Happy Breastfeeding Awareness Month! This month, The DONA Doula Chronicles will provide doulas with a series of articles dedicated to breastfeeding so that we can better inform and support nursing mothers. Look for online resources for doulas and much more in the coming weeks. Today we share information on risk factors to successful breastfeeding and suggestions on how doulas can support nursing in those critical early hours and days from researcher, author and speaker, Barbara Wilson-Clay.
About the Author: 
Barbara Wilson-Clay has been a lactation consultant in private practice in Austin, Texas since 1987 specializing in difficult breastfeeding cases. Barbara helped found the Texas Chapter of Healthy Mothers/Healthy Babies, the Texas Breastfeeding Coalition and the non-profit Mothers Milk Bank at Austin.She has been a La Leche League Leader since 1981.Barbara’s research and com mentaries have appeared in The Journal of Human Lactation, Current Issues in Clinical Lactation, Birth Issues, Breastfeeding Abstracts, The International Breastfeeding Journal, the ICEA Journal, and Archives of Disease in Childhood. She participates on the editorial review boards of several professional journals. She has served as the ICLA representative to the International Board of Lactation Consultant Examiners(IBLCE) where she sat on the Ethics and the Exam committees. A clinical photographer as well as an LC and lecturer, Barbara is (with Kay Hoover) the author of the internationally acclaimed text book, The Breastfeeding Atlas, now in its 5th edition.
Doula Support for Early Breastfeeding
Doula care is one of the most impactful ways that birth outcomes can be improved. The role of the doula in early breastfeeding support can also help women reach their goals of a satisfying and successful transition to motherhood. And yet, many doulas may not be aware of new and important research into risk assessment for mothers and babies for whom early breastfeeding does not go smoothly.
In the past two decades, research has identified a number of maternal and infant factors that may contribute to delays in breastfeeding being well-established. These include for mothers: long, difficult labor, instrument assisted delivery, cesarean section, postpartum hypertension (swelling of limbs), thyroid disorders, diabetes or insulin resistance, obesity, excessive blood loss/anemia, infection, retained placental fragments, previous breast surgery or unusual breast development, and challenging nipple configurations (flat, inverted, large, long).
For the infant the clearly identified risk factors are: premature (including late preterm) birth, small for gestational age infant, birth injury, congenital deformity, tongue-tie, conditions that impact muscle tone, syndromic conditions (Down’s, etc.), receding chin, illness, compromised respiratory function, multiple births, and early separation from the mother.
How can the doula assist when these risk factors are present? First, reassure families that there is no “sell by” date on breastfeeding. Many babies take a while to breastfeed well and will go on to enjoy months and years of normal breastfeeding. But to protect that option, there are three important rules to follow:
Feed the Baby: A weak or starving baby cannot effectively remove milk from the breast. If milk is not removed, supply will quickly down-regulate. Many early problems are simply outgrown, so ensuring calories to the baby is critical. The safest milk is mother’s own, so it may be necessary to express milk to feed to the baby until things stabilize. Colostrum can be easily spoon fed to newborns to help maintain blood sugar levels and to help the baby begin to pass meconium and avoid jaundice.
Protect the Milk Supply: Calibration of a full milk supply is time sensitive. If a mother waits two to three weeks to begin expressing, she may never regain a full supply. In the presence of known risk factors, the most current research indicates it is best to begin hand-expressing colostrum within the first hour. If colostrum remains in the breast longer than three hours, it signals the brain to reduce production. It is especially critical to ensure that the breast is well emptied during engorgement. A combination of eight pumping and hand expressions within each 24 hour period gives the best milk volumes and provides an insurance policy that the mother will have a good supply when the baby is being transitioned back to at breast feedings.
Protect Breast Focus: Skin-to-skin holding (kangaroo care) lowers infant and maternal stress hormones, protects infant body temperature, and increases beneficial milk producing and releasing hormones, and ensures that the infant has time to practice at the breast. These practice sessions may be very brief if the infant is very small or weak, but the eventual transition to full breastfeeding is made easier if the infant maintains this proximity to the breast. Encourage the mother to be patient and to have reasonable expectations as the risk factors are systematically managed and things stabilize.
Evidence Based Resources on Breastfeeding for Doulas:
Academy of Breastfeeding Medicine (ABM). ABM Protocol Committee. ABM Clinical Protocol #22: Guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35 weeks’ gestation. Breastfeeding Medicine 2010; 5(2):87-93.Agnostoni C. Small-for-gestational-age infants need dietary quality more than quantity for their development: The role of human milk. Acta Paediatrica 2005; 94(7):827-829.
Bonuck K, Stuebe A, Barnett J, et al. Effect of primary care intervention on breastfeeding duration and intensity. Am J Pub Health, Dec. 19, 2013.
Brownell E, Howard CR, Lawrence RA, et al. Delayed onset lactogenesis II predicts the cessation of any or exclusive breastfeeding. J Pediatrics 2012; 161(4):608-614.
Buckley KM, Charles GE. Benefits and challenges of transitioning preterm infants to at-breast feedings. International Breastfeeding Journal 2006; 1:13. Online.Caughey A, Sandberg P, Zlatnik M, et al. Forceps compared with vacuum: rates of neonatal and maternal morbidity. Obstetrics & Gynecology 2005; 106(5 Pt 1):908-912.
Chapman D, Perez-Escamilla: Identification of risk factors for delayed onset of lactation, Journal of the American Dietetic Association 1999, 99(4):450-54.
Chen D, Nommsen-Rivers L, Dewey K. Stress during labor and delivery and early lactation performance. American Journal of Clinical Nutrition 1998; 68(2):335-344.
Dewey K, Nommson-Rivers L, Heinig M, et al. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics 2003; 112(3):607-619.
Evans KC, Evans RG, Royal R, et al. Effect of caesarean section on breast milk transfer to the normal term newborn over the first week of life. Arch Dis Child Fetal Neonatal Ed 2003; 88(5):F380-382.
Hall R, Mercer A, Teasley S, et al: A breast-feeding assessment score to evaluate the risk for cessation of breast-feeding by 7 to 10 days of age, Journal of Pediatrics 2002; 141:659-64.
Hilson J, Rasmussen K, Kjolhede,C: High Prepregnant Body Mass Index is Associated with Poor Lactation Outcomes Among White, Rural Women Independent of Psychosocial and Demographic Correlates, Journal of Human Lactation 2004; 20(1):18-29.
Huggins, K, Petok,E, and Mireles,O: Markers of Lactation Insufficiency, in Current Issues in Clinical Lactation 2000, ed. K. Auerbach, Pg 25-35.
Humenick S and Hill P: Breast engorgement: patterns and selected outcomes, Journal of Human Lactation 1994, 10(2):79-86.
Hummel P, Fortado D. Impacting infant head shapes. Advances in Neonatal Care 2005; 5(6):329-340.
Hurst N: Lactation After Augmentation Mammoplasty, Obstetrics & Gynecology 1996, 87(1):30-34.
Issler R, Wilson-Clay B. Slow weight gain and failure to thrive. in Core Curriculum for Lactation Consultants, ed. R. Mannel, P Martins, M Walker. Burlington, MA: Jones and Bartlett Learning. 2013. pg. 849-865.
Kramer M, Demissie K, Yang H, , et al: The Contribution of Mild and Moderate Preterm Birth to Infant Mortality, Journal of the American Medical Association 2000, 284:843-849.
Lawrence RA, Lawrence RM. Breastfeeding: a guide for the medical profession (7th ed). Philadelphia, PAL Elsevier Mosby, 2011. pp. 343, 346-347, 492, 542-543.
Mannel R. Defining lactation acuity to improve patient safety and outcomes. Journal of Human Lactation 2011; 27(2):163-170.
Mejiri A, Dorval VG, Nuyt AM, et al. Hypoglycemia in term newborns with a birth weight below the 10th percentile. Paediatr Child Health 2010; 15(5):271-275.
Morton J, Hall J, Wong RJ, et al. Combining hand techniques electric pumping increases milk production in mothers of preterm infants. Journal of Perinatology 2009; 87(11):757-764.
Morton J, Hall J, Wong RJ, et al. Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants. Journal of Perinatology 2012; 32(10):791-796.
Parker L, Sullivan S, Krueger C, et al. 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 2012; 32(3):205-209.
Peitsch W, Keefer C, La Brie R, et al: Incidence of Cranial Asymmetry in Healthy Newborns, Pediatrics 2002, 110(6):e72.
Pressler JL, LaMontagne LL, Hepworth JT, et al: Behaviors of macrosomic newborns compared to nonmacrosomic newborns: effect of delivery by cesarean section. Journal of Neonatal Nursing. 2001;7:106-164.
Walls V, Glass R: Mandibular Asymmetry and Breastfeeding Problems: Experience from 11 cases, Journal of Human Lactation 2006; 22(3):328-334.
Wilson-Clay B, Hoover K. The Breastfeeding Atlas (5th ed). Manchaca, Tx: Lactnews Press. 2013.
Wilson-Clay B, Maloney B: A Reporting Tool to Facilitate Community-Based Follow-up for At-risk Breastfeeding Dyads at Hospital Discharge, in Current Issues in Clin Lact 2002, ed.K. Auerbach, Jones and Bartlett, Boston. Pg.59-66.