In order to analyze best practice in breastfeeding, it is important to examine application of existing policy, breastfeeding management under difficult circumstances, as well as developmental theory and family theory. In this way, a full picture can be drawn as a guideline for health professionals as well as the infant's mother and family. In 1991 the World Health Organization (WHO) formalized a system of best practice called the Ten Steps to Successful Breastfeeding. The program was designed to overcome the barriers to breastfeeding that had become prevalent in hospitals throughout the world. Because policy and best practice are entwined, this system is used here as a framework for illustrating best practice.
In complicated breastfeeding circumstances, policies such as the WHO Ten Steps to Successful Breastfeeding, should still be used as a guideline, however modifications and addition strategies may need to be implemented - according to the complication. These complications may arise from conditions effecting the mother (such as sore/cracked nipples), or from conditions affecting the infant (such as being preterm).
Administrators and health care professionals have a key responsibility in supporting best practice in breastfeeding. The immediate outcomes of best practice policy should be the improved emotional and physical wellbeing of both mother and infant. Developmental and family theory however, can used to illustrate the rollover effect implementation of best practice can also bring to the family and wider society.
Best practice in normal breastfeeding circumstances
Over time a number of best practice recommendations have been established. The World Health Organisation's Ten Steps to Successful breastfeeding, as listed by Biancuzzo (2003: 182), provides an evidenced based approach for achieving better clinical outcomes. Application (and adaptations) of this approach have proven to be highly beneficial to mother, infant and family.
Step 1: Have a written breastfeeding policy that is routinely communicated to all health care staff
WHO gives a clear directive that facilities offering maternity services should write a breastfeeding policy that is routinely communicated to all health care staff. This should function as the cornerstone for establishing and maintaining an environment that fosters breastfeeding. Weak or incomplete policies or those that have been created without the input or support of multiple disciplines are likely to be ineffective. "WHO has suggested components of a policy, but the exact content and format must be determined by the facility itself. By incorporating the main ideas from the Ten Steps to Successful Breastfeeding, the facility can better move forward with educating their staff and establishing evidence based practice for care" (Biancuzzo, 2003: 185).
Step 2: Train all health care staff in skills necessary to implement this policy
Biancuzzo, goes on to outline how initiation and continuation of breastfeeding have been linked to effective staff education. These programs are likely to be effective if they are mandated by administration. A strong staff development program, although not the only solution to improving practice, is a vital component of improving the birth environment to foster better feeding. Staff who are knowledgeable are better able to teach mothers and implement best practices.
Step 3: Inform all pregnant women about the benefits and management of breastfeeding
The many benefits of breastfeeding to infant, mother and society need to be outlined to pregnant women to help encourage them to breastfeed. By following best practice, the full range of benefits can be maximized. According to Minchin (2002: 9) "Extensive research on the biology of human milk and on the health outcomes associated with breastfeeding has established that breastfeeding is more beneficial than formula feeding. Breastfed infants experience fewer cases of infectious and noninfectious diseases, as well as less severe diarrhea, respiratory infections, and ear infections. Mothers' who breastfeed experience less postpartum bleeding, earlier return to prepregnancy weight, and a reduced risk of ovarian cancer and premenopausal breast cancer. Furthermore, breastfeeding is cost beneficial to families and an ecologically sound practice that protects the environment."
Step 4: Help mothers initiate breastfeeding within one hour of birth
According to Coombs & Moreland (2000: 1093-1094), new mothers should initiate breastfeeding as soon as possible after birth. When mothers initiate breastfeeding within one hour of birth, the baby's sucking reflex is strongest and the baby is more alert. Early breastfeeding is associated with fewer night-time feeding problems, longer continuation, and better mother/infant communication. Babies who are put to breast earlier have been shown to have higher core temperatures and less temperature instability. "Immediately following delivery, the healthy infant should be placed on the mother's chest or upper abdomen, at this point skin to skin contact between the mother and infant not only improves maternal bonding, but facilitates more effective breastfeeding."
Step 5: Show mothers how to breastfeed
While in hospital, every woman who breastfeeds her infant should be given instructions about breastfeeding. According to Gagliardi & Sinusas (2001: 982), the mother needs to be counseled on aspects such as positioning, techniques to ensure satisfactory latching on, and sounds from the infant indicating swallowing during feeding. Especially in the case of first time mothers, it is important that a designated health professional talk with the mother approximately 48 hours after the infant is discharged from the hospital.
Immediate evaluation of the breastfeeding interaction is best accomplished through direct observation. Some special situations that effect milk production, ejection and transfer can usually be overcome by using targeted clinical strategies. Ongoing evaluation is also valuable and can be enhanced by a visiting nurse or community nursing initiatives.
Step 6: Give newborn infants no food or drink other than breast milk, unless medically indicated
"Exclusive breastfeeding, especially during the neonatal period, has been shown to be advantageous in most clinical situations. The indiscriminate distribution of formula - either as in-hospital supplements to top-up or replace breastfeeding, or as part of a discharge gift - is counterproductive to the initiation and continuation of breastfeeding. Strategies to reduce formula use, and eventually eliminate acceptance of free formula, can be undertaken after other breastfeeding promotional activities are completely espoused by staff" (Fomon 2001: 1003).
Step 7: Practice rooming-in; allow mothers and infants to remain together 24 hours a day
Many studies have outlined the benefits of rooming in. Prodromidis et al (2001: 196-200) found that rooming in (either beside the mother's bed, or in bed with her) facilitates unrestricted access to the breast, and give the mother time to learn to know her baby and gain confidence in handling him or her, (while still having access to help if required). The study also found that rooming was associated with the mothers looking at, talking to and touching their babies in a more intimate way. This not only facilitated breastfeeding, but also bonding and attachment. The breastfed babies who roomed in - breastfed more frequently, gained weight more rapidly and continuing to breastfeed for longer.
Step 8: Encourage breastfeeding on demand
Rooming in and breast feeding on demand should be an integral part of breastfeeding best practice policy. Several studies have illustrated the evidence based clinical benefits of these strategies. Coombs & Moreland (2000:1094), sum up the findings as follows. "Breastfeeding on demand means feeding when the baby shows early signs of hunger, such as the rooting reflex, or when the baby is awake and his or her hands are coming to the mouth. Rooming in allows the mother to respond to feeding cues much more effectively than a busy nurse could. Breastfeeding on demand promotes more frequent feeding, which prevents sore nipples, breast engorgement and early weaning".
Step 9: Give no artificial teats or pacifiers to breastfeeding infants
Graham et al (2002: 601) outlines how clinical studies show that pacifiers (dummies) provide no benefit for the infant unless they are medically indicated. Pacifiers in fact can have a negative effect on breastfeeding technique and duration. Unnecessary use of pacifiers can be minimized through education programs and best practice policies aimed at changing the knowledge and attitudes of parents and providers.
Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic
Programs offering postpartum support for mothers have been shown to increase the continuation of breastfeeding. These programs may be based in the health care system, they may be mother-to-mother support groups, or lay counselors. "Consideration should be given to providing supplementary support as part of routine health service provision. There is clear evidence for the effectiveness of additional professional support in prolonging breastfeeding. WHO/UNICEF training courses appear to be an effective model for professional training. Lay support is effective in promoting exclusive breastfeeding, and face-to-face support appears to be more effective than support by telephone". Sikorski et al (2003).
Best practice in complicated breastfeeding circumstances
In circumstances where there are complications creating barriers to breastfeeding, adaptations of policies such as the WHO Ten Steps to Successful Breastfeeding, should still be utilised; however addition strategies may need to be implemented according to the complication. These complications may arise from conditions effecting the mother (such as breast and nipple problems), or from conditions affecting the infant (such as being preterm).
Strategies for managing sore/cracked nipples in breastfeeding
The examination of best practice as it applies sore/cracked nipples in breastfeeding mothers, is a good example because occurrence of this problem is relatively common.
Prevention is often the best strategy. According to Renfrew et al (2000: 26-29), the majority of cases of cracked and sore nipples are usually the result of incorrect positioning and attachment of the infant at the breast. Good preventative strategies include: ensuring the mother knows the principles of good positioning/latch-on, as well as the importance of not using pacifiers (which can interfere with suckling behaviour). Another preventative strategy is air drying the nipples for several minutes each day, allows the nipple tissue to dry. This reduces the effects of having a dark environment with a sweet, moist medium for bacterial growth.
Treatment strategies are very important in counteracting problems that have already occurred. Lang (2001: 76-77) suggests professionals should instruct mothers in the following treatment strategies.
At the time of feeding:
*Begin the milk flow before putting the baby to the breast by hand expressing a little milk on to the nipple.
*Beginning feeding on the unaffected or less sore breast first may help. The more vigorous suckling action that may occur at the start of feeding is gentler when the infant is attached to the sore nipple.
*Attach and position the baby correctly. If pain continues, the infant can be correctly repositioned and reattached.
*To remove the infant from the breast, the mother should slide her little finger into the infant's mouth. This breaks the seal made by the infant's lips around the areola, thus preventing incorrect detachment.
*If needed, giving the baby 10-15ml of breastmilk before the feed begins, may help reduce the initial vigour of the baby's suck.
*Instruct the mother to discontinue using practices or products that may exacerbate sore nipples. These may include the use of creams or ointments she may be allergic to, not changing wet breast pads promptly, or using nipple shields.
Between feeds or expressing:
*Suggesting the removal brassiere and breast pads until the nipples are healed, can help.
*Keeping the breasts exposed to the air under loose clothing of natural fibres can hasten the healing process.
*If the mother finds the pain from sore/cracked nipples seriously interferes with breastfeeding, she can express her breastmilk and rest her breasts for one or more feeds. She can give her milk to her baby by cup or by gastric tube if this is considered appropriate. Once her breasts feel more comfortable, she can resume breastfeeding.
Ongoing evaluation is essential, and no presumption about problem resolution should be made. "Direct observation of the nipples, questioning of the mother about her comfort, and the general status of the infant are perhaps the most important outcome criteria. If problem resolution cannot be verified, the root of the problem must continue to be pursued and corrective strategies initiated. Sore nipples are not an expected consequence of breastfeeding, but a signal for help." (Biancuzzo 2003: 337).
Strategies for managing preterm infants in breastfeeding
Infants born before term have greater needs which can alter feeding management. Lang (2001: 122) outlines the main features of preterm infants as being a weak suck, tiring easily, and a lack of coordination in sucking/swallowing/breathing. She goes on to outline that some infants are born so much before term that they are unable to accomplish direct breastfeeding, and require indirect breastfeeding (human milk given via some other means). Ultimately the aims are to establish and maintain the mother's milk supply, and establish or transition the infant to full direct breastfeeding. Best practice strategies help facilitate direct breastfeeding, even when indirect or supplemented feedings may be simultaneously required.
Wight, N. (2003: 330-332) suggests professionals should instruct mothers in the following treatment strategies.
*Until a preterm infant gives some indication that he or she is ready to take milk directly from the breast, the mother must express milk to be used for indirect feeding. This also helps her maintain her production and supply.
*Whenever possible, the mother should be encouraged to hold her infant. Skin-to-skin contact is best as this gives the infant familiarity with the mother's scent and feel of the breast, and encourages bonding in difficult circumstances. Additionally it helps stimulate the mother's milk supply and gives unlimited access to the breast.
*Between 32 and 34 weeks and sometimes as early as 30 weeks, the baby will show signs if being more awake and of not been satisfied by either continuous tube feeds or intermittent feeds via the gastric tube. When this occurs, it is worth encouraging the mother to express directly into the infant's mouth and for cup feeds to gradually be introduced.
*Gradually the mother should be encouraged to hand express on the nipple so the baby can taste it. If the baby wants to try suckling, make sure positioning and attachment are correct.
*Assure the mother that the preterm infant organizes his or her sucking pattern differently than a mature infant. Initially sucking is for short periods with frequent rests in between. Gradually sucking will last for longer periods before resting occurs. Support and encouragement of the mother are thus vital.
*For many preterm infants when they are initially learning to breastfeed, supplementation or replacement of feeds is necessary via a nasal or oral gastric tube or cup, with either expressed milk and/or formula milk. Low birthweight formulae are sometimes prescribed when the infant's weight gain is very slow or static. If any formula milk needs to be used, mix it with the mother's own milk (where possible), because absorption is likely to be more efficient.
*If a baby is taking milk at the breast, providing it is more than just a few sucks, wait until the baby indicates that he or she is hungry before supplementing or feeding again. This encourages natural feeding patterns.
*Weighing the infant every second day is a useful way of assessing progress once the infant is able to regulate his or her own intake and feed times.
Breastfeeding and developmental theory
The importance breastfeeding plays in healthy physical development has long been known. More recently, considerable interest has been raised about the potential effect of breastfeeding on cognitive development. "Long chain polyunsaturated fatty acids, available in breast milk, are important for brain growth and development. Observations in some studies on neurologic and cognitive outcomes in breastfed children have led to the hypothesis that the early visual acuity and cognitive function of these children is greater than in nonbreastfed children" Black et al (2000: 31).
A recent study finding a positive correlation between breastfeeding and psychomotor development is outlined in Gomez et al (2003: 35). The study enrolled 249 babies from two rural and urban areas. Cognitive development was assessed at the age of 18 months with results showing that adjusted scores on the mental development index were 4.6 points higher in infants breastfed for longer than four months than in those breastfed for less time.
Breastfeeding and family theory
Breastfeeding is at the heart of the family because it is an expression of love, care, protection, and nurturing. Because breastfed babies are healthier than those who receive breastmilk substitutes, families save on time and money that would be spent on visits to the family doctor and on purchasing medicines. "Breastfeeding enables families to achieve greater self sufficiency, thus reducing their dependency on commercial products." (Sharma & Petosa, 1999: 1311).
The effects of breastfeeding on the family unit are manifold. Family members grow and develop as focus shifts to the new baby. "In a family where unrestricted breastfeeding is practiced, the interfamilial relationships shift as the new baby's needs become the focal point. Siblings must share their parents and less time will be available to meet their needs, however they generally come to reflect their mother's attitude about breastfeeding and parenting. If the mother is relaxed and secure about her role, the older children will reflect this ease." (Black et al, 2000: 49-50).
Black et al goes on to sate that the father finds himself in a position of nurturing the mother while striving to establish his bond with the new infant. A father who takes advantage of attachment-style fathering is more likely to be sensitive to the new mother's feelings and feel that he is a contributing partner in the new family. This giving of self is emotionally fulfilling and contributes to the forming of the new family.
Policy and breastfeeding best practice are interrelated. By utilizing and adapting policies such as the WHO Ten Steps to Successful Breastfeeding, administrators and health care professionals have a framework with which to guide them in best practice initiatives. The interplay of policy, education, encouragement, support, and follow up - all enhance best practice dynamics. In circumstance where complications exist, best practice requires existing policies be modified and customized to the individual patient for optimum outcomes. Developmental and family theory support the important part best practice plays in the ongoing health of the infant, mother, family unit and wider society.
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Black, F., Jarman, L. & Simpson, J. 2000, The Management of Breastfeeding, Boston: Jones and Bartlett Publishers
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Fomon, S. 2001, 'Feeding normal infants: Rationale for recommendations' Journal of the American Dietetic Association, 101(9): 1002-1005
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Gomez-Sanchiz, M., Canete, R., Rodero, I., Baeza, J., and Avila, O. 2003 'Influence of breastfeeding on mental and psychomotor development' Clinical Pediatrician, 42(1): 35-42
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Prodromidis, M., Field, T., & Arendt, R. 2001 'A comparison of rooming-in versus minimal contact' Birth, 22(4): 196-200
Renfrew, M., Woolridge, M. & McGill, H. 2000, Enabling women to breastfeed. A review of practices which promote or inhibit breastfeeding - with evidence-based guidance for practice. Leeds: University of Leeds Press
Sharma, M. & Petosa, R. 1999 'Breastfeeding and the wellbeing of families' Journal of the American Dietetic Association, 97(11): 1311-1313
Sikorski, J., Renfrew, M., Pindoria, S. & Wade, A. 2003 'Support for breastfeeding mothers' (Cochrane Review). In The Cochrane Library, Issue 2
Wight, N. 2003 'Breastfeeding the preterm infant' Pediatric Annals, 32(5): 329-337
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