Making More Milk Presented by Diana West, BA, IBCLC Increasing Milk Production 增加奶量 中文翻譯台灣母乳哺育聯合學會王淑芳副教授 / 楊誠嘉醫師 Presented by Diana West, BA, IBCLC dw

Transcription

1 目 錄 1.Making More Milk:Assessing and uncovering cause of low milk supply and its treatment 1 2. 母嬰親善醫院中的嬰兒室新方向 28 3.Surprising Causes of Low Milk Production 國際認證泌乳顧問的角色與展望 57

2 Making More Milk Presented by Diana West, BA, IBCLC Increasing Milk Production 增加奶量 中文翻譯台灣母乳哺育聯合學會王淑芳副教授 / 楊誠嘉醫師 Presented by Diana West, BA, IBCLC [email protected] GET A HEAD START 好的開始 MAXIMIZING MILK PRODUCTION CAPABILITY 發揮最大的奶水製造能力 Copyright 2010 by Diana West, BA, IBCLC 1

3 Making More Milk Presented by Diana West, BA, IBCLC MAXIMIZE MILK PRODUCTION BEFORE BIRTH 產前就開始發揮奶水製造的能力 Express Milk Before Baby is Born 在嬰兒出生前開始擠奶 Old method recently rediscovered in Australia 一個最近在澳洲發現的舊方法 (Cox, 2006) Gentle hand expression once or twice a day 一天溫和地擠奶 1-2 次 MAXIMIZE MILK PRODUCTION BEFORE BIRTH 產前就開始發揮奶水製造的能力 Significant benefits 顯著的好處 May increase milk production capability 可能增加奶水製造的能力 Collected colostrum can be used as supplementation 收集初乳供日後補充使用 Teaches hand expression! 教導用手擠乳技巧 Validates mothers need to prepare for breastfeeding 滿足母親學習母乳哺育的需求 Copyright 2010 by Diana West, BA, IBCLC 2

4 Making More Milk Presented by Diana West, BA, IBCLC MAXIMIZE MILK PRODUCTION BEFORE BIRTH 產前就開始發揮奶水製造的能力 Express Milk Before Baby is Born 在嬰兒出生前開始擠奶 Safety concerns??? 安全考量? No evidence for causing preterm labor 沒有導致早產的實證 2009 pilot study by Forster et al 2009 年 Forster 等人之先驅研究 43 women hand expressed 2x/day from week 位婦女在 36 週後開始一天擠奶 2 次 No evidence of fetal compromise 沒有證據顯示會危害到嬰兒 2009 study by Ishii 2009 年 Ishii 的研究 110 women continued breastfeeding through pregnancy compared to 774 women who did not breastfeed during pregnancy 110 位在孕期持續母乳哺育婦女與 774 位沒有在孕期持續母乳哺育婦女相比較 No statistically significant difference in labor initiation 進入產程之時間沒有顯著差異 Oxytocin surges MUCH stronger with orgasm! 性高潮反應所釋放的催產素作用比擠奶所釋放的強多了! MAXIMIZE MILK PRODUCTION BEFORE BIRTH 產前就開始發揮奶水製造的能力 Express Milk Before Baby is Born 在嬰兒出生前開始擠奶 Begin from 35 th week of pregnancy 在懷孕 35 周開始 Each day after taking hot shower when breasts are warm 每天熱水淋浴後乳房溫熱時開始 Stop expressing if cramps or contractions 如果有痙攣或宮縮時停止 Use periodontal syringes to draw up expressed colostrum 以空針抽取所擠出來的初乳 Use same syringe for 48 hours, refrigerating in between 48 小時內可使用同一個空針容器, 並置於冰箱保存 Freeze syringes in zip-close bag 將空針置於密封袋冷凍保存 Bring to hospital to use as supplementation 帶到醫院作為奶水補充 Defrost under warm running water 在流動的溫水中溫熱奶水 Copyright 2010 by Diana West, BA, IBCLC 3

5 Making More Milk Presented by Diana West, BA, IBCLC FACILITATE BREASTFEEDING 促進母乳哺育 Delay bathing of mothers and babies as long as possible 儘可能延後產後母親與嬰兒洗澡的時間 Babies placed on their mothers chests immediately after birth with their hands free smear amniotic fluid onto the breasts as they use their hands and face to find them 產後即刻將寶寶放到媽媽的胸前, 嬰兒擺動自如的雙手會將羊水抹在乳房上, 循著羊水的味道, 嬰兒靠著雙手及臉可以自己找到乳房 (Varendi,, 1996; Varendi,, 1997) Smell of amniotic fluid orients to breasts like tracking beacon 羊水的味道是引導嬰兒找到乳房的線索 Critical biological sequence 重要的生物性本能 Helps babies cue into their natural latching instincts 刺激嬰兒展現自己含奶的本能 MAKE LATCHING EASY 輕鬆泌乳 Allow baby to latch himself 允許嬰兒自己含上乳房 Mother leaning back so gravity helps 母親向後躺發揮重力作用 NOT fully flat 不是完全的平躺 Gravity hold s baby s chest firmly against mother 重力有助於嬰兒的胸部穩穩的貼緊媽媽 Increases baby s sense of stability & security 增加嬰兒安定與安全的感受 Baby reaches to take nipple 嬰兒靠近將乳頭含上 For more info: Suzanne Colson 進一步資訊 : 請上 Suzanne Colson 網站 : Copyright 2010 by Diana West, BA, IBCLC 4

6 Making More Milk Presented by Diana West, BA, IBCLC BABY-LED LATCHING 嬰兒主導式含奶 Photo credit: newborns.stanford.edu Snuggle baby high up between mom's breasts 嬰兒舒服溫暖的躺在媽媽乳房中間 Mother automatically strokes baby s back 媽媽本能的輕拍嬰兒的背 Baby will begin bobbing down to a breast to self-attach 嬰兒慢慢開始擺向乳房 Mother only needs to support, not to guide 媽媽只要支托住嬰兒, 不要嘗試操控 More info: Baby-Led Breastfeeding by Kittie Franz, Dr. Christina Smillie 進一步資訊 : 請看 Kittie Franz, Dr. Christina Smillie 製作之 Baby-Led Breastfeeding 影片 MAXIMIZE MILK REMOVAL IN FIRST TWO WEEKS 盡量在產後兩周內將奶水移出 Maximize milk removal to calibrate high lactation capability 盡量將奶水移出可以提升泌乳能力 Hormonal receptors seem to be established in the breast in first 2-3 weeks in response to milk removal 產後頭 2-3 周奶水製造之荷爾蒙接受體似乎與奶水的移出高度相關 The more milk that is removed, the higher milk production capability will be for this baby 奶水移出愈多, 製造嬰兒需要的奶量愈多 Calibration process restarts for each baby 每個嬰兒都可以再度啟動泌乳過程 Extra milk removal even if only just during this time helps create the highest possible set point 即使只在某個時候才移出多餘的乳汁, 都非常有助於創造最高的關鍵性奶量 Copyright 2010 by Diana West, BA, IBCLC 5

7 Making More Milk Presented by Diana West, BA, IBCLC HORMONES AND RECEPTORS 荷爾蒙與接受器 Hormones need receptors to act on a target organ 荷爾蒙需要一個接受器才能在目標器官上發揮作用 Each hormone has its own receptor 每個荷爾蒙都有其專屬接受器 There are receptors in each organ of our body 體內每個器官都許多接受器 The more receptors, the more effective hormones are 接受器愈多, 荷爾蒙反應愈好 Hormone 荷爾蒙 Receptor 接受器 Not enough receptors hormones less effective 接受器不足, 荷爾蒙反應不佳 HAND EXPRESS COLOSTRUM 用手擠出初乳 Photo credit: newborns.stanford.edu 2009 study by Dr. Jane Morton and Colleagues at Stanford 2009 年 Dr. Jane Morton 與其同事在 Stanford 的研究 Expressing colostrum at least 6x/day in first 3 days pp increases later milk production by avg 45% 產後頭 3 天, 每天以手擠出初乳 6 次以上, 日後泌乳量平均可增加 45% Morton J, Hall JY, Wong RJ, Thairu L, Benitz WE, Rhine WD. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. J Perinatol Jul 2. Copyright 2010 by Diana West, BA, IBCLC 6

8 Making More Milk Presented by Diana West, BA, IBCLC HAND EXPRESS COLOSTRUM 用手擠出初乳 Hand expression often more effective to remove colostrum in first 3 days 產後頭 3 天, 用手擠奶可以更有效移出初乳 Moves thick colostrum more easily through breast 可以更容易將濃稠的初乳移出 Pumps pull fluid into the areola 擠乳器將液體抽拉到乳暈內 Compounds LGII areolar edema 形成泌乳第二期 ( 成熟奶來時 ) 乳暈水腫 Makes it harder to baby to latch 增加嬰兒含奶困難 Learning how to hand express is a handy skill 學會如何用手擠奶技巧將很實用 Photo credit: newborns.stanford.edu CATCHING UP: MAKING MORE MILK 追奶 : 增加奶量 Copyright 2010 by Diana West, BA, IBCLC 7

9 Making More Milk Presented by Diana West, BA, IBCLC TARGETING THE TREATMENT TO THE CAUSE 對症下藥 Treating the actual underlying problem increases the chance of improving lactation 針對潛藏問題處理, 增加追奶成功的機率 Also may be beneficial for mother or baby far beyond breastfeeding 同時對母親及嬰兒雙方的好處超過母乳哺餵本身 Insulin resistance 胰島素不耐 Tongue restriction 舌頭活動受限 Sensory processing disorder 感覺異常 CONSIDER THE GOAL 了解目標 Increasing Prolactin 增加泌乳素 Milk production 奶水製造 Increasing oxytocin 增加催產素 Milk ejection 奶水排出 Copyright 2010 by Diana West, BA, IBCLC 8

10 Making More Milk Presented by Diana West, BA, IBCLC INCREASING PROLACTIN (MILK PRODUCTION) 增加泌乳素 ( 奶水製造 ) Increasing milk removal 增加奶水自乳房移除 INCREASE BREASTFEEDING FREQUENCY 增加母乳哺育頻率 Number one cause of low milk production 奶水分泌不足的首要導因 Easiest to reverse 最容易改善 In first few weeks, mothers with vulnerable supplies should not allow longer than 2-3 hours between daytime feedings or longer than one 4-5 hour sleep stretch each day 在產後頭幾週, 對奶量感到不足的媽媽, 白天至少每 2-3 小時須餵奶一次, 夜裡睡覺時餵奶頻率也不應低於 4-5 小時一次 Copyright 2010 by Diana West, BA, IBCLC 9

11 Making More Milk Presented by Diana West, BA, IBCLC INCREASE BREASTFEEDING FREQUENCY 增加母乳哺育頻率 Suggest a babymoon (vacation at home with baby) 建議一個與嬰兒的 " 蜜月期 " ( 放假時和嬰兒在家裡待在一起 ) Spend 2-3 days in bed together, cuddling and nursing 花 2-3 天一起待在床上, 擁抱及餵奶 Take magazines, snacks, and beverages 帶著雜誌, 點心和飲料 Read, nap, knit, talk on the phone, or watch television 閱讀, 午睡, 針織, 講電話, 或看電視 PUMPING TO REMOVE MORE MILK 以擠奶器移出更多奶水 Pro 好處 Can be helpful in increasing milk production, especially if baby is not nursing well or does not nurse for comfort 可有助於提高奶水產量, 尤其是嬰兒吃得不好或安撫性餵奶也進行的不好時 Con 缺點 Can quickly exhaust and overwhelm a new mother, especially one with older children 對新手媽媽而言, 很容易疲累也壓力太大, 尤其是同時有一個較大小孩的母親 Introduces a mechanical, unnatural aspect 呈現一個機械且非自然的餵哺方法 Copyright 2010 by Diana West, BA, IBCLC 10

12 Making More Milk Presented by Diana West, BA, IBCLC PUMPING TO REMOVE MORE MILK 以擠奶器移出更多奶水 No one right way to go about it 沒有唯一正確的方法 Encourage flexibility 鼓勵有彈性 Determine what she can do and what she can feel good about it 了解哪些事情母親可以做, 以及哪些事情可以使母親更舒服 Rather than feeling guilty for what didn't happen 而不是為沒做到的事情感到罪惡感 Not necessary to be evenly spaced 擠奶間隔無需均等 PUMPING TO REMOVE MORE MILK 以擠奶器移出更多奶水 Empty the breast as thoroughly as possible 盡可能地移出乳汁 Hospital grade usually best after milk comes in 在奶水來 ( 來奶 ) 後, 醫院級擠奶器效果最好 Manual pump next best 手動式擠奶器效果次之 Copyright 2010 by Diana West, BA, IBCLC 11

13 Making More Milk Presented by Diana West, BA, IBCLC PUMPING TO REMOVE MORE MILK 以擠奶器移出更多奶水 Length of pumping session 每次擠奶持續時間 Amount of time varies by woman and pumping session 時間長短因人 因擠奶時段不同而異 Avoid watching the clock 不要看著時鐘擠奶 She ll learn when her breasts feel drained 母親會感覺到乳房被排空了 Pump for 2-5 minutes after the milk stops flowing rapidly and the breast seems drained 在奶陣停止快速流出後再擠奶 2-5 分鐘, 乳房似乎排空了 Feed baby any expressed milk 擠出的奶水盡可能的餵給寶寶 PUMP FLANGES 擠奶器托杯 Ensure the pump flange fits 確保擠奶器與乳頭大小合宜 Most women need a larger size than the standard 24 mm 大部分女性需要大於標準尺寸 24 毫公分 (Meier, 2004) Some brands now providing two sizes in kits 一些品牌現在會同時提供兩種尺寸設備 Nipple should move freely without rubbing sides of tunnel 乳頭可以自在的在管道內移動, 而不會摩擦到邊緣 Should be noticeable movement of areola 注意乳暈在托杯內的移動性 Copyright 2010 by Diana West, BA, IBCLC 12

14 Making More Milk Presented by Diana West, BA, IBCLC PUMPING OPTIONS 擠奶的其他可能選擇 Pump after feeds 在親自餵奶後擠奶 Appropriate when: 合宜的時機, 當 : Baby is leaving a lot of milk in the breast 乳房中仍有大量乳汁留下 Baby only sucks well when milk is flowing strongly 寶寶只有在奶水流速快時才吸得好 PUMPING OPTIONS 擠奶的其他可能選擇 Pump between feeds 在兩次餵奶間擠奶 Good option if seeing only a little milk is discouraging 如果對於很少奶量而沮喪時的最佳選擇 Provides visible feedback 回饋立即可見 To her body, may become more of an extra session rather than the continuation of feeding session 對母親身體而言, 形同增加一次的餵奶, 而非延長一次餵奶時間 Downside: there may be less milk in breast for baby if he wakes up too soon 缺點 : 如果嬰兒太快醒來, 可能會感覺乳房中奶水較少 Copyright 2010 by Diana West, BA, IBCLC 13

15 Making More Milk Presented by Diana West, BA, IBCLC PUMPING OPTIONS 擠奶的其他可能選擇 Pump during night 夜裡擠奶 Takes advantage of any higher prolactin levels 掌握夜間泌乳素較高的優勢 Since sleep deprivation can reduce prolactin, important to balance 由於睡眠剝奪也會降低泌乳素分泌, 重要的是如何取得平衡 At least once per night, if possible 盡可能每天晚上至少擠奶一次 Don't set an alarm, but if she happens to wake, use that opportunity 不需要設定鬧鐘, 利用母親剛好醒來的機會 Sedating effects of oxytocin help return to sleep 催產素的放鬆作用也助於母親再度入眠 PUMPING OPTIONS 擠奶的其他可能選擇 Power-Pump (for 2-3 days) 強力擠奶 (2-3 天 ) Useful when mother having hard time getting in enough pumping sessions 當母親無法安排足夠的擠奶時段 5 minutes many times a day (10-20) 一次給 5 分鐘, 一天擠好多次 (10-20 次 ) Copyright 2010 by Diana West, BA, IBCLC 14

16 Making More Milk Presented by Diana West, BA, IBCLC PUMPING OPTIONS 擠奶的其他可能選擇 How to Power-Pump 如何強力擠奶 Place pump in convenient location in home 將擠奶器放在家裡容易取得的位置 Every time she passes it, use for 5-10 minutes 每次經過的時候就擠 5-10 分鐘 Pump as often as every 45 minutes 每 45 分鐘就可以擠奶一次 Pumping more often may not be helpful 過度頻繁可能不會有幫助 No need to refrigerate milk or wash kit in between 無須每次將擠出來的奶水放入冰箱中, 或是清洗泵套設備 PUMPING OPTIONS 擠奶的其他可能選擇 How to Power-Pump 如何強力擠奶 Continue pumping into same bottle and kit for 4-6 hrs, depending room temperature 在室溫下, 每 4-6 小時中持續將奶水擠在同一個瓶子中 After 4-6 hrs, take accumulated milk to refrigerator, wash kit, start fresh for the next 4-6 hour period 4-6 小時後, 將累積的奶水放入冰箱保存, 清洗泵套設備 If mom uncomfortable not washing, just put whole kit with pumped milk in refrigerator 如果母親不能接受不用在每次使用後清洗設備的話, 可以將整個泵套連同奶水一起放入冰箱 If there are pets in the house, consider placing pump parts on high level 如果家中有寵物, 則要將擠奶器放在比較高的地方 Copyright 2010 by Diana West, BA, IBCLC 15

17 Making More Milk Presented by Diana West, BA, IBCLC PUMPING OPTIONS 擠奶的其他可能選擇 Pump while nursing 在親自餵奶時同時擠奶 (+) Double stimulating! 加倍刺激 (+) Takes advantage of baby s superior milk ejection stimulation 善用嬰兒誘發噴乳反射的能力 (-) Can be over-stimulating for some women 對某些婦女而言可能刺激過強 (-) Can be awkward and difficult 可能覺得尷尬和困難 Easier with practice 熟能生巧 BREAST COMPRESSIONS 乳房施壓 Easy and very effective 容易且非常有效 Enhances milk removal by adding pressure inside breast to propel milk through ducts for easier removal by baby or pump 在乳房外給予額外的壓力, 有助於嬰兒或擠奶時的奶水移出 Copyright 2010 by Diana West, BA, IBCLC 16

18 Making More Milk Presented by Diana West, BA, IBCLC BREAST COMPRESSIONS 乳房施壓 Hold breast with thumb on top and fingers underneath (or vice versa) 拇指在上, 其於手指在下的握住乳房 ( 或是手指上下相反握法 ) Far back on breast away from areola 放在乳房上遠離乳暈的位置 Compress tissue between fingers and thumb gently but firmly 手指予以輕柔且穩定壓向乳房組織 Hold the compression until milk ejection slows (or baby s swallows slow) 維持壓力直到奶水不再流出來 ( 或是嬰兒吞嚥變慢時 ) Should not hurt or pinch ducts 不要弄傷或是擠壓乳腺管 HAND EXPRESS AFTER PUMPING 在使用擠奶器後用手擠奶 There is usually more milk that can be expressed 大部分都可以擠出更多乳汁 More milk removed = more milk that will be made 更多乳汁被移出 = 更多乳汁可以被製造 Photo credit Dr. Jane Morton Copyright 2010 by Diana West, BA, IBCLC 17

19 Making More Milk Presented by Diana West, BA, IBCLC BREAST COMPRESSIONS + PUMPING + HAND EXPRESSION 乳房施壓 + 擠奶器 + 手擠奶 Study by Dr. Jane Morton and colleagues at Stanford Dr. Jane Morton 及其夥伴在 Stanford 的研究 Morton J, Hall JY, Wong RJ, Thairu L, Benitz WE, Rhine WD. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants..j Perinatol Jul 2. ADDRESS HORMONAL ISSUES 處理荷爾蒙相關問題 Many mysterious low milk production situations are caused by hormonal imbalances 許多原因不明的乳汁製造不足情況是荷爾蒙失調所造成 Possible culprits: 可能的嫌疑狀況 Thyroid 甲狀腺 Causes milk ejection problems 引起噴乳反射問題 PCOS/infertility 多囊性卵巢症候群 / 不孕症 Prolactin 泌乳激素 Progesterone 黃體素 Can t be fixed retroactively 無法回朔確定 Copyright 2010 by Diana West, BA, IBCLC 18

20 Making More Milk Presented by Diana West, BA, IBCLC ACUPUNCTURE AND ACUPRESSURE 針炙與穴道按摩 Have been used to treat low milk production for over two thousand years 用來治療母乳製造不足已有超過兩千年歷史 Many research studies show effectiveness 很多研究報告顯示有效 (Kvist, 2007; Jenner, 2002; Nedkova, 1995; Clavey, 1996; Sheng, 1989) ACUPUNCTURE AND ACUPRESSURE 針炙與穴道按摩 In Traditional Chinese Medicine, insufficient milk is result of one of two disharmonies in qi (pronounced chee), the flow of energy throughout the body: 在傳統中醫, 認為奶水不足是兩種氣血之一失調所造成 spleen qi deficiency (pi qi xu) 脾氣虛 breasts are soft and milk production is inadequate 乳房軟且乳汁製造不足 liver qi stagnation (gan qi stagnation) 肝氣鬱結 breasts are distended but not flowing 乳房充盈但乳汁運行受阻 May also help the release and flow of milk when the breasts have been engorged or inflamed 在乳房腫脹或發炎時, 也可以幫助乳汁移出 Copyright 2010 by Diana West, BA, IBCLC 19

21 Making More Milk Presented by Diana West, BA, IBCLC TAKING A BREAK FROM THE HAMSTER WHEEL 有時要從倉鼠輪中跳下來休息一下 Never-ending cycles of supplementing, breastfeeding, and pumping can be exhausting, overwhelming 漫無止盡的反覆輔助餵食, 哺餵母乳及擠奶可以是非常累人且令人無法承受的 Especially with older children 尤其是還有較大的孩子 JUST PUMP for 2-3 days (8-10x/day) 只擠奶兩三天 (8-10 次 / 天 ) Feed baby pumped milk by alternate method 以其他方式餵嬰兒擠出的乳汁 Gives her a few days off to catch her breath 讓她休息幾天可以喘口氣 May increase milk from thorough, consistent milk removal 若能充分持續移出乳汁, 仍可維持乳汁分泌 Most babies return easily to breast after this short time 大部分嬰兒在短時間分離後仍可輕易的回到乳房上喝奶 WHEN ALL ELSE FAILS: 當所有方法都失敗時 : TAKE A NAP! 小睡片刻 When she s at the end of her rope 當她已經智窮力竭 a nap can do wonders! 小睡片刻會有意想不到的效果 Someone else feeds baby pumped milk for as long as mom can sleep 儘量讓媽媽睡久一點, 這當中就由其他人以擠出的母乳餵食嬰兒 Her perspective likely to dramatically improve 她對哺奶的觀點可能會有極大地改善 MORE MILK: Sleep increases prolactin 更多的乳汁 : 睡眠增加泌乳激素分泌 Copyright 2010 by Diana West, BA, IBCLC 20

22 Making More Milk Presented by Diana West, BA, IBCLC INCREASING OXYTOCIN (MILK EJECTION) 增加催產素 ( 噴乳反射 ) Nerve stimulation 多刺激神經 Reducing inhibitors 減少抑制因子 WARMTH 溫暖 Warm, moist compresses applied to breasts just prior to nursing or pumping 餵奶或擠奶前熱濕敷乳房 Commercial products 商業化產品 Rice-filled sock 塞滿米的短襪 Lightly dampen and microwave ~30 sec (warm, not hot) 輕微弄濕後微波 30 秒 ( 溫而不燙 ) Warm, wet washcloth 溫濕的毛巾 Hot showers 熱水澡 Nursing baby in bath 邊泡澡邊餵奶 Copyright 2010 by Diana West, BA, IBCLC 21

23 Making More Milk Presented by Diana West, BA, IBCLC RELAXATION 放鬆 CHILDBIRTH RELAXATION TECHNIQUES 生產時的放鬆技巧 RELAXATION 放鬆 PSYCHOLOGICAL RELAXATION 心理上的放鬆 Envision anything that gives a feeling of peace and well-being 想像任何可以帶來平靜與幸福感覺的事物 Lying in the sun or sitting beside a mountain lake 想像躺在陽光下或坐在山中湖畔 Copyright 2010 by Diana West, BA, IBCLC 22

24 Making More Milk Presented by Diana West, BA, IBCLC RELAXATION 放鬆 PHYSICAL RELAXATION 生理上的放鬆 Concentrate on progressively relaxing muscles from toes to scalp, while breathing deeply 在深呼吸時, 集中意志力於從腳到頭漸進式放鬆肌肉 RELAXATION 放鬆 AUDITORY NARRATIVES PROVIDE GUIDED RELAXATION 利用語音敘述提供引導式的放鬆 Shown to increase milk production (Feher, 1989) 研究證實可以增加乳汁製造 Quiet Moments for Mothers: Pumping by Robin Frees, BA, IBCLC ( Letting Down by James Wierzbicki and Betsy Feldman (Willow Music) A Bond Like No Other by Anji, Inc. ( Breastfeeding Meditation by Sheri Menelli ( Pumping Secrets by Jenniffer Milone ( Copyright 2010 by Diana West, BA, IBCLC 23

25 Making More Milk Presented by Diana West, BA, IBCLC CHIROPRACTICS 整脊治療 May help when spinal vertebrae misaligned and compressing or irritating spinal nerves (subluxation) 當脊椎骨錯位壓迫或刺激脊神經可能有幫忙 ( 脊椎骨脫位 ) Helps restore nerve communication in key areas 幫助恢復某些關鍵區域的神經傳導 Three recent case studies reported (Vallone, 2007) 最近有三位個案報告 First mother made plenty of milk for first baby, but not enough for second 第一位母親在頭胎可以製造充分乳汁, 但第二胎卻不夠 Second mother had back pain and low milk production 第二位母親有下背痛與乳汁分泌不足 Third thought baby's suck was the problem 第三位母親認為嬰兒吸吮是造成乳汁不足的問題 Chiropractor found nothing wrong with the baby s suck 整脊治療師發現嬰兒吸吮並沒有問題 Found several vertebral problems in mother 反而發現母親有一些脊椎問題 Within the first few treatments, milk supply increased and eventually reached 100% 在經過幾次治療後, 乳汁供應就增加且最後都能達到 100% BREAST MASSAGE 乳房按摩 Brings milk forward for easy removal 讓乳汁流暢方便移出 Helps stimulate milk ejection 幫助刺激噴乳反射 One study found % more milk removed when pumping with massage than without it (Jones, 2001) 有篇研究發現擠奶時合併按摩比沒有按摩多增加 40-50% 的乳汁 Copyright 2010 by Diana West, BA, IBCLC 24

26 Making More Milk Presented by Diana West, BA, IBCLC BREAST MASSAGE 乳房按摩 Work from chest forward toward nipple with kneading or circular hand movements, using comfortable pressure 以舒適的力道用手從胸壁往乳頭揉捏或環狀按摩 Don't limit to feeding time 不必只限制用於餵奶時間 Breast massage for general stimulation and enhancement practiced in several cultures 在許多文化中都有使用乳房按摩來廣泛刺激與增強泌乳 TOUCH 觸摸 Any form of nipple stimulation can encourage milk ejection 任何形式的乳頭刺激都可以促進噴乳反射 Gentle tickling, rolling, twiddling, or pulling 輕柔搔觸, 滾動, 撚弄或牽引 Reverse pressure softening 反向壓力軟化 ( 用於乳頭乳暈水腫 ) Shoulder massages and back rubs 肩膀按摩和背部撫摩 Massage shoulder close to neck while nursing / pumping 在餵奶或擠奶時按摩肩頸部位 Stimulates a milk ejection accupressure point 刺激可以引起噴乳反射的穴位 Copyright 2010 by Diana West, BA, IBCLC 25

27 Making More Milk Presented by Diana West, BA, IBCLC TOUCH 觸摸 Spine walk knuckles on either side of spine, from neck to waist 沿著脊椎兩側, 從脖子到腰部, 用指關節按壓 May cause shiver or chill sensation that triggers milk ejection 可以引起打哆嗦的感覺而引發噴乳反射 FUTURE POSSIBILITIES 未來發展可能 Prolactin dermal patch? 泌乳激素皮膚貼片? Current study at the Massachusetts General Hospital to synthesize recombinant prolactin Massachusetts General Hospital 目前已有製造合成泌乳激素的研究 Breast cancer research on turning cell growth off and on via stem cells 乳癌研究上可以利用幹細胞來控制細胞成長的開啟與關閉 Has already led to new breast tissue growth in mice from single stem cell 已經可以利用單一幹細胞在老鼠身上誘發新的乳房組織成長 Possibilities for replacing tissue damaged from breast surgery or incomplete development (hypoplasia) 可能用來修復乳房手術或乳房發育不全的組織傷害或缺損 Copyright 2010 by Diana West, BA, IBCLC 26

28 Making More Milk Presented by Diana West, BA, IBCLC KEY POINTS ABOUT INCREASING MILK PRODUCTION 增加泌乳量的重點 Maximize milk production capability in mothers with vulnerable supplies 讓乳汁供應不足的母親其乳汁製造能力加強到最大限度 Maximize milk removal in first 2-3 weeks to calibrate milk supply as high as possible 在前 2-3 週將乳汁移出量增加到最大限度, 將乳汁供應量校準到越高越好 Focus on methods that remove more milk 著重於移出更多乳汁的方法 Target increasing milk strategy to techniques or galactogogues that increase prolactin or oxytocin 在增加泌乳量策略中, 把可以增加泌乳素或催產素的技術或發奶劑列入目標 Questions? 問題? Thoughts? 想法? Comments? 指教? Each mother defines her own success 甚麼叫做成功母乳哺餵, 是由每一位母親自己定義, 而不是由他人來決定 Copyright 2010 by Diana West, BA, IBCLC 27

29 2010/9/29 台大醫院親子同室照護模式之實施現況 台大醫院婦產部 產科主任李建南醫師 1 大綱 What 什麼是親子同室 Why 為什麼要親子同室 How 如何親子同室 ~~ 預防與應 變措施

30 2010/9/29 Why-- 為什麼要親子同室 目的 了解寶寶的生活習性, 學習育嬰技巧 依寶寶生理時鐘隨時哺餵母乳, 提高成 功哺餵母奶機率 提昇父親共同參與感與責任感 提供相處時間, 建立親子關係 3 好處 Why-- 為什麼要親子同室 了解寶寶的生活習性及學習育嬰技巧, 增進父母親自信心及成就感 促進家人及寶寶熟悉彼此的味道 聲音 表達方式 接受較少的感染源 嬰兒比較有安全感 母親有較充足的休息

31 2010/9/29 實證資料 寶寶在媽媽身邊較有安全感, 促使媽媽和寶寶有較好的睡眠品質, 寶寶的啼哭行為也比較減少 (Mosko,Richard,& McKenna, 1997) 親子同床可以減少嬰兒瘁死症候群 (SID) 及感染的機率 (Rush,1989;UNICEF,2004; London Department of Health,2000) 5 實證資料 親子同室能促進媽媽及寶寶熟悉彼此的味道 聲音 表達方式及作息活動, 因而加強為人父母的自信心, 進而減少父母虐嬰及忽視嬰兒的行為 (O'Connor,1989)

32 2010/9/29 How-- 如何親子同室 24 小時親子同室率 搬遷前後自然產剖腹產 搬遷前 13.8% 6.8% 搬遷後 60.7% 52.1% 7 How-- 如何親子同室 照護模式與護理人力配置改變 搬遷前 床數 產後病房 :37 床嬰兒室 :40 床 人力 人力分開派班 搬遷後產婦床數 :48 床 人力整合

33 2010/9/29 How-- 如何親子同室 * 搬遷前二年進行嬰兒室與產後病房護理人員交叉訓練 ( Crossing training ) * 新生兒科主治醫師協助教育訓練 -- 親子同室期間新生兒緊急狀況之處理 " * 品管中心啟動護理人員執行新生兒急救 (9595) 處理流程實際演練 * 嬰兒室與產後病房護理人員具備新生兒基本救命術 (NRP) 訓練資格 9 9 產婦病房內設嬰兒洗澡專區 How-- 如何親子同室

34 2010/9/29 臺大醫院推動母乳哺餵相關事項說明書 親愛的媽媽 : 您好! 恭喜您添了可愛的小寶寶, 並選擇了最完美的母乳來哺育您的寶寶 美國小兒科醫學會建議哺餵母乳的嬰兒除非有醫療上的需要, 不應給予添加物, 所以護理人員將不會常規性地給予寶寶添加糖水或配方奶, 其理由如下 : 1. 餵食配方奶較容易有過敏 腹瀉情形 2. 給予寶寶吸吮奶嘴後較容易發生乳頭混淆, 造成寶寶不願意吸吮母親之乳房 3. 配方奶跟母乳比較起來較不容易消化, 會延長餵奶時間, 減少寶寶吸吮乳房之頻率, 而影響母親奶水的分泌, 且寶寶沒有獲得初乳, 亦容易增加黃疸的機會及嚴重性 4. 因為嬰兒吸奶不頻繁且嬰兒沒有吸出奶水, 母親較易有乳房腫脹 乳腺炎及沒有乳汁分泌之情形 為使您能順利的哺餵母乳, 貼心地建議您於產後儘早開始哺餵母乳, 並實施親子同室 依嬰兒的需求餵食且不提供嬰兒奶瓶及奶嘴, 此外, 亦鼓勵您於夜間哺餵母乳, 不但可減少因夜間泌乳激素分泌較多所引起的脹奶不適, 且能維持奶水的供應, 並促進哺乳成功及寶寶健康 親子同室期間, 請您特別注意感染控制及寶寶的安全, 應嚴格限制訪客, 每次最多只能有兩位, 訪客年齡應在 14 歲以上 ( 寶寶之兄弟姐妹除外 ), 接觸寶寶前亦務必確實洗手, 且應讓寶寶在您的視線範圍內 ( 包括上洗手間時 ), 勿讓寶寶獨自一人留在病房 ( 若有事離開可暫時將寶寶推至護理站或嬰兒室 ), 將寶寶置於大床時應將床欄杆拉起, 以避免寶寶跌落 請您詳閱以上內容並簽名, 若仍有疑問, 我們會竭誠為您說明與服務 產婦簽名 : 祝福您 能夠順利成功哺餵母乳 台大醫院敬啟 11 How-- 如何親子同室 親子同室期間, 三班護理人員皆會到病房探視母親及新生兒, 且給予 育嬰手札, 教導母乳哺餵及育嬰技巧

35 2010/9/29 How-- 如何親子同室 護理人員護理指導項目 : (1) 說明新生兒情況記錄表之填寫方式及體溫記錄單內容 (2) 教導注意保暖及預防體溫降低的技巧, 並說明體溫測量與判讀方法, 請母親回覆示教 (3) 教導衣服 尿布更換之技巧及大 小便之觀察 (4) 教導母乳哺餵技巧及吐奶 嗆奶之處理 (5) 教導臍帶護理之技巧, 並請母親回覆示教 (6) 教導感控與安全注意事項, 請家屬於接觸新生兒前應確實洗手 限制訪客人數, 將寶寶置於大床時應將床欄拉起, 以避免寶寶跌落, 且勿將新生兒獨自留在病房內等 (7) 若新生兒體溫低於 36.5 或有特殊情況 ( 如呼吸急促 發紺 不正常之行為表現等 ), 應立即通知護理人員處理 13 親子同室 ~~ 預防與應變措施 護理站確認嬰兒失竊後 Code Pink 通報兒醫防災中心 兒醫防災中心 通報中控室 嬰兒失竊 指揮保全員前往主要出入口進行管制 使用兒醫廣播 - 粉紅色信號 中控室通報廣播 中控室通報駐警隊 兒醫各單位人員於就近之出入口協助管制 全院廣播 - 粉紅色信號 支援駐警前往兒醫大樓進行管制及搜索 駐警小隊長進駐防災中心擔任現場總指揮 確認完成管制作業開始進行嬰兒搜尋

36 2010/9/29 親子同室之新生兒出現生命跡象不穩定 ( 發紺 心搏過慢或過快 意識不清 活力不佳等 ) 由在場醫護人員給予緊急處理, 如評估呼吸 心跳 膚色 拍背與清除呼吸道等並通知護理站人員新生兒 9595 護理站人員通知急救專線 9595, 全院廣播 : 新生兒 9595, 兒醫大樓,11PE/11PW 病房, 病床號 第一組新生兒 9595 輪值醫師護士 * 各 1 人備急救箱速往廣播之產後病房作急救處置 (ambu-bagging) 並協助轉送病嬰.( 醫師決定是否當場插管 ) 急救小組用嬰兒推車將嬰兒速送至 11PB 嬰兒室入院觀察室做進一步之急救處置 ( 路線如下圖 ) 產後病房醫護人員攜急救設備至床旁並進行 BLS(suction O 2 supply ambu bagging 等 ) 俟急救小組接手後協助穩定家屬情緒 由產後病房醫護人員向家屬解釋初步情況並告知嬰兒去處 新生兒急救處理流程 穩定後轉送病嬰至 10F 新生兒加護病房 第二組負責醫師速至 NICU 待命上班時間 : NICU fellow + Resident 值班時間 : 總值和 ICN 值班醫師對患嬰進行適當的急救處理, 與婦產部醫護人員討論後, 由 leader 陪同婦產科醫師向家屬解釋並辦理住院後續觀察及照顧 15 Thanks For Your Attention

37 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC Surprising Causes of Low Milk Production 令人驚訝的乳汁分泌不足的原因 中文翻譯台灣母乳哺育聯合學會毛心潔醫師 / 楊靖瑩醫師 Presented by Diana West, BA, IBCLC [email protected] DISCLOSURE 講者簡介 I am the author or co-author of: 本人是以下這些書的作者或共同作者 The Womanly Art of Breastfeeding, 8 th edition 女性的哺乳藝術 Ballantine Books, 2010 The Breastfeeding Mother s Guide to Making More Milk 哺乳母親製造更多奶水的指引 McGraw-Hill, 2008 Breastfeeding After Breast and Nipple Procedures 乳房及乳頭手術後的哺乳 Hale Publishing, 2008 Clinician s Triage Tool 臨床醫師篩檢工具 International Lactation Consultant Association, 2007 Defining Your Own Success: Breastfeeding After Breast Reduction Surgery 定義自己的成功 : 縮胸手術後的哺乳 La Leche League International, 2001 I have no other disclosures 我沒有其他的介紹了 Copyright 2010 Diana West, IBCLC 36

38 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC IN THIS TALK. 今天的演講中 We will discuss a few of the lesser known causes 我們會討論一些比較少見的原因 It is likely you already know about some 很可能你已經知道一些了 We all see a piece of the puzzle 我們都看到了拼圖的其中一片 Hopefully you will find a few missing pieces 希望你能找到拼圖的其他部份 Many Causes of Low Milk Production! Primary Production Failure Delayed Lactogenesis II Secondary Production Failure Mechanical Gastric Bypass Spinal Cord Injury Chest Injury Glandular Scarring from Previous Breast Infection Radiation Therapy Breast/Nipple/Chest Surgery Poland s Syndrome Early Puberty Hormonal Birth Control Type I Diabetes Pregnancy Advanced Maternal Age Thyroid Dysfunction PCOS Theca Lutein Cysts Hormonal Insufficient Glandular Tissue Circumstantial Mastitis Anti-Galactagogues Extreme Crisis/Stress Hypertension Anemia OBD Obesity Edema Retained Placenta PP Hemorrhage Labor Stress Maternal Labor Meds Birth Issues Physiological or Anatomical Behavioral Inability to Latch Oral Defensiveness Breast Refusal Nursing Strike Fussiness Nipple Confusion Flow Preference Infant Issues Physiological or Anatomical Suck Dysfunction Tongue-Tie Palatal Variation or Cleft Facial Anomalies Breathing Dysfunction Small Lower Jaw Recessed Lower Jaw Prematurity or SGA Cardiac Dysfunction Nervous System Dysfunction Sensory Processing Disorders Illness or Infection Maternal Management Insufficient Milk Removal Infrequent Feedings Poor Latch/Position PP Depression Severe Dietary Deficiency Severe Dehydration Sleep Training Scheduled Feedings Copyright 2010 Diana West, IBCLC 37

39 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC 乳汁分泌少有許多原因! 原發性製造不足 泌乳開始延遲 次發性製造不足 腺體因素 接受胃繞道手術脊髓損傷胸部外傷之前乳房感染造成乳腺疤痕組織放射線治療乳房 / 乳頭 / 胸腔手術 波蘭式症候群性早熟使用荷爾蒙成份避孕第一型糖尿病懷孕母親年齡較大甲狀腺功能不佳多囊性卵巢症候群黃體囊腫 內分泌因素 乳腺組織不足 環境因素 乳腺炎退奶藥極大危機 / 壓力 高血壓貧血水腫肥胖 水腫胎盤殘留產後出血生產壓力生產過程中使用藥物生產措施 生理與解剖構造方面 行為方面 無法含乳口腔防衛拒絕乳房拒絕哺乳煩躁不安乳頭混淆流速偏好 與嬰兒有關的因素 生理或解剖構造方面 吸吮功能不佳舌繫帶上顎構造變異或顎裂臉部發育異常呼吸功能不佳小下巴下巴後縮早產兒或低出生體重新生兒心臟功能不佳神經系統功能不佳感覺統合疾病生病或感染 與母親處理有關 移出奶水不足不常餵食含乳 / 抱嬰姿勢不佳產後憂鬱嚴重營養不良嚴重脫水訓練睡眠習慣固定時間餵食 PRIMARY CAUSES 原發性的原因 Maternal anatomy or physiology reduces milkmaking capability 母親解剖或生理上的因素使製造奶水的能力降低 Hormonal 與內分泌相關 Structural 與構造相關 Functional 與功能相關 Copyright 2010 Diana West, IBCLC 38

40 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC SECONDARY CAUSES 次發性的原因 External factor reduces milk removal 外在的因素使奶水移出減少 Infant 與嬰兒有關 Physiological or anatomical 生理或解剖方面 Circumstantial 環境方面 Behavioral 行為方面 Mother 與母親有關 Management 處理方面 Primary Causes 原發性的原因 Copyright 2010 Diana West, IBCLC 39

41 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC ADVANCED MATERNAL AGE 母親年齡較大 Elderly gravida = 35+ 高齡產婦 : 35 歲以上 Observation/anecdotal 觀察 / 口耳相傳 Not absolute 並非絕對 Many make plenty of milk 很多有豐沛的奶水量 Some only have problems with later babies 有些在餵後面的孩子時才出現問題 POSSIBLE CAUSES 可能的原因 Theory of aging: receptor resistance (Dean Ward, MD) 與老化有關的理論 : 接受體有抗性 Fertility problems extending to milk production 受孕的問題延伸至奶水製造 May be natural result of aging process 可能是自然老化的結果 May be underlying hormonal problem 可能潛藏內分泌的問題 Simple busyness, insufficient milk removal 單純因為忙碌, 移出奶水不足 LUTEAL PHASE DEFECT 黃體期缺陷 Not enough progesterone in second half of menstrual cycle 月經週期後半黃體素分泌不足 Common cause of miscarriage 流產的常見原因 The higher the progesterone levels in pregnancy, the better the milk production is postpartum (Ingram, 1999) 懷孕期間的黃體素濃度越高, 產後的泌乳狀況越好 Many informal reports of progesterone supplementation during pregnancy connected to better milk production 許多非正式的報告指出, 懷孕期間補充黃體素與奶水分泌較佳有關 Case report of woman with LPD (Bodley, 1999) 黃體期缺陷婦女的案例報告 First successful pregnancy, no breast growth, very little milk 第一胎成功懷孕, 乳房沒有發育, 奶水量很少 Second pregnancy, progesterone treatment, milk production normal 第二胎懷孕, 接受黃體素治療, 奶水分泌正常 Progesterone inhibits prolactin, so treatment must be during pregnancy 黃體素會抑制泌乳激素, 所以治療必須是在懷孕期間 Copyright 2010 Diana West, IBCLC 40

42 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC GESTATIONAL OVARIAN THECA LUTEIN CYSTS 懷孕期卵巢黃體囊腫 Ovarian cyst that secretes high levels of testosterone (10-150x normal) DURING PREGNANCY 在懷孕期分泌大量雄性素 ( 正常的 倍 ) 的卵巢囊腫 Suppresses prolactin, inhibiting milk synthesis 抑制泌乳激素, 抑制奶水生成 (Betzhold, Hoover, and Snyder, 2004; Hoover and Platia, 2002) Very rare 非常罕見 Occurs more often in women with history of: 較常見於合併以下疾病婦女 Diabetes, irregular menstrual cycles, hypothyroidism, polycystic ovary syndrome, pre-eclampsia, congenital malformations, gestational trophoblastic disease 糖尿病, 月經週期不規則, 甲狀腺功能低下, 多囊性卵巢症候群, 子癲前症, 先天 異常, 妊娠滋養層細胞疾病 14-25% develop virilization (male characteristics) 14-25% 有男性化特徵 (McClamrock, 1992) Resolves without treatment in about 4 weeks 未經治療大約四週後自然消退 POLYCYSTIC OVARIAN SYNDROME (PCOS) 多囊性卵巢症候群 Multiple ovarian cysts (Glueck, 2004) 多發性卵巢囊腫 Can cause high levels of testosterone, estrogen, and insulin 會造成高濃度的雄性素, 雌性素和胰島素 Can cause low progesterone 會造成低濃度黃體素 Can cause infertility 會造成不孕 Possible symptoms: 可能出現的症狀 Hirsutism (excess body hair) 多毛症 ( 體毛過多 ) Alopecia (balding) 脫髮 ( 禿頭 ) Obesity 肥胖 Masculine characteristics 男性化表徵 Insulin resistance 胰島素抗性 Hypoplasia (insufficient glandular tissue) 乳腺發育不良 ( 腺體組織不足 ) Treatment with Metformin often increases milk production 用 Metformin 治療通常可以增加奶水的製造 Copyright 2010 Diana West, IBCLC 41

43 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC THYROID DYSFUNCTION 甲狀腺功能失調 All three types can reduce milk production 以下三種情形均會減少奶水分泌 Hyperthyroid 甲狀腺功能亢進 Hypothyroid 甲狀腺功能低下 Postpartum thyroiditis 產後甲狀腺炎 Rat studies give new clues why 老鼠的實驗提供新的線索解釋 (Marasco, 2006; Hapon, 2003; Varas, 2002, Varas, 2005) Reduced milk ejection from oxytocin inhibition 催產素受到抑制導致噴乳反射減少 Not inhibited milk synthesis 不影響奶水生成 Commonly associated with anemia and pp hemorrhage 常與貧血及產後出血相關 Need comprehensive (not screening) test (TSH + Total or Free T3 + Total or Free T4) 需要詳盡檢查 ( 不是篩檢而已 ) TSH range for fertility/pregnancy: or even (Mandel, 2005) TSH 在準備懷孕 / 懷孕期的正常範圍 : 或 Even borderline cases tend to improve with treatment 即使在邊緣值的病患接受治療後都會改善 OBESITY 肥胖 Risk factor for delayed LG II and poor milk production 泌乳第二期延遲與乳汁分泌不足的危險因子 (Rasmussen, 2001; Rasmussen, 2002) May lower prolactin response to suckling (Rasmussen, 2004) 可能降低泌乳激素度對吸吮的反應 Low milk production more likely in obese (greater than 36 BMI) Caucasians and Hispanics than those of African decent 比起非裔婦女, 肥胖的 (BMI 超過 36) 白種人和西班牙裔婦女較易有奶水製造不足的問題 (Chapman et al, 1999; Kugyelka et al, 2004) May result from hormonal problem also affecting milk production (hypothyroidism, PCOS, insulin resistance) 肥胖可能是源自內分泌的異常, 而該內分泌的異常同時會影響奶水製造 ( 甲狀腺功能低下, 多囊性卵巢症候群, 胰島素抗性 ) Gastric-bypass surgery 胃繞道手術 Underlying obesity likely cause of milk production problems 本身的肥胖可能是導致奶水製造問題的原因 Copyright 2010 Diana West, IBCLC 42

44 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC ANATOMICAL ABNORMALITIES 解剖方面的異常 Insufficient Glandular Tissue (Hypoplasia) 乳腺組織不足 ( 發育不良 ) Characteristic anatomical presentation (Huggins, 2000) 解剖上的特徵 Widely spaced breasts (more than 3 fingers) 乳房間距很寬 ( 超過三根手指 ) Significantly asymmetrical breasts 兩側乳房明顯不對稱 Bulbous areola(s) 球狀乳暈 Lack of fullness under breasts 乳房下方不飽滿 Long tubular shape 長 管狀 乳房 Lack of veining 沒有血管分布 Many variations, range of severity 變異性大, 嚴重度不一 May not be able to achieve full milk production 可能無法達到足夠的奶水製造量 Not all have low milk production 並非全部都會奶水製造不足 STRATEGY 因應策略 R/O underlying hormonal dysfunction 排除本身的內分泌疾病 Maximize milk removal 盡量增加奶水移出 Consider galactagogues 考慮增加奶量的藥物 Goat s rue combined with prolactin-stimulating galactagogues 山羊芸香加上刺激泌乳激素的發奶藥 Type 1 第一型 Type 2 第二型 Type 3 第三型 Type 4 第四型 Huggins, K., Petok, E., Mireles, O. Markers of Lactation Insufficiency: A Study of 34 Mothers. Current Issues in Clinical Lactation 2000, Copyright 2010 Diana West, IBCLC 43

45 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC Hypoplastic Breast Types 發育不良的乳房型態 GIGANTOMASTIA 巨乳症 Extreme breast tissue overgrowth 乳房組織過度發育 Often triggered by pregnancy 通常因懷孕誘發 Breastfeeding difficult or impossible 哺乳有困難或不可能 May be able to breastfeed normally after reduction surgery (depending on type of surgery) 縮胸手術後仍有可能正常哺乳 ( 與手術的形式有關 ) Often have free nipple graft surgery 通常用自由乳頭皮瓣術式 Severs ducts 切斷乳管 Lessens capability 減少乳房組織 Copyright 2010 Diana West, IBCLC 44

46 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC ANATOMICAL ABNORMALITIES 解剖異常 Congenital Poland s Syndrome 先天波蘭式症候群 Absent chest muscle 缺乏胸部肌肉 Chest often concave on affected side 患側胸部凹陷 Usually missing breastbone (sternal) portion of the pectoralis muscle 通常胸骨側的胸大肌 (pectoralis muscle) 未發育 Breast tissue missing or hypoplastic 乳房組織未發育或發育不良 May be missing nipple/areola on absent breast 患側乳房可能沒有乳頭 / 乳暈 Incidence 1:10,000-1:100,000 births 發生率約每 1 萬 ~10 萬生產數會有一個病例 3x more common in boys than girls 男性發生率是女性的三倍 Affects right side twice as often as left 右側發生率是左側的兩倍 ANATOMICAL ABNORMALITIES 解剖異常 Congenital Poland s Syndrome 先天波蘭式症候群 Usually webbed fingers (cutaneous syndactyly) on same side hand 患側的手指常常合併蹼狀指 (cutaneous syndactyly) 的發生 Severity varies 嚴重度不一 STRATEGY 因應對策 Maximize milk production on functional breast 讓具有功能的另一側乳房盡量製造最多的奶水 Consider galactagogues 考慮發奶藥物 Goat s rue + prolactin-stimulating galactagogues 山羊芸香加上刺激泌乳激素的發奶藥 Copyright 2010 Diana West, IBCLC 45

47 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC AUGMENTATION 隆乳手術 Why did she want to increase her breast size? 為何婦女想增加乳房尺寸? Was it to enhance her body contour or correct asymmetry 是為了美化身體曲線或是矯正不對稱? Hypoplasia? 發育不良? Periareolar incisions or implants above the muscle most likely to reduce milk production capability 在乳暈周圍切開或在肌肉上方植入異物最容易減少奶水製造能力 NIPPLE PIERCINGS 乳頭穿孔 Nipple piercings are widely reported to NOT affect breastfeeding 乳頭穿孔已被大量報告不會影響哺乳 However SCARRING from piercings can cause nipple damage and obstruct ducts 然而穿孔造成的疤痕可能導致乳頭受傷或乳腺管阻塞 Areola piercings may be more problematic 在乳暈上穿孔可能造成較多問題 Copyright 2010 Diana West, IBCLC 46

48 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC CHEST SURGERY 胸腔手術 When MOTHER was infant 當母親在嬰兒期時, 接受 Sternotomy 胸骨切開 To treat cardiac or pulmonary dysfunction 為了治療心臟或肺部疾病 Since early 1990s, surgeons place incisions in the future inframammary fold area to preserve lactation capability 從 1990 年代開始, 外科醫師將手術切口改到將來的乳房下緣皺摺處以保留泌乳功能 (Nakamura, 1997; Deutinger and Dominag, 1992) Most current mothers were born before 1990 現在的母親大部份都在 1990 前出生 Pneumothorax drainage during NICU care (Rainer, 2003) 在新生兒加護病房為了治療置放胸管引流 GLANDULAR SCARRING 乳腺疤痕組織 From previous breast infection at any time of life 先前任何時期的乳房感染所造成 Abscess 膿瘍 Prolonged pathological engorgement 過度延遲病理性的腫脹 Mastitis 乳腺炎 (Strickler, 2005) Copyright 2010 Diana West, IBCLC 47

49 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC Secondary Causes 次發性的原因 BEHAVIOR 行為 Sensory Processing Disorders 感覺傳導的紊亂 Sensory input over-interpreted 感覺輸入被過度解釋 Central nervous system (CNS) problem, not conscious behavior 中樞神經的問題, 不是意識的行為 May become sensory defensive 可能變成感覺防禦 Avoid bothersome sensations 避免討厭的感覺 May not breastfeed well (Weiss-Salinas and Williams, 2001) 可能無法順利哺乳 Overwhelmed by sensory input 對感覺的輸入不知所措 May arch away from breast, cry, latch poorly, let go of breast frequently, or clamp down on nipple 可能拱起身體離開乳房, 哭泣 含乳不良 經常放開乳房或緊咬住乳頭 Copyright 2010 Diana West, IBCLC 48

50 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC BREATHING PROBLEMS 呼吸的問題 Hypotonic larynx (laryngomalacia) 軟侯症 ( 喉頭軟化症 ) Arytenoid tissue and epiglottis prolapse into airway with inhalation 吸氣時, 勺狀軟骨組織和會厭軟骨往呼吸道脫垂 Most common cause of stridor 引起喘鳴 (stridor) 最常見的原因 Worse when lying on back (supine) 當仰躺時惡化 ( 仰臥 ) Better with head hyperextended 將頭部呈現過度伸展時改善 Louder on inspiration (breathing in) 吸氣時比較大聲 Begins within the first few days of life or up to 2 months (but not at birth) 出生的幾天後或兩個月大前開始出現 ( 而不是在出生時 ) May worsen over the first few months then eventually symptom-free around 24 months 可能在前幾個月會惡化, 然後最終約在 24 個月大症狀消失 BREATHING PROBLEMS 呼吸的問題 Hypotonic trachea (tracheomalacia) 氣管軟骨軟化 Tracheal collapses during coughing, crying, or feeding 氣管在咳嗽 哭泣或餵食的時候塌陷 Causes expiratory stridor 造成吐氣時的喘鳴 Worsens with supine position, crying, and respiratory infections 在仰臥 哭泣和呼吸道感染時會惡化 Copyright 2010 Diana West, IBCLC 49

51 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC SUBMUCOSAL CLEFTS 黏膜下顎裂 SUBMUCOSAL CLEFT 黏膜下顎裂 Submucosal Cleft (Merritt, 2005) 黏膜下顎裂 Split in the muscle of the soft palate 裂開發生在軟顎的肌肉裏 Very difficult to visualize 很難用眼睛看出來 30% also have bifurcated uvula 30% 併有分岔的懸壅垂 When a bifurcated uvula is present, look for a submucosal cleft 看到分岔的懸壅垂時, 尋找黏膜下顎裂 Copyright 2010 Diana West, IBCLC 50

52 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC TONGUE-TIES 舌繫帶 Frenulum = membrane under tongue 繫帶 = 舌頭下方的薄膜 Caused by incomplete separation of tongue from base of mouth at 12 weeks gestation 舌頭在妊娠 12 週時從口腔底部分離不完全所造成 Can restrict tongue movement 會限制舌頭的活動 May be attached anywhere from base of tongue to tip 可能黏在舌根到舌尖的任何部位 May be a small notch when tongue extends (frenulum holds it back) 當舌頭向前伸時可能形成一個小小的 V 型凹跡 ( 繫帶將舌頭拉住 ) Tongue extension beyond gum line or lips difficult or impossible 舌頭要伸出超過牙齦或嘴唇很困難或不可能 Uncomfortable and fatiguing 不舒服而且很疲憊 Sucking blisters are tell-tale sign 吸吮造成的水泡是明顯的表徵 TONGUE-TIES 舌繫帶 Tongue-tie 舌繫帶 Classic (Type I) 典型 ( 第一型 ) Posterior (Type III, Type IV) 後方 ( 第三型, 第四型 ) More restrictive 更具限制性 Tongue cannot elevate from midline or cup to channel milk 舌頭無法從中線往上提起或形成杯狀讓奶水流入 Causes more damage to mother s nipple 對母親的乳頭造成更多的傷害 Less effective in removing milk 移除奶水比較沒有效率 Type IV is hidden by curtain of mucosal tissue 第四型是隱藏在黏膜組織的 窗簾 後 Copyright 2010 Diana West, IBCLC 51

53 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC TYPE II 第二型 TYPE III 第三型 TYPE IV 第四型 TYPE I 第一型 TONGUE-TIE TYPES 舌繫帶的類型 I & II: anterior webs 前方呈蹼狀 III & IV: posterior membranes 後方呈薄膜 TONGUE-TIES 舌繫帶 If the frenulum is too restrictive, tongue can t: 如果繫帶的限制性太大, 舌頭將無法 : Extend 伸展 Helps grasp and stabilize breast 幫助抓握與穩定乳房 Cup 呈柸狀 Sides can t curl up to stabilize breast in mouth 兩側無法捲起讓乳房穩定在口腔中 Lift 上提 Both tip AND middle can t lift to touch palate 舌尖和舌中兩者都無法向上提起去碰觸硬顎 Groove 呈溝狀 A groove isn t formed to channel milk to throat 無法形成一條溝讓奶水流向喉 When young baby cries, entire tongue should lift 當新生兒哭的時候, 整個舌頭應該向上提 Copyright 2010 Diana West, IBCLC 52

54 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC MURPHY MANEUVER TO IDENTIFY TONGUE-TIE TIE 利用 MURPHY 手法 發現舌繫帶 (DR. JAMES MURPHY) Press your little finger at side of tongue base and sweep across 將你的小拇指在按壓在舌頭基部的某一側, 然後橫掃至另一側 No resistance more than a small speed bump Most likely no problem 感受到的阻力不會超過像越過小型 減速丘 那樣 大致上應該是沒問題 RED FLAGS for tongue impairment 舌頭損傷的紅色警 Large speed bump you can get past w/ little effort tree trunk" frenulum 稍為使力可以通過的大型減速丘 樹幹 " 狀繫帶 Short, wide band of tissue buried in the floor of the mouth and attached to the base of the tongue 短而寬的帶狀組織埋在口腔的底部並且黏在舌頭的基部 Looks like there isn't enough there to be a problem 看起來好像沒有足夠的理由認為是有問題的 戒 MURPHY MANEUVER TO IDENTIFY TONGUE-TIE 利用 MURPHY 手法 發現舌繫帶 (DR. JAMES MURPHY) RED FLAGS for tongue impairment 舌頭損傷的紅色警 Unable to sweep finger across w/o pulling back to "jump over a fence 手指無法橫掃過去, 除非往回拉才能 越過籬笆 Frenulum is a fibrous band attached closer to the front of the tongue 繫帶是條纖維帶狀物, 黏在靠近舌頭的前端 May be buried underneath the floor of the mouth 可能埋在口腔的底部 May be visible as an external web 可能可以看到一個類似外露的網狀物 A narrow white streak running down the middle of the floor of the mouth 一條狹窄白色條紋從上而下位在口腔底部的中央 Piano wire frenulum (type IV) 戒 鋼琴絲 繫帶 ( 第四型 ) 53 Usually extends to the front of the tongue like a string 通常像一條絲線, 伸展到舌頭的前端 Pushing your finger into it often causes tongue tip to tilt downward, and tongue center to pull down and crease along middle 用你的手指推動它往往造成舌頭尖端傾斜向下, 舌頭的中心被往下拉, 沿著中央形成褶痕 Copyright 2010 Diana West, IBCLC

55 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC IDENTIFYING TONGUE-TIE 發現舌繫帶 Grooved Director tool can be very helpful Grooved Director 手術工具可能非常有用 FRENOTOMY 繫帶切開術 Frenotomy 繫帶切開術 Best done in baby s first year 最好在嬰兒一歲前進行 Can be done with topical anesthesia 能在局部麻醉下進行 Procedure takes 5-10 minutes 手術需時 5~10 分鐘 Can take 2-4 weeks to notice improvement 可能需要 2~4 週才明顯改善 Often incision is not deep enough with types III and IV 通常第 III 和 IV 型的切口會不夠深 Incomplete release can cause more nipple pain 切開不完全可能造成更多的乳頭疼痛 If pain is not completely improved or tongue still cannot move freely, reevaluate 如果疼痛無法完全改善或舌頭無法靈活活動, 重新評估 Scar tissue rare, but possible, restraining tongue 疤痕組織罕見, 但可能產生, 再次讓舌頭受限 Copyright 2010 Diana West, IBCLC 54

56 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC It doesn t usually get better with age! 這個情況通常不會隨著年齡漸長而改善! Extension capability does not rule out tongue-tie 伸展能力並不能排除舌繫帶 Copyright 2010 Diana West, IBCLC 55

57 Surprising Causes of Low Milk Production presented by Diana West, BA, IBCLC Questions? 問題? Thoughts? 想法? Comments? 建議? Each mother defines her own success 每個母親都有她自己的成功定義 Copyright 2010 Diana West, IBCLC 56

58 2010/9/29 IBCLC 國際認證泌乳顧問在台現況與展望 What is IBCLCs? Why do we need IBCLCs? How can become an IBCLC? 慈濟技術學院王淑芳博士國際認證泌乳顧問 (IBCLC: NO ) 國際認證母乳教育專家國際認證母乳同儕諮詢員行政院衛生署母乳哺育種子講師 And, after What I Have Been Doing as an IBCLC? Faces of IBCLCs in Taiwan. 1 2 專有名詞 ILCA: 國際泌乳顧問協會 International Lactation Consultant Association IBLCE: 國際泌乳顧問認證組織 International Board of Lactation Consultant Examiners IBCLCs: 國際認証泌乳顧問 International Board Certified Lactation Consultants CEUs: 核心教育時數 Core Education Units 何謂 國際認證泌乳顧問 -IBCLCs? 是經由國際泌乳顧問認證委員會報名資格審核且通過考試後所頒發之 國際證照

59 2010/9/29 有關 IBCLCs 全世界 69 個國家, 超過 名 為全世界 65 個國家保險給付制度承認之證照 ; 同時也是唯一被國際泌乳顧問組織 - ILCA(International Lactation Consultant Association) 所承認的母乳諮詢專業能力認證資格 WHY DO WE NEED IBCLCS? 5 6 笑增強母乳的健康效能 愛笑的母親哺餵母乳降低嬰兒過敏反應的效果較佳 母乳最好 -Journal of Psychosomatic Research, 62, 699. 母乳媽媽的心聲

60 2010/9/29 Why do we need IBCLCs? 工作人員的諮詢技巧不良, 有時造成母親過多的壓力, 甚至對於母乳相關問題無法提供正確且持續的支持 換言之, 由具有正確知識與諮詢技巧之專業人員提供婦女產前及產後相關諮詢服務將有助於全面提昇完全母乳哺育率與持續率 為什麼需要有 IBCLC 通過認證後, 對下列對象有幫助 : 需要協助的媽媽和嬰兒 其他想轉介媽媽給泌乳專家的專業人員 健康機構想 對母乳哺餵提供更好的支持 改善實務工作 教育和訓練員工 成為國際認證泌乳專家的你 有時侯證書可突顯出您的價值感 9 10 如何成為國際認證泌乳顧 IBCLCs Ⅰ. 合格的背景 醫療相關專業人員 泌乳專業學系 ( 亞洲區目前極少此類 ) 完成申請批准過之泌乳顧問課程者 Ⅱ. 60 小時泌乳專業教育 /CEUs ( 無論以中文或英文應試 ) : 在報名考試前 5 年內完成, 內容需符合考試大綱 Ⅲ.1000 小時臨床諮詢經驗 Lactation specific education hours CEUs 泌乳專業教育時數 內容範疇 有關母乳哺育及人類泌乳的資訊 著重於泌乳顧問工作時面對母親及嬰兒所必須使用的實際協助與諮詢技巧 以科學的原則及最新資訊及泌乳相關研究為基礎 符合專業倫理規範

61 2010/9/29 IBCLE 考試大綱 1. 母親及嬰兒解剖學 (19~33 題 ) 2. 母親及嬰兒一般生理學及內分泌學 (19~33 題 ) 3. 母親及嬰兒一般營養學和生化學 (10~16 題 ) 4. 母親及嬰兒免疫學和感染性疾病 (10~16 題 ) 5. 母親及嬰兒病理學 (19~33 題 ) 6. 母親及嬰兒藥理學 毒物學 (10~16 題 ) 7. 精神醫學 社會學 人類學 (10~16 題 ) 8. 成長的變數和發展的里程碑 (10~16 題 ) 9. 學術研究的判讀 (4~8 題 ) 10. 道德和法律的議題 (4~8 題 ) 11. 公共衛生 (4~8 題 ) 12. 技巧 (19~33 題 ) 13. 母乳哺育的裝備和技巧學 (10~16 題 ) 13 有關教育時數認定 60 小時時數中相同性質課程或主題不宜重複 上課證明必須是正式的文件 ; 包括研習證明, 或是醫院主管簽名且蓋有官坊的證明 由考生自行製作且缺乏正式認證簽署的紀錄表格, 恕不接受 (IBLCE 賦予國家聯絡人負責核對檢附的上課證明是否與報名表填寫之課程內容及時數符合 ) 14 Lactation specific clinical practice hours/bc Hours Breastfeeding counseling 泌乳臨床服務時數 15 須提供具體個案証明, 証明 BC 經驗 BC 經驗包括 : 一對一諮詢或追蹤 ( 當面或電話 ) 至少 50% ( 可以 100%); 通常是在醫院 診所或社區單位或認可的志工諮詢 電話或 諮詢也可以 ( 上限 25%) 教育課程 ( 上限 25%), 例如母乳哺育課程或產前團體 生產教育 新手父母課程中有關母乳哺育的部份亦可計算

62 2010/9/29 不能計算成 BC Hours 管理行政文書時數 交通 通勤時間 個人的母乳哺乳經驗 朋友及家人的諮詢 在一般嬰兒室照護正常寶寶 常規支持或推動更多母親哺餵母乳的活動 個人實習時數, 例如助產士訓練時期時數不能算入 考試表格填寫 注意 報名表一定要完全以英文填寫 務必確認相關聯絡資料的正確性 ( 及 5 碼郵遞區號 ) 寄交報名表前務必依檢核表一一核對及排列 相關資格條件由考生之實務指導者 (Direct supervision) 或單位主管簽署認證 由任何兩位能 推薦 您的母乳諮詢能力的人寫推薦信即可, 無須一定要是 IBCLC 填寫報名表有不清楚之處請務必電話詢問 名字姓 通訊資料 5 碼郵遞區號 / 過去 5 年之母乳諮詢經驗工作機構職稱內容期間總週數週時數總時數 BC%/ 時數 個人特殊需求行動不便懷孕中文應試字典 指導主管親筆簽名 / 為您的 BC 經驗背書

63 2010/9/29 CERP: 繼續教育認可點數 過去 5 年之泌乳教育時數日期地點課程名稱研習證明泌乳教育時數 60 小時泌乳教育時數必須於報名時完成 Continuing Education Recognition Points L-CERP Lactation specific CERP E-CERP Ethics specific CERP R-CERP Related CERP 目前工作單位及地址 PROFESSIONAL DETAILS Registered Nurse/ 專業 Degree in / 學歷 SIGNED STATEMENT 個人聲明 ( 人格健全 ) Signature of Applicant 考生簽名 23 報名相關提醒 中文試卷應考條件 : 每年年底前 15 人完成報名 一旦試題翻譯為中文, 台灣則一律採中文應考 考試時間 : 每年 7 月最後一週的星期一 2,3 月底前報名費有優惠 ( 約澳幣 );4 月底報名截止 ( 約澳幣 370) 報名時 60 小時教育時數必須完成且檢附證明 所有證明文件可以直接以中文影本繳交 報名前請慎重考慮後! 報名後申請取消, 退費金額不到一半 ( 請見報名表收費說明 )

64 2010/9/29 重要提醒 考試資訊 再叮嚀 為了節省航空郵資, 繳交資料請以雙面影印 所有報名相關資料務必於 12/2/3/4 月底前 5 日前寄給 IBLCE 台灣聯絡人 : 王淑芳花蓮市 建國路二段 880 號 一律採團體報名 費用由國家聯絡人統一繳交後, 以澳洲匯入當天匯率計算後通知大家 所有相關證件資料必須於報名時一併繳交 ( 含 60 小時教育證明 ), 資格不符合或資料不全, 直接退件 中文試卷翻譯條件 : 每年年底前 15 人完成報名 1000 小時泌乳臨床服務時數,2011 年起須檢附個案紀錄之 服務證明 60 小時泌乳專業教育 /CEUs,2012 年起增加為 90 小時, 且內容需符合考試大綱 報名時 60 小時教育時數必須完成且檢附證明 應試提醒與考試結果 上下午各 2.5 小時, 共 175 單選題 早上 75 題臨床彩色照片題 下午 100 情境題 答錯不倒扣, 儘量每題都答 試題紙上可以寫或計算 結果會在 10 月上旬會個別通知 通過標準乃依當年考生水平而定 全球平均及格率在 65-68% 左右 ( 台灣平均約 85%) 平時落實服務母乳家庭, 考前用心準備練習 勝過神明保佑及天地祈福 建議書單 - 實用問題處理教科書 Biancuzzo, M. Breastfeeding the Newborn: Clinical Strategies for Nurses. Mosby, Brodribb, W. (ed) Breastfeeding Management. Australian Breastfeeding Association, Lauwers, J, and Swisher A. Counseling the Nursing Mother. Jones & Bartlett, 4th Edition The Royal College of Midwives, UK. Successful Breastfeeding. Churchill Livingstone, Mohrbacher, N, and Stock J. The Breastfeeding Answer Book. La Leche League International, Linda J. Smith. Comprehensive lactation consultant exam review. Jones and Bartlett Publishers, /c

65 2010/9/29 建議書單 - 專業教科書 建議閱讀書單 - 臨床圖譜書 Lawrence, Ruth and Lawrence, Robert. Breastfeeding: A Guide for the Medical Profession: Elsevier Mosby, ILCA Core Curriculum for Lactation Consultant Practice. Walker, M (ed), Jones & Bartlett, Riordan, J. Breastfeeding and Human Lactation. Jones & Bartlett, Auerbach, K and Riordan, J. Clinical Lactation: a visual guide. Jones & Bartlett, Wilson-Clay, B and Hoover, K. The Breastfeeding Atlas 3rd edition. Lactnews Press, Austin Texas, Denise Both Kerri Frischknecht; 王淑芳總編譯, 哺乳問題的診斷與治療 : 圖解指南 Breastfeeding an illustrated guide to diagnosis and treatment, 台灣愛思唯爾 相關組織出版品或網站 Academy of Breastfeeding Medicine ILCA World Health Organization, Geneva La Leche League International 網路學習網址 : AND AFTER PASSED

66 2010/9/29 What I Have Been Doing as an IBCLC? 從概念到實踐 評估 Asses 三 A 歷程 行動 Act 分析 Analyze 從概念到實踐 人 - 服務內容 / 成立宗旨 1. 為什麼夠資格開設母乳特別門診 ( 老師的經驗及魅力不是一般護理人員可以達到的 ) 2. 母乳特別門診有何特別 ( 要如何區隔與一般衛教護理師做區隔 ) 3. 如何讓醫院認同 低投資報酬率 的看診方式 ( 花蓮慈濟目前母乳哺育特別門診為一人一小時, 一個診限掛 4 人 ) 從概念到實踐 事 - 法規流程 1. 事先申請設立此診注意事項 : 例如法令規範 職稱 病歷紀錄 ICD9 2. 收費依據. 母乳特別門診如有電話諮詢收不收費. 母乳特別門診如有出去家訪有收費嗎? 3. 服務範疇 : 依照 IBLCE 制定之 IBCLCS 工作規範手冊 4. 如何宣傳

67 2010/9/29 從概念到實踐 找出進入醫院系統的介面平台 與關鍵人物討論可行性及討教醫院生態 注意, 隱惡揚善是重要的溝通訣竅 強調優勢, 爭取主管認同 與國際同步 配合國家政策 符合性別照護 以及機構文化形象 當然 低投資報酬率 就無需主動提及啦! 37 慈濟醫院母乳哺育特別門診眾人牽成 38 母乳哺育特別門診 服務型態 : 約診 家庭訪視及電話訪談 服務時間 : 每週四下午 2-5 點 服務場域 : 婦產科一診 服務範圍 : 產前諮詢 生產準備 乳房問題 家庭調適 性生活 等相關議題 收費方式 : 宣傳特惠價 400 元 / 次 ; 家訪另計交通費 150 元 / 次 從概念到實踐 成效評估 97 年 1 月至今, 由限掛 3 人增加至 5 人, 服務近 300 個母乳家庭 求診原因 : 產後哺育問題為主 ( 家人覺得奶水不足 寶寶哭鬧 乳房問題 早產兒哺育 ) 另 ; 哺乳性生活及產前諮詢亦偶見 看診個案之 6 個月完全母乳哺育率近 8 成

68 2010/9/29 困境 諮詢與治療之迷思電話諮詢如何收費? 誤認為 女 醫師主動追蹤之人力與時間耗損行政系統之 醫師 簽名?? 如何擴大服務量行銷及推廣計畫 從概念到實踐 反思 物 - 成效評核 1. 看診紀錄如何呈現與轉為效能數據 2. 約診如何滿足不定性需求 3. 跨領域 / 部門聯盟之成效 4. 回診率背後的意義 展望 結合親善醫院評鑑制度 慧澤大眾 全面健保化 爭取設置專業科系 增加國內 IBCLC 人數之餘

69 2010/9/29 IBLCE Country Coordinators (CC) 國家聯絡人 協助 IBLCE 考試相關事宜 郵寄或上傳相關考試資訊 確保考生及 IBCLCs 個人資訊之隱私性 義務性協助文件翻譯 處理及審核考試文件 寄發報名表 安排監考官及考場 協助 CERP 積分申請 規劃及提供再認證課程相關資訊 45 5 年再認證 CERPs 再認證要求提出 75 CERPs 證明, 且 : 50 小時 L (lactation related) CERPs 5 小時 E(ethics) CERPs. 其餘的 20 小時 CERPs 可以是 L, E or R (related) CERPs 46 再認證 CERPs- 與國際接軌 參加國際研討會 2011 年 7 月 日美國聖地雅哥 ( 摘要 ) 再認證 CERPs- 自學精進 線上 Health e-learning 月 日瑞士

70 2010/9/29 再認證 CERPs- 上課與發表 參加台灣母乳哺育聯合學會課程 一天 (5-8 小時 ) 課程, 認證費 100 元 報到簽名及填具 IBCLC 編號 國家聯絡人會在收到 CERPs 證明後寄出 列印後存留於 CERPs 信封中 發表文章 / 碩博士論文 (75CERPs) 出發 才會到達目標 感恩 期望