| | The lactation consult: Problem solving, teaching, and support for the breastfeeding familyAbstract Requests from parents for lactation support have increased significantly in primary care settings. Pediatric nurse practitioners with the ability to assess the newborn as well as the breastfeeding couple are a valuable asset. This article seeks to identify early predictors of breastfeeding problems and how to perform a lactation consultation to address these concerns. Good infant weight gain and maternal comfort while nursing are described as key evaluation criteria when assessing the nursing couple. The importance of achieving a good latch at the breast is stressed. A step-by-step guide to both the lactation consultation and common latch-on techniques are reviewed.
“It's all in the latch.” Lactation consultants preach about a good latch at the breast. Many nurse practitioners working with new mothers know it is important. But how can you confirm that a mother has achieved a good latch when breastfeeding her newborn? Very simply, the latch is correct when the infant is receiving colostrum or milk and the mother is free from pain. The helping professional must focus on both of these questions simultaneously when working with the nursing couple.
The gold standard for proof of milk transfer from the breast to the infant is audible swallowing. In the first few days of life, infants often suck six or seven times before swallowing the thick colostrum. By the time the infant is 3 to 5 days old, a mother's milk has “come in,” and many swallows may be heard following each letdown. A mother will have several letdowns with each feeding as oxytocin stimulates the letdown of breast milk every 6 to 10 minutes during a feeding (Biancusso, 1999; Huggins, 1999). This is evidenced by bursts of swallowing, pauses, and more bursts of swallowing. It is important to remember that infants may appear to be high on the areola and have visible jaw movements but not be transferring milk from the mother's breast. The presence of a drop of milk on the end of the nipple when the infant releases the breast also may fool the practitioner. Only when you hear repetitive swallowing deep in the infant's throat can you be reasonably certain that the infant is receiving milk. You may need to place your ear close to the infant's head to ascertain quiet swallowing. Nutritive nursing is confirmed by a steady weight gain of approximately 1 oz per day in the newborn period. Conversely, increasing weight loss confirms that a problem does indeed exist.
The second key to a good latch at the breast can be determined by asking the mother one question: Is the breastfeeding painful? If a mother denies pain, appears comfortable, and is willing to relax and allow the infant to determine the length of the feeding, latch on is correct from the mother's perspective. Often in the first few days of nursing there is nipple tenderness at the initial moment of latch on to the breast. When the latch is correct, pain should begin to subside within a few sucks and essentially disappear within 1 to 2 minutes. Many mothers seek lactation help after discharge from the hospital with cracked, bleeding, or scabbed nipples. They may report that “Many nurses saw me breastfeed and they all said the baby was latched on right!” The presence of damaged nipples proves this was not correct. A common mistake occurs when the helping professional focuses on the appearance of the infant at the breast and milk transfer but fails to confirm that the breastfeeding is comfortable. Painful nursing causes nipple damage that may not be visible for two to three days. Hospital staff may never know that their breastfeeding assessments were incomplete or leading to future problems. So, if the mother says it hurts, the latch is not correct even if the infant is swallowing milk. Only the mother can confirm a good latch from the standpoint of her personal comfort.
Who needs a lactation consult after discharge from the hospital?  Breastfeeding is a codependent relationship. The infant's ability to breastfeed affects the mother's milk supply. Maternal problems affect the infant's ability to receive adequate milk for growth. All concerns must be addressed promptly to avoid a rapid downward spiral toward premature weaning. The primary care physician or pediatric nurse practitioner (PNP) can identify breastfeeding infants with potential problems by reviewing the hospital history. Increased weight loss, hypoglycemia, infrequent nursing, or maternal reports of poor feeding are predictive of early problems. Phone contact with the mother within 1 or 2 days of discharge also is a good triaging tool. The normal newborn often is sleepy during the hospitalization period but should begin to wake for more frequent feedings soon after discharge. When real or potential problems are suspected, a lactation consult is required. This assessment of the infant, mother, and breastfeeding couple working together is the essence of the lactation consult. When one or more of the following circumstances are present, a lactation consult is warranted (Biancusso, 1999, Huggins, 1999, Lawrence and Lawrence, 1999, Newman and Pitman, 2000):
•Inability of the infant to latch on to the breast within 8 to 12 hours after birth
•Absence of audible swallowing during breastfeeding (in the first 3 to 4 days of life, several sucks may be noted before colostrum is swallowed; when the mother's milk comes “in,” a swallow should follow many sucks)
•Infant output of fewer than 6 wet diapers and fewer than 3 stools in 24 hours (output may diminish briefly around the third day before the onset of milk production)
•Newborn weight loss near or exceeding 10% of birth weight during the first week of life
•Maternal pain with breastfeeding and/or visible nipple damage
•Maternal history of flat or inverted nipples, endocrine and/or fertility problems, breast surgery, or the absence of breast changes during pregnancy
•Presence of a medical problem likely to affect normal breastfeeding, for example, ankyloglossia (tongue-tie), neurologic impairment, Down syndrome, cleft lip or palate, or other congenital anomalies
Begin by creating a comfortable environment for the mother It is helpful to remember that a woman may have little exposure to family members or friends who breastfed their infants. She may view her breasts primarily in a sexual context and so feel uncomfortable receiving help with breastfeeding. She needs time to adjust to her new role of breastfeeding mother. New mothers are also tired and overwhelmed. An unwillingness to accept lactation help may actually reflect a need to hide feelings of inadequacy. It is challenging for the busy professional to allow adequate time for the mother to move comfortably through the lactation assessment. Obviously, the relaxed mother is better able to focus and absorb the information provided. When the father has joined the mother, include him in your conversation. Suggest that he observe and listen so that he can help the mother at home. Strive to solidify each parent's role as caretaker of the new baby. Proceed step by step through a lactation consultation Just as each provider finds a comfortable and efficient approach to perform a well-child assessment, practice helps the PNP proceed smoothly through a lactation consultation. It may be easier for a new mother to begin the evaluation by focusing on her infant. Listen to the mother's opinion about how her baby feeds. Take your time and examine the infant carefully. Finally, help the mother to breastfeed, observing for clues that might direct you to the cause of any problems. The following steps suggest a logical strategy for the health professional to obtain information and problem solve during the lactation assessment:
•Obtain the infant's weight. Compare the current weight to birth weight, and, if possible, discharge weight. Continuing wei-ght loss suggests a problem for most infants 5 days of age or older unless the infant demonstrates frequent and sustained swallowing during the consult.
•Obtain the mother's feeding history. Listen carefully to what the mother believes to be the problem(s).
•Examine the infant, focusing on alertness, hydration, neurologic tone, the presence of jaundice, or the existence of congenital anomalies.
•Put on a glove and examine the infant's tongue, palate, and lingual frenulum. Assess the infant's ability to suck, noting the position of the tongue and any rigidity or poor muscle tone.
•Query the mother about any breast changes during her pregnancy and since the delivery of her baby. Ask about the existence of any thyroid or fertility problems. If she has other children, inquire if any breastfeeding difficulties occurred with these infants.
•Note the current condition of the mother's breasts. Check for the presence or absence of colostrum or milk, signs of nipple damage, and asymmetric or v-shaped breasts that might indicate glandular insufficiency.
•Using a comfortable armchair or a breastfeeding pillow, help the mother position the baby for nursing. (See the section on “Helping the Mother and Newborn Achieve a Good Latch.”) Evaluate the latch; listen for audible swallowing and carefully observe the mother's comfort level.
•Allow time for the mother to demonstrate that she can implement your suggestions without your participation.
Provide written instructions to reinforce your teaching and serve as a reference for the mother when she returns home. Follow-up is essential, so plan a subsequent office visit or a phone call to confirm that any problems are resolving. Helping the mother and newborn achieve a good latch Many articles have been written and lectures given regarding the best latch-on technique. Undoubt-edly there are merits in many techniques and drawbacks to some for individual mothers. The recommendations below are meant to provide a simple yet tried-and-true approach that is successful for many mothers. Remember, if the baby is swallowing milk and the mother is breastfeeding comfortably, you have accomplished your goal. The football hold and modified cradle hold often are easiest for the struggling mother or baby. Below are descriptions of these holds. To avoid confusion, the feminine gender will refer to the mother; the male gender will refer to the infant. You may need to practice with a doll and memorize the basic steps to each technique before attempting to help a mother. The football hold The football hold is often best for the mother and infant experiencing difficulty achieving an effective latch on. This position allows the mother to support both her infant's head and her breast simultaneously. It is easier for her to visualize the latch-on process. The sleepy or disinterested infant may be more alert in this position. The football hold is often more comfortable for mothers who had a Cesarean section. Assist the mother with the football hold as follows:
1.Provide a comfortable armchair with pillows or a nursing pillow. Tuck the infant into a “V” position at his mother's side with his legs parallel to her back (see Figure 1).
2.The infant's head should rest in the palm of his mother's hand. The infant's head rests in his mother's right hand when nursing at the right breast; his head rests in her left hand when feeding at the left breast. The mother's forearm supports her infant's neck and back.
3.Have the mother support her breast with her free hand. See “The Moment of Latch On” below.
4.Use multiple pillows if necessary to support the mother's hand and arm. The mother may remove the hand supporting her breast as long as she remains comfortable.
Modified cradle hold The modified cradle hold position works well when the mother prefers the cradle hold but has difficulty controlling the infant's head or supporting her breast for latch on. Women with larger breasts as well as those with shorter arms may feel more comfortable with a modified cradle hold.
1.Position the infant on his side, stomach to stomach with his mother. The baby should be resting against the mother's upper abdomen, not lying low near her lap. Use a nursing pillow or multiple smaller pillows for comfort and support.
2.If nursing at her right breast, have the mother support her infant by placing his head in the palm of her left hand. Her left forearm should support the baby's back and maintain the stomach-to-stomach position (see Figure 2).
3.When nursing on her right breast, have the mother use her right hand to support her breast. Have her support her left breast with her left hand when feeding on the left breast. See “The Moment of Latch On” section that follows.
4.Once the infant has latched on, the mother may remove the hand supporting her breast if she remains comfortable.
The moment of latch on No matter how “perfect” the mother's positioning for breastfeeding, the infant primarily is responsible for a good latch and effective nursing. The mother can be a critical facilitator by making the nipple and areola easily available to the infant, but in the end only the baby can latch and breastfeed. You may help the mother to facilitate a good latch by following these suggestions:
1.Have the mother support her breast using a “C” hold. Be certain that her thumb and fingers are positioned well behind her areola (see Figure 3).
2.The mother can lightly touch the tip of her nipple to the center of her infant's mouth. Have her squeeze a drop of milk onto the nipple tip if possible. It is best to avoid overstimulating the infant's mouth and to “invite” the infant to latch on.
3.Wait until the infant opens yawn-wide. His tongue should be down on the floor of his mouth. Note his lingual frenulum and see if the infant can extend the tip of his tongue past his lower lip. The tongue must be able to curl around the bottom of the areola in order to suck effectively and avoid pain for the mother.
4.Point the nipple tip straight toward the back of the infant's throat (see Figure 4). Mothers often aim their nipple up so they can SEE the infant latch-on around the nipple. Injured nipple tips occur when the roof of the infant's mouth bangs on the upturned nipple during feeding. Red, abraded, or scabbed nipple tips may suggest this problem.
5.Confirm that the infant's lips are rolled out so that a thin lip line is visible around the entire areola at latch on. Sucking is less effective as well as painful when either lip is rolled inward.
Listen to confirm audible swallowing and ask the mother if she has any breast pain. Initial latch-on pain should resolve quickly when the latch is correct. Even when a mother has visible damage to her nipples, latch-on pain should ease significantly when the positioning and latch are correct. The PNP and lactation support Many mother-baby pairs experience at least one concern or problem requiring assistance from a knowledgeable health provider. Prompt assistance can determine whether breastfeeding is successful or the mother weans prematurely. As Dr Jack Newman, co-author of The Ultimate Breastfeeding Book of Answers, states, “The principle always holds: the better the latch, the more easily the baby gets the mother's milk” (Newman & Pitman, 2002). From the maternal perspective, the most common concern often is how to resolve painful breastfeeding. To help achieve effective and comfortable breastfeeding, the focus of this discussion has been the early assessment of the breastfeeding couple and achieving an efficient and comfortable latch at the breast. The PNP with lactation skills is ideally qualified to assess both the infant's well-being as well as breastfeeding effectiveness. Reimbursement mechanisms for her services are already in place in the practice setting. Primary care offices that routinely offer lactation assessments or early well-child appointments that focus on breastfeeding can increase patient satisfaction and duration rates (Gross et al. 1998, Sikorski & Renfrew, 1999). National certification by the International Board of Lactation Consultant Examiners (IBLCE)2 is a natural next step for the nurse practitioner seeking to enhance her knowledge in this area. The National Association of Pediatric Nurse Practitioners (NAPNAP) promotes the concept of a family of pediatric providers-pediatricians and PNPs all working in partnership to care for children (Brady, 2004). The teaching and support inherent in the lactation consult can establish the PNP as an integral part of a child's “pediatric health care home.” References ReferencesBiancusso, 1999.
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