing opportunity to increase production

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Credit:Daisy Laparra

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Case: Delayed lactation

7 d.o. baby girl

Exclusively at-breast feeding

12 gram weight increase in past 3 days

What else do you suggest?

1. Stop trying to nurse - it’s not worth it if the milk volume hasn’t increased by now
2. Pump every 3-4 hours, offer the breast up to 1-2x/d
3. Keep offering the breast at every feed and pump when you have time / energy

Energy focused on pumping is likely most effective method of breast drainage

As production increases and/or baby improves, parent can likely transition to less pumping and more BFing

<

Credit:Daisy Laparra

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Case: Delayed lactation

7 d.o. baby girl

Exclusively at-breast feeding

12 gram weight increase in past 3 days

What else do you suggest?

1. Stop trying to nurse - it’s not worth it if the milk volume hasn’t increased by now
2. Pump every 3-4 hours, offer the breast up to 1-2x/d
3. Keep offering the breast at every feed and pump when you have time / energy

Baby has demonstrated that supply or transfer are inadequate

This advise does not help build supply

Energy should be spent on most effective method of breast drainage*

<

Credit:Daisy Laparra

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Case: Non-latching baby

Case: Non-latching baby

6 w.o. baby boy

Parent is pumping 7x/d, 90-100 mL / session

Baby has never latched consistently

Parent really wants to try to nurse

How do you proceed?

1. Advise against trying to latch - it has been too long
2. Suggest switching from pumping 7x/d to latching every 2-3 hours
3. Encourage continuing pump routine, add in 1-2 latch attempts per day

Credit:Maria Fernanda

Case: Non-latching baby

6 w.o. baby boy

Parent is pumping 7x/d, 90-100 mL / session

Baby has never latched consistently

Parent really wants to try to nurse

How do you proceed?

1. Advise against trying to latch - it has been too long
2. Suggest switching from pumping 7x/d to latching every 2-3 hours
3. Encourage continuing pump routine, add in 1-2 latch attempts per day

Credit:Maria Fernanda

Principle #3: (Try to) meet the parent’s goals

It is almost never too late to teach a baby to latch

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Case: Non-latching baby

6 w.o. baby boy

Parent is pumping 7x/d, 90-100 mL / session

Baby has never latched consistently

Parent really wants to try to nurse

How do you proceed?

1. Advise against trying to latch - it has been too long
2. Suggest switching from pumping 7x/d to latching every 2-3 hours
3. Encourage continuing pump routine, add in 1-2 latch attempts per day

Credit:Maria Fernanda

This is likely too much to ask baby to do

Assess a latching attempt (incl pre/post-feed wt and milk transfer) before suggesting

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Case: Non-latching baby

6 w.o. baby boy

Parent is pumping 7x/d, 90-100 mL / session

Baby has never latched consistently

Parent really wants to try to nurse

How do you proceed?

1. Advise against trying to latch - it has been too long
2. Suggest switching from pumping 7x/d to latching every 2-3 hours
3. Encourage continuing pump routine, add in 1-2 latch attempts per day

Credit:Maria Fernanda

Principle #2: Protect the milk supply (by pumping)

Parent can increase latch attempts as baby improves

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Case: Non-latching baby

6 w.o. baby boy

Parent is pumping 7x/d, 90-100 mL / session

Baby has never latched consistently

Parent really wants to try to nurse

What may help baby latch better?

1. Offer the breast when baby is partially fed and/or sleepy
2. Use a nipple shield
3. Wait until baby is very hungry

Credit:Maria Fernanda

Case: Non-latching baby

6 w.o. baby boy

Parent is pumping 7x/d, 90-100 mL / session

Baby has never latched consistently

Parent really wants to try to nurse

What may help baby latch better?

1. Offer the breast when baby is partially fed and/or sleepy
2. Use a nipple shield
3. Wait until baby is very hungry

Credit:Maria Fernanda

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Content babies are often more agreeable to trying new / difficult skills

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Case: Non-latching baby

6 w.o. baby boy

Parent is pumping 7x/d, 90-100 mL / session

Baby has never latched consistently

Parent really wants to try to nurse

What may help baby latch better?

1. Offer the breast when baby is partially fed and/or sleepy
2. Use a nipple shield
3. Wait until baby is very hungry

Credit:Maria Fernanda

<

Some babies transition from bottle to breast better with a shield AND

It’s important to continue pumping to stimulate and drain breasts

>

Case: Non-latching baby

6 w.o. baby boy

Parent is pumping 7x/d, 90-100 mL / session

Baby has never latched consistently

Parent really wants to try to nurse

What may help baby latch better?

1. Offer the breast when baby is partially fed and/or sleepy
2. Use a nipple shield
3. Wait until baby is very hungry

Credit:Maria Fernanda

<

This is likely to backfire - baby and parent may be more stressed, less able to develop this skill

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Deep dive

Credit: Dana Tentis

Microlearning: What Every Physician Needs to Know

https://abm.memberclicks.net/need-to-know-videos

Protocols

International Conference (Nov 2024, Schaumburg IL)

http://bfmed.org

http://lacted.org

5-Day Core Content Course

2-Year Deep Dive Comprehensive Course

Breastfeeding Medicine Conference (Sept 2024, Madison WI))

Specific Opportunities

https://www.aap.org/en/pedialink/breastfeeding-curriculum/

Self-directed online curriculum (public access)