BREASTFEEDING CONNECTION

BREASTFEEDING CHALLENGES IN THE EARLY POSTNATAL PERIOD: ONGOING DIFFICULTIES

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.

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 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 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.

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.

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

(2009) and Morton et al (2009) found that using a combination of hand expression, breast compression and pumping can maximise milk supply (Fig.1). The Morton technique was primarily developed for mothers of pre-term babies not feeding at the breast, but the principles are applicable when there are milk supply issues for babies of any gestation.

Galactagogues are frequently recommended for the therapeutic management of a low milk supply, when strategies for increasing supply have been exhausted. Prescribing pharmaceuticals for low milk supply is an ‘offlabel’ use of medication which raises ethical and professional questions for the individual midwife regarding the appropriateness of this prescribing. Galactagogues, or substances marketed as galactagogues such as lactation cookies, are likely to be in common use by women in Aotearoa as well as in Australia. A cross-sectional study with 1,876 respondents in Australia found that use was common, with 60% of the participants using galactagogues such as lactation cookies (47%), brewer’s yeast (32%), fenugreek (22%), and domperidone (19%). Perceived effectiveness was described as highest for domperidone, and over 23% of the domperidone users described experiencing multiple side-effects compared to 3% for those taking herbal remedies (McBride et al., 2021). Evidence gaps about effectiveness and safety of galactagogues have been identified (Zizzo et al., 2021).

PRONG TWO: SUPPORTING THE INFANT TO LATCH AND BREASTFEED Easy, frequent, stress-free access to the breast is a key strategy when an otherwise well infant is having issues with latching. There are maternal and infant factors that impact on latching issues for well, full-term babies. For infants it may be anatomical variations, or iatrogenic causes that can be slow to resolve, such as those caused by birth trauma, or separation from the mother, leading to limited time to ‘practise’ at the breast. Maternal issues include some nipple variations such as inverted nipples, or postpartum stress and/or pain.

Infants communicate their responses to events surrounding feeding by state-behaviour, physiologic and/or motor behaviours, and the environment for breastfeeding needs careful consideration, alongside sensitive responses to a distressed infant. Infant cues for feeding need to be clearly understood, as do signals of distress. A distressed infant will be unable to latch and will need calming and comforting before a breastfeed can be attempted or

FIG.1 – MORE MILK USING HANDS + PUMP

1000

Milk Volume (ml) 800

600

400

200

0

1 2 3 4

Weeks 5

Hand expression + pump Pump and hand 6 7

Pump only 8

From Maximising Milk Production with Hands-On Pumping, by Dr Jane Morton, 2017. (https://med.stanford.edu/newborns/professionaleducation/breastfeeding/maximizing-milk-production.html). Copyright by Dr Jane Morton.

re-attempted. Breast-seeking behaviour is seen in hungry, alert infants, or mildly sleepy and mildly hungry infants, but not in frantically crying infants (Smillie, 2008). Positional stability is an important part of stress-free feeding and the infant needs to be well supported, with complete contact with the mother’s body, including infant foot support. Svennson et al. (2013) found that skin-toskin contact during breastfeeding enhanced positive maternal feelings and shortened the time to resolve latching problems in a cohort of infants (n=103) 1-16 weeks postpartum. The laid-back position for breastfeeding has been shown to support effective latching at the breast compared to traditional positions, and may also reduce the incidence of nipple pain and nipple trauma (Wang et al, 2021). Infant chin contact with the breast is one of the triggers for the inborn neurobehavioural feeding programme, as is skin-to-skin contact with the mother (Watson Genna & Sandora, 2008). A common problem for temporarily disorganised (in the feeding sense) infants is when the tongue is not lowered on the approach to the breast, resulting in an ineffective latch, the infant releasing the nipple, and mothers sometimes thinking the infant does not want to feed. Making time for the infant to practise licking, nuzzling and mouthing on the mother’s chest is helpful. If the infant starts sucking before latching at the breast, the latch attempt needs to wait until the sucking stops (Watson Genna & Sandora, 2008). Another issue to consider is the infant who may have been forcefully pushed on to the breast, who has learned to associate distress with a breastfeeding attempt. Avoiding any pressure at all behind the infant’s head is critical for these infants and a laidback breastfeeding position is ideal in these situations. For some non-latching infants, another strategy to try is for the mother to stand to breastfeed, as this distraction, and change from the usual position can help. The infant’s body is supported, but will ‘drop’, vertically placing the infant in an alignment position that may support a latch. Adding a gentle bounce while standing and breastfeeding can also help an infant continue breastfeeding. Walking while breastfeeding is a recommendation for supporting an infant who is going through a breastfeeding ‘strike’ (Glover & Wiessinger, 2008). In some situations, a well-fitting (for the mother and infant), appropriately used, ultra-thin silicone nipple shield can support infants to latch in the short-term. For some women, including those with bilateral inverted nipples, a longerterm use of nipple shields may be necessary.

PRONG THREE: SUPPLEMENTARY FEEDING When there is a latch, lactation and/or breastfeeding issue, supplementary feeds are going to be necessary until there is a resolution of one or all of the challenges. The primary goals remain feeding the infant, and optimising the maternal milk supply. Supplements should be given in a way that preserves breastfeeding, with attention paid to the volumes of milk given (limiting to what is necessary for newborn physiology), and supporting the infant to continue practising at the breast (Academy of Breastfeeding Medicine, 2017). Any feeding plan needs to be developed in consultation with the mother, and take into account manageability, feasibility and sustainability. For example, it is unrealistic to expect a fiveday old non-latching infant to take all their milk requirements via a spoon or syringe. For mothers who have a low milk supply and whose infants have managed to latch at the breast and are sucking well, a supplementary system using a tube linked to the supplement can be used during a breastfeed to ensure the infant receives the volume needed, until milk supply increases. For infants who are still unable to latch, there are other devices that can be tried, such as finger-feeding, although the evidence for their effectiveness is limited. If the only feasible option is a bottle and teat, there are ways to try and minimise any negative effects on breastfeeding, which are addressed in the next section.

PRONG FOUR: AVOIDING OR REDUCING COMPLICATIONS Avoiding or reducing complications of any device used to support latching and breastfeeding requires frequent assessment of the issues; reviews of whether the strategy is working, how the mother is managing, and if and when devices can be removed. These assessments include: maternal and infant wellbeing; the use of a breast pump; supplementary feeding; use of supplementary feeding tubes, cups, bottles and teats; finger feeding; and nipple shields. Avoiding the use of bottles, where possible, can be supportive of breastfeeding, although there are situations when bottles and teats may need to be used, and in some cases, they may continue to be the only option. Interestingly, a Cochrane Systematic Review (2021) found that for pre-term infants, the use of a cup instead of a bottle increased the extent and duration of full and any breastfeeding in pre-term infants up to six months post-discharge, which is a significant finding (Allen et al, 2021). If using bottles and teats for feeding, it is important to elicit a rooting reflex and a wide mouth gape from the infant before inserting the teat. Mimicking the pace, flow and position of breastfeeding by using paced bottle-feeding is also recommended. Paced bottle-feeding principles include

responsiveness to infant feeding and other cues, holding the infant in a slightly reclined position, holding the bottle in a more horizontal position, taking pauses during the feed, and moving the infant position from right to left, just as with changing breasts during a breastfeed (Toronto Public Health).

WEIGHT ASSESSMENT AND INFANT OUTPUT After lactogenesis II (which occurs around day three but may be delayed), infant urination frequency and volume over a 24-hour cycle should be increasing on a daily basis. By day five, a minimum of 6-8 wet nappies with clear or pale urine over a 24-hour period is expected. Neonatal output is a strong indicator of weight alterations after lactogenesis II. Scant, dark or strongsmelling urine can indicate poor fluid intake, and subsequent infant assessment and breastfeeding evaluation should be a priority (Laing & Wong, 2002). A systematic review found the clinical findings observed in cases of breastfeeding-associated neonatal hypernatremia were decreased urine output, poor feeding, jaundice, high temperature, and irritability or lethargy (Lavagno et al, 2016). Urates in the nappy after day five and/or failure to progress to transitional stools by day five suggests breastfeeding difficulties, and a thorough breastfeeding and weight assessment is necessary (Academy of Breastfeeding Medicine, 2017).

Weight assessment may be promoted as the only reliable indicator of breastfeeding effectiveness, and weight loss patterns used as a foundation from which clinical decisions about infant-feeding care plans are made (Noel-Weiss et al., 2011). Paul et al., (2016) suggest that the majority of newborns take more than a week to return to birthweight and may take longer. Infants who have had a caesarean birth on average take longer to regain their birth weight than those following normal birth. The National Institute for Health and Care Excellence (NICE UK) Faltering Growth Guideline (2017) states that if infants have lost more than 10% of their birth weight in the early days of life, or they have not returned to their birth weight by three weeks of age, that a referral to paediatric services is warranted, but only if there is evidence of illness, marked weight loss, or failure to respond to feeding support.

Some infants, who have had a slow start to breastfeeding but are otherwise well, may take longer to return to birthweight than 14 days (Gonzalez-Viana et al., 2017). Weight monitoring is only one indicator of the health and wellbeing of an infant (Brodribb, 2019). Noel-Weiss et al. (2011) and Noonan (2011) suggest that the reliance on weight assessments alone may result in midwives missing red flags, and inaccurately differentiating physiological from pathological weight loss. Weight assessment should be considered one assessment strategy, incorporated within a holistic breastfeeding evaluation that includes the mother's experience of breast fullness, observing infant breastfeeding behaviour, observing milk transfer, and other indications of adequate infant hydration (Noonan, 2011). Kent et al., (2021) demonstrated that after support from health professionals, women were able to identify the signs that their infant was receiving sufficient breastmilk. This included waking for feeds, alertness when awake, number of wet nappies, attachment and sucking patterns, and recognising changes in firmness of the breast before and after feeding. Breastfeeding challenges such as delay in transitional milk production or nipple pain can impact on the positive signs that women are looking for. Understanding breastfeeding challenges and how to overcome them is important for midwifery practice.

CONCLUSION For mothers of infants who continue to have latching difficulties, long-term feeding decisions may need to be made at some point, and options explored such as whether to continue expressing breast milk for bottle-feeding. In terms of milk supply issues, sometimes lactation does not increase despite all efforts, and at some point the midwife may need to support the breastfeeding woman with a change of plan. The woman may decide to continue breastfeeding with supplements, or to stop breastfeeding. Combination feeding may be a realistic option for many women if the infant has managed to latch at the breast. Breastfeeding is important to women who plan to breastfeed and the cessation of exclusive breastfeeding can be experienced as unexpected and devastating, leaving women with grief and feelings of loss and failure (Ayton et al., 2019). Research suggests how important it is to understand women's breastfeeding intentions, as the highest risk of postnatal depression was found among women who had planned to breastfeed but found themselves unable to (Borra et al., 2015). Breastfeeding difficulties, or stopping breastfeeding before being ready, has been associated with an increased risk of postpartum depression (Dennis and McQueen, 2009). Brown et al., (2016) found that issues with pain and physical breastfeeding were most indicative of postnatal depression in comparison to psychosocial reasons, which highlighted the importance of spending time with new mothers to help them with breastfeeding issues such as latching. The research evidence highlights the importance of providing breastfeeding support to women who plan to breastfeed, and compassionate support for women who intended to breastfeed but either did not breastfeed, or didn't meet their own breastfeeding goals. Enabling mothers to come close to their infant and to feel connected, regardless of whether they are breastfeeding or not, and understanding what experiencing severe breastfeeding difficulties means for women, is important (Palmér et al, 2012). square

Key points

• Early support for breastfeeding/ latching challenges is essential to protect breastfeeding, and breastfeeding assessments are important.

• Going home with an infant who is still not latching effectively at the breast, or suckling well, is a challenge.

• A four-pronged approach is needed (1) protect milk supply, (2) support the infant to latch and breastfeed, (3) feed the infant, and (4) avoid complications from any introduced interventions.

• Scaffold oxytocin responses - facilitate conditions that create a ‘maternal nest’/“oxytocin tent”.

• Weight assessment should be considered one assessment strategy, incorporated within a holistic breastfeeding evaluation.

• Understanding loss of breastfeeding grief and the impact severe breastfeeding difficulties may have on women’s wellbeing is important.

• For detailed information about alternative feeding methods see

Toronto Public Health’s Breastfeeding

Protocols for Health Care Providers:

Protocol #18 Alternative Feeding

Methods.

References available on request.