Office of Nutrition Services
350 Capitol Street • Room 519 • Charleston, WV 25301-3715
phone: 304-558-0030 • fax: 304-558-1541

Breastfeeding Update

The articles listed below have appeared in the Breastfeeding Update, a semi-annual newsletter published by the Office of Nutrition Services for medical and health care professionals. These articles provide information regarding breastfeeding, related problems and solutions, and current data related to breastfeeding. If you have any questions about this material, please contact our Breastfeeding Coordinator at 304-558-0030.

For more information on Breastfeeding and WIC contact your local agency.

Breastfeeding and Birth Control

- by Connie Neuner, IBCLC, Breastfeeding Education Coordinator, WV Bureau for Public Health/Office of Nutrition Services/WIC

Using the wrong kind of oral contraceptive while breastfeeding in the early months can sometimes bring breastfeeding to a quick end. Since a new nursing mother may leave the hospital with birth control pills, it is important that she be prescribed a type that will not interfere with her ability to lactate.

Regular birth control pills, because of the higher amount of estrogen, can cause a rapid decrease in milk production. Progestin-only contraceptives do not interfere with milk production. These include progestin-only mini-pills, the Depo-Provera injection, and Norplant. Ideally, even the use of progestin-only contraceptives should be delayed until baby is 3 weeks old. After the first four months the question of which hormonal method of birth control to use for lactating women is not a concern.

The State Health Department's Family Planning Program has recently added the progestin-only oral contraceptive, Micronor, to its list of available contraceptives. Because of the very high cost of this progestin-only OC, it is recommended that it only be prescribed for breastfeeding women. Micronor is being added on a trial basis to test the frequency of demand for such a pill. Progestin-only Depo-Provera injections are also available through Family Planning Programs.

According to the Institute for Reproductive Health, the following early postpartum birth control methods are recommended for lactating women who are not fully breastfeeding:

  • Depo-Provera injection
  • Progestin-only oral contraceptive
  • Norplant implant
  • Barrier Methods.

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Breastfeeding Promotion Campaign Goes National

- by Connie Neuner, IBCLC, Breastfeeding Education Coordinator, WV Bureau for Public Health/Office of Nutrition Services/WIC

From coast to coast "Loving Support Makes Breastfeeding Work" will become a household slogan! The West Virginia WIC Program will sponsor part of a national breastfeeding promotion campaign to be "launched" during World Breastfeeding Week, August 1 through 7. You and your patients will see and hear media messages encouraging community support for breastfeeding.

Because of the explosion of research during the last fifteen years proving that human milk for babies is far superior to commercial baby formulas, USDA in 1995 funded a large-scale project designed to:

  • improve public and medical support of breastfeeding
  • increase breastfeeding rates among WIC participants
  • increase referrals to WIC for breastfeeding education and support

The end result of this breastfeeding promotion project is ready to debut this August. Newly developed client education materials and mass media materials focus on three breastfeeding issues of concern to women: embarrassment, competing demands on mothers time, and lack of support. The messages are upbeat and contemporary. They include practical and reassuring responses to these concerns.

Support for a mother's decision to nurse her child is the major theme throughout these campaign messages. Even though more West Virginia mothers are choosing to initiate breastfeeding, the length of time they continue to breastfeed is not increasing. Mothers tell us that they are not getting the support and information they need to feel confident about continuing to nurse their infants. Much of breastfeeding success comes from mother's confidence in her ability to nourish her child. That confidence must come from encouragement, help, and support from those around her.

Because this support must also come from the medical community, physicians, midwives, hospital staff and public health nurses are encouraged to update their knowledge and skills to support lactating women and their babies. WIC Program Breastfeeding Specialists and board-certified lactation consultants can help your staff better assist mothers with breastfeeding questions. Your patients expect and deserve the most accurate and supportive advice you can provide.

If you and your staff would like samples of new breastfeeding education materials or educational videos for loan, contact the West Virginia Office of Nutrition Services/WIC Program at 304-558-0030.

Remember, "Your Support Makes Breastfeeding Work" for your patients.

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Going Public--Discreetly Nursing in Public

- by Connie Neuner, IBCLC, Breastfeeding Education Coordinator, WV Bureau for Public Health/Office of Nutrition Services/WIC

If your patient expresses concern about breastfeeding in public, here are some tips you can give her:

Where to Go: Find a place to sit. Try a quiet corner in a fast food or other restaurant or store; Department stores often have women's lounges with chairs or fitting rooms; Park benches; Create privacy by turning away from the crowd even slightly.

What to Wear: Wear loose fitting, un-tucked shirts or front button tops; long, full tops work well; Wear layers--cardigan sweaters, jackets, or scarves are good.

How to Position Baby: If wearing a loose shirt, hold baby close to you and lift your shirt from the bottom over the baby's head, just high enough for baby to find the breast. Shirt should drape over baby's head. If wearing a buttoned shirt, unbutton from the bottom (waist) to just below the breast and slip baby in to nurse. Throw a baby blanket, sweater, jacket, or scarf over your shoulder and baby.

Body Language: Body language can attract attention or divert it. If you're watching your hand unbutton your shirt, others will follow your gaze. Minimize the attention you give your clothing. Meet people's eyes and smile, or create your own privacy zone by reading a book or focusing on something else.

Practice: Try feeding in front of a mirror so you can see if anything is exposed, and practice adjusting your clothes.

Be proud of what you are doing for your child. Act comfortable and natural and it will become easy.

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Offering Breastfeeding Options to Your Patients.

by Michelle Cissel, IBCLC

Ms. Cissell is a Board Certified Lactation Consultant, with the Shenandoah Valley Medical System/WIC Program.

Many women return to work or school after the birth of their child, some within a few weeks of delivery. For this reason, many women choose not to breastfeed. If they could be informed of the many options breastfeeding offers, more might decide to breastfeed, even if only for a while. Increasing her infant feeding options can enable the new mother to feel more confident about balancing family and work schedules- and reap the health rewards that come with breastfeeding.

Lets look at some of these breastfeeding options and the necessary planning that goes with them. A breastfeeding woman who plans to return to work or school has the following choices in regards to breastfeeding: a) wean before returning to work or school, b) have the baby's care giver use formula while the mother breastfeeds when at home, or c) express her milk for the baby's care giver to use in bottles and breastfeed when at home.

Weaning before returning to work:

This option provides the baby with the benefits of short term breastfeeding:

  • Colostrum provides abundant amounts of antibodies and immunoglobulins that enhance baby's immune system. The health protective potentials of human milk are related to the amount of human milk an infant receives. Short term nursing gives short term health benefits that are not available from commercial formulas.
  • Breastfeeding during the early weeks reduces postpartum bleeding and stimulates the mother's uterus to return to pre-pregnancy size faster.
  • Short term breastfeeding provides priceless bonding between mother and infant. The health benefits of breastfeeding for only a few weeks may be temporary, but effective breastfeeding gives mother and baby both satisfaction and a healthier start in life. The mother will need to be given weaning information to ensure her comfort and reduce her risk of complications due to improper weaning. Gradual weaning will also be more acceptable to baby.

Using commercial formula while at work/school:

More and more businesses offer supportive breastfeeding policies. They are learning how breastfeeding can make a difference in the health, satisfaction, and medical costs of their employees. However, some women are uncomfortable with the idea of expressing milk at work or they are unable to pump at work due to the nature of their job or the lack of a private, clean place to express milk. Providing commercial formula for the day care giver to feed baby while mother is at work/school and breastfeeding while she is at home is an acceptable alternative. It is better than no breast milk at all. Mother should be encouraged to breastfeed exclusively for at least 3-4 weeks postpartum before introducing a bottle.(If early supplementation is medically necessary, methods other than bottles may be used to deliver milk to the baby.) Two weeks before returning to work or school, the mother can gradually start weaning to a commercial formula for the 2-3 feedings when she would normally be at work, and breastfeed when she would normally be home. If she does this gradually over the two weeks before returning to work or school, she will prevent any discomfort. If mother weans to formula more suddenly, she needs to know that her breasts will get full and possibly uncomfortable while at work due to the missed feedings. She should be prepared for leakage and should be given information on hand expression to make herself comfortable. The feeling of fullness will decrease as the weeks progress. Frequent nursing on her days off will help maintain her milk supply.

While the health benefits of breastfeeding are reduced with the introduction of formula, combination feeding is better than formula alone. Breastfeeding is the easiest way to reconnect with her baby when mother gets back home.

Expressing milk at work or school for use by day care provider:

By choosing to express her milk, a mother knows she is giving her baby the best nourishment possible. She also saves her family money and improves the health of her baby. A healthier baby leads to less missed work days due to caring for a sick child. Again, mother should be encouraged to breastfeed exclusively for 3-4 weeks postpartum before introducing a bottle. About 2 weeks before returning to work/school she should begin expressing and storing her milk. She will need a good electric breastpump for repeated long term pumping.

The electric breastpumps available at drug and discount stores are only meant for an occasional missed feeding. They may not stimulate and empty the breasts well enough for an extended period of time to maintain a good milk supply. The cost of renting an efficient electric pump is much less than the cost of the formula she would otherwise need. (Medela, Inc. even has a foot pump that works well and can be purchased at a reasonable price–No electricity or batteries needed!). There is always the option of hand expression. Some women can hand express as successfully as others can pump.

By giving women options, we enable them to make an educated decision about whether or not to breastfeed their baby. No matter which option she chooses, she will need support. Help is available to breastfeeding women from La Leche League, board-certified lactation consultants, the WIC Program, breastfeeding support groups, and friends or family with breastfeeding experience. Good breastfeeding information and local support enable a smooth transition to work with added comfort and satisfaction.

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One Physician's Way of Providing Breastfeeding Information

In August the American Academy of Pediatrics/American College of Obstetrics/Gynecology national offices sponsored the second breastfeeding training conference for physicians at AAP national offices in Oakbrook, Illinois. Dr. Michal Young, neonatologist, D.C. General Hospital, Washington, DC, was a speaker at the conference. In Dr.Young's neonatology practice all new mothers are given the following information about the difference between breast milk and commercial formulas. The information conveys this physician's belief that breast milk is the preferred infant food choice for all infants. Mothers in this urban, inner-city practice are given this material and advised to make their own choice. Dr. Young does not believe that "guilt" comes into play when a patient is given accurate information about optimum health practices. Dr. Young gives permission to share the following material with other physicians:

Mothers who choose to formula feed please be aware of the following:

  • Formula is an inferior substitute for breast milk.
  • Unlike breast milk, formula does not contain substances that will fight colds, ear infections, diarrhea, and pneumonia in your baby.
  • Unlike breast milk, formula does not contain substances that improve brain function - i.e. breast-fed infants have higher IQ's later in life than formula fed infants.
  • Breastfeeding helps you lose weight–you burn extra calories daily while breastfeeding.
  • It costs $1000 per year to formula feed. Even if you are receiving WIC formula, remember, it is a supplement. The formula will run out before the month does. WIC supplies more food for a mother to eat when she is breastfeeding.
  • Formulas try to imitate breast milk - why give your child second best when they can have the real thing!
  • Unlike breast milk, formula cannot help protect your baby from diabetes and cancer.

Breast milk is the best milk for your baby. Unless you have the AIDS virus, or are taking drugs that will cause harm to the baby you should breastfeed. Anything less is less than the best for your baby. Its your choice. Please choose wisely.

Michal A. Young, MD, FAAP Division of Neonatology, Dept. Pediatrics D.C. General Hospital

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Physician Guide to Assessing Early Breastfeeding

by Marianne Neifert, MD

Dr. Neifert is the medical consultant to the Health One Lactation Program in Denver and a member of the AAP Work Group on Breastfeeding. Adapted from the Academy of Breastfeeding Medicine News &Views Vol. I. Fall, 1995.

As physicians and other health care providers are being called upon to evaluate newborns within the first few days after discharge, they need specific criteria to accurately assess whether breastfeeding is off to a successful start or whether intervention is necessary to correct early difficulties which may lead to more serious problems later.

Infant Weight Criteria

A naked infant weight and the calculated percent weight loss from birth are the most accurate measures of the baby's nutritional status and the adequacy of breastfeeding. Peak weight loss occurs just prior to milk "coming in," usually on the 3rd day of life. The period of weight loss after birth is short-lived. If breastfeeding is going well, babies will not continue to lose weight after abundant milk production begins. Physicians traditionally have been trained to accept up to 10% loss from birth weight as being normal. Yet, very few breastfeeding infants will lose this much unless breastfeeding problems are present. Tolerating 10% weight loss and calling it normal only serves to delay intervention when infants could benefit from early modifications in breastfeeding frequency or techniques.

Shortly after milk comes in abundantly, thriving breastfed infants will gain approximately an ounce per day during the early weeks of life. Steady weight gain should commence by 5 days of age and most breastfed babies will surpass their birth weight by 10-14 days unless the baby fails to obtain sufficient milk. "Faltering" infant weight in the early weeks of breastfeeding should not be considered a normal pattern. It is suggestive of inadequate milk intake by the infant, which shortly will lead to diminished milk production. For this reason, early intervention to improve milk delivery to the baby is essential. This does not mean to simply discontinue breastfeeding, but to improve breastfeeding effectiveness or to supplement, if necessary.

Infant Elimination

An infant's elimination pattern is one of the most sensitive indicators of the adequacy of milk intake.

Shortly after mother's milk has became abundant, a thriving breastfed newborn should void colorless urine at east 6 times daily. With inadequate infant intake, mothers often report a "brick dust" appearance in the diaper due to precipitated urate crystals (not uncommon in the first 2 days of life, but considered abnormal later.)

At about the 4th or 5th day of life, well-nourished breastfed infants typically begin to pass sizable (not a small stain) loose, yellow "milk stools," resembling cottage cheese and mustard after most feedings. Between 4 days and 4 weeks of age, a thriving breastfed baby typically will pass at least 4 such "milk stools" each day. Dark transition stools, infrequent movements, or scant volume of stools in the young breastfed infant are common indicators of insufficient milk intake. A weight check is in order when an infrequent stooling pattern is present after the mother's milk has "come in". By one month of age, stooling frequency gradually diminishes in breastfed infants.

Frequency of Feedings

Inadequate feeding frequency is a common, preventable cause of insufficient milk. A mother must be prepared to nurse her new baby whenever the infant fusses, roots, sucks the hands, just acts hungry or of course cries. Crying is the late sign of hunger, however.

Newborns should nurse approximately 8 to 12 times in 24 hours, usually taking both breast at each feeding. Mother should nurse her baby every 1 2 to 3 hours during the early postpartum weeks to maximize her milk supply and assure adequate infant intake. A single longer night interval of about 4 hours is common. A mother should be instructed to awaken a non-demanding baby to nurse at least every 3 hours during the daytime. She should alternate the side on which feedings are started because the infant suckles more vigorously at the first breast. Pacifiers should be withheld until a consistent pattern of acceptable weight gain has been established.

Duration of feedings should be approximately 15 minutes per breast, during which the infant's swallowing can be seen and heard by mother. Infants are unlikely to obtain sufficient milk by suckling less than 10 minutes per breast in the early weeks of life, while feedings that last more than 50 minutes usually signal ineffective nursing.

Infant Behavior

Once milk has "come in," a mother should hear her baby swallow regularly during feedings and see evidence of milk in the baby's mouth. This observation is subjective, however, and does not always correlate with objective measures of intake.

Generally, a breastfed baby should appear satisfied after nursing and sleep between feedings. Excessive crying, continual sucking on fists, or constant need for a pacifier sometimes signify persistent hunger.

Exaggerated physiologic jaundice in a breastfed infant may be a marker for inadequate breastfeeding, it must be distinguished from breast milk jaundice which usually becomes noticeable at the end of the first week of life and peaks during the second or third weeks of life. Jaundice should raise the physician's suspicions and trigger a more detailed evaluation of brestfeeding behavior. The physician should be reassured that:

  • Baby was put to breast within 1 hour after delivery
  • Baby has been nursed every 1 and 1/2 - 3 hours, both in hospital and at home
  • Mother observes baby swallowing
  • Baby has received no supplemental foods by artificial nipple, unless medically necessary

Maternal Breast Evaluation

Lactogenesis, or the onset of copious milk secretion, usually occurs 2-4 days postpartum. Primary failure of lactogenesis occurs rarely. Assessment of maternal breasts by prenatel care providers can reveal inverted nipples or a surgical scar. Surgery may severed lactiferous ducts, impairing milk drainage. Abnormal breast development and lack of pregnancy-induced changes may be associated with insufficient lactation.

The leading preventable cause of insufficient milk is failure to accomplish regular, effective milk emptying once postpartum breast engorgement occurs. When an infant is unable to empty the breasts effectively, prescribing an electric breast pump can preserve milk supply while efforts are being made to improve baby's breastfeeding technique.

Most women experience slight nipple discomfort at the beginning of feedings during the first few days of nursing. However, severe nipple pain, pain lasting throughout feedings, or pain persisting beyond one week postpartum is atypical and suggest that the baby is not positioned correctly at the breast. It is important that hospital OB, postpartum, and newborn nursing staff be trained in teaching and assessing proper infant latch-on. Improper infant latch-on not only causes sore nipples, but also impairs milk flow and leads to diminished milk supply and inadequate infant intake.

Early assessment allows for the timely detection and treatment of breastfeeding problems that can jeopardize success.

By collaborating with community breastfeeding referral services, care providers can help most women overcome early difficulties. Even when breastfeeding appears to be going well, remember that new mothers require our affirmation, encouragement, and ongoing support to assure the continuation of breastfeeding.

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The Role of Obstetricians, Family Practice Physicians and Midwives in Breastfeeding Success

- by Connie Neuner, IBCLC, Breastfeeding Education Coordinator, WV Bureau for Public Health/Office of Nutrition Services/WIC

As an obstetrician, family practice physician or a midwife, you play an important role in breastfeeding success. Your patients look to you for information and guidance on how to nurture themselves and their unborn baby during pregnancy. The prenatal care that you and your staff provide is vital to a positive pregnancy outcome.

The choice your expectant mothers make on how they will feed their newborns is an important step in laying a solid foundation for their baby's growth and development. We'd like to enlist your help in informing your patients on the benefits of breastfeeding. The West Virginia Bureau for Public Health, Office of Nutrition Services/WIC Program has been working to increase awareness of the value of breastfeeding to expectant mothers, their families, employers, and communities across West Virginia. However, we know that your support and assistance is a key to our effort.

If you would like help with staff training in lactation management or resource materials such as pamphlets or videotapes, please contact Connie Neuner, IBCLC, WV WIC Program, at 304-558-0030.

Ways You and Your Staff Can Help Your Patients:

  • Discuss the benefits of breastfeeding with your patients.
  • Display up-to-date brochures, posters, or videotapes with breastfeeding information.
  • Make sure your staff is knowledgeable on breastfeeding issues and obstacles. Know how to work through obstacles for a positive breastfeeding experience.
  • Encourage your local hospital to appraise its breastfeeding support practices so that nursing mothers receive appropriate information and assistance. (Model hospital policies and protocols on breastfeeding support are available from the WV WIC Program.)
  • Provide a list of support services such as lactation consultants, a local La Leche League, local WIC Program Breastfeeding Specialists, or WIC Program Breastfeeding Peer Counselors.

Help Us Support the Healthiest Feeding Practice for Mother and Infant - Breastfeeding.

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Suggested Consistent Management Messages for Mothers

These messages were developed with the input of the Health Care Professional subcommittee of the Breastfeeding Promotion Consortium and the National Breastfeeding Leadership Roundtable.

With consistent messages in the community for the early postpartum period (until baby's first check-up), we hope that the duration of breastfeeding will begin to increase. Further management messages can continue to be age-appropriate as baby grows and breastfeeding questions change.

The following messages are offered as a suggestion for distribution among health care professionals, and for use by breastfeeding task forces.

Mothers Remember: Making Milk is Easy. Here's How.

  • Breastfeed soon and often
    • As soon as possible after birth is best - within 1st hour
    • 8-12 times each day in the early weeks is usual to build milk supply
  • Be sure you and baby are both comfortable
    • Help baby latch on correctly with wide open mouth as he latches on and lips flanged out
    • Hold baby close - chest to chest - use pillows to lift baby to breast level
  • Avoid bottles and pacifiers during the first 2 weeks
    • They can confuse baby's sucking and reduce milk supply
    • Breast milk alone is all most babies need
  • Notice signs of plenty of milk
    • Swallowing sounds when baby suckles
    • Wet diapers (6-8 each day after day five, 3-4 heavy disposables)
    • 2-3 stools each day, turning yellow & soft by day four
    • Usually happy baby (all babies cry some)
    • Normal weight gain (7-10% weight loss at first, then 1/2-1 oz. gain per day after day 6
  • Call when you have questions - request competent information from physician, mid-wife, WIC Program, hospital staff
    • We all need help when learning something new
    • Express questions & concerns early, before problems develop
    • Competent advice will support breastfeeding while finding solutions to problems

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