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Time for Primary Care Breastfeeding Support

case study medical education team-based lactation care Feb 27, 2023
Primary care doctor examining crying newborn baby with a stethoscope.

Imagine running 20 minutes behind in clinic, and your next patient is a 4-day-old breastfeeding infant here for their first outpatient visit.  Before walking into the room you glance at the baby’s weight and see they are 11% below birth weight.  What can you do in this 15 minute visit to support breastfeeding?

Dig a little deeper

You learn that breastfeeding was going well in the hospital, but since discharge the infant has been increasingly fussy, having trouble latching, and falling asleep at the breast. Mom is extremely engorged with painful breasts. On exam the baby is sleepy and jaundiced as well as 11% below birth weight. Otherwise the exam is normal.

In just a few minutes you have identified that milk is available and mom is engorged.  Because of the engorgement, the infant is having trouble latching and therefore not gaining, which is most likely contributing to worsening jaundice from inadequate intake.

Recognize breastfeeding support as a medical concern

Addressing weight loss and hyperbilirubinemia are not the only medical concerns. It is equally important for the baby’s long-term health to support breastfeeding. And, even better, your clinical support of breastfeeding addresses weight gain and jaundice concerns. You could instruct the parents to offer a 1 to 2-ounce bottle of formula after each feeding to address weight gain and jaundice, but that recommendation decreases milk supply and sabotages breastfeeding. Only one plan addresses all three medical concerns: the plan that supports breastfeeding. 

Know your limits

If you don’t feel comfortable providing breastfeeding support, you are not alone. As health care providers, we received limited breastfeeding education in our training. Choosing targeted CME can help. It is with this in mind that I created a course focused on primary care provider support in the first weeks postpartum. With a brief amount of education, you are on track to support families with focused counseling points and practical guidance. Families will appreciate you taking the time to learn more.

In the meantime, if you do not have the skills, share with families videos on latch, hand expression and breast massage; all are helpful resources for navigating early postpartum challenges. Also, developing relationships with and referring to local lactation professionals provides families with access to ongoing instruction on the practical skills. In the short term, if the baby is not latching, instruct the family to express milk and refeed for the next 24 hrs until they are seen.

Share some practical guidance

If you do feel comfortable providing practical breastfeeding support, this case study offers the opportunity for three practical areas of instruction: latch, hand expression, and/or engorgement management. Given the limited time, start with one skill, planning close follow-up for further instruction:

  1. Hand expression: Teaching hand expression as a first step helps in all three areas.  By reviewing hand expression, you help protect milk supply by expressing milk. Until the infant’s latch improves, hand expression ensures milk is available to be re-fed, which addresses weight gain. Additionally, hand expression softens the engorged nipple and areola, which often makes it easier for the infant to latch to an engorged breast.
  2. Latch: Briefly watching the latch and providing pointers on positioning, with the goal of resolving pain and ensuring a deeper latch, addresses weight gain and milk supply by facilitating improved milk removal. 
  3. Engorgement: Immediate pain relief is invaluable. Reviewing that cool compresses and gentle light touch massage toward the armpit helps decrease the pain of engorgement is immediately helpful.  You can always refer the family to our Therapeutic Breast Massage in Lactation video as a free educational intervention that takes moments to provide.

Providing practical guidance on a topic helps the family move forward with a personalized plan. And remember: even when time is limited, and prevents thorough instruction, your initial guidance demonstrates your commitment to breastfeeding as important and impacts breastfeeding outcomes.

Close Follow-up 

Planning close follow-up is critical. With 11% weight loss, the family will need to be seen the next day. If you have the training and time, schedule the family for a visit the next day when you have more time to problem solve and work through difficulties. If not, then refer them to a lactation professional in your community for additional help, or even better, provide team-based care at your office. Team-based LC/PCP care lets families know you prioritize breastfeeding, helps you remain connected, minimizes the number of appointments a family needs to coordinate, and facilitates communication. By working side by side with a lactation consultant, both of you continue to learn, expand your knowledge, and improve the breastfeeding support families receive.

Your support matters

The possibilities of support we can provide in a 15-minute visit are endless. In the brief visit we can identify the challenge, show our commitment to the family’s continued breastfeeding, educate on a breastfeeding supportive plan, and provide close follow-up. The choices we make as primary care providers during our visits can be the difference between a family continuing to breastfeed or not. 

Breastfeeding families need our support. You can do it!

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