Improving the Quality of Maternity Care in North Carolina:

The Role of Rooming-in in Breastfeeding Success:

Ten Steps 6, 7, and 8

Outline

• Anatomy and physiology of lactation

• Impact of disruption/support mediated by Steps 6, 7, and 8

• What do we do that creates barriers or provides support for rooming-in?

Skin-to-skin with Rooming-in:

Allows the normal physiological cascade to occur

• Any separation reduces mother/baby skill building as well as teaching opportunities

• Any separation reduces frequency of suckling• Any separation can lead to destructive and

unnecessary supplementation• Any separation increases the risks of hyperbili,

hypoglycemia, weight loss, engorgement, and other ‘disasters’ for the breastfeeding dyad

• Any separation may disrupt several of the Ten Steps• AND• Avoiding separations may mean change in current

practice norms and clinician behaviors.

CBI, 2009

ANATOMY

The Alveolus(Lawrence, p. 81)

Modified from Vorherr H: The Breast:

Morphology, Physiology and Lactation.

New York, Acadmeic Press. 1974.

Physiology: Complex Neuro-endocrine-Mammary - Ovarian/placental interaction

• Pregnancy– mammary tissue growth

during pregnancy

– needs prolactin

– Prolactin inhibitingfactor (PIF) fromhypothalamus,

• Birth– Milk present in third

trimester

– PIF stops secondary to catecholamines fromdopaminergicimpulses; mediated bydrop in progestins

• Lactogenesis– Mediated by oxytocin (let-

down/muscle contraction) and prolactin in the earlydays/weeks

– Oxytocin responsive to smell and touch of infant

– Prolactin responsive to suckling

– (Later, milk supplymediated primarily byemptying and FeedbackInhibitor of Lactation (FIL))

• Impact of Separation

DEMAND DRIVES SUPPLY

Fullness feeds back and inhibits lactationDelayed emptying and engorgement increase levels of FIL

(milk whey protein) that down-regulates PRL receptors.

Let Down

Latch

Moving Milk

TEN STEPS6. Give newborn infants no food or drink other

than breast milk unless medically indicated.7. Practice rooming-in:

allow mothers and infants to remain together 24 hours a day

8. Encourage unrestricted breastfeeding

Rooming in• Reduces risk of supplements

– Prelacteal feeds of any sort impact initiation, continuation • (Israel et al 1980, Nylander 1991)

– Supplements after discharge decreases duration • (Martines et al 1989, Perez-Escamilla)

– Supplement use increases illness

– Commercial samples if present tend to be used

• Supports

– Higher full breastfeeding rates

– Increased milk production • (Mapata et al 1988, Yamauchi 1990)

– Co-sleeping, which increases night feedings • (McKenna, Ball)

Is supplementation

the result of disruption of the

physiological cascade, or from

old standard practices?

Percent of U.S. breastfed children who consume infant formula

in addition to human milk

Source: CDC NIS 2011

Barriers and FacilitatorsBarriers

• Older nurses and physicians

• Staffing constraints

• Interference in mothers’ choices

• Increasing C/S rate

• Assumptions re: culture

• Lack of self efficacy among nurses

• Perceptions

• Nights: Staff practices

• Lack of BF skills among night nurses

• Visitors in L&D

• Pacifiers for “fussy” babies

• Not perceived as important learning time

Facilitators

• Growing desire for breastfeeding

• Management support for Ten Steps

• Medical and nursing staff recognize benefits of breastfeeding to health care and health system

• Including breastfeeding support in evaluation

• Hands on training in new practices and skills

Next: Identifying and overcoming the perceived barriers

In your teams:1. Discuss and ensure that all are on board with the

need to achieve rooming-in at least 22/24 hours, and preferably 24/24 -- Is there a comfort level with the mutual understand

anatomy and physiology, and how separation disrupts normal?

2. Discuss the current status of rooming-in, 24/7 in your facility-- Are you nearly there? Far from achieving it? Why?

3. List barriers and facilitators: Discuss how you might address each. -- Consider QI, staff evaluation, formula control measures,

policy and policy adherence, etc.

Normal breasts are functionaland are seen everywhere:

Help ensure that the baby can do its job!

Skin to skin and starting the first feed

Medianminutes after birth

6 Opening the eyes

11 Massage-like hand movement on mother’s breast12 Hand-to-mouth movement

21 Rooting movement

25 Hand to nipple27 Licking

80 Sucking

Matthiesen A-S, et al. Postpartum Maternal Oxytocin Release by Newborns: Effects of Infant Hand Massage and Sucking. Birth. 2001;28(1):13-19.

92%92%

80%

Sk

in t

o s

kin

Ro

uti

ne

95%

72%

Breastfeeding at discharge

Breastfeeding at 1-4 months

Breastfeeding at 12 months

Successful first feed

58%58%

46%

20%

0%

Bottom line: Mothers who held their infants skin-to-skin breastfed 43 days longer than mothers who did not.

Anderson GC, et al. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews. 2007;3.

Improved EBF in hospital after implementing the Baby-friendly Hospital Initiative

5.50%

33.50%

0%

5%

10%

15%

20%

25%

30%

35%

40%

1995 Hospital with minimal

lactation support

1999 Hospital designated as

Baby friendly

Perc

en

tag

e

Exclusive Breastfeeding Infants

Adapted from: Philipp BL, Merewood A, Miller LW et al. Baby-friendly Hospital Initiative improves breastfeeding initiation rates in a US hospital setting. Pediatrics, 2001, 108:677-681.

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