9/11/2017

Human Milk & Breastfeeding

Diane Lynn Spatz, PhD, RN-BC, FAAN

Professor of Perinatal Nursing &
Helen M. Shearer Professor of Nutrition
University of Pennsylvania School of Nursing
Nurse Researcher & Director of the Lactation Program
The Children's Hospital of Philadelphia (CHOP)
Clinical Coordinator of CHOP’s Mothers’ Milk Bank

Clinician Educator Role

• University of Pennsylvania-mentor & teach BSN, MSN & PhD students
• N361-Case Study-every fall & spring (except Spring 2019)
• The Children’s Hospital of Philadelphia-oversee all lactation &
breastfeeding activities

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Lancet 2016 Series

• The deaths of 823,000 children and 20,000
mothers each year could be averted
through universal breastfeeding, along
with economic savings of US$300 billion

Lancet 2016 Series

• Not breastfeeding is associated with lower
intelligence & economic losses of about
$302 billion annually or 0.49% of world
gross national income

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World Health Organization

• WHO states all infants need exclusive human milk feeds for 6
months-yet < 40% of infants actually are!

Formula Marketing is
Pervasive
• Thailand • Germany

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Lancet 2016 Series

• The retail value of formula industry is projected
to reach US $70.6 billion by 2019

Not Breastfeeding Costs $$$$

• $578 million per year in federal
funds is spent by WIC to purchase
Worldwide
infant formula < 40% infants receive
• $2 billion per year is spent by exclusive human milk
for 6 months
families on infant formula
• Annual health care costs may be
reduced by a minimum of $3
billion

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Health Disparities
• Across racial/ethnic groups
• Initiation rates
• White = 84.3%
• Hispanic = 83.0%
• Black = 66.3%

• Poverty ratio
• Highest ratio = 91.7%
• Lowest ration = 72.8%

• Role of WIC
• Ineligible = 91.1%
• Not in WIC but Eligible = 82.0%
• WIC enrolled = 74.1%

Journal of Perinatal and Neonatal Nursing (2004)

18(4), 412-423.

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Ten Steps for Promoting/Protecting

Breastfeeding in the Vulnerable
Infant
• Step 1: Informed • Step 6: Non-nutritive
decision sucking
• Step 2: Establishment & • Step 7: Transition to
maintenance of milk breast
supply • Step 8: Measuring milk
• Step 3: Human milk transfer
management • Step 9: Preparation for
• Step 4: Feeding the discharge
infant the milk • Step 10: Appropriate
• Step 5: Skin-to-skin care follow-up

*10 years of published outcomes from CHOP & other institutions worldwide

Spatz 10 Steps at TGH

• Increase in number of
mothers pumping < 6
hours post-delivery
• Increase in patient
satisfaction
• Increase in # of infants
receiving human milk as
first feed
• Human milk at discharge
rate increase 3 fold!
Note: all were statistically significant findings!

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How do families make

decisions?
• How did you come to the decision of how to
feed your baby?

• Mothers and their families may know that

breastfeeding is “good” but do they really know
HOW human milk works and WHY exclusivity of
breastfeeding matters?

• How many women know what formula is?

• How many women think their babies need formula

in addition to breastfeeding?

Top Ten Reasons Why Women

Don’t Want to Breastfeed
• #1O: I was raised on formula and I turned out fine
• #9: I want my partner to bond with my baby too
• #8: I don’t want my boobs to sag
• #7: I don’t want the baby on my breast
• #6: I have to go back to work
• #5: I don’t want to have to follow a special diet
• #4: My breasts are too small (or too big)
• #3: I don’t want to do it in public
• #2: I can get formula for free from WIC
• #1: It hurts to breastfeed

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Lee et al, (2009)

Social Sciences Quarterly

FAMILY SUPPORT-HOW DOES

MOTHER DEFINE HER FAMILY?

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Heterosexual Couples When

Male Partner is Involved
• Research
demonstrates that
the single most
influential family
member is the father Dads, If I could, I would
of baby http://www.projectbreastfeeding.com
/
• So where should
interventions be
targeted

Two Female Partners

• Partner who is
pregnant is
predominant
breastfeeding
mother

• Does other mother

want to induce
lactation?
• Hard work!

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Two Male Partners

• No substantive peer-
reviewed published
manuscripts that
men can lactate

• Should they be given

information about
accessing human
milk if they adopt an
infant?

Transgender Men
• If breasts are present-can
breastfeed
• Preferred terminology
“chest feeding”

• Wolfe-Roubatis, E. &
Spatz, D. L. (2015).
Transgender Men &
Lactation: What nurses
need to know. The
American Journal of
Maternal Child
Nursing,40(1): 32-38. doi:
10.1097/NMC.000000000
0000097.

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Other Support
• Paternal and maternal
grandmother

• Other family members

• Friends, co-workers,
school mates

• The environment!

Many women do not initiate

breastfeeding due to
culture, lack of family
support, lack of education &
exposure to breastfeeding

STEP 1: INFORMED DECISION

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CHOP Rates
 99% pumping initiation
 Over 86% discharged on human milk
Mean/median duration 8 months (range
0.25 to 30 months)
Statistically significant higher exclusive
breastfeeding rates at 3 months and 6
months compared to state & national
averages
Martino, K., Wagner, M., Froh, E. B., Hanlon, A. L., & Spatz, D. L. (2015). Post
discharge breastfeeding outcomes of infants with complex anomalies that require
surgery. Journal of Obstetric, Gynecologic, and Neonatal Nursing: Journal of
Obstetric, Gynecologic, and Neonatal Nursing, 44(3), 450-457. doi:10.1111/1552-
6909.12568

TEACHING FAMILIES THE SCIENCE OF

HUMAN MILK & BREASTFEEDING

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Top 5 Reasons
Human Milk=Medical Intervention

• Protection from infection

• NEC
• Feed tolerance
• Brain development & developmental
outcomes
• Protection from both short & long term
health illnesses

Protection from Infectious Processes

• Decreased incidence and
severity of:
• RSV
• Respiratory infections
• 72 % reduction!
• Gastroenteritis & diarrhea
• 64% reduction!
• Ear infections
• 23-50% reduction!
• Urinary tract infections

• AAP 2102, Lancet 2016

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Human Milk is Powerful!

• Vicky Greene-first year
biosciences student at
South Devon College in
Paignton, England plated
bacteria M. Luteus, E.
Coli, & MRSA
• http://www.scarymommy.
com/viral-picture-breast-
milk-petri-dish-bacteria/

Brain Development &

Neurodevelopmental Outcomes
• Human milk results in more white matter development
• Improved scores on tests of neurodevelopmental outcomes

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HUMAN MILK INFLUENCES HEALTH

IN ADULTHOOD

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Human Milk Influences

Our Health into Adulthood

• Reduction in Type 1 and

Type 2 Diabetes
• Reduction in overweight
and obesity
• Potential less
cardiovascular risk
• Lower blood pressure
• Lower cholesterol

Heart Function
• Preterm-born individuals fed exclusively human milk as infants
had increased left and right ventricular end-diastolic volume
index (+9.73%, P = .04 and +18.2%, P < .001) and stroke volume
index (+9.79%, P = .05 and +22.1%, P = .01) compared with
preterm-born individuals who were exclusively formula fed as
infants.

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Protection into Adulthood

• Reduction in Obesity
• For every extra week that the child was breastfed, the
likelihood of the child being obese at age 2 declined by 0.82%
[95% CI -1.8% to 0.1%]
• For every extra week that the child was exclusively breastfed,
the likelihood of being obese declined by 0.66% [95% CI -1.4
to 0.06%]

Top 7 Components of Human Milk

• Human milk oligosaccharides
• Antibodies
• Anti-oxidants
• Lactoferrin
• Osteopontin
• White blood cells
• Stem cells

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Human Milk Oligosaccharides

• One liter of mature human milk contains 10-15
grams!
• Cow’s milk has <0.05 grams!

• Over 200 different ones

• Pre-biotic = promotes the growth of beneficial

microorganisms in the intestines

• Anti-microbial

• http://www.bodelab.com/

Human Milk Oligosacchrides

• Pro-biotic = a substance that stimulates the growth
of microorganisms, especially those with beneficial
properties (such as those of the intestinal flora)
• Promote growth of bifidus in gut
• Increase acidity of gut/decrease pathogens
• Resistant to low pH and intestinal enzymes
• Can find in urine and feces and in systemic
circulation!

• http://www.bodelab.com/

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Protein in Human Milk

• Lactoferrin
• Immunomodulation
• Anti-bacterial
• Iron absorption
• Prebiotic activity
• Growth stimulating activity

*Bo Lonnerdal’s research

Osteopontin (OPN)
• 138 mg/Liter of human milk
• Only 18 mg/L in bovine & only 9 mg/L in formula
• OPN can be internalized into human intestinal
epithelial cells

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The Power of Pumping!

• http://www.chop.edu/service/breastfeeding-and-
lactation/home.html

Power of Pumping

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CHANGING HOW WE MESSAGE HUMAN

MILK & BREASTFEEDING TO FAMILIES

Personal Breastfeeding Goals

versus Breastfeeding Success
• What does term • Based on the dose
“success” mean? dependent response
of human milk-help
mothers and their
families set short-
term, mid-term, and
long-term goals for
the provision of
human milk &
breastfeeding

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Is Breastfeeding Always
“Natural”?
• Do we do women a
disservice by how
breastfeeding is
promoted?

• Women may face

challenges-it is our
job to help them
know how to work
through them!

Maybe the Message

Needs to be Changed?
• Research demonstrates
that if women and their
families understand
why & how human
milk/breastfeeding is
essential and empower
them to do so –women
are more likely to
persevere through any
breastfeeding
challenges

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Key Hormones of Lactation

 Estrogen and progesterone and human placental
lactogen rapidly decrease following the delivery of the
placenta

 Prolactin
 Stimulates milk production
 Responsible for milk biosynthesis
 Oxytocin
 Stimulates milk ejection
 Causes uterine contractions

Lactogenesis I
• Begins at 16 weeks of
pregnancy
• Delivery of placenta;
Day 0 to about Day 4

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Breastfeeding after Cesarean!

• Baby can go to breast
even in operating
room!

Milk Volume Colostrum

• During days 0-4, only small amounts of colostrum are
expected to be produced
• Infants on average only consume 15 + 11 grams during
first 24 hours
• Per feed intake is only 1.5 + 1.1 grams

• Critical role of colostrum

• Save it ALL!

Santoro and colleagues (2010) Pediatrics; 156:29-21

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Milk Volume & Stomach Sizes

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Give me Two Weeks!!

• Moms only job should be to
eat, sleep, and breastfeed
(or pump)

• Critically window of
opportunity

• Turning on prolactin
receptor sites!

• First two weeks-set mom

up for rest of breastfeeding
experience!

Milk Volume-Mature Milk

• By day 5
• >500 mls/24 hours
• During first 6 months
• Range 440-1220 mls/24 hours
• R vs. L

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Teach Me How to Breastfeed

RISK FACTORS FOR LACTATION

CHALLENGES

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Milk Supply Woes!

Delay Lactogenesis II Low Milk Supply
• Primigravida • Breast surgery
• Obesity • Reduction
• Diabetes/GDM • Augmentation through
• PIH/Pre- nipple
eclampsia/Magnesium • Glandular hypoplasia
Sulfate
• PCOS (?) • Delayed or infrequent
• Infertility (?) pumping or
• Antenatal exposure to breastfeeding in first
steroids week!

Supplementation Woes!
• Jaundice • Get mother
• Hypoglycemia pumping!
• Weight loss
• Supplement in
smallest amounts

• Lots of skin to skin!

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Neonatal Weight Loss due to IV

Fluid Exposure in L&D
◦ Noel-Weiss, et al. (2011) International Breastfeeding
Journal
 At 72 hours, there was a positive correlation between
grams of weight lost and all maternal fluids (p =
0.007).
◦ Chantry & colleagues (2011) Excess weight loss in
first-born breastfed newborns relates to maternal
intrapartum fluid balance Pediatrics
 Excessive fluid exposure associated with excessive
infant weight loss!
 200 mls/hour or 100-200 mls/hour compared to
<100 mls/hour

In Birth Hospital
• Skin to skin
• Keep mom and baby
together 24 hours day
• Start mom’s pumping!
• Monitor stool output
• Urine output-late
indicator
• Supplement
• Preferably with donor
milk

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Appropriate Supplementation
Why not use donor milk?

Mother/Infant Lactation
Strategies
• Optimize maternal milk making capacity
• Consider medication to optimize Prolactin levels
• Rent hospital grade breast pump
• Baby Weigh Scale to measure milk transfer
• Ensure that mother is breastfeeding/pumping during
the night with no more than one 5 hour stretch
• Goal is 8 or more breastfeeding/pumping sessions per
24 hour period!

• *Key message-any amount of milk that mother can provide is

valuable & irreplaceable!

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PUMPING FOR MATERNAL INFANT

SEPARATION &
RETURN TO WORK OR SCHOOL

Randomized Control Trial!

• Parker, L.A., Sullivan, S., Krueger, C., Kelechi, T., &
Mueller, M.M. (2012). Effect of Early Breast Milk
Expression on Milk Volume and Timing of Lactogenesis
Stage II Among Mothers of Very Low Birth Weight
Infants: A Pilot Study. Journal of Perinatology. 32(3):205-
9
• Mothers who pumped within 1 hour had (compared to mothers
who pumped within 6 hours):
• Significantly more milk during the first 7 days (P=0.05)
• Significantly more milk at week 3 (P=0.01)
• Significantly earlier lactogenesis stage II (P=0.03).

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Manual Expression will Not

Provide Adequate Vacuum to
Establish Normal Milk Volume
• Geddes, D. T. and colleagues (2008) in Early Human
Development
• Peak vacuum (-145 + 58 mmHg) occurred with the tongue was at the
lowest position
• Milk flow through the milk ductules was observed at this time

• Vacuum is likely KEY for milk removal

• Hands only techniques will not result in

adequate suction vacuum to establish
full milk volume

Normal Milk Supply

• Mothers who breastfed term infants on demand
produced 556-705 mls/24 hour period of milk
by day 6
• The normal range of milk production is 440-1220
mls/24 hour period is maintained until 6 months
of lactation
• Average 750-800 mls

Kent, Mitoulas, Cregan, Ramsay, Doherty, Hartmann (2006) Pediatrics

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Milk Production is Vital!

• Hill & Aldag (2005). Milk volume on day 4 predictive of lactation
adequacy at 6 weeks for mothers of non-nursing preterm infants.
Journal of Perinatal & Neonatal Nursing: 19(3): 273-82

• Milk volume & frequency of expression

on day 4 are significant predictors of
milk supply at 6 weeks

• Production of less than 500 mls/day by

end of week 2 = less than adequate milk
production long term

CHOP Parameters for Pumping

• Pump is at bedside

• Mother initiates expression of milk immediately

post delivery
• Instruct mother to pump for goal of 8
pumps/24 hours in order to establish
milk supply
• Initiation technology® used for all mothers
regardless of infant’s gestational age at birth

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Return to Work or School

• Pump at least 2 weeks prior to return date
• Morning sessions best time to pump
• High quality –double electric pump
• Hospital grade pump increases efficiency and decreases
time spent pumping
• $65 per month x 12 months = $780 per year
• Part-time versus full-time and/or flexible work hours

• Pumping & breastfeeding during night are essential to

sustain supply

WHY DONOR MILK?

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Donor Milk Position Statement

• Details out both for-
profit and non-profit
(HMBANA) milk
banks
• Major focus on the
safety and history of
HMBANA milk banks
• Extensive screening &
maternal serological
testing
• Holder pasteurization
& post-pasteurization
milk cultures

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Donor Milk Position Statement

• Donor milk is not a
replacement to
mom’s own milk but
a bridge
• Discusses priority for
VLBW infants & that
donor milk may be
indicated in other
populations (GI,
surgical)

Donor Milk Position Statement

• No clear indications
of when to wean
from donor milk

• Money should not

barrier to use of
donor milk

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Donor Milk Position Statement

• Informal milk sharing
discussed
• Commerce driven
versus commerce-free
is different
• Don’t buy milk on
internet

• What is a family
cannot access
pasteurized donor
human milk?

Donor Milk = Satisfaction

10/30/15-CHOP
officially became the
18th HMBANA milk bank
in the United States!

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Resources
• CHOP’s website
• http://www.chop.edu/service/breastfeeding-and-
lactation/home.html

• Department of Women’s Health

• http://www.womenshealth.gov/breastfeeding/

Resources
• United States Breastfeeding Committee
• http://www.usbreastfeeding.org/

• Centers for Disease Control breastfeeding data

• http://www.cdc.gov/breastfeeding/

• Mother to Baby –a service of the non-profit Organization of

Teratology Information Specialists, is dedicated to providing
evidence-based information about medications and other
exposures during pregnancy and while breastfeeding
• http://mothertobaby.org/

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Pennsylvania Breastfeeding
• Pennsylvania Department of Health
• http://www.health.pa.gov/My%20Health/Womens%20Health
/Breastfeeding%20Awareness/Pages/default.aspx#.Vo_ShPkrK
01

• CHOP is ranked #1 in the state for breastfeeding initiation

rates!

Breastfeeding in Philadelphia
• Philadelphia Department of Health
• http://www.phila.gov/health/MCFH/BreastfeedingPromotion.
html

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Resources Specific to African

American/Black Women
• It’s Only Natural Campaign
• http://womenshealth.gov/itsonlynatural
• Mocha Moms
• http://www.mochamoms.org/
• Reaching Our Sisters Every Where
• http://www.breastfeedingrose.org/
• Black Mothers Breastfeeding Association
• http://blackmothersbreastfeeding.org/

Does it All Matter?

• 1995-2000
• My first NIH Grant!
• Used MSN prepared
nurses to improve
human milk &
breastfeeding for LBW
infants

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Thank You!
• To contact me:
spatz@nursing.upenn.edu

For more information:

http://www.aannet.org/edge-runners--10-
steps-to-promote-and-protect-human-milk

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