BREASTFEEDING CONNECTION
BREASTFEEDING CHALLENGES IN THE EARLY POSTNATAL PERIOD: ONGOING DIFFICULTIES
maternal intrapartum medication, including synthetic oxytocin and fentanyl (Brimdyr et al., 2015; Bell et al., 2013; Torvaldson et al., 2006) may have been resolved in terms of infant interest in feeding, infant feeding cues, and feeding sequence organisation, but latching difficulties may persist and milk supply may be under threat. If the reason for the latching problem seems obvious, this will have provided a useful starting point for resolution, and supportive interventions may have already been introduced on the postnatal ward and a feeding plan developed.
Breastfeeding is considered to be a public health priority because evidence shows it is a major determinant of short and long-term infant health, as well as being significantly important for maternal health. This ongoing series of clinically focused breastfeeding articles in Midwife are designed to support midwives by providing evidenced-based and informed updates.
When the otherwise well, non-latching infant goes home, a four-pronged approach is needed so that the woman’s milk supply is protected, and the infant can be supported to continue practising latching and breastfeeding, while being fed expressed breast milk, donor milk, infant formula, or a combination of one or more of those options. Avoidance of complications from any introduced intervention is the fourth prong. Maternal stress, fatigue, despondency and pain may be compromising oxytocin responses, which exacerbate the primary breastfeeding challenge – whatever that may be. In this sense, the provision of oxytocin-releasing conditions for mothers and their infants could be viewed as the underpinning strategy that supports all four prongs. As described in the May edition of Midwife, the creation of a physiologic breastfeeding space (normal/physiological and not pathologic) to support oxytocin responses, which can be visualised as a ‘maternal nest’ or as described by Monbiot (2018) an “oxytocin tent”, is paramount.
CAROL BARTLE POLICY ANALYST
Key threads woven throughout these articles have been: the critical importance of mother and infant skin-to-skin contact; the need for supportive birth recovery practices; support and protection for the development of infant breastfeeding skills; and the provision of oxytocin-releasing conditions for mothers and their infants. These key issues remain just as important for the support of breastfeeding initiation and establishment after the first few days post-birth. Supporting breastfeeding when challenges remain after discharge from a postnatal facility is the focus of this article. TAKING A BREASTFEEDING CHALLENGE HOME AFTER A MATERNITY FACILITY BIRTH – THE FOUR PRONGS Early support for challenges is essential to protect breastfeeding, and full breastfeeding assessments to diagnose challenges and identify contributing variables are necessary (Stuebe, 2014). The cornerstones of infant feeding: suckling; swallowing; and breathing, are complex tasks and must work in unison for safe and effective feeding (Wolf & Glass, 1992). The majority of well, term, or near-term newborn infants, will manage to co-ordinate feeding at birth, or after their birth recovery. Research suggests that approximately 1% of children in the general population will experience swallowing
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difficulties, although the incidence rate is higher in some populations, such as in infants with cerebral palsy (Dodrill & Gosa, 2015). Feeding issues related to neurological issues are too complex to include in this article, which is focused on the well, nonlatching infant. Going home with an infant who is still not latching effectively at the breast, or suckling well, is a challenge for multiple reasons, not the least of which is the expanse of work that needs to be done by the woman (and infant) to achieve breastfeeding, and the amount of support needed from the midwife. A slow start to breastfeeding related to infant exposure to
Going home with an infant who is still not latching effectively at the breast, or suckling well, is a challenge for multiple reasons, not the least of which is the expanse of work that needs to be done by the woman (and infant) to achieve breastfeeding, and the amount of support needed from the midwife.
PRONG ONE: MILK SUPPLY When infants are not actively breastfeeding, lactation is fragile, so support to successfully latch and breastfeed is urgent. When lactation is pump-dependent with minimal, if any breastfeeding, there are multiple issues to consider, such as how effective the breast pump is, how often and how long expressing episodes are, and whether all of the available milk is being removed during this time. Access to a good breast pump is important, but there are many cheap and ineffective pumps on the market, and because cost is prohibitive for some families, issues of inequity and access should be considered by midwives. The longer an ineffective pump is being used as the sole, or main, method of milk removal, the less likelihood there will be of achieving full lactation due to the downregulation of prolactin. Involution of the breast will begin to occur if milk is not removed regularly from the breasts. Morton
