Breastfeeding Education Nursing CE Course

es, proteins, and fats (APA, 2019b). There are two types of mature milk: foremilk and hindmilk. Foremilk is secreted at the beginning of each feeding session and contains water, vitamins, and protein. Mature milk may appear thinner and watery or even bluish when first secreted (American Academy of Pediatrics [AAP], 2019b). Hindmilk is emitted after the initial release of foremilk and contains higher levels of fat, necessary for weight gain (APA, 2019b). Hindmilk has a creamier appearance (AAP, 2019b).

Breastfeeding Education

Feeding cues

It is crucial to identify feeding cues for when the infant is ready to breastfeed:

When babies are hungry, they are more alert and active. They may put their hands or fists to their mouths, make sucking motions with their mouth, or turn their heads looking for the breast. If anything touches their cheek, such as a hand, they may turn toward the hand, ready to eat. This sign of hunger is called rooting. Offer your breast when your baby shows rooting signs. Crying can be a late sign of hunger, and it may be harder for the baby to latch if they are upset (U.S. Department of Health and Human Services [USDHHS], n.d., p. 18).

Breastfeeding latch

A successful latch is essential for successful breastfeeding (APA, 2019a). Some signs of a good latch include:

• The latch is comfortable and pain-free.
• The infant’s chest and stomach rest against the mother’s body, so the infant’s head is straight.
• The infant’s chin touches the mother’s breast.
• The infant’s mouth opens up wide around the breast, with the areola fully in the mouth.
• The infant’s lips turn out.
• The infant’s tongue cups under the mother’s breast.
• The infant’s ears “wiggle”.
• The mother/nurse can hear or visualize swallowing (U.S. Department of Agriculture, n.d.b; USDHHS, 2018).

Some infants may have difficulty with latching on. Several tips the nurse can encourage the mother to try are: tickling the infant’s lips with the nipple to entice the infant to open wide, pulling the infant close so their chin and lower jaw moves into the breast first, and watching the lower lip to aim it far from the base of the nipple, so baby encloses the areola (USDHHS, n.d.).

If breastfeeding is painful, the mother should break the infant’s suction of the breast by placing a clean finger into the corner of the infant’s mouth. Then, attempt to latch on again. Breastfeeding should be comfortable and pain-free. Some infants may have ankyloglossia, which is more commonly known as “tongue-tied”. These infants have a tight or short lingual frenulum, which is the piece of tissue attaching the tongue to the floor of the mouth. They may be unable to extend their tongue past their lower gum line or properly latch the breast. Ankyloglossia can cause slow weight gain in the baby and nipple pain in the mother (USDHHS, n.d.; USDHHS, 2018).

Breastfeeding positions

    There are multiple breastfeeding holds or positions that the nurse can show breastfeeding mothers. Mothers may use different holds for separate feedings. Commonly used holds are the cross-cradle hold, the cradle hold, the clutch or football hold, the straddle hold, or the side-lying position. 

• The cross-cradle hold (see Figure 2a) is useful for premature babies or babies with a weak suck as this hold gives extra head support and may help the baby stay latched. The baby is held with the arm opposite from the breast being used, while the infant’s body is facing the mother. The mother supports the baby's head by placing her palm at the base of the baby’s head.
• The most commonly used is the cradle hold (see Figure 2b). This position allows the baby to be placed with their head on the mother’s forearm near the bend of the elbow while the infant’s body is facing the mother.
• The clutch or football hold (see Figure 2c) is helpful for women who have had a cesarean birth or have large breasts, flat or inverted nipples, or a strong let-down reflex.  The baby is held at the mother’s side, lying on their back, with their head at the level of the nipple and their legs and feet extending along the mother’s side and behind her. The mother supports the baby's head by placing her palm at the base of the baby’s head.
• The straddle or laid-back hold (See Figure 2d) is a more relaxed and baby-led approach. The mother lies back on a pillow and places the baby against her body with the baby's head just above and between the breasts. The baby will gravitate and wiggle towards the nipple. The mother supports the baby's head and shoulders as needed. If done correctly, an advantage of this hold is increased comfort for the mother and improved positioning for the child without occupying one or both of the mother’s hands.
• The side-lying position (see Figure 2e) is useful if the mother has had a cesarean birth, but also allows her to rest while the baby breastfeeds. The mother lies on her side with the baby facing her. The mother pulls the baby close, so the baby faces the mother’s body (USDHHS, 2018).   

How to know if an infant is receiving enough breast milk

Most babies will lose weight initially after birth, but then will gain about two-thirds to one ounce each day after the first week. The nurse should educate the family about the following signs that the baby is getting plenty of breast milk: 

• Has five to eight wet diapers daily after the first 48 hours of life, with clear or pale-yellow urine. 
• Has two to three loose, seedy bowel movements per day after the first 24 hours of life.
• Switches between short sleeping periods and wakeful, alert periods.
• Is satisfied and content after feedings.
• Breasts may feel softer after feeding (USDHHS, n.d.).

Health benefits

Low rates of breastfeeding add more than $3 billion a year to medical costs for mothers and infants in the United States (CDC, 2019b). Breastfeeding has health benefits for the infant and mother. Even if a mother is ill, the antibodies produced by her body will pass to the infant. This passive immunity significantly decreases the chances that a breastfeeding baby will suffer from ear infections, vomiting, diarrhea, pneumonia, urinary tract infections, or certain types of spinal meningitis (AAP, 2019a). The AAP (2019a, para 2) reports that infants who breastfed exclusively for at least four months were less likely than formula-fed babies to be hospitalized for croup, bronchiolitis, pneumonia, or a similar lower respiratory tract infection. The CDC reports a reduced rate of all of the following conditions in breastfed babies:

• Asthma,
• Obesity,
• Type 2 diabetes,
• Ear and respiratory infections,
• Sudden infant death syndrome (SIDs),
• Gastrointestinal infections,
• Necrotizing enterocolitis (CDC, 2019b).

Meanwhile, there is a reduced risk of the following for mothers who breastfeed:

• High blood pressure,
• Type 2 diabetes,
• Ovarian cancer,
• Breast cancer (CDC, 2019b).

The AAP lists several other potential benefits of breastfeeding. They cite evidence that breastfeeding protects babies born to families with a history of allergies, compared to formula-fed babies. In these at-risk families, babies who were exclusively breastfed for at least four months had a lower risk of milk allergy, atopic dermatitis and wheezing early in life. The long-term benefits of breastfeeding on allergies remain unclear, and studies have not carefully evaluated the impact on families without a history of allergies. Infants who breastfeed for more than six months are less likely to develop childhood acute leukemia and lymphoma as compared to those who receive formula. Although the etiology is not fully understood, studies indicate a 36-50% reduction in the risk of SIDs amongst breastfed infants. Recent research even suggests that breastfed infants are less likely to be obese in adolescence and adulthood and are also less vulnerable to developing both type 1 and type 2 diabetes (AAP, 2019a).

Special populations

Mother’s breast milk improves growth and neurodevelopment and decreases the risk of necrotizing enterocolitis and late-onset sepsis, which are all critical features for premature infants especially. However, providing human milk to very premature infants can be challenging. To maximize milk supply, new mothers with children in the neonatal intensive care unit (NICU) should begin pumping within 6–12 hours of delivery and should be encouraged to pump 8 – 12 times per day, ensuring that they empty the breasts with each pumping session (Underwood, 2013).

In utero, term infants undergo rapid growth in the third trimester of pregnancy as they receive nutrition through both the placenta and swallowed amniotic fluid without any caloric expenditure for temperature regulation or gas exchange. Premature infants have higher nutritional requirements on a per kilogram basis than term infants for this reason. Human milk may be fortified for any premature infants with birth weight less than 1,500 grams to assist with growth. Human milk fortifier powders are developed from bovine milk to supplement critical nutrients such as protein, calcium, phosphorus, and vitamin D (Underwood, 2013).

Contraindications to breastfeeding

According to the CDC (2018b), there are rare conditions that contraindicate breastfeeding. These include an infant who has been diagnosed with galactosemia, a mother who is infected with human immunodeficiency virus (HIV), a mother who is infected with human T-cell lymphotropic virus type I or type II, a mother who is using an illicit street drug, or a mother who has suspected or confirmed Ebola virus disease (CDC, 2018b). However, even these are not absolute contraindications. For example, the AAFP (2019) suggests exclusive breastfeeding for the first six months and continued breastfeeding for twelve months even in HIV-positive mothers if they reside in areas with high rates of infant diarrhea and respiratory illness. These mothers and babies should be treated adequately with antiviral medications if this is considered. They recommend avoiding breastfeeding from a single breast if active herpes lesions are present on that breast but encourage continued breastfeeding from the contralateral side until the lesions heal. Finally, in the case of active untreated tuberculosis infection or acute varicella infection in a mother, the AAFP recommends separating the mother from the infant physically but encourages continued pumping of breast milk to feed to the infant via bottle (AAFP, 2019).  

Storage guidelines

Human milk can be collected, stored, and frozen. Various factors (milk volume, room temperature when breast milk is expressed, temperature fluctuations in the refrigerator and freezer, and cleanliness of the environment) can affect how long breast milk can be stored safely (CDC, 2019a). The CDC provides the following guidelines to follow for proper storage of breast milk:

Before storing or handling breast milk, the caregiver should wash hands with soap and water to prevent contamination.  Breast milk can be expressed by hand or with a manual or electric pump and should always be stored in breast milk storage bags or clean, food-grade glass or BPA-free plastic containers with tight-fitting lids. Breast milk should not be stored in the door of the fridge or freezer to ensure constant temperatures during storage. If it is not going to be used within four days, freeze breast milk immediately after pumping to ensure optimal quality. Label bags with the date the milk was pumped and the amount for ease-of-use later. Frozen breast milk can be safely stored in an insulated cooler with freezer packs for up to 24 hours when traveling. The oldest breast milk should always be thawed/used first. Thaw breast milk in the refrigerator (use within 24 hours) or in warm water if to be used within 2 hours, but do not refreeze. If heating breast milk, do not use a microwave, as this can destroy vital nutrients and create hot spots which can cause burns. Instead, serve breast milk cold, room temperature, or heat in a sealed container in a bottle warmer or pot of warm water (CDC, 2019a).

Common Problems faced by Breastfeeding Mothers

The nurse should encourage breastfeeding mothers to get as much sleep as possible, adequate nutrition and fluid intake, and wear a supportive, well-fitting bra to avoid many of the following issues (USDHHS, n.d.). Common problems faced by breastfeeding mothers include plugged ducts, sore nipples, engorgement, mastitis, low milk supply, and fungal infections.

Plugged ducts

A plugged duct occurs when a milk duct does not drain properly, causing pressure to build up within the duct and inflammation in the surrounding tissue. This usually occurs in one breast at a time and presents as a sore, tender lump with no associated fever. To treat a plugged duct, the nurse should encourage the mother to breastfeed as often as every two hours on the affected side. The nurse should also instruct the mother to massage the area behind/above the plugged duct, apply warm compresses to the area, and wear a well-fitting, supportive bra (USDHHS, n.d.).

Sore nipples

Sore nipples may be related to an improper latch. A good latch will help decrease nipple soreness. After breastfeeding, the nurse should encourage mothers to express a few drops of milk and gently rub it on the nipples with clean hands as human milk has natural healing properties and oils that soothe. Education should also include allowing the nipples to air-dry after feeding and wearing a soft cotton shirt. The mother should wear a bra that is supportive but not too tight or put pressure on the nipples. Nursing pads should be changed often to keep the nipples clean and dry. The mother should avoid using harsh soaps or ointments that contain astringents on the nipples. The mother should wash the nipples and breasts with clean water. Creams, hydrogel pads or a nipple shield may be used, but usually not until after a consultation with a lactation consultant (USDHHS, n.d.).

Engorgement

Engorgement occurs when the breasts are not fully emptied. This can happen when the breast milk is transitioning from colostrum to mature milk or when feedings or pumping sessions are skipped. Engorgement presents with breasts that are hard, warm, red, tender, feel full, and painful, and may also be accompanied by a low-grade fever. Engorgement usually resolves in a few days but can lead to plugged ducts or a breast infection if not addressed. The nurse should encourage the mother to breastfeed first from the engorged breast and promote milk flow by applying a warm washcloth to the breasts or taking a warm shower. The nurse should educate the mother that she may need to express breast milk before nursing or attempt a reverse pressure softening massage while breastfeeding to soften the breast and make it easier for the infant to latch, as well as increase the duration or frequency of feedings. Between feedings, the mother can place cold compresses on the breasts to reduce swelling and pain. If pumping, do not wait more than four hours between pumping sessions (U.S. Department of Agriculture, n.d.a; USDHHS, n.d.).

Mastitis

Mastitis is a breast infection that can occur at any time during lactation, with the majority of cases occurring during the first six weeks (Amir, 2014). Signs and symptoms of mastitis may include: 

• Breast tenderness and warmth,
• Breast swelling,
• Thickening of breast tissue,
• Pain or burning sensation continuously or while breastfeeding,
• Skin redness, possibly in a wedge-shaped pattern,
• Yellowish discharge from the nipple resembling colostrum,
• Fever of 101° F (38.3° C) or greater,
• Nausea/vomiting, 
• flu-like fatigue and achiness (Mayo Foundation for Medical Education and Research, 2019b; USDHHS, n.d.).

As milk stasis is often the initial causative factor for mastitis, the nurse should educate all mothers on the importance of frequent feedings/pumping sessions of adequate length to empty the breasts regularly (Amir, 2014). The nurse should encourage mothers to breastfeed more frequently (at least every two hours), starting on the affected breast, positioning the infant at the breast with the chin or nose pointing to the blockage, massaging the breast from the blocked areas to the nipple, and expressing milk to assist with milk drainage (Amir, 2014; USDHHS, n.d.). A 10-day course of antibiotics may be needed if symptoms don’t improve within 12-24 hours or if the woman is acutely ill. As the most common pathogen in mastitis is penicillin-resistant S. aureus, the preferred antibiotics are usually penicillinase-resistant penicillins, such as dicloxacillin (Dycill, Dynapill, Pathocil) or flucloxacillin (Flopen, Floxapen, Staphcillin) 500 mg by mouth four times per day (Amir, 2014). The nurse can also recommend over-the-counter pain relievers such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) for symptom relief (Mayo Foundation for Medical Education and Research, 2019b).

Low milk supply

Some women have difficulty producing enough breast milk after a complicated labor, delayed initiation of breastfeeding, separation due to the baby being preterm, formula substitution, cracked nipples, or maternal illness. The nurse should offer a referral to a lactation consultant who can assist with breastfeeding. Antipsychotic drugs can increase pituitary prolactin secretion and breast milk production through dopamine antagonism, but the gastrointestinal motility drugs metoclopramide (Reglan) and domperidone (Motilium) are most commonly used off-label as galactagogues. The breast changes necessary to maintain increased milk production take approximately two weeks of daily medication to develop, although a slight increase in prolactin can be seen as early as eight hours after the first dose. The current recommendations of 10–14 days is based on limited research, however (McGuire, 2018).

Certain herbs may also increase milk supply. Fenugreek is the most commonly used herb to increase milk production. The recommended daily dose is 3.5-6 grams daily. Blessed thistle can also be used but is best when used in conjunction with fenugreek. Blessed thistle comes in a capsule or tea form and is taken three times a day. Alfalfa is also taken in conjunction with fenugreek. Goat’s rue is another galactagogue that is taken along with a blend of fenugreek and other herbs. It is available as dry leaves for tea or capsules (APA, n.d.). 

The nurse should encourage mothers to focus on adequate hydration, breastfeeding correctly with a proper latch/positioning, breastfeeding more often, pumping immediately after feeding to ensure the breast is completely empty, and offering both breasts at each feeding to increase milk supply. The nurse should also remind mothers that while most mothers produce enough breast milk to feed their babies, most worry about not producing enough. The nurse should calmly review the signs that the baby is getting enough to eat, such as adequate wet diapers, bowel movements, and behavioral signs of satiety (USDHHS, n.d.)

Fungal infections

Fungal infections can form on the nipple or the breast due to an overgrowth of the Candida organism. Signs of a fungal infection include:

• Nipple soreness that lasts more than a few days,
• Pink, flaky, shiny, itchy, or cracked nipples, 
• Deep pink and blistered nipples, 
• Breasts that ache, or
• Shooting pains in the breast during or after feedings (USDHHS, n.d.).

Antifungals can be prescribed to treat fungal infections. Nystatin cream (Nystop, Nyamyc) is commonly prescribed. Fluconazole (Diflucan) may be used for resistant cases (Berens et al., 2016). Fluconazole (Diflucan) treatment is typically recommended for two weeks, and the mother can continue breastfeeding. Fungal infections can take weeks to clear up. To avoid spreading the infection, the nurse should instruct the mother to change disposable nursing pads often, wash any towels or clothing that come in contact with the yeast in very hot water (above 122° F), wear a clean bra every day, and wash their hands and the baby’s hands often. Boil all breast pump parts that touch breast milk, pacifiers, bottle nipples, or toys the baby puts in their mouth daily. After one week of treatment, instruct caregivers to replace all pacifiers and nipples (USDHHS, n.d.).

Evidence-based Nursing / Implications for Nursing

According to the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN, 2015), 98% of all births in the U.S. occur in hospitals where nurses are the primary source of care, supporting women from labor and birth through discharge. They go on to point out the vital role that nurses play in preparing, educating, encouraging, and supporting women to both initiate and continue breastfeeding (AWHONN, 2015, para 10). 

WHO and UNICEF launched the Baby-friendly Hospital Initiative (BFHI) to help motivate facilities providing maternity and newborn services worldwide to implement the Ten Steps to Successful Breastfeeding. The implementation guidance for BFHI emphasizes strategies to scale up to universal coverage and ensure sustainability over time. The direction focuses on integrating the program more fully in the healthcare system, to ensure that all facilities in a country implement the Ten Steps. The ten steps include:

1a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions.

1b. Have a written infant feeding policy that is routinely communicated to staff and parents.

1c. Establish ongoing monitoring and data-management systems.

2. Ensure that staff has sufficient knowledge, competence, and skills to support breastfeeding.

3. Discuss the importance and management of breastfeeding with pregnant women and their families.

4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.

5. Support mothers to initiate and maintain breastfeeding and manage common difficulties.

6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.

7. Enable mothers and their infants to remain together and to practice rooming-in 24 hours a day.

8. Support mothers to recognize and respond to their infants’ cues for feeding.

9. Counsel mothers on the use and risks of feeding bottles, teats, and pacifiers.

10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care. (WHO, 2019b).

According to the WHO:

There is substantial evidence that implementing the Ten Steps significantly improves breastfeeding rates. A systematic review of 58 studies on maternity and newborn care published in 2016 demonstrated clearly that adherence to the Ten Steps impacts early initiation of breastfeeding immediately after birth, exclusive breastfeeding and total duration of breastfeeding (WHO, 2019b, para 3). 

Future Research/directions

Society can play a role in improving the health of families by supporting breastfeeding. Mothers need continuity of care to reach their breastfeeding goals, which is achieved by consistent, collaborative, and high-quality breastfeeding services and support (CDC, 2019b). Support from their families, friends, communities, clinicians, health care leaders, employers, and policymakers can greatly improve the chances of success for a mother who wishes to breastfeed successfully (USDHHS, 2011, para 1).

While research exists on breastfeeding, the USDHHS identifies significant knowledge gaps that deserve to be filled with evidence-based information to provide patients with the highest-quality assistance possible. For example, what are the barriers to breastfeeding in place among specific populations with lower rates of breastfeeding, and how can those barriers be addressed? What are the economic advantages for employers of breastfeeding amongst working mothers? Which interventions increase breast milk supply consistently with minimal or no adverse effects for the mother and baby? (USDHHS, 2011).

AWHONN (2015) supports the legislation, policies, and public health initiatives that ensure the right to breastfeed, increase the rate of initiating and maintaining exclusive breastfeeding in the United States, raise awareness of the benefits of breastfeeding, and expand research related to breastfeeding. Such initiatives include the following:

• Protecting mothers that choose to breastfeed in public and private locations with legislation, while ensuring breastfeeding is not included in indecency legislation.
• Public health campaigns that encourage women of all cultures to breastfeed, especially families of African‐American, Native American, and Asian‐Pacific Islander descent.
• Allowing lactation to qualify as a valid exemption from jury duty (or defer service for a year).
• Ensuring the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) breastfeeding program and the CDC have adequate funding and support for peer counselors, federal breastfeeding campaigns, and other resources.
• Ensuring that lactation services and breastfeeding supplies (scales, pumps, etc.) are adequately covered by both public and private health insurance plans.
• Support lactating women in the workplace with requisite breaks and private areas (not bathrooms) to pump or breastfeed through legislation and corporate policy. 
• Paid maternity leave through enhanced family medical leave policies to increase the opportunity to establish and maintain exclusive breastfeeding and flexible scheduling to continue breastfeeding for up to a year. 
• Ensure the NIH and other organizations receive adequate funding for breastfeeding research.
• Clarification of the marketing recommendations for artificial nipples/bottles within the International Code of Marketing of Breast‐milk Substitutes.
• Development and maintenance of nurse home visiting programs to help mothers with breastfeeding after discharge through funding and other support.
• For infants admitted to NICU units, establish or improve access to donor breast milk through enhanced insurance coverage in public and private plans (AWHONN, 2015, p. 148-149).

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