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PQCNC Human Milk Initiative Well Baby Track Learning Session 1 - Focus area #2b: Rooming in Contribution during the Maternity Stay by Miriam Labbok, MD
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Improving the Quality of Maternity Care in North Carolina:
The Role of Rooming-in in Breastfeeding Success:
Ten Steps 6, 7, and 8
Outline
• Anatomy and physiology of lactation
• Impact of disruption/support mediated by Steps 6, 7, and 8
• What do we do that creates barriers or provides support for rooming-in?
Skin-to-skin with Rooming-in:
Allows the normal physiological cascade to occur
• Any separation reduces mother/baby skill building as well as teaching opportunities
• Any separation reduces frequency of suckling• Any separation can lead to destructive and
unnecessary supplementation• Any separation increases the risks of hyperbili,
hypoglycemia, weight loss, engorgement, and other ‘disasters’ for the breastfeeding dyad
• Any separation may disrupt several of the Ten Steps• AND• Avoiding separations may mean change in current
practice norms and clinician behaviors.
CBI, 2009
ANATOMY
The Alveolus(Lawrence, p. 81)
Modified from Vorherr H: The Breast:
Morphology, Physiology and Lactation.
New York, Acadmeic Press. 1974.
Physiology: Complex Neuro-endocrine-Mammary - Ovarian/placental interaction
• Pregnancy– mammary tissue growth
during pregnancy
– needs prolactin
– Prolactin inhibitingfactor (PIF) fromhypothalamus,
• Birth– Milk present in third
trimester
– PIF stops secondary to catecholamines fromdopaminergicimpulses; mediated bydrop in progestins
• Lactogenesis– Mediated by oxytocin (let-
down/muscle contraction) and prolactin in the earlydays/weeks
– Oxytocin responsive to smell and touch of infant
– Prolactin responsive to suckling
– (Later, milk supplymediated primarily byemptying and FeedbackInhibitor of Lactation (FIL))
• Impact of Separation
DEMAND DRIVES SUPPLY
Fullness feeds back and inhibits lactationDelayed emptying and engorgement increase levels of FIL
(milk whey protein) that down-regulates PRL receptors.
Let Down
Latch
Moving Milk
TEN STEPS6. Give newborn infants no food or drink other
than breast milk unless medically indicated.7. Practice rooming-in:
allow mothers and infants to remain together 24 hours a day
8. Encourage unrestricted breastfeeding
Rooming in• Reduces risk of supplements
– Prelacteal feeds of any sort impact initiation, continuation • (Israel et al 1980, Nylander 1991)
– Supplements after discharge decreases duration • (Martines et al 1989, Perez-Escamilla)
– Supplement use increases illness
– Commercial samples if present tend to be used
• Supports
– Higher full breastfeeding rates
– Increased milk production • (Mapata et al 1988, Yamauchi 1990)
– Co-sleeping, which increases night feedings • (McKenna, Ball)
Is supplementation
the result of disruption of the
physiological cascade, or from
old standard practices?
Percent of U.S. breastfed children who consume infant formula
in addition to human milk
Source: CDC NIS 2011
Barriers and FacilitatorsBarriers
• Older nurses and physicians
• Staffing constraints
• Interference in mothers’ choices
• Increasing C/S rate
• Assumptions re: culture
• Lack of self efficacy among nurses
• Perceptions
• Nights: Staff practices
• Lack of BF skills among night nurses
• Visitors in L&D
• Pacifiers for “fussy” babies
• Not perceived as important learning time
Facilitators
• Growing desire for breastfeeding
• Management support for Ten Steps
• Medical and nursing staff recognize benefits of breastfeeding to health care and health system
• Including breastfeeding support in evaluation
• Hands on training in new practices and skills
Next: Identifying and overcoming the perceived barriers
In your teams:1. Discuss and ensure that all are on board with the
need to achieve rooming-in at least 22/24 hours, and preferably 24/24 -- Is there a comfort level with the mutual understand
anatomy and physiology, and how separation disrupts normal?
2. Discuss the current status of rooming-in, 24/7 in your facility-- Are you nearly there? Far from achieving it? Why?
3. List barriers and facilitators: Discuss how you might address each. -- Consider QI, staff evaluation, formula control measures,
policy and policy adherence, etc.
Normal breasts are functionaland are seen everywhere:
Help ensure that the baby can do its job!
Skin to skin and starting the first feed
Medianminutes after birth
6 Opening the eyes
11 Massage-like hand movement on mother’s breast12 Hand-to-mouth movement
21 Rooting movement
25 Hand to nipple27 Licking
80 Sucking
Matthiesen A-S, et al. Postpartum Maternal Oxytocin Release by Newborns: Effects of Infant Hand Massage and Sucking. Birth. 2001;28(1):13-19.
92%92%
80%
Sk
in t
o s
kin
Ro
uti
ne
95%
72%
Breastfeeding at discharge
Breastfeeding at 1-4 months
Breastfeeding at 12 months
Successful first feed
58%58%
46%
20%
0%
Bottom line: Mothers who held their infants skin-to-skin breastfed 43 days longer than mothers who did not.
Anderson GC, et al. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews. 2007;3.
Improved EBF in hospital after implementing the Baby-friendly Hospital Initiative
5.50%
33.50%
0%
5%
10%
15%
20%
25%
30%
35%
40%
1995 Hospital with minimal
lactation support
1999 Hospital designated as
Baby friendly
Perc
en
tag
e
Exclusive Breastfeeding Infants
Adapted from: Philipp BL, Merewood A, Miller LW et al. Baby-friendly Hospital Initiative improves breastfeeding initiation rates in a US hospital setting. Pediatrics, 2001, 108:677-681.
Slide 4.1.5