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Transitioning Baby to the Breast

©2012 Nancy Mohrbacher, IBCLC,

FILCA 1


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



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



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



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



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?


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?




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


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



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

100

200

300

400

500

600

700

800

900

0 1 2 3 4 5 6 7 8 9 10

ml

weeks

Daily average of supplement given to baby

ave MyS

ave F

Transitioning Preterm Babies to the Breast



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


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


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



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


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




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




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



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


• 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




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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