Breastfeeding

by
Assoc. Prof. Dr. Susanha Yimyam

Faculty of Nursing, CMU

Aveoli

Milk duct
Areola
Nipple

Myoepithelial cells

Lactiferous sinus
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Breast & Nipple Assessment

Breast:
size, tenderness, engorgement, swelling, redness,
and for heat
Nipple: asses for:
1. Size: too small or too large?
2. Crack or Fissure in nipple:
red, scratched, blister, bleeding, or tender.
3. Short, flat, or inverted nipple:

Wallers Test
Place thumb and forefinger on the edges of
the areola (dark area around
the nipple) just behind nipple.
Squeeze the tissue gently.
If the nipple is flat or inverted, it will flatten or
retract into the breast instead of remaining erect.

Normal nipple

Hoffmans maneuver

Short nipple

Flat/ invert
nipple

for short, flat & invert nipple

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Assessment for Successful Breastfeeding

Influencing factors:

1) Maternal factors:
- Mothers beliefs, attitudes, and intention
- Mothers knowledge: learn about the mechanism of
milk production and ejection, foods & beverages that
promote lactation drink as well as appropriate rest.

2) Infant factors:
- Physical abnormalities or other sucking problems.
Examined and tested for sucking reflex.

3) Health care provider factors: play an important role to promote and support
breastfeeding. Empower mothers to be confident when breastfeeding.
Nursing consultation for better care
Other factors: advertisement of formula during hospital stay &
hospital policy; separation of infant and mother after birth.

Preparation for Breastfeeding

1. Breast & nipple care: clean water while bathing; avoid applying
soap or chemicals to nipple and breast.
2. Breast massage: promote the let-down reflex
for producing and ejecting milk.
3. Separation from infant, express breast milk 10-12 T/day,
then at least 10 T/day thereafter, to stimulate prolactin
4. Suitable maternity bra: supports breasts
to prevent pressure against the milk duct
& deformity of breasts as well as relieve pain.
No wire bras.
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Preparation for Breastfeeding

5. Healthy foods, consume about 500 Kcals and drink
about 2,000-3,000 ml more than pre-pregnancy
consumption per day. High protein, milk every day.
Avoid salty, sweet and preserved foods, alcohol and
caffeine beverages and foods that create gas such as
those found in the cabbage family (all cabbage,
broccoli, cauliflower) and some beans.
Consult physician before taking any medication.
6. Adequate rest (8-10 hours at night and 1/21 hour at midday).
7. Appropriate postpartum exercise daily.
8. Relaxation both physically and mentally.
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nut s

beans

Techniques for breastfeeding

The principle of three suckling: promptly suckling,
frequent suckling and correct suckling.

Promptly suckling: WHO & UNICEF start at - 2 hrs after

birth: sensitive period. It also helps establish early bonding.
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Techniques for breastfeeding

The principle of three suckling: promptly suckling,
frequent suckling and correct suckling.

Frequent suckling: breastfeeding every

2-3 hrs in order to increase milk production
and ejection, and decrease infant jaundice.
After initiating breastfeeding, the mother
should then breastfeed on demand, or at
least every 3 hours during the day and at
least every 4 hours at night.
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Techniques for breastfeeding

The principle of three suckling: promptly suckling,
frequent suckling and correct suckling.

Correct suckling is very important because most

breastfeeding problems occur from incorrect suckling.
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1. Wash mother hands before breastfeeding.

2. Awake the infant to breastfeed
3. Privacy, quiet place for relaxation and
concentration.
4. Position properly for optimal
breastfeeding: cradle hold, clutch
position or football hold, modified
clutch position and side lying position.
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Cradle hold

Side-lying

Transitional hold

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5. Mother supports her breast is compressed

slightly so that an adequate amount of breast
tissue is taken into the mouth with latch-on.
6. During breastfeeding: Eye contact, the
infants gum on areola, stimulate infant
awaken to feed once again if the infant
stops sucking.
7. Breastfeed on both breasts; feeding
about 10-15 minutes to stimulate prolactin
and oxytocin and not express the milk as it
is considered to be hind milk that is,
higher energy (richer in fat) than fore-milk.
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8. To change breasts or to stop

feeding, push one finger into the
corner of the babys mouth.

9. Burp the infant

by placing infant
on mothers lap
or her shoulder
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10. Not supplement the childs diet with

formula, food or drink except when
medically indicated
11. No artificial treats or pacifiers:
nipple confusion. If not suckling from
breast; medicine dropper or cup.
12. Manual express breast milk
at least 6-8 times a day for
10-20 minutes in each time.
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Objective: Promote let-down reflex by stimulating milk production & ejection.

1. Conducted after bathing as the mothers hands & body is

clean
2. Begin at the base of the breast
close to areola to remove breast milk
from milk ducts through lactiferous sinus,
which is located under areola
3. Methods
3.1 Mother applies one hand to support
the breast and then apply 4 fingers of another
hand side to deep circular massage from the
base of breast into areola.
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3.2 The mother places her hands against

the chest wall with her fingers encircling
the breasts. She gently slides her hands
forward until the fingers overlap.
4. After breast massage, mother should express
breast milk by placing her hand just behind the
areola, with the thumb on top and the fingers
supporting the breast.
The action is repeated to simulate the suckling
of the infant. Moving the hands around the
areola allows compression of all sinuses and
completes removal of milk from the breast.
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5. Suggest appropriate bra for supporting breasts.

6. Begins breast massage until milk produces

enough to satisfy the infants need:
6.1 The infant can sleep for 1 - 3 hours
6.2 For exclusive breastfeeding, urine output
of infant is about 6-8 times/day.
6.3 The infant will increase weight about 125
gm./day or observation of infants skin.
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 Insufficient breast milk supply

Engorged breast
- Hot compression
- Expression of breast milk

Crack or Fissure in nipple

Short, flat, or inverted nipple
Inhibition of breast milk
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Causes:
- Delayed initiated breastfeeding, seldom
suckling, and incorrect suckling.
- Supplementing with other foods or drink.
- Maternal malnutrition.
- Postpartum hemorrhage and/ or postpartum
infection.
- Medications (oral pill).
- Lack of confidence in breastfeeding.
- Undesired breastfeeding.
- Maternal stress and anxiety.
- Fatigue or insufficient rest.
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Problem solving:

- Increase frequency & duration of suckling on demand.

- Correct suckling for mothers and infants position.
- Mental support mother for physical and mental
relaxing
- Encourage confidence & support breastfeeding.
- Encourage hot compresses and breast massage to
promote let-down reflex
- Using lact-aid nursing.
- Suggest mother get adequate foods & drink.
- Suggest mother get adequate rest.
- Prevent hemorrhage and infection
- Consult physician before taking any medications.

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Causes: 2 phases:
1. Early engorged breast, vascular or lymph congestion.
2. Late engorged breast, accumulation of milk.
This could be cause by delayed initiation, seldom suckling/ incorrect suckling.
Signs and symptoms:
Enlarged, warm, heavy in weight, tight, red or
visible vascular under the breast, tender, fever
milk when, and in some cases, axillaries lymph Normal suckling Infant suckling on
nodes are enlarged.
engorged breast
When mother experiences breast engorgement, the areola is tight and the
nipple is flat, making it difficult for the infant to latch-on. Mother may also feel
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extreme pain if the root of problem is not solved or breast milk is not drained.

Prevention:
1. Suggest mother to breastfed frequently,
every 1-2 hours or 10-12 times a day during a
few days after birth, then every 2-3 hours or
10 times a day.
The infant should be breastfed on both
breasts and after breast milk is wellestablished on demand. If the infant cannot
suck, the mother should express breast milk.
2. Exclusive breastfeeding; no
supplementing foods or drink.
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Problem solving
Early engorged breast
1. Remind the mother this is normal & will disappear
within a few days.
2. Encourage infant to feed on schedule with correct
suckling until milk is finish or breast is soft.
3. Before breastfeeding, mother should apply hot
compresses to the breast since.
4. Breast massage in order to soften breast and nipple.
5. If mother feels extreme pain during feeding, medicine
can be given to relieve pain.
6. Suggest mother to wear appropriate bra.
7. If mother does not feel better within 24 hours, she
should consult with her physician.
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Late engorged breast

1. Encourage the infant to suck frequently
and correctly.
2. After breastfeeding, mother should
express breast milk by hands or electric
breast pump, in order to relieve pain from
breast and enhance milk production.
3. Suggest mother to wear suitable bra for
support.

Electronic Pump
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Objective: Promote pain relief during milk production.

Procedure:
1. Position mother in a comfortable sitting.
4. Help mother remove her blouse and place it
under her axillaries.
5. Use a big towel to cover mothers lap to
prevent from getting wet.

6. Place a towel in warm water; wrings and compresses mothers breast slight rolling.
7. Re-dip towel in warm water and repeat until mother feels comfortable.
8. Wipe nipple dry. Encourage mother to wear a well-fitting bra.
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Objectives:
1. Relieve engorged breast pain.
2. Stimulate regular and continued milk production for infant feeding
especially LBW infants whose hospital stay is long.
3. Collect milk for hospitalized infant or during outside work.
4. Stimulate the milk glands.

Procedure:
1. Wash hands before expressing milk.
2. Remove her blouse and place it under her axillaries.
3. Use large towel to cover mothers lap to prevent her from
getting wet.
4. Hot compress & Breast massage.

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Procedure (Cont.):
5. If mother does not desire to collect breast
milk, she can express milk into the
kidney bowl. 6. If mother would like to keep breast milk for infant,
mother should clean the nipple with a wet cotton,
then, squeezing milk for 2-3 times before start to
collect milk and next, squeezing milk through the
milk container (bottle).
While expressing milk, the mother should slightly bend
her body down so that the milk will flow into the container.
The mothers breast should not touch the bottle. Once the
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bottle is filled, it should be stored in the refrigerator or in

Procedure:
1. Wash hands before breast pump.
2. Remove her blouse and place it under her axillaries.
3. Use a large towel to cover mothers lap for prevents
mother to get wet.
4.1 Mother uses unskilled hand to support breast, wellfitted covering the flange over the areola, a
collecting chamber is under. Slight squeeze a bulb
as creating a vacuum and gentle releasing it, then
milk flows to a collecting glass-chamber. Next,
move a rubber bulb pump carefully and pours milk
to the container.

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4.2 Like hand breast pump, mother uses unskilled hand to

support breast, well-fitted covering the flange over the
areola, a collecting chamber is under. Then, milk flows
to a collecting glass-chamber by electric mechanism.
Repeat expression until clear both side breast pump.
5. Storage in freezer.
6. Feeding breast milk via cup

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Causes:
1. Incorrect position/ breast engorgement: tight and flat
areola, infant is able to suck only the nipple instead of
areola.
Lactation is decreased so as to cause the infant sucks
vigorously, accordingly increasing inflammation.
2. Mother does not break the suction before removing
the infant from the breast.
3. Incorrect nipple cleaning such as rubbing vigorously
while bathing or using soap to clean the nipples.
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Preventions:
1. Correct breastfeeding positioning, lubricate the nipple by
mother slight squeezes the breast and applies breast milk to the
nipple. Open the infants mouth wide before latching on, well-fit
hold during breastfeeding by chin-breast.
If mother feels nipple pain after 1-2 minutes of sucking,
remove the infant from the breast and try to latch on once again.
2. Do not drag the nipple from the infants mouth while infant is sucking.
3. Clean the nipples no more than twice a day.
4. Breastfeed frequently or follow infants demand in order to engorged
breast, and then infant strongly suckling.
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Problem solving:
1. Evaluate breastfeeding position of mother, breast and areola engorgement.
2. Feed on the less-sore breast first.

3. Gently massage the sore nipple before

feeding & Express a little milk by hand in
order to help the infant to latch-on well.
4. Suggest mother to hold the infant in a
comfort position & alternate positions of
feeding to prevent repeated suckling
point.

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5. Correctly remove the infant from the breast & expresses

hind milk to the nipple for enhancing wound healing.
Air-dry nipples ~ 10-15 min. before wearing a bra.
6. Cracked or bleeding, stop sucking on that side for 24-36
hour; expressing milk by hand, and temporarily feed
using spoon or cup.
7. If the wound is not better, dry wound using a 20 Watt
light 1218 inches away from the nipple for 10
minutes, 2-3 times a day or using a hair dryer 6-8
inches away from the nipple.
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Problem solving:
1. Assure mother that her infant is able to suck. Infant
may not adequately grasp the areola early on. If mother
is patient and trains the infant to suck frequently, within
1-2 weeks the areola will become more elastic and the
infant can grasp the areola properly.
2. Mother should pull the nipple before breastfeeding by one of these methods
2.2 Nipple puller
including: 2.1 Hoffmans maneuver

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Problem solving (Cont.):

3. Assist the mother to correctly position the infant.
4. Mother supports the breast and then compresses hand
around the lateral margin of the areola in order to reduce
the areola size for ease of latching-on.
5. In case of extreme breast engorgement, compressing
with warm water & then express a little milk to soften
areola in order that infant will latch on well.
6. In case the nipple does not erect, suggest that the
mother use a nipple shield, which is made of thin rubber
to help the infant breastfeed.

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Problem solving (Cont.):

7. Apply Lact-aid-nursing by using formula
supplementation during breastfeeding.

8. In case the nipple shield does not work, suggest mother to

express milk and cup-feeding.
9. After the infant is satisfied, suggest mother to cover nipple
with a breast cup by gently inserting the nipple through the
hole, then rotate the air-hold to the top and the base of a
breast cup presses on areola then the nipple is everted.

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Indicators:
1. Infant death.
2. Infant with congenital defect or illness, premature
labor, cleft lip or palate, and abnormal GI system.
3. Infant has allergy to mothers milk.
4. Mother has HIV infection, heart, pulmonary
disease, or other disease.
5. Mother receives medication that can transport
through breast milk.
6. Mother has intensive mastitis.
7. Mother has psychological or neurological problem.

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Procedure:
1. Suggest mother to wear a supportive

bra.
2. Do not express, suck, pump or massage
the breast as this will encourage
engorgement.
3. Do not place heat compress on breasts
as it will stimulate vasodilatation and
milk glands to produce milk and

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References
Lowdermilk, D.L., Perry, S.E., & Piotrowski, K.A. (Eds.). (2004).
Maternity & Womens Health Care (8th Ed.). St.Louis: Mosby.
Pillitteri, A. (2003). Maternal & Child Health Nursing: Care of the
childbearing & childrearing family (4th Ed.). Philadelphia:
Lippincott Williams & Wilkins.
Reeder, S.J., Martin, L.L., Koniak-Griffin, D. (1997). Maternity
Nursing (18th Ed.). New York: Lippincott.
Varney, H. (1997). Varneys Midwifery (3rd Ed.). Sudbury, MA:
Jones and Bartlett Publishers.

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Question & Answer

Thank You for Your Attention

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