Chapters Transcript Breastfeeding Basics for Outpatient Pediatricians: Supporting Mom and Baby Until the Milk Comes In Leanne DePalma, MD, presents on "Breastfeeding Basics for Outpatient Pediatricians: Supporting Mom and Baby Until the Milk Comes In." Well, good morning, everyone, and thank you for joining Early Bird Rounds today. Um, today we have Doctor Leanne De Palma, who specializes in pediatric hospital medicine. Before we get started, I just have a reminder that after every session, you should receive an email with the slides and a short survey link to fill out and give us feedback each week. We really appreciate those who have participated in the survey, and we continue to ask everyone to take that survey survey after each session and just let us know. Your thoughts, and this will allow us to continue our bird rounds and to improve it. Um, and then also the reminders to just keep your cameras turned off and your mic's muted during the session, and that there's always time for questions at the end, you can put those in the chat or on mute at that time, and then um the QR code will be put up at the end for you all to scan for credit, and we'll go ahead and turn our attention over to Doctor DiPalma. Hey, good morning. Everyone can hear me fine? Yeah, um, I'm greatly Leanne DePalma. Um, I am a pediatric hospitalist at WashU. I'm also a certified lactation consultant. So, um, I love talking about breastfeeding and breastfeeding medicine, so I'm really excited to talk to you guys today. Um, but just, um, breastfeeding. So when I was given this topic, it's a really wide topic. So I wanted to kind of focus in on just those first few postpartum days when um mom and baby are just getting established in that breastfeeding relationship and we're waiting for that milk to come in and kind of getting everything established and what we can do to support that mom and baby during that time. So, besides answer here, I have no financial disclosures. So, um, objectives for today, I want to talk about just a better way to um assess breastfeeding by taking a more detailed breastfeeding history and uh Uh, get, reviewing those risk factors, um, for delayed lactogenesis, so we know what moms might be at risk for breastfeeding problems. Um, review the indications for supplementation for breastfed baby and indications for pumping for moms that are nursing, and then talk about that triple feeding those moms that are doing it all. They're nursing, they're pumping, they're bottle feeding, and how we can, um, support those moms. So, when we um are assessing breastfeeding, we often ask just these open-ended questions, which is how, you know, we're taught from the beginning and ask open-ended questions, and these are good questions, but just how is breastfeeding going? Is the baby feeding well? Is your milk in? And a lot of those questions are good to start, um, they're also relying on the mom to have some idea about Um, how breastfeeding should be. And so when you have a mom that doesn't know what breastfeeding should be like, it's maybe her first um time nursing, then, um, sometimes I'll have mom say, oh, it's going great, and then when I actually see the baby feed. Uh, the latch is really bad or the baby really isn't doing anything nutritive. So we want to ask a little bit more detailed questions to assess what's really going on there rather than just like, is it going on? Mom says, great, and we actually have a baby who isn't, you know, transferring any milk. So, How is the latch, uh, might be a better question. Again, we're relying a little bit on to know what the latch should be like. So, um, is the latch comfortable? Little better question or you having pain with feeding. So just getting into a little more detail, um, and then like when you're asking about the milk coming in asking about more like, are you restful? Is there milk leaking? So just asking more detailed questions. Um. So the specific things I would want to ask about when I'm assessing breastfeeding, obviously, how often is the baby feeding? How many feeds do we get in 24 hours? How long is the baby feeding? Um, are they on there for 10 minutes each side? That's usually a pretty good amount of time, 10 minutes per breast to empty the breast, and some babies will go longer, and that's excellent. Um, and, um, are they waking up to feed on their own? Are we having to wake them? Is the baby sleepy or active at the breast, those type of things? And then we want to know about what the supply is like. Um, does the mom feel any fullness or changes in her breast? Are the breasts more full before they feed and less full after, firmer or softer before and after feeds, those type of things can tell us a little bit about what the supply might be like. Um, when mom's milk starts to come in, she may notice dripping or leaking of milk from the breast. Um, we may start to see milk in the baby's mouth as a sign of milk transfer. And then pumped milk volumes can be a proxy for um how much supply mom has, but it's not a perfect proxy um because mom may be pumping right after the baby just emptied the breast. So, um, if the baby did a fairly good job of emptying, and then mom pumps, she may not get much and we can't say, oh, then you have no milk. So that you wanna just take with a grain of salt how much mom is pumping. The other thing is that Depending on how the fli fits and how mom is, how much um. You know, sections she's able to do and those type of things, the pump again, pumping might not be a perfect proxy for how much milk mom actually has in her breast, and what the baby is able to get out. This is a really important one that I always tell parents to watch where the signs of sanity in the infant. The baby wakes up with hunger cues, they say they're hungry, and they go to the breast, and then um After they are um. They eat, they are drowsy, they no longer show those hunger cues, and those um signs of sanity last for 1 to 3 hours. It's a really good sign that the baby transferred milk and got what they needed from the breastfeed. Obviously, infant output, like stools and urine and their weight gain, um, are a great way to assess that the baby's eating enough, but that takes time, so it's uh harder to assess from feet to feet. Um, transfer of milk, like seeing and hearing swallows. I'd love to teach parents, um, what a swallow sounds like or looks like when the baby is actually on the breast, just that soft little. Clicking noise when the baby is on the breast because um when they start to be able to see the head, then they can know, oh, my baby is actually like swallowing my milk. Um and again seeing that milk in the baby's mouth like as they come off the breast, um, knowing that that some milk is being transferred. And then the quality of the latch is another important assessment to the breastfeed, and this is something that um everyone may have different levels of um comfort with being able to assess, um, and does require you possibly to watch the latch. Um, although there are things that you can, um, even just describe to the parents, like, here's the things to look for. There's a lot of great handouts out there too that you can give to parents with like some pictures, um. Just to say, here's what you should look for when you see your baby on the breast. Um, and you do want to ask what that quality of the latch, cause if the latch quality is one of the problems and that's something you would need to kind of help um get the mom or maybe some intervention and help um with that latch. So we're talking about a good latch. Um, we want to talk about the baby being in a neutral position, so they aren't there with their head turned and kind of trying to spend their whole feet with, you know, turning their neck and also using all these extra neck muscles, but they're just in a nice neutral position. Um, they're kind of coming at the breasts with their nose not lined up to the nipple, so they get that asymmetric latch with the upper lip, just over the nipple and most of the breast in the in the bottom part of the mouth. And then that their mouth is really wide open as you see in these two pictures over on the right side of the screen, um, not a narrow mouth but a wide open mouth, and the bottom lip is curled out, not under. The nose is real up close to the breast, and the cheeks are rounded, they aren't dimpled, they're sucked in. And then, um, as much of the um areola is mouth as you can get, but basically just more than the nipple. I put these two different pictures on here just to demonstrate that. Um, The both of these you just have a good latch with plenty of the breasts in the mouth, but as you see the bottom picture, this baby has almost all the moms areola in the mouth. And this baby on the um top also has a really nice deep latch, lots of breast tissue in his mouth, but there's no way this baby would ever get this mom's whole areola in his mouth. It's just too large. And so that's just a difference that moms have. Some moms have very large areolas, and that baby is never gonna do the whole thing. So telling the mom get all the areola in the baby's mouth is, um. Just impossible for some moms because of the size of the areola. So just say get as much of the breast in the baby's mouth as you can get a nice big bite, but not um all of the areola necessarily cause it just depends on what the mom's breasts are like. So, um, when you're, uh, the next thing you wanna assess is, um, if the mom supplies and, and I just wanna get a little bit into that, um. And a background of what that process is for the milk coming in as we say. Um, so lactogenesis one is that secretory differentiation. That's when the glandular tissue is, um, differentiating, it's kind of expanding, and that occurs during pregnancy. So that's what moms experiences their breast kind of got bigger, um, during pregnancy. Um, but lactogensis too, that's what most of us are talking about when we say did your milk come in. And that's secretory activation, and that is increasing volumes of milk, and that's in response to both hormones and the regular removal of milk. So, um, what's important here is that anything that is impacting um that regular removal of milk or things that impact that normal hormonal cascade around the time of like pregnancy that our delivery, those are the type of things that might impact. Um mom's having that normal, um, milk coming in at the normal timing. This slide looks busy, but it's just a reminder of the different hormones that play a role in um this lactogenesis. So, way back here in puberty, um, the milk uh glands uh form, but uh during pregnancy, when you have increasing amounts of estrogen and progesterone, um, all those glands are gonna expand, you'll get even more of them. And then in response to a sudden drop in estrogen and progesterone and a rise in prolactin, the um Mil will start the glands will start to make increasing amounts of milk, um, and that's this um lactogenesis too. Oh, I don't know, it just happened to my screen. OK. Sorry. Um, so, lactogenis2 is largely a result of that, those, um, hormones and that hormone cascade that occurs as part of labor and delivery. So estrogen and progesterone suddenly drop, and then prolactin peaks at the time of delivery. Um, and then prolactin will, uh, rise again and spike in response to the infant suckling or or nipple stimulation. So, um, that, uh, regular, um, Baby going to the breast or regular nipple stimulation from, for example, pumping is important to keep that prolactin level up. But you'll see in this chart there's also these other um hormones uh listed down here, such as glucocorticoids, insulin thyroid hormones, these insulin-like growth factors that have also been shown in other studies to play a role in um. Your milk production. And so this is just a reminder that there are a lot of other factors and possible, you know, disease processes that may also impact mom's milk supply. And so we're thinking about risk factors and things that may impact that. Just keeping in the back of our mind, like, for example, insulin, so that's why, oh mom has diabetes, maybe that's gonna impact our milk supply. Um, and obviously the other um hormone in here is oxytocin, which causes our milk letdown. That's actually gonna cause those. Myoepithelial cells around the ducts to squeeze and release the milk, and that raises in response to mom bonding with the baby during skin to skin time we get those feel good hormones and then you get that let down um reflex. Um, again, When you um have increasing levels of um prolactin, glucocorticoids, and regular milk removal, you will have tightening of these tight junctions between your uh mammary epithelial cells, which allows the cells to, to then uh control what goes into the milk and make plenty of milk, but when You um have either low levels of these hormones, the prolactin, corticoids, or like high progesterone or milk accumulation, um, that occurs with either not regular removal of milk or things like mastitis. These tight junctions get leaky and um then the milk kind of leaks out, puts pressure on the cells, and then, um, they make less milk. So keeping in mind all those things you know about how that monk is made and those hormones involved, then um we can put together these maternal risk factors um for delayed lactogenesis. So things like diabetes and thyroid disease, um, Can um put moms at risk for delayed lactogenesis, um, preeclampsia, hypertension, um, dehydration, things that might impact that blood supply to the breast as well. Um, and then anything that kind of impacts that, uh, labor and that normal cascade of hormones that results in that prolactin surge at birth, um, like a C-section, um, or things like that, um. And then, um, moms who are having their first baby are just more at risk for delayed lactogenesis than moms that have had a baby before. Um, and then insufficient glandular tissue is actually a very specific problem, not really, it's not about small breasts, it's about, um, not having enough glandular tissue like developed at the time of puberty. Those ones will have a very specific like tubular shaped breast, so, um, not just small breasts, but an abnormal shape to the breast. Um, and then having previous breast surgery that may have affected like the nerves or to the nipples or or severed the ducts could also impact um mom's milk supply. And most of the baby factors um that will result in delayed lactogenesis are things that might make the baby kind of a slow or pokey feeder like being premature or very small babies that might be at risk for hypoglycemia. Babies with jaundice, who sometimes aren't very strong beaters. Um, and then, um, babies that are separated from their moms, multiples just because, um, they tend to sometimes be premature, but also because it's just a lot harder for mom to make enough milk for these babies. And then inappropriate supplementation is a huge one because it's just that um we start supplementing those babies and then they aren't hungry to go to the breast. So that's a big one where we're interfering and causing them a delay in the milk coming in. So, these indications for supplementation are the list that we use at um the nurseries where WaU hospitalists work. Um, but we'll certainly see babies unfortunately, that uh get supplemented without these indications, but we are trying harder all the time to use only these medical indications to supplement a breastfed baby. Um, Hypoglycemia again should be um babies that um. Have hypoglycemia that's um it won't come up with breastfeeding so we can certainly give um a baby who has a low blood sugar, the glucose gel, that's what we use our nurser and let them try to breastfeed and see if that brings their sugar up. If it's refractory to breastfeeding, then they should be supplemented. Um, Weight loss, when it gets more than 10% and there's no sign that milk is coming, then they should also be supplemented. But many babies, when they get right to that 10% uh mark are right around that time when the milk is starting to come in. So stuff is starting to turn around. So it's OK to just, um, let them continue to feed at the breast because, um, the milk is starting to come in right around the time they get to that 10% mark. For the late return babies, we usually will start supplementing them around that 24 hours of age, if they're really not feeding well, knowing that these babies tend Um, not to turn around on their own very quickly. They tend to stay kind of um slow feeders and not have a lot of stamina, so we have a lower threshold for starting the supplementation. Of um Those babies, and then a baby that is not feeding well, even when there is a good milk supply there also should be supplemented. Um, But um Most of these other ones, like very rarely do I see a baby that actually looks truly dehydrated in the early days, um, in the nursery or like um just isn't making any stool or delayed or you know, prolonged meconium. Um, severe hyperbilirubinnemia doesn't happen a lot where they actually are dehydrated, but uh could be an indication of supplementation, um. And then this happens, obviously, um. Probably the most common reason we have to stop them is because the mom and baby have to be separated because one of them are sick. Um, and then there are a few radiologic procedures or medications that we should absolutely not feed baby for, uh, feed breast milk um to the baby or if mom just has intolerable pain. So this is this a fairly short list of absolute contraindications to breastfeeding. Um, maternal HIV, um, only if mom is not on suppressive therapy. So moms who are on suppressive therapy can breastfeed. Um, it's just a shared decision you're making with that mom, um, but it absolutely safe as long as she's on suppressive therapy with low. Uh, viral load for that mom to uh breastfeed. Um, there are certainly some maternal medications, but it is a shorter list than you think. We have lots of moms that get told they can't breastfeed, um, but when we look up the medicines, they're actually probably safer than people think. So some of the biologics or immune modulators like that are commonly used for uh rheumatoid arthritis or Crohn's, for example, those um are probably the most common ones they see where we really tell moms probably shouldn't breastfeed on this. Um, the best resource I like for looking at the maternal medications is Lactamed, um, which you can just Google Lactamed, or the website is here, which, um, isn't really easy to remember unless you bookmark it. But it's an NIH database. And, um, because there are a lot of nice randomized controlled trials about, um, breastfeeding women for most drugs, this will, uh, database kind of compiles. Any case reports or anything about any moms who um have breastfed on different medicines, you can just put in the name of the medicine and we'll give you any published thing about um mom's nursing on that medicine so that you can kind of see it all in one place and then you share decision making with the parents. Um, hepatitis C is only a contraindication to breast if there's actual bleeding from the nipples. Otherwise, it's safe. Um, there's some radiologic procedures because of, um, contrast, um, that you should temporarily, um, not breastfeed, but once that contrast is cleared, you can breastfeed again. Um, obviously, illicit drug use, um, we should not let mom breastfeed her baby. We don't include, um, THC in this, although we do counsel the mom about, um, the dangers and risk of that. Um, moms are in chemo or radiation, um, generally should not breastfeed. Active HSV lesions on the breast. Um, moms with active TB should not breastfeed. The milk itself is safe. It's just the close having mom and baby that close, it's not recommended. The baby actually be directly on mom's breast because of the active TB. And then obviously have Ebola, which I have not had that come up, um, brucellosis or HTLV are contraindications to breastfeeding, and babies with classic galactosemia. Um, so when does mom need to pump, um, For late preterm infants, um, I would recommend getting that mom started pumping right away. Late preterm infants generally, um, are going to be pretty poor feeders. They don't have a lot of stamina, so even when they do start to go to the breast, they aren't great at um milk transfer or emptying the breast fully. So having the mom, um, start pumping. Right away is um pretty good thing to do just to get that milk supply going. The same for multiples because it's just hard for mom to keep up with the supply needed, you know, babies are going to the breast. Um, for other like full term babies, I would not necessarily start a on pumping unless the baby were still having poor feeding after 24 hours of life. But I would give that mom the 1st, 24 hours, um, and even babies that do almost nothing in the 1st 24 hours, hardly latch at all. Um, more important to let that mom rest, um, spend time skin to skin, try and expression. Just give her that baby time to try to figure out it in the 1st 24 hours rather than start pumping right away. If mom and baby are separated, then they could start pumping right away. And then anytime you start um supplemental feedings on a baby, you should have the mom start pumping. So, triple feeding is what um I refer to as this moms who are doing it all. They're feeding their baby at the breast, Mom is also pumping, and then the baby is getting um supplements, so that could be her mom's express milk or uh formula or it could be donor milk, but baby is basically being bottle fed as well. It is pretty common at discharge um for late preterm infants, um, when moms have delayed lactogenesis, so they're putting the baby to the breast, but they really don't have much milk there, or babies that don't, um, have a good latch, so they just aren't really doing much at the breast at all or latching on much or those mom's babies that got separated early on, so they're still playing some catch up. Um, it is not a sustainable long-term plan. I always try to stress that with, um, the parents knowing that this is just a temporary, we got to get you to a different plan long term, because it's so exhausting. And if we don't kind of have a some kind of plan for transition, then what most moms will do is just quit the breastfeeding and just sprattle feed their babies. So, um, These families are gonna need close follow-up for support getting that baby back to breastfeeding, if that is their ultimate goal, um, usually we checks cause again, most of these are not strong feeders, and then guidance on how long do I need to supplement my baby, how long do I need to keep pumping, um. So, this is probably one of the top questions is when, when can I stop supplementing, like how long does my baby need to keep doing this bottle? And it's variable, um, and probably depends on the reason they're doing triple feeding. For some babies, it's gradual as the breastfeeding increases, and for some they can set more abruptly once the milk is in. So again, if you have a baby that's just really waiting for mom's milk to come in, they have a good latch, but mom's milk has just been delayed. Then once mom's milk comes in, that baby may take right off and feed at the breast and not need any more supplements. When you have a baby, um, that doesn't, isn't a strong breast feeder, um, but even when there is milk there, then they're just gonna take a little longer to, um, Gradually get to full breastfeeding. So the kind of questions you wanna ask when you're thinking about decreasing the supplements or how's the baby's weight gain? What is the milk supply like, and again, how you assess that or Are the breasts full before feeds, less full or softer after the feeds? Are there is there milk leaking or dripping from the breast? And then if mom is pumping, as mom's here trophy are, you can generally use um those volumes as a proxy for the supply. Um And then, um, how is the milk transfer? So assessing the transfer of the milk, listening or looking for swallows in the babies at the breast. Is the baby satisfied if they go to the breast? Is the baby go to the breast and then still seems super hungry? They're still rooting, they're still smacking their lips, they're still fussing, fussing, or do they go to the breast and they're like, Totally drowsy, like I could take a nap and no sign, no interest in taking a bottle or anything. And then obviously, um there are voids and stools. Another great thing to do is um a weighted feed, so the baby is um At a time to feed in your office, you can weigh the baby with a dry diaper on, let the baby feed, and then weigh the baby again with that diaper on. The reason you're gonna weigh them with a diaper on and not naked is because if they poop or pee anytime during that feed, um, You just wanna keep that diaper on so that you aren't trying to figure out, um. What to do with that? Oh, they peed and how do I assess like the loss of it. So you just weigh them with the dry diaper on and then if they pee in that diaper, just weigh them with the wet diaper on. And, um, every gram that they gained is a milliliter of, uh, milk they took in during that feed. Um, and then babies that have other risk factors for poor feeding are babies you might want to consider, like just supplementing a little longer, like the late preterm babies, if they have poor tone or jaundice or any other increased metabolic demands, just keep those in the back of your mind. And then, um, moms always want to know, do I need to pump because um most moms find pumping pretty um annoying, um, so the best rule of thumb is if the baby takes supplement, mom needs to pump to replace that feed. Um, and so, um, before mom's milk comes in, if she's still waiting for the milk to come in, then I would advise her to pump for 10 to 20 minutes each time the baby takes that bottle. And after mom's milk pumps in, she should just pump until her last drop of milk. Then that is a pretty time she's emptied the breast. If you're trying to increase the supply, then pump for 10 to 15 minutes after the last drop. Um, if the baby is starting to feed more at the breast, then mom can start to gradually decrease the pumping. So anytime the baby skips taking the supplement, um, so they went to the breast this time, didn't show any hunger cues, so you didn't need to give the bottle. Then you also don't need to pump. um. And so they can gradually decrease both the supplements and the pumping over time in that way. Um, a lot of people who are pumping around the clock and feeding bottles around the clock. I'll ask about, do I have to every time? What about overnight? Mom's exhausted. Can she sleep? Can dad, her partner just wake up and give a bottle and um It's definitely um a reasonable question. Um, this study, it wasn't in premature babies uh for NICUs um in the UK, but it's probably applicable to some of these triple feeding moms. What they did was, uh, collected data on the pumping and pumping frequency and milk volume on days 4, 14, and um 21. And Um, I think the useful information in this study is that, um, yes, how often you express or pump is important determinant of your milk yield. So, um, this is the data and this graph from day 21 and um What it shows is that um the moms that pumped more than 8 times a day over here and all the way on the right size of graph, um, were able to get um the best milk yield, um, this little dotted line on the graph that goes um horizontally here. That uh signifies 7150 mLs for the day, which is kind of the um UNICEF uh recommendation of like the minimum amount you should get at day 21. So you see that most of the moms that are pumping 8 times a day were getting at least that amount. But there were some moms that pumped only 6 to 7 times a day, they were also able to get that amount. So for some moms, pumping only 6 to 7 times a day was sufficient. Um, the, but if you pumped less than 6 or 7 times a day, you really weren't gonna get enough milk. So what that is, OK, maybe it's OK to skip like 1 pump a day. The other thing they looked at was the longest gap between pumping times, um, and so they looked at a gap of less than 6 hours, a gap between 6 and 7 hours, or a gap more than 8 hours, and um, what they found was that, um, You could still get pretty significant amount of milks and and still hit that target goal, as long as you didn't have any gaps that were less than. Uh, that were more than 6 hours, sorry. So, um, And they also found that there wasn't any significant difference, um. If moms had like a longer gap during the nighttime hours, it seemed to be that like pumping at night was most important because you just didn't want to have any big gaps and you want to get all your pumps in a day or in a 24 hour period, not really because you had to pump at night, if that makes sense, so. Um, I think we could use this to say, yes, you probably could take one break less as long as you don't go more than 6 hours, um, and still get enough milk, but if your supply is really dropping off, you, you may need a pump more often. So as we start to kind of bring all this stuff together, um, what we need to remember is each time is gonna experience the breastfeeding in a unique way. So we want to ask more objective questions, um, when we're assessing how the feeding is going. Um, we wanna try to think about those risk factors, um. For delayed lactogenesis, so we can recognize who's at risk for breastfeeding difficulties, so we can get those sometimes the support they need. Um, and remember that in these first weeks life, the frequency, the volume, the duration of feed, it's changing every day. The first day like we're like, oh, they don't have to feed that much, and then the second day we say, oh they actually they need to be feeding now more often, and then they go from, oh, they can take just 10 mLs and then they have to take 30, so parents can get so confused. It's something I hear so often. They say, well, yesterday you told us this and today you told us this, and the baby just keeps changing day to day. So it can get really hard to follow a feeding plan. So I think what helps um the most for parents is setting really clear expectations and making really clear written plans. Um, I love to give her written feeding plan to parents when they leave the nursery, so it's really clear to them what they're watching for, when to supplement, when to pump, all those things. And then having really close follow up because again, the baby is gonna change the plan, they're gonna start doing something different, and that plan is gonna change. So, when I give a feeding plan, I always break it down to 3 steps. Step 1, feed the baby, step 2, maintain that milk supply, and step 3 is maintain the focus on the breast. So I have put this example feeding plan in here. I kind of, um, it, there's a lot of texts and I put it in here so that you guys have this available if you have the slides. um, so I know it's a lot on these slides, but this is pulled from the feeding plan that I have in Epic. If you would want to see it, you can always go into Epic and um it's just called infant feeding plan. If you know how to like steal a smart face from someone, um, you're welcome to, um, Uh, take this feeding plan if it's of interest to you, but, um, this is what my feeding plan looks like that I give to parents and so I put in there, you know, feed your baby every this many hours, usually it's every 3. Um, and then make sure to just put in a little extra detail here about like feeding in a quiet alert state. Um, I usually will put in here, don't spend more than 10 number of minutes attempting um to feed. Uh, specifically I know a baby is going to have to take a supplement. We don't want feeding overall to take more than 20 to 30 minutes. So sometimes we gotta limit that time at the breast so that the baby has time to get their supplement in. And then I like to include these signs of a good feed, like a good latch with minimal pain, um, audible swallows, um, and then after the feeding your baby should seem satisfied, they should fall asleep or rest comfortably. And then if they still show the hunger cues, which I list here in this feeding plan, then you should offer a supplement. Um. Uh, off of the supplement if your baby did not latch or they have the hunger cues. Um, I do include in my feeding plan the supplement volumes. Most of the babies by the time they are going home from the nursery are over 48 hours, so they've hit this 30 mL uh minimum. Um, And then step 2 of the plan is established and maintaining that milk supply. So this means a regular um expressing or pumping the milk, and again letting them know they should pump if the baby doesn't latch or the baby gets a supplement. And then I put in there the pumping plan is and so for some moms I'll say pump every time, for some moms I will say pump only if your baby takes uh um. They, um, supplement. Usually if the mom's milk is not yet in when they go home, I will tell them to pump every time. That the baby is due to feed until their milk comes in. But if the mom has uh milk in, then I would tell her to maintain her supply, just pump anytime her baby takes a supplement. And then I would usually give her a time frame for pumping using um that 10 to 15 minutes when you're waiting for the milk to come in, and then once mom's milk is in, they can pump for however long it takes them to empty the breast. And then the last step I always include is maintaining focus on the breast. And so what this means is I'm not just letting a baby chug that milk. Um, so you can feed with a spoon cup or syringe in those beginning days, but that really is only helpful for low volumes. When you get volumes. More than like 15 mLs or so. It's going to take them so long to feed, like from a syringe, and then you're really gonna increase your risk of choking when you're trying to syringe those larger volumes. So after you get to those larger volumes, you really are gonna have to bottle feed, but I do always recommend paste bottle feeding, and I have a video of that to show you all, so that we can talk about what paste bottle feeding means, but it's a way of bottle feeding. That keeps the baby feeding in a nice slow pace, which helps them when they try to return back to the breast. And then also just don't underestimate the importance of that skin to skin time that promotes um the oxytocin helps mom baby bond, and helps to get babies in body temperature, blood sugar, and stress hormones. And then this last slide is just this video piece bottle feeding, and this is my little baby, um, who, he was born at 32 weeks, so he's not a full term guy, but he's feeding pretty well in this video. And so, um, what you'll notice first off is that we have him in this sideline position. So for pace bottle feeding you would want to use like a sideline position. Like this, or you can set them more upright, but I like to show parents say, you know, to support their heads with this kind of see um shape of your hand and then supporting their body along your arm. And this is similar way that I show parents to hold their baby when they're breastfeeding their baby, and then again, put them in that sideline position, or you can hold them more upright, and then you're gonna hold the bottle. In this horizontal position, so you're not holding a bottle vertical up and down where it's just gravity is just letting that milk flow straight in. And um, What you're gonna see is that he starts feeding, and then he's gonna start just kind of chugging, just sucking, sucking, sucking sucking. He doesn't stop right away to like swallow and breathe. So then, um, this is my wife feeding him, so she's gonna um tilt the bottle down. Just so that there isn't milk in the nipple, and he will have to stop, so a, take a breath, and then when he does that, she'll tilt the bottle back up and put milk back in the nipple. So this method um allows us to pace him, and then you see the neck, he kind of resumes feeding after that pace that she does, and then you'll see that he kind of paces himself. He sucks a couple times and then he stops and swallows and breathes on his own. So if babies pace themselves, you don't have to keep moving the bottle, but when they don't pace themselves, you just do it for them. Um, And what's good about this method is that you don't have to take the bottle out of their mouth when they start chugging or choking or anything, and then the baby doesn't have to keep kind of relatching and reentering themselves every time that they get out of sync. They just keep that bottle in their mouth, they keep latched on. And it's just a little tilt, so it doesn't disturb them that much. It just kind of paces them, they suck and breathe, and then they just resume feeding. So I'll show you what that looks like here. And here's where you see he's gonna start to kind of really chug. So he has no milk in there, and he's gonna take a little swallow, take a breath, and then she's gonna return the milk to him. And now he took another big sip, and he stopped, he took a breath. And now he's gonna start sucking again. So after she paced one and the next time he did it himself. So that's how pasal feeding works, and it just helps them keep that pace of swallow breed, so they don't um kind of chug the bottles. OK, so that is everything I have. Um Any questions that I can answer? Thank you so much for that very nice presentation. It looks like, oh, yes, you all are welcome to unmute, um to ask any questions or put them in the chat, and I will put the QR code up for you all to scan for credit. Your little one was adorable in that video. Thank you, thank you. He is, he just came home from the NICU on Tuesday, so he's, oh wow, congratulations your baby home, yeah. We did get one comment in the chat. I'm not sure if you can see it. It's not a question, but just rather thank you. OK. Alright, thanks. Any questions? Well, if not, we really appreciate your time this morning, Doctor DiPalma and for everyone joining and yeah, we hope you all have a great weekend. All right, thanks guys. I have a great day. You too. Bye. Created by Presenters Leanne DePalma, MD Assistant Professor, Pediatrics Division of Hospitalist Medicine View full profile
