US Pharm. 2009;34(9):25-33.
The profession of pharmacy has effectively transitioned from a product-focused profession to one that emphasizes patient care.1-6 Patient trust, a broad professional knowledge base, convenient access, and services that frequently are free make pharmacists ideal confidants regarding health care issues that are considered uncomfortable or taboo. Breastfeeding mothers often approach pharmacists for counsel, not only concerning issues related to medication or devices and products, but also regarding the act of breastfeeding and its accompanying concerns and difficulties.7,8 In a survey of 47 pharmacists in Rhode Island, almost 50% reported getting inquiries about breastfeeding and medication safety on a weekly or daily basis, but 85% felt uncomfortable advising breastfeeding mothers.8
The pharmacy-school curriculum often includes information about the anatomy and physiology of the breast, appropriate medication use for breastfeeding mothers, and breastfeeding devices and products. Unfortunately, breastfeeding education for pharmacists rarely extends beyond these topics. Common deficits in patient counseling include 1) an understanding of mothers' common issues and concerns about breastfeeding and 2) knowledge about breastfeeding and techniques. This article describes important breastfeeding counseling tips and techniques for the pharmacist, in addition to common patient concerns and experiences with breastfeeding.
Understanding a New Mother's Concerns
A 70-item survey designed to provide insight into breastfeeding difficulties was administered to 164 mothers in a Midwestern urban community.9 The goals were to compare mothers' concerns and attitudes prior to breastfeeding with their actual experiences postchildbirth and to identify reasons for discontinuing breastfeeding. The population of mothers was stratified to include women of various ages, ethnicities, income levels, and educational levels who had given birth to at least one child or were expecting a child. TABLE 1 provides a ranking of mothers' top five concerns and experiences.
The most common concerns mothers had prior to breastfeeding, ranked in order of frequency, are as follows.9
1. Breastfeeding Will Be Painful: The number-one concern of mothers prior to breastfeeding--pain upon breastfeeding--is a reality. Mothers should be advised to expect varying levels of discomfort and to be aware that the pain should subside with time. New mothers may simply need encouragement to bear with the discomfort for the benefits to the child.
Begin by identifying the cause of the pain. Possible sources of pain may include improper latching onto the breast, thrush, mastitis, or breast engorgement.
Improper latching may be addressed by ensuring that the nipple is deep in the infant's mouth. The longer the baby is latched, the sorer the mother may become; therefore, the mother should consider feeding more frequently for shorter periods of time. If the pharmacist believes that the mother may have thrush or mastitis, she should be referred directly to a physician. Sudden, severe, or unexplainable pain in the breast of an experienced breastfeeding mother or chronic pain in the breast of a newborn's mother warrants a referral to a physician.10
Breast engorgement often is experienced between the second and fifth days of breastfeeding initiation. It occurs when milk production escalates, causing activity in the breast tissue and an increase of blood to the area. Also known as letdown, breast engorgement can cause swollen, hard, hot, and painful breasts. Applying a warm-water compress near the nipple prior to feeding or massaging the breast lightly while the infant is feeding may relieve the engorgement. If the breasts are swollen or edematous, cold packs between feedings may provide relief and reduce the swelling.11
Another recommendation to help alleviate sore nipples is to nurse first on the side that is less sore, since the baby will feed more vigorously on the first breast presented. Before the baby is removed from the breast, the mother should detach the infant from the nipple by using her finger to break the suction between the baby's tongue and the nipple; this will reduce nipple damage. Once feeding is completed, the nipple can be coated with breast milk and allowed to dry to provide a natural protectant for the sore breast. A breastfeeding mother also should allow the breast to dry and be exposed to air as much as possible. She may consider applying pure lanolin to relieve the soreness and moisturize the nipple. Finally, breast shells may be used to encase the nipple and prevent it from rubbing against the bra.11,12
2. I Won't Know How to Help My Baby Latch Onto My Breast: The infant often does not naturally attach to the breast in the correct position. Improper attachment can be a source of frustration to the mother and result in pain, underproduction or overproduction of breast milk, leaking, or engorgement. Proper attachment begins with positioning the infant in a way that allows him or her to access a sufficient expanse of nipple and breast. The infant's mouth should be wide open, with lips turned outward. A wide-open mouth can be achieved by tickling the infant's cheek or lips with the nipple or a finger. Unlike the teat of a bottle, the nipple does not contain milk; the baby's mouth must press behind the nipple to the milk sinuses to release milk from the breast. The infant should not be sucking for milk or chewing on the nipple; rather, he or she should suckle the breast, which is a deep, continuous motion indicated by the movement of the infant's ears. To ensure optimal attachment, the baby should be allowed to feed as soon as he or she shows signs of hunger.11 A lactation consultant can work with the mother to ensure that all elements are in place.
3. I Might Not Produce Enough Milk: Unrestricted breastfeeding is helpful for overcoming an insufficient milk supply. It is important to feed the infant at the first sign of hunger. Crying is the infant's final plea of desperation to eat. Oxytocin released from the posterior pituitary gland causes milk-producing cells to contract and eject milk. Anxiety or distress can lead to the inhibition of oxytocin release, causing the flow of milk to stop. Recommend that the new mother not rush breastfeeding and to breastfeed in a quiet, comfortable environment. Suggest that she talk to the infant as she feeds. Massaging the breast in a light circular motion may assist with relaxation and stimulate oxytocin release.11 A lactation consultant or physician may suggest alternative pharmacologic therapies.
4. Breastfeeding Will Be Inconvenient: Both breastfeeding and bottle-feeding require a time commitment. With formula-feeding, bottle preparation and constant care and cleaning of equipment are required; however, bottle-feeding provides opportunities for others to feed the infant. Although breastfeeding requires energy from the mother, some research indicates that it can be less physically exhausting than bottle-feeding and may reduce stress for both mother and infant.11 Breast milk is readily accessible and requires no preparation. Use of a breast pump provides some freedom and allows other people to feed the baby.11 Working mothers need access to a private, clean area to breastfeed. State regulations vary concerning breastfeeding in the workplace.13 Reassure the mother that, according to research, women who breastfeed miss fewer workdays to care for sick infants.14
5. I Would Be Embarrassed to Breastfeed: Embarrassment often stems from a mother's fear of leaking milk and the necessity of exposing the breast in order to breastfeed. Pharmacists should stock and recommend breast pads for the bra to manage leaking. In addition, the mother can halt the leaking by pressing her hand against the nipple for a minute or two.11 Patterned clothing helps lessen the visibility of spots.15 Mothers should be encouraged to feed their babies as often as possible. A mother should initially feed at least eight to 12 times in a 24-hour period; once feeding is established, she may reduce this to eight feedings in 24 hours.16 Nursing cover-ups that hook around the mother's neck and hang over the infant reduce breast exposure. Encourage social networking with other mothers to assist in overcoming fears and embarrassment.14
Tips for the Pharmacist
Be Prepared to Explain Why Breastfeeding Is Important to Both Baby's and Mother's Health: New mothers may not fully understand the benefits of breastfeeding. Breast milk confers immunity in the infant and changes its composition in accordance with the baby's nutritional needs.8,11,16,17 In 2007, the Agency for Healthcare Research and Quality published a summary of systematic reviews, meta-analyses, comparative trials, and prospective cohort and case-control studies on breastfeeding; maternal and infant health outcomes in developed countries were included as well. This summary found correlations between breastfed infants and reduced risks of otitis media, gastroenteritis, respiratory tract infection, dermatitis, asthma, obesity, diabetes, childhood leukemia, sudden infant death syndrome, and enterocolitis. Benefits to the mother included reduced risks of type 2 diabetes and breast and ovarian cancer.18 Breastfeeding has a lifelong effect on the health and wellbeing of both mother and child; during the first 4 months of life, however, only 1 in 3 infants is breastfed exclusively.19
Recognize That Breastfeeding Does Not Come Naturally to All New Mothers: Although breastfeeding seems natural, it is a learned art. Often, more than one observation of a feeding session by a lactation nurse is required to ensure that a mother is experiencing effective breastfeeding.14 Encourage the mother to trust in her own body and be confident that 99% of the breastfeeding problems she may experience can be resolved.11
New mothers often have preconceived ideas regarding breastfeeding. Some may be averse to breastfeeding because of a friend's or relative's negative experience; some may be in a contemplative stage; others may have a desire to breastfeed, but feel overwhelmed by the process. New mothers may also fear personal failure, possible lifestyle changes, or embarrassment, or they may have little to no support system. Pharmacists should actively ascertain the mother's attitudes and concerns. Ask open-ended questions such as, "What do you think about breastfeeding?" or "What have you heard about breastfeeding?" Acknowledge and affirm the mother's worries. Validating her feelings can break down barriers and dispel myths.14
Identify Mothers Who Are Undereducated, Under Age 21, or Socioeconomically Disadvantaged: These "at risk" mothers are less likely to breastfeed.20,21 A discussion with such mothers could begin with the financial advantages of breastfeeding, which opens the door to a discussion of its health advantages. It is estimated that eliminating the need to purchase infant formula for 1 year can save $1,000 per child.22,23
Be Ready to Provide Methods of Support to New Mothers: Determine the mother's social support systems or lack thereof, and be prepared to make a recommendation. This may include the provision of written educational material or expert consultation. TABLE 2 gives educational resources and options for professional lactation support.
Pharmacists may be reluctant to counsel about breastfeeding owing to lack of knowledge, inability to relate to new mothers, embarrassment, or their own personal preference, which may not coincide with that of the mother. As well, mothers may have concerns or preconceived ideas that pose barriers to breastfeeding. Indeed, breastfeeding is a challenge. It presents obstacles and may not always be the best choice for every mother. However, pharmacists have an obligation to be prepared to provide competent and confident holistic patient care.1 Health care providers should be knowledgeable, remain open-minded, and offer unbiased guidance and support.24,25
1. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. 2006.
www.acpe-accredit.org/pdf/ACPE_Revised_PharmD_Standards_Adopted_Jan152006.pdf. Accessed March 7, 2008.
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2. American Association of Colleges of Pharmacy. Center for the Advancement of Pharmaceutical Education: educational outcomes 2004.
www.aacp.org/resources/education/Documents/CAPE2004.pdf. Accessed June 13, 2008.
3. American Pharmacists Association. 2008 House of Delegates report of the Policy Committee. Presented at the APhA 2008 Annual Meeting and Exposition. March 2008.
www.pharmacist.com/Content/NavigationMenu3/AboutAPha/HouseofDelegates/APhA_House_of_Delega.htm [membership required]. Accessed May 15, 2008.
4. Greiner AC, Knebel E, eds. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003.
5. O'Sullivan T, Hammer DP, Manolakis PG, et al. Pharmacy experiential education present and future: realizing the Janus vision. A background paper for the AACP APPI Summit to advance experiential education in pharmacy. June 3, 2005.
http://courses.washington.edu/pharm560/APPI/Background_Paper.pdf. Accessed June 5, 2008.
6. Speedie M. Introductory experiential education: a means for introducing concepts of healthcare improvement. Am J Pharm Educ. 2006;70:145.
7. Grear MR. Lactation support: a niche opportunity. US Pharm. 1996;21(suppl):10-22.
8. Ronai C, Taylor JS, Dugan E, Feller E. The identifying and counseling of breastfeeding women by pharmacists. Breastfeed Med. 2009;4:91-95.
9. Helms SL, Darbishire PL. Data from unpublished survey; 2008.
10. Zeretzke K. Yeast infections and the breastfeeding family: helping mothers find relief for symptoms and treatment for the infection preserves the breastfeeding relationship. Leaven. 1998;34:91-96.
11. Vinther T, Helsing E. Breastfeeding: how to support success. Copenhagen, Denmark: World Health Organization Regional Office for Europe; 1997.
www.euro.who.int/document/e57592.pdf. Accessed July 17, 2009.
12. New York City Department of Health and Mental Hygiene. Encouraging and supporting breastfeeding--revised. City Health Information. 2009;28(suppl 1):1-8.
www.nyc.gov/html/doh/downloads/pdf/chi/chi28-suppl1.pdf. Accessed August 17, 2009.
13. La Leche League International. A current summary of breastfeeding legislation in the U.S.
. Accessed July 30, 2009.
14. Shannon T, O'Donnell MJ, Skinner K. Breastfeeding in the 21st century: overcoming barriers to help women and infants. Nurs Womens Health. 2007;11:568-575.
15. La Leche League. How can I deal with my leaking breasts?
www.llli.org/FAQ/leak.html. Accessed July 8, 2009.
16. American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2005;115:496-506.
17. Miller LC, Cook JT, Brooks CW, et al. Breastfeeding education: empowering future health care providers. Nurs Womens Health. 2007;11:374-380.
18. Agency for Healthcare Research and Quality. Breastfeeding, maternal & infant health outcomes. Structured abstract. April 2007.
www.ahrq.gov/clinic/tp/brfouttp.htm. Accessed June 6, 2009.
19. World Health Organization. Promoting proper feeding for infants and young children.
www.who.int/nutrition/topics/infantfeeding/en/index.html. Accessed June 11, 2009.
20. Kong SK, Lee DT. Factors influencing decision to breastfeed. J Adv Nurs. 2004;46:369-379.
21. Santa-Donato A. Promoting breastfeeding. AWHONN Lifelines. 2001;5:10-12.
22. Ball TM, Wright AL. Health care costs of formula-feeding in the first year of life. Pediatrics. 1999;103:870-876.
23. Weimer JP. Economic benefits of breastfeeding: a review and analysis. Food Assistance and Nutritional Research Report No 13. Washington, DC: US Department of Agriculture Economic Research Service; 2001.
24. Kuan LW, Britto M, Decolongon J, et al. Health system factors contributing to breastfeeding success. Pediatrics. 1999;104:e28.
25. Smale M, Renfrew MJ, Marshall JL, Spiby H. Turning policy into practice: more difficult than it seems. The case of breastfeeding education. Matern Child Nutr. 2006;2:103-113.