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BREASTFEEDING EDUCATION IN HOME VISITING PROGRAMS Allie Stevens, MS November 14, 2014 BREASTFEEDING EDUCATION IN HOME VISITING PROGRAMS Allie Stevens, MS November 14, 2014

Icebreaker What have you heard about breastfeeding? 2 Icebreaker What have you heard about breastfeeding? 2

Breastfeeding Can Be a Touchy Subject • We’re here to: – Educate you about Breastfeeding Can Be a Touchy Subject • We’re here to: – Educate you about the science that supports breastfeeding – Make recommendations about how to incorporate breastfeeding into your home visits • We are NOT here to: – Make judgments about how anyone feeds their babies – Tell you how to do your job 3

Today’s Agenda • The Benefits of Breastfeeding • Breastfeeding Difficulties • How You Can Today’s Agenda • The Benefits of Breastfeeding • Breastfeeding Difficulties • How You Can Help • Prenatal Messaging • Postpartum Messaging Research-based tips are included throughout the presentation 4

Warm-Up Breastfeeding reduces the risk of which of the following diseases in children? a)Diabetes Warm-Up Breastfeeding reduces the risk of which of the following diseases in children? a)Diabetes b)Cancer c)Asthma d)None of the above e)All of the above 5

Warm-Up When should babies begin drinking water? a)Immediately after birth b)At one week c)At Warm-Up When should babies begin drinking water? a)Immediately after birth b)At one week c)At one month d)At 6 months 6

Warm-Up Colostrum is… a)A vaccine for newborns b)The first milk a mother produces c)Fat Warm-Up Colostrum is… a)A vaccine for newborns b)The first milk a mother produces c)Fat a mother burns from breastfeeding d)A skin condition caused by soy formula 7

THE BENEFITS OF BREASTFEEDING (or the harms of formula-feeding) THE BENEFITS OF BREASTFEEDING (or the harms of formula-feeding)

How long should mothers breastfeed? • American Academy of Pediatrics and World Health Organization: How long should mothers breastfeed? • American Academy of Pediatrics and World Health Organization: infants should be exclusively breastfed for the first 6 months of life • What do we mean by exclusive? – WHO: “the infant only receives breast milk without any additional food or drink, not even water. ” • AAP: Continue with complementary foods for at least 12 months • WHO: Continue with complementary foods for at least 2 years DID YOU KNOW? Research shows that infant feeding discussions should begin before the baby is born and continue through 6 months – visits lasting 30 minutes to 2 hours have been successful

Infant Health Benefits • Breastfeeding reduces the risk of… – Ear infections – Diarrhea Infant Health Benefits • Breastfeeding reduces the risk of… – Ear infections – Diarrhea – Severe lower respiratory tract infections (i. e. pneumonia) – Eczema (a skin condition) – Asthma – Obesity – Type 1 and 2 diabetes – Childhood leukemia – SIDS – Necrotizing enterocolitis (death of intestinal tissue that usually happens to preemies) 10

Mother Health Benefits • Breastfeeding reduces the risk of… – Type 2 diabetes – Mother Health Benefits • Breastfeeding reduces the risk of… – Type 2 diabetes – Breast cancer – Ovarian cancer • Stopping breastfeeding early may also make moms more at risk for postpartum depression 11

Breast Milk versus Formula 12 Breast Milk versus Formula 12

Formula Concerns • No benefits for baby’s underdeveloped immune system • Gas and constipation Formula Concerns • No benefits for baby’s underdeveloped immune system • Gas and constipation • Cleanliness and preparation dangers • Manufacturing errors • Economic burden – formula is expensive! That said, there are legitimate reasons parents feed their babies formula 13

BREASTFEEDING DIFFICULTIES If it’s so great, why doesn’t everyone do it? BREASTFEEDING DIFFICULTIES If it’s so great, why doesn’t everyone do it?

Lack of Paid Maternity Leave • The U. S. is one of two countries Lack of Paid Maternity Leave • The U. S. is one of two countries in the world without any mandated paid maternity leave • 58% of U. S. employers provide partial-pay maternity leave – Average length = 1. 5 weeks • Only 9% of U. S. employers provide full-pay maternity leave – Average length = 2. 2 weeks • Lack of workplace support for breastfeeding

Stigma Against Breastfeeding in Public • Illinois law: – Women are allowed to breastfeed Stigma Against Breastfeeding in Public • Illinois law: – Women are allowed to breastfeed in public if they choose – Breastfeeding is not an act of public indecency • But… cultural stigma makes women uncomfortable breastfeeding in public • Restrooms are not clean so mothers should try not to breastfeed in them! 16

Additional Barriers to Breastfeeding • Intense formula marketing, portrayal of bottles as normal – Additional Barriers to Breastfeeding • Intense formula marketing, portrayal of bottles as normal – Easy formula access at WIC • Breastfeeding is natural, but it is also a learned activity that takes practice – Mothers may need lactation support – International Board Certified Lactation Consultants (IBCLCs) may be expensive • Lack of social support 17

HOW YOU CAN HELP The role of home visitors in breastfeeding education HOW YOU CAN HELP The role of home visitors in breastfeeding education

Motivational Interviewing: What is it? Motivational interviewing is a person-centered, directive method of communication Motivational Interviewing: What is it? Motivational interviewing is a person-centered, directive method of communication for enhancing motivation to change by exploring and resolving ambivalence • “Giving advice with permission” • Non-authoritarian – responsibility to change is ultimately left with the family • More evocative (to draw out) than coercive (to bring about through force) • More supportive than argumentative • Emphasizes why to change rather than how • Timing plays a crucial role 19

Motivational Interviewing Foundations • Based on the following ideas: – Self-Regulation Theory: gaps between Motivational Interviewing Foundations • Based on the following ideas: – Self-Regulation Theory: gaps between our values/ideals and how we’re behaving cause distress causes behavior change – Stages of Change Model: there is a natural process to change – Motivation requires a person to be ready, willing and able – Respect 20

Principles of Motivational Interviewing • Develop discrepancy – A difference between behavior and goals Principles of Motivational Interviewing • Develop discrepancy – A difference between behavior and goals motivates a person to change – Creating awareness of consequences • Roll with resistance – A signal to respond differently – Avoid arguing for change • Support self-efficacy – Belief that one can change is an important motivator – Family is responsible for choosing and carrying out change • Express empathy – Use reflective listening 21

Techniques: O. A. R. S. • Open-Ended Questions – Invite person to talk freely Techniques: O. A. R. S. • Open-Ended Questions – Invite person to talk freely versus answering with a “yes” or “no” • Affirmations – Nodding, looking in the eye encourages person to continue talking • Reflections – Reflective or active listening: repeat or paraphrase what the person shares, understand the underlying feeling in their statement and repeat that to them encourages them to share more • Summarization – Gather the person’s statements from the conversation and present them back to the person in a “bouquet” 22

Techniques: Elicit-Provide-Elicit • Elicit: – “Could you tell me what you know about breastfeeding? Techniques: Elicit-Provide-Elicit • Elicit: – “Could you tell me what you know about breastfeeding? ” • Provide: – “What we know is that formula can actually put your baby at risk for a variety of diseases. ” – “Research shows that breastfeeding can reduce the risk for illnesses like ear infections and pneumonia. ” • Elicit: – “What do you think about what I just said? ” – “What do you think your next step should be? ” HOME VISITING TIP Breastfeeding advice should be consistent. Research also shows that it shouldn’t be combined with many non-breastfeeding messages to make sure advice doesn’t “get lost” 23

Techniques: Recognize Change Talk • Desire: “I would like to breastfeed” • Ability: “I Techniques: Recognize Change Talk • Desire: “I would like to breastfeed” • Ability: “I could breastfeed” • Reasons: “Breastfeeding helps make my baby healthy” • Need: “I’ve got to breastfeed” • Commitment: “I’m going to breastfeed” Encourage and strengthen these statements – this is where summarization or “bouquet” skills come into play! 24

Techniques: Elicit Self-Motivational Statements • Use change rulers – You: “On a scale of Techniques: Elicit Self-Motivational Statements • Use change rulers – You: “On a scale of 1 -10, 10 being the most important, how important is it for you to breastfeed? ” – Mother: “I’d say a 5. ” – You: “Ok, why did you rate this a 5 instead of, say, a 3? ” • Explore the pros and cons • Look forward (explore goals) • Look back (to a time when they were successful) • Ask for elaboration or examples • Imagine extremes • Come alongside 25

PRENATAL MESSAGING How to introduce breastfeeding before birth 26 PRENATAL MESSAGING How to introduce breastfeeding before birth 26

How Should You Introduce Breastfeeding? • Consider easing into the topic of infant feeding, How Should You Introduce Breastfeeding? • Consider easing into the topic of infant feeding, particularly if you have more than one prenatal visit • First prenatal visit (or beginning of only prenatal visit): – Get to know parent, as you usually do – Educate parents about how to understand general baby behavior: • Infant cues • Crying • Sleep HOME VISITING TIP Research shows that, generally, more breastfeeding-focused visits over a longer period of time help moms be the most successful at breastfeeding

Infant Cues 1. Parents should watch and listen to their babies right away – Infant Cues 1. Parents should watch and listen to their babies right away – Babies are born with the ability to use cues to let us know what they need – Develop your own “language” 2. Taking care of a new baby can be confusing. – Uncoordinated and can mix up their cues – Alertness 1 -2 hours after birth: use this time to get to know each other and practice feeding 28

Infant Cues 3. Babies use “engagement cues” when they want to interact – Look Infant Cues 3. Babies use “engagement cues” when they want to interact – Look at what they’re interested in, face is relaxed (will smile if old enough), older babies try to touch and taste – Look for signs they’re getting tired 4. Babies use “disengagement cues” when they need a break – Close eyes, turn face away, arch or twist body, muscles tense, frown – Reduce stimulation; may take detective work to figure out the problem 29

Infant Cues 5. Babies “cluster” cues to deliver important messages – Hungry: move head Infant Cues 5. Babies “cluster” cues to deliver important messages – Hungry: move head back and forth, pull hands and knees towards face, sucking, may start crying if not fed right away – Full: relax muscles, slow down eating, hand fall away from face, fall asleep 6. It may take a lot of practice to master feeding. – Coordinating breathing and sucking can be tricky, but babies learn fast – If not, speak to a lactation consultant, nurse or doctor to get help – Practice by feeding baby every time she uses hunger cues 30

Crying 1. Crying babies are not always hungry – Tired, dirty diaper, over-stimulated, too Crying 1. Crying babies are not always hungry – Tired, dirty diaper, over-stimulated, too cold, too hot, startled, scared, bored, lonely, sick, in pain, frustrated 2. Crying increases dramatically on the second day. – Work hard to give cues (usually hunger cues), but aren’t very coordinated – Healthy and normal for babies to feed frequently 3. Paying close attention to babies can mean less crying – Anticipate trouble – lights, sounds, visitors, new experiences – Address cues early – respond to disengagement cues before tears begin – Learn from mistakes – no one is perfect 4. Babies are soothed by repetition – Singing, rocking or riding in a car – Try just one technique at a time, over and over – More than one technique at a time may over-stimulate baby and make her more upset 31

Sleep 1. Young babies are not supposed to sleep through the night – They Sleep 1. Young babies are not supposed to sleep through the night – They need to eat; newborn tummies are tiny and need frequent feeds – They wake up to stay safe; remind of “back to sleep” 2. Dreaming helps babies’ brains develop – Babies sleep differently than adults – The dreaming stage is a light stage of sleep; this is why babies wake up easily 3. Over time, babies do begin to sleep longer – 6 -8 weeks: usually only a few nighttime feedings – 4 months: fall asleep in deep sleep, concentrate longest stretch of sleep at night – 6 months: sleeps through the night, more or less 32

Sleep 4. Healthy newborns wake up a lot. – Reassure that this is hard Sleep 4. Healthy newborns wake up a lot. – Reassure that this is hard on parents, but is best for babies 5. Sometimes, newborns sleep too much. – This can be a sign of trouble – Wake baby to feed using repetition: • Undress baby • Change diaper • Change baby’s position • Talking or singing in different voices 33

Introducing Breastfeeding • At the second visit (or end of the only prenatal visit) Introducing Breastfeeding • At the second visit (or end of the only prenatal visit) – To transition to a breastfeeding discussion, consider reviewing Infant Cues and Crying Motivational Interview Scripting: Elicit: “Ok, so infant feeding is a topic closely related to crying. Could you tell me what you have heard about breastfeeding? ” Provide: “Thanks for sharing that. Would you be interested in hearing what I know about breastfeeding? ” Elicit: “What do you think about that information? ” 34

“It’s Only Natural” Video HOME VISITING TIP Research shows that additional breastfeeding resources – “It’s Only Natural” Video HOME VISITING TIP Research shows that additional breastfeeding resources – like your toolkit and this video! – can reinforce home visiting information and helps parents learn. 35

PRENATAL MESSAGING Helping mothers-to-be decide how to feed their infants 36 PRENATAL MESSAGING Helping mothers-to-be decide how to feed their infants 36

Resources to Help Parents Decide • Consider sharing information from the beginning of this Resources to Help Parents Decide • Consider sharing information from the beginning of this presentation: – Infant health benefits – Mother health benefits – AAP and WHO recommendations: ONLY breastfeeding for 6 months with no food or water, continue breastfeeding for 1 -2 years with food – Breastfeeding is free – formula costs about $1, 500 a year! – Play the Breast Milk versus Formula game • Remember what we learned about motivational interviewing: – Respectful, non-authoritarian, supportive, empathetic, support self-efficacy – Emphasize it is the mother’s choice; be understanding of any challenges that worry her and reassure her that any breastfeeding is better than none! – Keep it light, consider sharing photos of ethnically similar celebrities who breastfeed HOME VISITING TIP: breastfeeding education should be culturally tailored!

Fact Sheets 38 Fact Sheets 38

Videos 39 Videos 39

Breastfeeding Decision Aid and Plan • Walk through pros and cons with mother • Breastfeeding Decision Aid and Plan • Walk through pros and cons with mother • Consider using change rulers to help motivate parents • Tell mothers it’s all right to make short-term plans – Breastfeeding for 6 months to 1 year may be overwhelming – Start with a two-week commitment (see worksheet in toolkit) – Remind mother that breastfeeding is a learned task and it’s ok if she needs help 40

Motivational Interview Scripting Elicit: “It sounds like you may be a little worried about Motivational Interview Scripting Elicit: “It sounds like you may be a little worried about breastfeeding. Could you share some of the concerns you have? ” Provide: “Those are very valid concerns. Would you be interested in hearing some ideas I have for making breastfeeding less daunting? ” Elicit: “After hearing that information, on a scale of 1 -10, 10 being the most important, can you tell me how much of a priority breastfeeding for the first two weeks will be for you? ” Elicit: “Ok, great. Can you tell me why you rated this as a 4 instead of a 2? ” 41

PRENATAL MESSAGING Teaching mothers what to expect in the hospital 42 PRENATAL MESSAGING Teaching mothers what to expect in the hospital 42

Birth and Breastfeeding • Encourage mothers to: – Breastfeed within 1 hour of birth Birth and Breastfeeding • Encourage mothers to: – Breastfeed within 1 hour of birth – Birth with as few “interventions” as possible • Sometimes “routine” labor and delivery practices can make breastfeeding difficult DID YOU KNOW? Research shows that home visitors can effectively support breastfeeding by visiting moms in the hospital! • Medications make babies (and mom!) less alert, which makes breastfeeding harder • Separation after birth can make breastfeeding harder • Elective c-sections are used too much in the U. S. (but some women do need them) – Consider doula support • Associated with fewer medications, less anesthesia, fewer complications and shorter labor Remind mothers that birth is a normal process, not an illness! 43

The Importance of Skin-to-Skin • Babies should be placed skin-to-skin with their mother immediately The Importance of Skin-to-Skin • Babies should be placed skin-to-skin with their mother immediately after birth or as soon as the mother is stable after a c-section – No tests or cleaning beforehand • Warmers are usually not necessary – Mom’s body warmed baby for 40 weeks! • Skin-to-skin… – Controls baby’s body temperature – Helps baby breastfeed – Helps mother-infant bonding – Calms mother and infant – Keeps baby’s blood sugar stable 44

The Importance of Rooming In • Baby stays in mother’s room 24 hours a The Importance of Rooming In • Baby stays in mother’s room 24 hours a day – No nursery time • Encourages: – Feeding on demand, which stimulates mother’s milk supply – Teaches mom baby’s cues and how to care for baby – Bonding – Less crying from baby • Different hospitals have different policies, so mothers should check beforehand 45

Motivational Interview Scripting Elicit: “So you’ve made the decision to breastfeed your baby. Birth Motivational Interview Scripting Elicit: “So you’ve made the decision to breastfeed your baby. Birth is tied very closely to breastfeeding. Could you tell me how you’re envisioning your birth going? ” Provide: “Thank you for sharing that. So you mentioned you’re considering an elective c-section. Would you mind if I shared with you the information I know about how c-sections may affect breastfeeding? ” Elicit: “After hearing that information, I thought it might be helpful to explore the pros and cons of c-sections versus vaginal births. What do you think some of these pros and cons might be? 46

Communication with Hospital Staff • Encourage mothers to create a birth plan and share Communication with Hospital Staff • Encourage mothers to create a birth plan and share it with their doctors and hospital staff • Birth plans address: – Breastfeeding wishes – Skin-to-skin – Rooming in – Emergency c-section wishes – Formula and pacifiers – Breastfeeding support resources • Mothers should also ask about inhospital breastfeeding support

Breastfeeding Health Care Professionals • International Board Certified Lactation Consultants (IBCLCs) – Experts in Breastfeeding Health Care Professionals • International Board Certified Lactation Consultants (IBCLCs) – Experts in breastfeeding – “A physical therapist for breastfeeding” – This is who to call when mom has breastfeeding troubles HOME VISITING TIP CLC or breastfeeding peer counselor trainings may be helpful for home visitors. – Could also be a nurse, dietician or physician • Certified Lactation Counselors (CLCs) – Less expertise than IBCLC – Great for supporting mothers as they learn to breastfeed and troubleshoot • Remember: doctors and nurses do not always support breastfeeding and may not be experts on it! HOME VISITING TIP It may be helpful for your organization to develop a referral relationship with an IBCLC or your local WIC lactation clinic. 48

PRENATAL MESSAGING Preparing mothers for the first few weeks of breastfeeding 49 PRENATAL MESSAGING Preparing mothers for the first few weeks of breastfeeding 49

How Breast Milk is Produced How Breast Milk is Produced

Positioning • There are many positions for breastfeeding • Mother should position herself comfortably, Positioning • There are many positions for breastfeeding • Mother should position herself comfortably, use pillows to support her body and relax • Position the baby: – Should be on his side, facing mother (no neck-twisting!). – Hold baby at the level of nipple so mother is not leaning forward. Using a pillow on the lap will help. – Use hand to form a “U” around the darker part of the breast (areola) and offer to the baby. – Thumb should be in line with the baby’s nose, with the rest of fingers on the other side of the breast. – Baby’s head should be tilted back a bit to make it easy to suck and swallow. 51

Latch • How to help infants latch properly: • Signs of a good latch: Latch • How to help infants latch properly: • Signs of a good latch: – The latch feels comfortable. – The baby’s chest is against mom’s body so the head doesn’t need to turn. – The baby’s mouth is filled with breast. – You hear or see the baby swallow. For some babies the only sign of swallowing may be a pause in breathing. – The baby’s ears “wiggle” slightly. – The baby’s lips turn out, not in. 52

Breast Milk is Unique • Stage 1: Colostrum – Thick, sticky milk produced in Breast Milk is Unique • Stage 1: Colostrum – Thick, sticky milk produced in small amounts for first few days after birth – Infant’s “first immunization” – Helps clear baby’s digestive tract • Stage 2: Transitional Milk – Milk begins to transition about 2 -5 days after birth – Combination of colostrum and mature milk 53

Breast Milk is Unique • Stage 3: Mature Milk – Appears about 2 weeks Breast Milk is Unique • Stage 3: Mature Milk – Appears about 2 weeks after birth – Thin, watery and bluish in color – Breasts will feel fuller, heavier and more sensitive • Foremilk vs. Hindmilk – Low-fat milk at beginning vs. high -fat milk at end of feeding – Drain each breast to give infant access to fat each feeding • Remind mothers that babies do not need any food or water for the first 6 months of life – This means no cereal in the bottle! 54

Babies Have Tiny Stomachs • This is why… – Colostrum is produced in such Babies Have Tiny Stomachs • This is why… – Colostrum is produced in such small amounts – Feeding on demand is important • It is normal for newborns to lose weight the first few days 55

Is Baby Eating Enough Food? • • Teach mothers to track their infants’ feedings Is Baby Eating Enough Food? • • Teach mothers to track their infants’ feedings and dirty diapers to make sure baby is eating enough Generally, babies should eat at least 8 times a day (about every 1 -3 hours) – Feeding on demand is important Baby’s Age Number of Wet Diapers Number of Bowel Movements Color and Texture of BMs Day 1 (first 24 hours after birth) 1 First usually occurs within 8 hours Thick, tarry and black Day 2 2 3 Thick, tarry and black Day 3 5 -6 3 Looser greenish to yellow Day 4 6 or more 3 Yellow, soft and watery Day 5 6 or more 3 Loose seedy, yellow color Day 6 6 or more 3 Loose seedy, yellow color Day 7 6 or more 3 Larger amounts of loose seedy, yellow color 56

How to Bottle-Feed • Do’s: – Do sterilize the bottle, formula container and all How to Bottle-Feed • Do’s: – Do sterilize the bottle, formula container and all other equipment before preparing – Do make sure the nipple hole is the right size – Do try different nipple shapes to see which the baby likes best – Do angle the bottle so the baby isn’t sucking in air – Do burp the baby a few times each feeding – Do encourage dad to feed using a bottle – it’s bonding time for him – Do wipe milk from baby’s teeth before putting her to bed – Do listen to baby’s hunger cues! • Don’ts – Don’t prop the bottle – Don’t warm a bottle in the microwave – Don’t let the baby fall asleep with a bottle in her mouth – Don’t ever put cereal in baby’s bottle! 57

PRENATAL MESSAGING Family and workplace/school support systems 58 PRENATAL MESSAGING Family and workplace/school support systems 58

Talking to Family About Breastfeeding • Grandmothers and fathers have a lot of influence Talking to Family About Breastfeeding • Grandmothers and fathers have a lot of influence in how babies are fed – Grandmothers: breastfeeding history or feeding misconceptions – Fathers: intimacy and bonding concerns • Educate family members about breastfeeding early – Include in home visits, if possible • Encourage father involvement in breastfeeding support • Teach older children to pitch in • Empower mother to tell her family how she wants to feed her baby HOME VISITING TIP Research shows that involving fathers and grandmothers in home visits can help moms breastfeed successfully.

Maternity Leave Planning • Encourage mothers to tell employers they plan to breastfeed • Maternity Leave Planning • Encourage mothers to tell employers they plan to breastfeed • Encourage mothers to take 6 weeks maternity leave, breastfeed exclusively and return gradually – Seek IBCLC or CLC support if they need to go back sooner • Help mothers learn to pump and remind them it takes practice • Help mothers complete a lactation and work plan (in toolkit) • Encourage mothers to find breastfeeding-friendly child care in advance • Remind mothers to be proud of any breastfeeding they can do! 60

Maternity Leave Planning • “Business Case for Breastfeeding” Resources – How to ask supervisors Maternity Leave Planning • “Business Case for Breastfeeding” Resources – How to ask supervisors for a private pumping space (4 x 5 foot space with electrical outlets, a lock and nearby access to running water) – How to negotiate break time for pumping – Sample policy for supporting breastfeeding employees – Lactation program assessment forms for businesses 61

POSTPARTUM MESSAGING Education once mother and baby are back at home 62 POSTPARTUM MESSAGING Education once mother and baby are back at home 62

Overcoming Challenges • Sore nipples • Low milk supply • Oversupply of milk • Overcoming Challenges • Sore nipples • Low milk supply • Oversupply of milk • Engorgement • Plugged ducts • Breast infection (mastitis) • Fungal infections • Nursing strike • Inverted, flat, or very large nipples • Encourage mothers to get help if problems worsen or don’t go away – Speak to an IBCLC, CLC or doctor – Call the National Breastfeeding Hotline at 1 -800 -994 -9662 • Remind mothers that they can breastfeed on most medications – Double check on Lact. Med

Revisit the Two-Week Plan • Check in with mothers and support them to reach Revisit the Two-Week Plan • Check in with mothers and support them to reach their 2 -week goal • After 2 weeks, encourage mother to make a 6 -week goal (see worksheet in toolkit) – This is when moms get into a “breastfeeding groove” – Milk has matured and well-baby visits have shown mom how breastfeeding is contributing to baby’s health Motivational Interview Scripting Elicit: So, how breastfeeding is going? Provide: It sounds like you’re having some challenges, but that you’re dealing with them well. Would you mind if I shared some information that may help you deal with these? Elicit: So, after hearing that information, on our 1 -10 scale, how confident do you feel that you’ll be able to reach your 2 -week goal?

Returning to Work or School • Encourage moms to wrap up any loose ends Returning to Work or School • Encourage moms to wrap up any loose ends in the plan they created while pregnant – Discuss pumping room, break time, milk storage with employer – Assess how breastfeeding-friendly their child care provider is – Practice pumping • Help moms prepare their infants for their return to work: – Teach infant to bottle-feed about 2 weeks before going back to work – Some babies “reverse cycle feed” • • Help moms develop a pumping schedule for work Share the daily work checklist resource with moms (in toolkit) 65

Pumping and Storing Breast Milk • Do’s – Do store milk in small amounts Pumping and Storing Breast Milk • Do’s – Do store milk in small amounts (1 -4 ounces) so it doesn’t go to waste – Do store milk at room temperature for 3 -4 hours (65 -80 degrees) – Do refrigerate milk for up to 3 days – Do freeze milk if you won’t use it within 3 days (for up to 6 months) – Do store milk in sterilized BPA-free milk storage bags or glass/hard plastic containers – Do label milk with the date it was pumped – Do thaw frozen milk by running containers under warm water – Do use thawed milk right away and only for that feeding • Don’ts – Don’t place milk near freezer door (to keep it from thawing when door opens) – Don’t microwave milk to thaw it – Don’t worry if frozen milk changes color – this is normal – Don’t save milk left in a bottle after a feeding – Don’t refreeze milk that has been frozen HOME VISITING TIP See the toolkit for a sample pumping schedule and a guide on storing thawed and fresh breast milk! 66

Family Planning • Using birth control with the hormone estrogen can decrease mom’s milk Family Planning • Using birth control with the hormone estrogen can decrease mom’s milk production – Progesterone-only birth control, copper IUD and barrier methods (like condoms) are better for breastfeeding • LAM is 98% effective if 3 conditions are met • If mothers want to use LAM, tell them that additional contraception is needed if breastfeeding declines! 67

Introducing Solid Foods • Remember: AAP recommends exclusive breastfeeding for the first 6 months Introducing Solid Foods • Remember: AAP recommends exclusive breastfeeding for the first 6 months and continued breastfeeding for 12 months with food • Teach parents the signs their baby is ready for solid food: – Infant can hold her head up, open her mouth when food comes towards her, move food to the back of her mouth to swallow – Infant’s birth weight should have approximately doubled • Introduce one food at a time and look for allergic reactions • May take up to 12 tries to accept a new food! • Good first foods: – Iron-fortified infant cereal, pureed meats, vegetables, fruits 68

SUMMARY • Home visitors can play an important role in encouraging breastfeeding • Infant SUMMARY • Home visitors can play an important role in encouraging breastfeeding • Infant feeding discussions should begin early • Breastfeeding has great health benefits for mom and baby • Formula-feeding is more work than many moms think • Mothers should try to feed their babies only breast milk for 6 months and continue breastfeeding along with food for at least 12 months – However, mothers should be proud of any breastfeeding they can do! • IBCLCs and CLCs are great breastfeeding resources 69

QUESTIONS? THANK YOU! 70 QUESTIONS? THANK YOU! 70