Breastfeeding Basics: Generalist to Generalist

1. Breastfeeding Basics: Generalist to Generalist Sharon Mass, MD, FACOG Jenny Thomas, MD, FAAP Margreete Johnston, MD, MPH, FAAP

3. Introduction Breastfeeding Promotion in Physicians� Office Practices Program Phase III aims to: Educate and support pediatric, obstetric, and family medicine residents; practicing physicians; and other healthcare professionals in effective breastfeeding promotion and management in racially and ethnically diverse populations toward the achievement of the Healthy People 2010 goals. The BPPOP III Program and this teleconference are supported by the Health Resources and Services Administration�s Maternal and Child Health Bureau and the American Academy of Pediatrics.

4. Healthy People 2010 recommendation 75% initiation in the early post-partum period 50% at six months of age 25% at one year of age The Healthy People 2010 goal is for 75% of newborns to be breastfed; for at least 50% to continue for six months and for 25% to continue for one year. Despite recommendations from these powerful national organizations, currently in the United States, approximately 60-70% of women initiate breastfeeding. Only half of those mothers are breastfeeding at hospital discharge. Six months later, only 20-30% are still nursing. The Healthy People 2010 goal is for 75% of newborns to be breastfed; for at least 50% to continue for six months and for 25% to continue for one year. Despite recommendations from these powerful national organizations, currently in the United States, approximately 60-70% of women initiate breastfeeding. Only half of those mothers are breastfeeding at hospital discharge. Six months later, only 20-30% are still nursing.

5. BPPOP III Residency Curriculum Pilot-testing began in July of 2006 at 7 test sites (CA, OH, MD, SC, NC, NY, TX) and 7 comparison sites (CA, MO, MN, NY, GA, OH, TX) Pilot-testing will conclude and the revised curriculum will be available to all residency programs in the fall of 2007

6. Objectives Encourage and support breastfeeding before and during pregnancy Fit breastfeeding assessment and management into your office visits Weave a web of breastfeeding support and resources in your community

7. ACOG Recommendation ��exclusive breastfeeding be continued until the infant is about six months old. A longer breastfeeding experience is, of course, beneficial�� -Educational Bulletin #258, Breastfeeding: Maternal and Infant Aspects The American College of Obstetricians and Gynecologists clearly recognizes breastfeeding as the preferred method of feeding for newborns and infants.The American College of Obstetricians and Gynecologists clearly recognizes breastfeeding as the preferred method of feeding for newborns and infants.

8. AAP Policy Statement - Pediatrics 2005;115:496-506 AAP Recommendation �Human milk is the preferred feeding method for all infants, including premature and sick infants, with rare exceptions.� Exclusive breastfeeding for the first six months of life Continuing for at least the first year of life with addition of solids Thereafter for as long as mutually desired by mother and child The American Academy of Pediatrics is even more definitive in their statements about breastfeeding and has numerous committees, a section and various documents to support their position.The American Academy of Pediatrics is even more definitive in their statements about breastfeeding and has numerous committees, a section and various documents to support their position.

9. AAFP Recommendation The AAFP recommends that all babies, with rare exceptions, be breastfed and/or receive expressed human milk exclusively for about the first six months of life. Breastfeeding should continue with the addition of complementary foods throughout the second half of the first year. Breastfeeding beyond the first year offers considerable benefits to both mother and child, and should continue as long as mutually desired. Family physicians should have the knowledge to promote, protect, and support breastfeeding. (1989) (2001)

10. Encouraging and Supporting Breastfeeding Before and During Pregnancy Sharon Mass, MD, FACOG

11. �Alone we can do so little; together we can do so much.� -Helen Keller Breastfeeding seems to be an issue that generates controversy and passion among supporters and non- supporters. Unfortunately the issue is often colored by personal opinion on the part of both the patient and the health care provider. One of the goals of BPPOP is to bring breastfeeding medicine to the mainstream, bread and butter pediatrician, family physician and ob-gyn so that we can all better serve our patients. Read quote� Breastfeeding seems to be an issue that generates controversy and passion among supporters and non- supporters. Unfortunately the issue is often colored by personal opinion on the part of both the patient and the health care provider. One of the goals of BPPOP is to bring breastfeeding medicine to the mainstream, bread and butter pediatrician, family physician and ob-gyn so that we can all better serve our patients. Read quote�

12. Obstacles to the Support of Breastfeeding Lack of broad social support Media portrayal of bottle-feeding as norm Insufficient prenatal breastfeeding education Insufficient provider education Disruptive hospital policies Maternal employment Commercial promotion of formula There are numerous obstacles to support of breastfeeding� These obstacles result in conflicting messages which confuse the patient. Today, we are going to look at some ways that the provider, obstetrician and pediatrician may begin to break down some of the barriers.There are numerous obstacles to support of breastfeeding� These obstacles result in conflicting messages which confuse the patient. Today, we are going to look at some ways that the provider, obstetrician and pediatrician may begin to break down some of the barriers.

13. Breastfeeding and the Obstetrician Most parents choose their method of infant feeding before delivery. Winikoff, O�Campo Physician counseling plays an important role in patient decision making. This fact is true for decisions about infant feeding as well. In fact, studies have shown that most parents chose their method of infant feeding before delivery. Despite the fact that most obstetrician gynecologists feel that they have a role in breastfeeding promotion, in many cases, they find themselves ill-prepared to do so.Physician counseling plays an important role in patient decision making. This fact is true for decisions about infant feeding as well. In fact, studies have shown that most parents chose their method of infant feeding before delivery. Despite the fact that most obstetrician gynecologists feel that they have a role in breastfeeding promotion, in many cases, they find themselves ill-prepared to do so.

14. Practitioner Knowledge and Attitude � It is the role of the physician to recommend breastfeeding to expectant mothers.� 88% residents 82% practitioners �Training provided �no� or �less than adequate� preparation to support breastfeeding patients.� 68% residents 79% practitioners Freed In 1985, Gary Freed undertook classic studies looking at breastfeeding knowledge, attitudes and training experience of ob, peds and family med residents and practicing physicians. Most respondants felt that it was their role to recommend breastfeeding to expectant mothers and that physician counselling is effective in promoting breastfeeding. Few had received specific instruction in how to do so. A similar study by ACOG in 2001 confirmed these findings. They further recognized that a minority of respondants felt well equipped to deal with common breastfeeding complaints. Only nine percent of respondants got all nine fact based questions correct. In fact, when I mentioned this lecture to my chairman, Joe Ramieri, he told me that he has NEVER received any formal breastfeeding education.In 1985, Gary Freed undertook classic studies looking at breastfeeding knowledge, attitudes and training experience of ob, peds and family med residents and practicing physicians. Most respondants felt that it was their role to recommend breastfeeding to expectant mothers and that physician counselling is effective in promoting breastfeeding. Few had received specific instruction in how to do so. A similar study by ACOG in 2001 confirmed these findings. They further recognized that a minority of respondants felt well equipped to deal with common breastfeeding complaints. Only nine percent of respondants got all nine fact based questions correct. In fact, when I mentioned this lecture to my chairman, Joe Ramieri, he told me that he has NEVER received any formal breastfeeding education.

15. Provider Encouragement and Breastfeeding Initiation Women who were encouraged to breastfeed were four times more likely to initiate breastfeeding than those that were not encouraged. Lu Percent of women who changed from bottle to breast after prenatal counseling 38% if counseled 8.5% if not Kistin In 2001 Lu et al surveyed 2017 women with children under three and received 1229 responses. They were asked to recall if their physicians and or nurses had encouraged them or discouraged them from breastfeeding. They found that women who were encouraged to breastfeed were four times more likely to initiate than those who did not receive encouragement Similarly, Kistin looked at 159 low income women and found that when counselling was offered prenatally, In 2001 Lu et al surveyed 2017 women with children under three and received 1229 responses. They were asked to recall if their physicians and or nurses had encouraged them or discouraged them from breastfeeding. They found that women who were encouraged to breastfeed were four times more likely to initiate than those who did not receive encouragement Similarly, Kistin looked at 159 low income women and found that when counselling was offered prenatally,

16. Provider Counseling and Breastfeeding at Six Weeks Perception of physician recommendation 38% - physician recommends breastfeeding 62% - physician had no preference Breastfeeding at six weeks 70% who thought physician favored breast 54% who thought physician had no preference 9% who thought physician favored formula DiGirolomo So why does it matter what we know or do? DiGirolomo looked at the mothers perception of the attitude of their physicians. They found that 38% of the mothers perceived that their physician recommended breastfeeding as the ideal feeding method. 62% perceived that their physician had no preference. Those that thought their physician preferred breastfeeding had higher rates of breastfeeding at six weeks Therefore, even perceived neutrality can adversely impact breastfeeding initiation and duration. Uninformed or misinformed physicians can give incorrect advice to families and thereby have a deleterious effect on there breastfeeding success.So why does it matter what we know or do? DiGirolomo looked at the mothers perception of the attitude of their physicians. They found that 38% of the mothers perceived that their physician recommended breastfeeding as the ideal feeding method. 62% perceived that their physician had no preference. Those that thought their physician preferred breastfeeding had higher rates of breastfeeding at six weeks Therefore, even perceived neutrality can adversely impact breastfeeding initiation and duration. Uninformed or misinformed physicians can give incorrect advice to families and thereby have a deleterious effect on there breastfeeding success.

17. So what can I, the busy ob-gyn, do? So what concrete steps can you take to assist your patients? The guilt factor is frequently mentioned as a reason NOT to push breastfeeding on patients. In fact, data has not shown encouraging breastfeeding to adversely affect the doctor patient relationship. I think of it the way I think of other lifestyle choices such as smoking or weight loss. There are clearly better choices in each of these cases � not smoking is healthier than smoking. Normal weight is healthier than overweight; breastfeeding is healthier than formula feeding. You would never think twice about recommending smoking cessation or weight loss to a patient. The same should be true for breastfeeding. Interestingly, a July 21, 2006 article in the Wall Street Journal questioned discharge packs on post-partum and concluded the article by quoting the Massachusettes Breastfeeding Coalition chair who stated �We�d never tolerate the thought of hospitals giving out coupons for Big Macs on the cardiac unit�� So what easy steps can you take?So what concrete steps can you take to assist your patients? The guilt factor is frequently mentioned as a reason NOT to push breastfeeding on patients. In fact, data has not shown encouraging breastfeeding to adversely affect the doctor patient relationship. I think of it the way I think of other lifestyle choices such as smoking or weight loss. There are clearly better choices in each of these cases � not smoking is healthier than smoking. Normal weight is healthier than overweight; breastfeeding is healthier than formula feeding. You would never think twice about recommending smoking cessation or weight loss to a patient. The same should be true for breastfeeding. Interestingly, a July 21, 2006 article in the Wall Street Journal questioned discharge packs on post-partum and concluded the article by quoting the Massachusettes Breastfeeding Coalition chair who stated �We�d never tolerate the thought of hospitals giving out coupons for Big Macs on the cardiac unit�� So what easy steps can you take?

18. 1. Ask early and often about breastfeeding Each annual GYN exam First prenatal visit Subsequent visits Nearly all pregnant women KNOW that breastfeeding is best. Reviewing the benefits with them has not been shown to motivate behaviour but your STRONG recommendation does. At prenatal visits, think about the way that you ask about breastfeeding. Think about the difference in message between: �are you planning to breast or bottle feed� and �Are you planning to breastfeed�Nearly all pregnant women KNOW that breastfeeding is best. Reviewing the benefits with them has not been shown to motivate behaviour but your STRONG recommendation does. At prenatal visits, think about the way that you ask about breastfeeding. Think about the difference in message between: �are you planning to breast or bottle feed� and �Are you planning to breastfeed�

19. 2. Examine the breasts Inverted nipples Prior surgery Breast asymmetry Tubular breasts (inadequate glandular tissue) Exudates/dermatitis There are few breast conditions that limit breastfeeding. Remember that a breast exam can be more than just a cancer exam. Examine women�s breasts, and if there are none of the concerning signs mentioned here, simply tell them that they should have no physical problem breastfeeding. Inverted nipples may make latching on more difficult, but are not prohibitive, especially if the nipples evert with squeezing or cold. Tubular, or hypoplastic breasts are underdeveloped in terms of the milk glands. They lack normal fullness and may look like �empty sacks�, may be more widely spaced, may have an elongated form and are often quite small. There may also be significant assymetry. The defining, concerning factor is that they do not enlarge during pregnany and there is no engorgement when the milk is supposed to come in after giving birth. This can represent a serious problem for breastfeeding. Obvious exudates and dermatitises should be evaluated before nursing. Breast HSV if active, is a contraindication to breastfeeding Patients who do have physical barriers but are committed to breastfeeding may need added support There are few breast conditions that limit breastfeeding. Remember that a breast exam can be more than just a cancer exam. Examine women�s breasts, and if there are none of the concerning signs mentioned here, simply tell them that they should have no physical problem breastfeeding. Inverted nipples may make latching on more difficult, but are not prohibitive, especially if the nipples evert with squeezing or cold. Tubular, or hypoplastic breasts are underdeveloped in terms of the milk glands. They lack normal fullness and may look like �empty sacks�, may be more widely spaced, may have an elongated form and are often quite small. There may also be significant assymetry. The defining, concerning factor is that they do not enlarge during pregnany and there is no engorgement when the milk is supposed to come in after giving birth. This can represent a serious problem for breastfeeding.

20. 3. Offer resources for prenatal education Books Classes Internet Know the proper resources for both you and your patients. The ACOG AAP handbook is a great starting point. Useful books and websites for both you and your patients are included at the end of the handouts.Know the proper resources for both you and your patients. The ACOG AAP handbook is a great starting point. Useful books and websites for both you and your patients are included at the end of the handouts.

21. ABM #5, AAP section on BF Pediatrics 2005;115:496-506 4. Delay routine postpartum procedures Place baby skin-to-skin Initiate breastfeeding in the first hour Delay vitamin K and eye prophylaxis Assist proper breastfeeding technique Avoid traumatic interventions (ie:suctioning) There are numerous intrapartum interventions that can adversely impact breastfeeding initiation. Some of these include use of labor analgesics, cesarean section, instrumental deliveries. Making small changes can make a big difference, as can your post-partum routine. Following the regimen above rather than whisking the baby away for weighing, measuring and warming as many of us do can result in the earlier establishment of effective suckling and feeding. This actually results in BETTER neonatal temperature control, metabolic stability and blood sugar stability.There are numerous intrapartum interventions that can adversely impact breastfeeding initiation. Some of these include use of labor analgesics, cesarean section, instrumental deliveries. Making small changes can make a big difference, as can your post-partum routine. Following the regimen above rather than whisking the baby away for weighing, measuring and warming as many of us do can result in the earlier establishment of effective suckling and feeding. This actually results in BETTER neonatal temperature control, metabolic stability and blood sugar stability.

22. 5. Encourage the ten steps � hospital policies to support breastfeeding Have a written breastfeeding policy that is routinely communicated to all health care staff. Train all healthcare staff in skills necessary to implement this policy. Inform all pregnant women about the benefits and management of breastfeeding. Help mothers initiate breastfeeding within one hour of birth. Show mothers how to breastfeed and maintain lactation, even if separated from their infants. The ten steps also known as the Baby-Friendly hospital initiative, was originally developed by the WHO/UNICEF as guidelines and evaluation criteria for maternity facilities. These steps have been extensively studies and SUFFICIENT evidence exists to FULLY justify implementation. Many are things that we do anyway. The ten steps also known as the Baby-Friendly hospital initiative, was originally developed by the WHO/UNICEF as guidelines and evaluation criteria for maternity facilities. These steps have been extensively studies and SUFFICIENT evidence exists to FULLY justify implementation. Many are things that we do anyway.

23. 5. Hospital policies to support breastfeeding (cont�d) Give newborn infants nothing other than breastmilk, unless medically indicated. Practice rooming in 24 hours a day. Encourage breastfeeding on demand. Give no artificial nipples or pacifiers. Foster the establishment of breastfeeding support groups. DiGirolomo et al found a relationship between the number of baby-friendly steps in place at a birth facility and a mothers breastfeeding success. Mothers experiencing NONE of the ten steps were EIGHT time more likely to discontinue breastfeeding in the first six weeks than women experiencing at least five of the stepsDiGirolomo et al found a relationship between the number of baby-friendly steps in place at a birth facility and a mothers breastfeeding success. Mothers experiencing NONE of the ten steps were EIGHT time more likely to discontinue breastfeeding in the first six weeks than women experiencing at least five of the steps

24. 6. Remove formula advertising from the office Formula advertising takes place in two primary forms, hospital discharge packs and advertising in magazines, TV and your office. Simply removing sign up sheets for free formula and obvious formula company advertising can improve breastfeeding rates in your office.Formula advertising takes place in two primary forms, hospital discharge packs and advertising in magazines, TV and your office. Simply removing sign up sheets for free formula and obvious formula company advertising can improve breastfeeding rates in your office.

25. �Just give a little formula�� �You�re tired, you should rest. We�ll feed the baby in the nursery tonight.� �A little formula here in the hospital won�t hurt.� Let�s touch base briefly on the highly charged issue of formula distribution. This is one of the issues that our feedback at my hospital has told us MOST confuses the patients. All of us have heard comments such as these from well-meaning nurses; some of you may have made similar statements. So, does it really matter? What do you think? How many people in the room think that if formula is JUSt given in the hospital that it can cause any harm? In fact, it can.Let�s touch base briefly on the highly charged issue of formula distribution. This is one of the issues that our feedback at my hospital has told us MOST confuses the patients. All of us have heard comments such as these from well-meaning nurses; some of you may have made similar statements. So, does it really matter? What do you think? How many people in the room think that if formula is JUSt given in the hospital that it can cause any harm? In fact, it can.

26. Hospital Supplementation Long breastfeeding intervals OR=1.1-1.3, p=0.0001 More than two bottle daily OR 1.7-4.8, p=0.001 Any supplement in the maternity ward � 3.9X higher chance of early cessation Hall, Bloomquist Hall looked at factors that contribute to early cessation of breastfeeding (in the first 7-10 days post-partum). They found that long breastfeeding intervals (such as allowing a mother to rest at night in the hospital) had a small effect on early cessation. More than two bottles daily had a more significant effect leading to 2-5X chance that a patient will stop breastfeeding by 10 days post-partum. Similarly, Bloomquist analyzed the relative risk of not breastfeeding in relation to different feeding routines in the early post-partum period. Supplementary feeding in the maternity ward was associated with a 3.9X higher risk of early cessation than not supplementing. Hall looked at factors that contribute to early cessation of breastfeeding (in the first 7-10 days post-partum). They found that long breastfeeding intervals (such as allowing a mother to rest at night in the hospital) had a small effect on early cessation. More than two bottles daily had a more significant effect leading to 2-5X chance that a patient will stop breastfeeding by 10 days post-partum. Similarly, Bloomquist analyzed the relative risk of not breastfeeding in relation to different feeding routines in the early post-partum period. Supplementary feeding in the maternity ward was associated with a 3.9X higher risk of early cessation than not supplementing.

27. Formula company discharge packs Decreased duration of exclusive breastfeeding Donnelly � Cochrane review This effect in the hospital is then further compounded by the distribution of the formula company �breastfeeding bags� A cochrane review confirmed that the distribution of commercial hospital discharge packs decreased the duration of exclusive breastfeeding in all populations. There was a disproportioonately larger effect on some of our most vulnerable mothers, those who were primiparous, less-educated, non-white. This effect in the hospital is then further compounded by the distribution of the formula company �breastfeeding bags� A cochrane review confirmed that the distribution of commercial hospital discharge packs decreased the duration of exclusive breastfeeding in all populations. There was a disproportioonately larger effect on some of our most vulnerable mothers, those who were primiparous, less-educated, non-white.

28. Risks of supplementation Interfere with the establishment of maternal milk supply (delayed lactogenesis) Increase risk of engorgement Alter infant bowel flora May cause nipple confusion Interfere with maternal-infant attachment Undermines maternal confidence in her ability to fully provide for her baby�s nutritional needs Shortened duration of EXCLUSIVE and ANY breastfeeding The thoughts are that supplementation, even just in the hospital may�The thoughts are that supplementation, even just in the hospital may�

29. 7. Offer post-partum resources Communication with other health care professionals Lactation consultants www.ilca.org �find a lactation consultant� Books Websites Once a patient leaves the hospital, the obstetricians job is not done. It is important that the patient be aware of resources for questions or problems. Again, your resource manual has some of the best ones for patients. An important resource to know is that ILCA�Once a patient leaves the hospital, the obstetricians job is not done. It is important that the patient be aware of resources for questions or problems. Again, your resource manual has some of the best ones for patients. An important resource to know is that ILCA�

30. 8. Know the medical management of common issues Perceived insufficient supply Engorgement Mastitis/Candidal infection Breast pain Similarly, it is important that you become facile with medical management of common issues� These are the four medical issues that the ob-gyns and sometimes even the pediatricians are most likely to encounter. If you can truly become facile with their management, you will do your patients a great service. The ACOG/AAP Breastfeeding Manual for Physicians is a good starting point.Similarly, it is important that you become facile with medical management of common issues� These are the four medical issues that the ob-gyns and sometimes even the pediatricians are most likely to encounter. If you can truly become facile with their management, you will do your patients a great service. The ACOG/AAP Breastfeeding Manual for Physicians is a good starting point.

31. 9. Know what products and medications are safe to use in breastfeeding women Contraception Medications http://toxnet.nlm.nih.gov (LactMed database) Again, the pertinent issues with contraception are listed in the handbook. An important new resource to be aware of is the National Library of Medicine�s new database on drugs and lactation. If you go to the site here and click on LACTNET you can investigate the safety of many of the medications that you may want to use in a lactating mother. Again, the pertinent issues with contraception are listed in the handbook. An important new resource to be aware of is the National Library of Medicine�s new database on drugs and lactation. If you go to the site here and click on LACTNET you can investigate the safety of many of the medications that you may want to use in a lactating mother.

32. Medications contraindicated in breastfeeding Bromocriptine Cocaine Cyclophosphamide Cyclosporin Doxorubicin Ergotamine Lithium Methotrexate Phencyclidine Phenindione Radioactive isotopes Radiolabeled elements Very few medications have an absolute contraindication in the breastfeeding other. For many other medications as with pregnancy the risks and benefits must be weighedVery few medications have an absolute contraindication in the breastfeeding other. For many other medications as with pregnancy the risks and benefits must be weighed

33. 10. Educate yourself ACOG/AAP Breastfeeding Handbook for Physicians www.aap.org www.acog.org Academy of Breastfeeding Medicine (Protocols + Journal) www.bfmed.org Finally, it is important that you continue to educate yourself. The breastfeeding handbook for physicians was designed to provide physicians in all specialties with a concise reference on breastfeeding and human lactation. The academy of Breastfeeding medicine is an organization that you can join and has launched a journal this spring. They also have protocols that can be downloaded for free.Finally, it is important that you continue to educate yourself. The breastfeeding handbook for physicians was designed to provide physicians in all specialties with a concise reference on breastfeeding and human lactation. The academy of Breastfeeding medicine is an organization that you can join and has launched a journal this spring. They also have protocols that can be downloaded for free.

34. Overall Conclusions All patients who wish to breastfeed should have optimal support to do so. It is important to offer patients a consistent message. Help patients make educated choices. Educate yourself. I truly believe that� All patients who wish to breastfeed should have optimal support to do so and that support depends on sending them consistent messages from all of us. When they, and you, make educated choices they can be better choices, and we all have healthier moms and babies.I truly believe that� All patients who wish to breastfeed should have optimal support to do so and that support depends on sending them consistent messages from all of us. When they, and you, make educated choices they can be better choices, and we all have healthier moms and babies.

35. �If you wish to go fast, go alone. If you wish to go far, go together.� -Old African Proverb I hope that I have provided you with some food for thought and a few tools that might help you enhance your patients breastfeeding success.I hope that I have provided you with some food for thought and a few tools that might help you enhance your patients breastfeeding success.

36. Breastfeeding Management in the Office � Fitting It In! Jenny Thomas, MD, FAAP

37. Caring for the Baby Use rounding as an opportunity to support, promote, and protect breastfeeding

38. Breastfeeding is normal �There is a reason behind everything in nature." - Aristotle

39. The Newborn Nursery Take a look at your hospital policies and modify protocols that may interfere with breastfeeding Work to implement the 10 steps Set daily goals for mom and help her understand normal feeding patterns Involve dad

40. The Newborn Nursery Watch output Recognize that jaundice is an indicator of poor feeding Understand glucose physiology and the role of ketone bodies in the breastfed infant Observe a feeding Ooze enthusiasm

41. The Newborn Nursery Know warning signs of poor intake including: Poor stool output Jaundice Nipple pain

43. Getting Ready for Discharge Anticipate frequent feedings Inform mom of resources Provide a way of recording output and set expectations for adequate intake See back in 2-3 days

44. In the Office Weight should be around discharge weight Ask about pain during feedings Make sure the stool is yellow Anticipate that the child should gain � ounce to 1 ounce a day and regain birthweight by 10 days

45. In the Office Train staff including receptionists, triage, and nurses Provide places for breastfeeding moms to feed their child Get rid of formula advertising Provide incentives Know community resources

46. Back to Work � suggestions for Mom Check into facilities at work Ask co-workers Flexible work schedules Breastfeed before leaving the infant and as soon as reunited Bring a picture of the baby

47. Back to Work Advocate for insurance coverage of pumps Advocate for supportive legislation

50. Weaving a Web of Breastfeeding Support Margreete Johnston, MD, FAAP

51. Factors Influencing Feeding Decisions

52. Community resources you can use!

53. Know your community Where are your mothers and newborns? birthing centers/ referral clinics

54. Think proactively Where do families gather with young children? Schools Playgrounds Churches and synagogues

55. Be a part Prenatally, where are women receiving info on breastfeeding? TV/media community papers Significant others Caregivers

56. Sources of Information

57. Introduce Yourself Introduce yourself to obstetrical personnel. Avail yourself to help with breastfeeding problems Compliment your health care team on prenatal care. Positive reinforcement works

58. Making It Work Hospitals can provide names of obstetricians with privileges in your area, drop a note with business cards Carve out some time in your schedule for education and networking, starting with rounds

59. Volunteer Speaking at prenatal classes Offer in-services to hospital staff, befriend lactation consultants Meet La Leche League people, attend meetings Know your WIC nutritionist Use your personal experiences to network advocacy in your own practice

60. Be an example for others� Baby friendly office Compliment any breastfeeding wherever appropriate Support mothers who are in the hospital with nursing babies, as a professional and a resource Find out where pumps can be bought or rented Build your own library on breastfeeding Respect and work with cultural differences

61. Clinical Faculty If you are affiliated with a university, offer in-service on AAP policies Breastfeeding speakers kit www.aap.org/breastfeeding Teach medical students and residents breastfeeding basics and advocacy Be aware of controversies and be able to discuss both sides of issues Join AAP Section on Breastfeeding

62. OBSTACLES

63. Remember to thank those that Help!

64. Let It Shine! Be proud of your breastfeeding advocacy.

65. Now that you know the basics� Please join us for the next BPPOP III Breastfeeding Teleconference that will focus on culturally effective breastfeeding care. If you are interested in signing up for the teleconference (date to be determined), please contact Becky Ramsey at bramsey@aap.org.

66. Let us know how we�re doing� Please visit http://www.surveymonkey.com/s.asp?u=929892511416 to fill out the short evaluation form for this teleconference. When your evaluation is submitted, you will be emailed your CME certificate for your participation in this educational activity. Thank you for participating in the BPPOP III Teleconference! If you have any questions or comments please contact Lauren Kotch at lkotch@aap.org.