SAINT LOUIS UNIVERSITY

School Of Nursing
Baguio, City

TEACHING CARE PLAN

BREASTFEEDING

Submitted by:

Canobas, Mariah Joy F.

BSN II C3

Submitted to:

MRS. JOSEFA CAPUYAN

Clinical Instructor
 TEACHING PLAN FOR BREASTFEEDING

DISCRIPTION OF THE LEARNER: The learners are first time mothers who just delivered their baby in the institution of Benguet General Hospital
and needs health teachings regarding breast feeding for their babys health and welfare.

LEARNING NEED: Importance and Advantages of Breastfeeding, proper positioning techniques, and additional knowledge about engorgement and
nipple sore.

LEARNING DIAGNOSIS: Knowledge Deficit: Breastfeeding related to lack of exposure.

GOAL: To have adequate knowledge about breastfeeding

Behavioral Learning Topic Outline Teaching Strategy Time Allotted and Method of Evaluation
Objectives (BLO) Resources Needed

Cognitive:

Be able to define Definition of One on one discussion. 3 minutes is allotted for Instant oral feedback
breastfeeding on breastfeeding defining breastfeeding in
own words own words.

Be able to define Definition of exclusive One on one discussion. 3 minutes will be allotted Instant oral feedback:
exclusive breastfeeding Ask what is exclusive for defining exclusive The patient will be able
breastfeeding on breastfeeding and breastfeeding in own to share her
their own patient will define in her words. understanding about the
understanding. own words and exclusive breastfeeding
understanding.
Respond to the answer
 by showing the data

Breastfeeding and its One on one discussion 3 minutes is allotted for Instant oral feed back
Be able to know importance of verbalization of ideas verbalization of ideas Enumerate 3 importance
importance of about importance of about the topics. A of breastfeeding.
breast feeding breastfeeding. pamphlet about
breastfeeding and its
importance.

Advantages of One on one discussion 3 minutes is allotted for Instant oral feedback
Be able to learn breastfeeding of advantages of discussion of Enumerate 3
the advantages of breastfeeding. advantages of advantages of
breastfeeding breastfeeding. breastfeeding.

Proper latching and One on one discussion 5 minutes is allotted for Instant oral feedback
Be able to know attachment techniques. on proper attachment the discussion of proper Enumerate at least 2
signs of proper and latching on latching and attachment signs of proper latching
latching and techniques. techniques. A pamphlet and 2 attachment
attachment of will be given to the client techniques.
baby as her reference.

Proper Diet for Lactating One on one discussion 4 minutes is allotted for Instant oral feedback
Mothers. on proper diet for the discussion of proper Enumerate 5 foods that
Be able to learn
lactating mothers. diet for a lactating are needed by a
proper diet for a
mother. A pamphlet will lactating mother.
lactating mother.
be given as a guide.
 Feeding cues One on one discussion 5 minutes is allotted for Instant oral feedback.
on feeding cues. the discussion of Enumerate at least 5
Be able to feeding cues. feeding cues.
understand
feeding cues

Psychomotor: Instant oral feedback

And by using a point
Be able to Mechanism of manual Demonstration-Return 5 mins is allotted for system
perform ways of breast milk expression demonstration demonstration of the
manual breast student nurse and 10 5= able to demonstrate
milk expression minutes is allotted for 3 ways of manual breast
return demonstration of milk expression
mother about manual
breast milk expression 3= able to demonstrate
2-1 ways of manual
breast milk expression

0= demonstrated 0 way
of manual breast milk
expression
Affective:

After health Importance of One on one discussion 10 mins is allotted for Instant oral feedback
teaching, client breastfeeding a baby up Demonstration-return discussion about how Client will verbalize that
will be able to to 6th months. demonstration client will be able to she will comply to all
incorporate incorporate health health teachings given.
methods of teachings in her daily life Client will also be able
proper as a breastfeeding to perform proper
 breastfeeding to mother. A pamphlet is breastfeeding
her baby as also given as a source techniques
evidenced by of reference.
proper
attachment and
latching.

REFERENCES:
MacDonald, C. (2014, JULY 31). Breastfeeding: A WINNING GOAL FOR LIFE. Retrieved July 9, 2016 from
http://www.wvi.org/experts/article/breastfeeding-winning-goal-life.
World Health Organization (2016). World Health Organization: BREASTFEEDING. Retrieved July 9, 2016 from
http://www.who.int/topics/breastfeeding/en/.
Help & Advice (November 6,2014). 11 Benefits of Breastfeeding for Baby. Retrieved July 10, 2016 from
https://www.lansinoh.com/en/help-advice/11-benefits-of-breastfeeding-for-baby?utm_campaign=Promoted
Pillitteri, A. (2007). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family, 5 th edition. Lippincott Williams &
Wilkins.
Thomas, C. L., Taber, C.W. (1997). Taber's Cyclopedic Medical Dictionary (18 th edition). Philadelphia: F.A.Davis.
Tortora, G.j. (1999). Principles of Anatomy and Physiology, 9 th edition. Wiley & Sons.
Ask Dr. Sears (n.d). 7 Ways Breastfeeding Benefits Mothers. Retrieved July 10, 2016 from http://www.askdrsears.com/topics/feeding-
eating/breastfeeding/why-breast-is-best/7-ways-breastfeeding-benefits-mothers
 WebMD. (n.d). Breastfeeding Overview. Retrieved July 10, 2016 from http://www.webmd.com/parenting/baby/nursing-basics.
 LEARNING CONTENT

BREASTFEEDING

Breastfeeding is the normal way of providing young infants with the nutrients they need for healthy growth and development. Virtually all
mothers can breastfeed, provided they have accurate information, and the support of their family, the health care system and society at large.

Colostrum, the yellowish, sticky breast milk produced at the end of pregnancy, is recommended by WHO as the perfect food for the newborn,
and feeding should be initiated within the first hour after birth.

EXCLUSIVE BREASTFEEDING
Exclusive breastfeeding means giving a baby only breast milk, and no other liquids or solids, not even water.
Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up
to two years of age or beyond.
Babies not exclusively breastfed in the first six months of life have a 14 times higher risk of death, including a 10 times greater risk of death
from diarrhea and 15 times greater risk death from pneumonia compared to infants who are exclusively breastfed.

ADVANTAGES OF BREASTFEEDING TO THE MOTHER

Reduces the risk of breast cancer. Women who breastfeed reduce their risk of developing breast cancer by as much as 25 percent. The
reduction in cancer risk comes in proportion to the cumulative lifetime duration of breastfeeding. That is, the more months or years a mother
breastfeeds, the lower her risk of breast cancer.

Reduces the risk of uterine and ovarian cancer. One of the reasons for the cancer-fighting effects of breastfeeding is that estrogen levels
are lower during lactation. It is thought that the less estrogen available to stimulate the lining of the uterus and perhaps breast tissue also, the
less the risk of these tissues becoming cancerous.

Lessens osteoporosis. Non-breastfeeding women have a four times greater chance of developing osteoporosis than breastfeeding women
and are more likely to suffer from hip fractures in the post-menopausal years.

Benefits child spacing. Since breastfeeding delays ovulation, the longer a mother breastfeeds the more she is able to practice natural
childspacing, if she desires. How long a woman remains infertile depends on her babys nursing pattern and her own individual baby.
 Promotes emotional health. Not only does breastfeeding benefit a mothers body, it also benefits her mind. Studies show that breastfeeding
mothers show less postpartum anxiety and depression than do formula-feeding mothers.

Promotes postpartum weight loss. Breastfeeding mothers showed significantly larger reductions in hip circumference and more fat loss by
one month postpartum when compared with formula-feeding moms. Breastfeeding mothers tend to have an earlier return to their pre-pregnant
weight.

Costs less to breastfeed. It costs around $1,200 a year to formula-feed your baby. Even taking into consideration the slight increase in food
costs to a breastfeeding mother, the American Academy of Pediatrics estimates that a breastfeeding mother will save around $400 during the
first year of breastfeeding.

The release of oxytocin from the posterior pituitary gland aids in uterine involution (the reduction in size of the uterus after childbirth). Oxytocin
is released whenever a mechanical stimulus is initiated by the sucking mechanism of the infant.
Successful breast-feeding can have an empowering effect, because it is a skill only a woman can master
Breast-feeding provides an excellent opportunity to enhance a true mutual bond between mother and child.

ADVANTAGES OF BREASTFEEDING TO THE BABY

1 Breast milk provides the ideal nutrition for infants. It has a nearly perfect mix of vitamins, protein, and fat -- everything your baby needs to
grow. And it's all provided in a form more easily digested than infant formula.
2 Breast milk contains antibodies that help your baby fight off viruses and bacteria.
3 Breastfeeding lowers your baby's risk of having asthma or allergies.
4 Plus, babies who are breastfed exclusively for the first 6 months, without any formula, have fewer ear infections, respiratory illnesses, and
bouts of diarrhea. They also have fewer hospitalizations and trips to the doctor.

5 Breastfeeding has been linked to higher IQ scores in later childhood in some studies.
6 What's more, the physical closeness, skin-to-skin touching, and eye contact all help your baby bond with you and feel secure.
7 Breastfed infants are more likely to gain the right amount of weight as they grow rather than become overweight children.
8 The AAP says breastfeeding also plays a role in the prevention of SIDS (sudden infant death syndrome).
9 It's been thought to lower the risk of diabetes, obesity, and certain cancers as well, but more research is needed.
10 Have a reduced risk for ear infections (otitis media) and gastroenteritis.
11 Get nutrients that help strengthen and develop their immature immune system in a way no other substance can.
12 Respond better to immunizations against Polio, Tetanus, Diphtheria, and Haemophilus influenza (bacterium that can cause a severe infection).
 13 Have optimal oral development because of their jaw movements and nutrients in breastmilk decrease the risk of tooth decay.
14 Are protected against respiratory infections including those caused by rotaviruses.
15 Are less likely to be hospitalized with pneumonia or bronchiolitis, and have a decreased risk of lower respiratory tract infections. .

Breast milk contains secretory immunoglobulin A (IgA), which binds large molecules of foreign proteins, including viruses and bacteria,
keeping them from being absorbed from the gastrointestinal tract (stomach) into the infant. Lactoferrin, is an iron-binding protein in breast milk
that interferes with the growth of pathogenic bacteria. The enzyme lysozyme in breast milk apparently actively destroys bacteria by lysing
(dissolving) their cell membranes, possibly increasing the effectiveness of antibodies. Leukocytes in breast milk provide protection against
common respiratory infectious invaders. Macrophages, responsible for producing interferon (a protein that protects against viruses), interfere
with virus growth. The bifidus factor is a specific growth-promoting factor for the beneficial bacteria Lactobacillus bifidus. The presence of L.
bifidus in breast milk interferes with the colonization of pathogenic bacteria in the gastrointestinal tract, reducing the incidence of diarrhea.
Breast milk contains the ideal electrolyte and mineral composition for human infant growth. It is high in lactose, an easily digested sugar that
provides ready glucose for rapid brain growth. The protein in breast milk is easily digested, and the ratio of cysteine to methionine (two amino
acids) in breast milk favors rapid brain growth in the early months. It contains nitrogen in compounds other than protein, so that an infant can
receive cell-building materials from sources other than just protein.

Breast milk contains more linoleic acid, an essential fatty acid for skin integrity and less sodium, potassium, calcium and phosphorus than do
many formulas. Breast milk also has a better balance of trace elements, such as zinc. These levels of nutrients are enough to supply the
infants needs, yet they spare the infants kidneys from having to process a high renal solute load of unused nutrients.
Breast-fed newborns appear to be able to regulate their calcium/phosphorus levels better than infants who are bottle fed. Decreased calcium
levels in a newborn can lead to tetany (muscle spasms).

Why is Breastfeeding Important for your Baby?

Breast milk helps keep your baby healthy.

It supplies all the necessary nutrients in the proper proportions.
It protects against allergies, sickness, and obesity.
It protects against diseases, like diabetes and cancer.
It protects against infections, like ear infections.
It is easily digested no constipation, diarrhea or upset stomach.
 Babies have healthier weights as they grow.
Breastfed babies score higher on IQ tests.
Breast milk changes constantly to meet babies' needs.
The milk changes in volume and composition according to the time of day, nursing frequency, and age of baby to promote healthy growth.
Breast milk is the perfect food for your baby.
Breast milk is always ready and good for the environment.
It is available wherever and whenever your baby needs it.
It is always at the right temperature, clean and free.
No bottles to clean.
Breastfeeding has no waste, so it is good for the environment.

Why is Breastfeeding Important for You? Mothers who breastfeed:

Have a reduced risk of Type 2 Diabetes and certain cancers such as breast cancer
May find it easier to return to what they weighed before they got pregnant
Strengthen the bond with their children
Making it Work You Can Do It!

Some helpful hints:

Breastfeed soon after birth and breastfeed frequently 8 to 12 times in a 24 hour period.
Hold your baby skin-to-skin.
Keep your baby with you in the hospital.
Do not give a pacifier or bottle until breastfeeding is well established.
Give only breast milk.

How to breastfeed?

Breastfeeding is a skill that needs to be learnt, and it can take time and practice to get the hang of it. There are lots of different positions for
breastfeeding. You just need to check the following points:
Are you comfortable? It's worth getting comfortable before a feed. Remember to relax your shoulders and arms when you feed.
Are your baby's head and body in a straight line? If not, your baby might not be able to swallow easily.
Are you holding your baby close to you, facing your breast? Support their neck, shoulders and back. They should be able to tilt their head back and
swallow easily, and shouldn't have to reach out to feed.
Is your baby's nose opposite your nipple? Your baby needs to get a big mouthful of breast from beneath the nipple. Placing your baby with their nose
level with your nipple will encourage them to open their mouth wide and attach to the breast well.
How to latch your baby on to your breast

Hold your baby close to you with their nose level with the nipple.
Wait until your baby opens their mouth really wide with the tongue down. You can encourage them to do this by gently stroking their top lip.
Bring your baby on to your breast.
Your baby will tilt their head back and come to your breast chin first. They should take a large mouthful of breast. Your nipple should go towards the
roof of their mouth.
How to tell if your baby is getting enough milk

Your baby will appear content and satisfied after most feeds.
They should be healthy and gaining weight after the first two weeks.
Your breasts and nipples should not be sore.
After the first few days, your baby should have at least six wet nappies a day.
After the first few days, they should also pass at least two yellow stools every day.
See more on building up your milk supply.
Breastfeeding premature and ill babies

If your baby is in a neonatal unit in hospital after the birth, you'll probably be encouraged to try kangaroo care. This means that when your baby is
ready, you can hold your baby against your skin regularly, usually under your clothes.
This skin-to-skin contact helps you bond with your premature baby and increases your milk supply.

LACTATION AND PROPER POSITIONING TECHNIQUES IN BREASTFEEDING

- Breast milk looks like nonfat milk. It is thin and almost blue-tinged in appearance.
- Before breastfeeding, mothers must wash their hands to be sure they are free of pathogens picked up from handling perineal pads or other
sources. Washing her breasts is not necessary unless she notices caked colostrums (first breast fluid characterized as a thin yellowish fluid
secreted by the breasts during the second trimester onwards but most evident in the first 2 to 3 days after birth and before the onset of true
lactation) on the nipples.
 - Brushing the infants cheek with a breast nipple stimulates a newborns rooting reflex. The baby then turns toward the breast. Do not try to
initiate a rooting reflex by pressing a babys face against the mothers breast; this will cause the child to turn away from the mother and toward
your hand.
- If a woman has large breasts, the infant may have trouble breathing while nursing because tissue presses against the nose. The mother can
prevent this happening by grasping the areolar margin of her breast between her thumb and forefinger, holding the bulk of the breast
supported while her infant feeds. This also makes the nipple more protruberant.
- Frequent feeding is advantageous to sustain a milk supply, because the more often the breasts are emptied, the more efficiently they will fill
and continue to maintain a good supply of milk.
- Help the infant break away from the breast when they are finished feeding. Insert a finger in the corner of the infants mouth or pull down the
infants chin to release suction. Otherwise, the baby may pull too hard on the nipple, causing crack or soreness.
-
POSITIONS:

1.The cradle hold

This classic breastfeeding position requires you to cradle your baby's head with the crook of your arm. Sit in a chair that has supportive armrests or
on a bed with lots of pillows. Rest your feet on a stool, coffee table, or other raised surface to avoid leaning down toward your baby.

Hold her in your lap (or on a pillow on your lap) so that she's lying on her side with her face, stomach, and knees directly facing you. Tuck her lower
arm under your own.

If she's nursing on the right breast, rest her head in the crook of your right arm.

Extend your forearm and hand down her back to support her neck, spine, and bottom. Secure her knees against your body, across or just below your
left breast. She should lie horizontally, or at a slight angle.

Best for: The cradle hold often works well for full-term babies who were delivered vaginally. Some mothers say this hold makes it hard to guide their
newborn's mouth to the nipple, so you may prefer to use this position once your baby has stronger neck muscles at about 1 month old. Women who
have had a cesarean section may find it puts too much pressure on their abdomen.
2. The cross-over hold

Also known as the cross-cradle hold, this position differs from the cradle hold in that you don't support your baby's head with the crook of your arm.
Instead, your arms switch roles.

If you're nursing from your right breast, use your left hand and arm to hold your baby. Rotate his body so his chest and tummy are directly facing you.
With your thumb and fingers behind his head and below his ears, guide his mouth to your breast.

Best for: This hold may work well for small babies and for infants who have trouble latching on.

3. The clutch or football hold

As the name suggests, in this position you tuck your baby under your arm (on the same side that you're nursing from) like a football or handbag.

First, position your baby at your side, under your arm. She should be facing you with her nose level with your nipple and her feet pointing toward your
back.

Rest your arm on a pillow in your lap or right beside you, and support your baby's shoulders, neck, and head with your hand. Using a C-hold (see
below), guide her to your nipple, chin first.

But be careful don't push her toward your breast so much that she resists and arches her head against your hand. Use your forearm to support
her upper back.

Best for: You may want to try this hold if you've had a Cesarean section (to avoid having the baby rest on your stomach). And if your baby is small or
has trouble latching on, the hold allows you to guide her head to your nipple. It also works well for women who have large breasts or flat nipples, and
for mothers of twins.

4. Reclining position

To nurse while lying on your side in bed, ask your partner or helper to place several pillows behind your back for support. You can put a pillow under
your head and shoulders, and one between your bent knees, too. The goal is to keep your back and hips in a straight line.
With your baby facing you, draw him close and cradle his head with the hand of your bottom arm. Or, cradle his head with your top arm, tucking your
bottom arm under your head, out of the way.

If your baby needs to be higher and closer to your breast, place a small pillow or folded receiving blanket under his head. He shouldn't strain to reach
your nipple, and you shouldn't bend down toward him. You may need to lift your breast, with your fingers underneath, so he can reach comfortably.

Best for: You may want to nurse lying down if you're recovering from a cesarean or difficult delivery, sitting up is uncomfortable, or you're nursing in
bed at night or during the day.

PROPER DIET FOR LACTATING MOTHER

a increase calcium and iron intake
b increase fluid intake of three liters per day
c increase caloric intake. Avoid alcohol drinking and smoking
d dont skip meals and have small frequent feedings

FEEDING CUES:

Common infant hunger cues include:

Early
Smacking or licking lips
Opening and closing mouth
Sucking on lips, tongue, hands, fingers, toes, toys, or clothing
Active
Rooting around on the chest of whoever is carrying him
Trying to position for nursing, either by lying back or pulling on your clothes
Fidgeting or squirming around a lot
Hitting you on the arm or chest repeatedly
Fussing or breathing fast
Late
Moving head frantically from side to side
How to Manually Express Breastmilk

Draining the Milk Reservoirs

1. Position the thumb (above the nipple) and first two fingers (below the nipple) about 1 to 11/2 from the nipple, though not necessarily at the outer
edges of the areola. Use this measurement as a guide, since breasts and areolas vary in size from one woman to another. Be sure the hand forms
the letter C and the finger pads are at 6 and 12 oclock in line with the nipple. Note the fingers are positioned so that the milk reservoirs lie beneath
them.

Avoid cupping the breast

2. Push straight into the chest wall

Avoid spreading the fingers apart.

For large breasts, first lift and then push into the chest wall

3. Roll thumb and fingers forward at the same time. This rolling motion compresses and empties milk reservoirs without injuring sensitive breast
tissue.

Note the position of thumb and fingernails during the finish roll as shown in the illustration.

4. Repeat rhythmically to completely drain reservoirs.

Position, push, roll...
Position, push, roll...

5. Rotate the thumb and fingers to milk other reservoirs, using both hands on each breast.
 Avoid These Motions

1. Do not squeeze the breast, as this can cause bruising.

2. Sliding hands over the breast may cause painful skin burns.

3. Avoid pulling the nipple which may result in tissue damage.

You can store your breast milk to keep it fresh for your baby in a number of ways:
At room temperature (no more than 25 degrees C), for up to six hours.
In a cool box, with ice packs, for up to 24 hours.
In a fridge (at four degrees C or colder), for up to five days. Store it at the back of the fridge, where it's coldest, away from meat,
eggs, or uncooked foods.
In a fridges freezer compartment, for two weeks.
In a home freezer (at minus 18 degrees C or lower), for up to six months.

If you're returning to work, try to get into the routine of expressing and storing your breast milk. This will keep your milk supply up, and your baby can
continue to get the benefits of your milk, even when you're not with him.

How you store your breast milk depends on how soon you want to use it. If you plan to use it within a few days, refrigerating is better than freezing.
Freezing destroys some of the substances in your milk that fight infection. Frozen breast milk is still a healthier choice for your baby than formula,
though.

Whether you choose to refrigerate or freeze your milk, you should:

Use sterilized containers. Opt for plastic bottles or plastic breast milk bags. Glass bottles may crack or chip.
Label and date your bottles and bags, and use up the oldest ones first.
Keep your breast pump clean. Wash the parts in hot, soapy water, and rinse them thoroughly before sterilizing.
Wash your hands before expressing and handling breast milk for storage. Keeping everything as clean as possible will make it less likely that
bacteria will grow in your stored milk.
PROMOTING ADEQUATE SUCKING
Often, a newborn being breast-fed drops off to sleep during the first few feedings. To stimulate both milk production effectively and ensure
adequate fluid intake, help the mother attempt to keep the infant awake, urging him/her to suck. To accomplish this, stroking the back of the
newborn, changing their position during feeding, rubbing their arms and chest, changing their diaper, gently tickling the bottom of a babys feet
are ways on waking the infant effective.
If the infant is not sucking well, the mother can use breast massage after a feeding to empty her breasts manually. This helps ensure good
milk production for the time when the infant is ready to suck.
TECHNIQUES FOR BURPING THE BREAST-FED BABY
Some infants seem to swallow little air when they are breast-fed, whereas others swallow a great deal. As a rule, it is helpful to bubble (burp)
newborns after they have emptied the first breast and again after the total feeding. Placing the baby over one shoulder and gently patting or
stroking the back is an acceptable position. However, this position is not always satisfactory for a small infant, who has poor head control.
Holding the baby in a sitting position on the lap, then leaning the child forward against one hand, with the index finger and thumb supporting
the head, is often the best position to use. This position provides head support but leaves the other hand free to pat the babys back. Laying
the baby prone across the lap is another alternative position.
PREVENTING OR RELIEVING ENGORGEMENT
The primary method for relieving engorgement is emptying the breasts of milk by having the infant suck as much as before.
If an infant cannot grasp a nipple strongly because of engorgement, warm packs applied to both breasts for a few minutes before feeding,
combined with massage to begin milk flow, often facilitates drainage and promotes breast softness so the infant can suck.
Manual expression or the use of a breast pump to complete emptying of the breasts after the baby has nursed can help maintain or promote a
good milk supply during the period of engorgement.
Assure the mother that symptoms of engorgement are healthy; it is an indication that her breasts are producing milk. Engorgement is only
temporary and should begin to subside 24 hours after it first becomes apparent.
PROMOTE HEALING OF SORE NIPPLES
Painful nipples result from the strong sucking action of a newborn.
This may be worsened by the following factors:
1 Improper positioning of an infant (failure to grasp the areola as well as the nipple)
2 Forcefully pulling an infant from the breast
3 Allowing an infant to suck too long at a breast after the breast is emptied
4 Permitting a nipple to remain wet from leaking milk
 To help prevent soreness, encourage the mother to position her baby slightly differently for each feeding. This helps prevent the same area of
the areola from receiving the majority of pressure.
Expose nipples to air by leaving her bra unsnapped for 10 to 15 minutes after feeding. Discourage the use of plastic liners that come with
nursing bras; it is preferable to have air always circulating around the breasts. Applying vitamin E lotion after air exposure may toughen the
nipples and prevent further irritation.
Advise mothers not to use a hand pump with sore nipples, because the pressure may cause fissures to worsen. An electric or battery-operated
pump usually can be used; these devices exert less pressure on the nipples.