Three to Five Days Postpartum: A Gap in Care

Continuous, ongoing lactation support is critical to prevent premature weaning from breastfeeding. As we head into World Breastfeeding Week 2024 and think about the theme Closing the Gap: Access to All, it is timely to think about closing the gap between hospital and outpatient breastfeeding support. 

Timely support

The value of primary care and team-based lactation support remains limited if the first visit is not scheduled in a timely fashion and does not include breastfeeding support.

In a recent conversation with lactation consultants regarding challenges integrating with primary care practices, one concern raised includes: many families have already quit breastfeeding before the first newborn check up at one week postpartum. While many factors, including adequate prenatal education, contribute, it is important to factor in the timing of the first visit; waiting 3 to 7 days after hospital discharge can be too long.

Challenges faced before the first outpatient visit

The most common challenges faced in the first 3 to 5 days after delivery include: 

• Increasing engorgement: Imagine the family who was latching well in the hospital and then gets severely engorged after hospital discharge at 4 days postpartum.  They find their baby won't latch and because of the swelling they have trouble expressing milk. 
• Cracked nipples: Imagine a breastfeeding parent with worsening cracked nipples. It is painful both to latch and to pump so they decide to do neither until they are seen. 
• Delayed lactogenesis: Imagine a mother who had gestational diabetes, cesarean section and her milk does not start to increase until 5 days postpartum.  Between hospital discharge at 48 hours and their first visit the infant becomes increasingly fussy with decreased wet diapers. 
• Jaundice: Imagine the infant with increasing jaundice.  They are sleepy with feeds, and while latching well in the hospital, are now only latching briefly before falling asleep. 

You cannot prepare for all scenarios prenatally. Rather, personalized care designed to match your family’s individual needs at that moment is needed. 

One week is a long time!  

A lot happens in that first week. Babies transition from small volumes of intake to 2 to 3 ounces per feeding. Successful latching can make the difference in establishing milk supply and resolving pain and cracked nipples. With the potential for over 40% of families to experience delayed lactogenesis, support in the first couple of days to establish milk supply, breastfeeding, and monitor infant weight gain is critical.

Close follow-up

When the practice I collaborate with implemented team-based lactation visits over 15 years ago we saw  the number of days between hospital discharge to first visit decrease from median 7 days to 3 days.  The practice saw a transition from lactation consultants seeing infants only if they were having difficulties at 1 to 2 weeks of age, to routinely seeing all infants.  Currently for the practice,  the median days between hospital discharge and first visit is within 48 hours, consistent with the the American Academy of Pediatrics  recommendations for infants to be seen within 48 hours of discharge if length of stay < 48 hours. These recommendations translate to the goal for most babies to be seen at around 3 to 5 days postpartum which perfectly corresponds to the window of time to evaluate and address latching difficulties, pain, engorgement, and delayed lactogenesis. 

Timing along with availability

When designing team-based breastfeeding care at the infant’s primary care provider, it is not just a matter of having a lactation consultant available at the pediatric office, but making certain the timing and access of that appointment is within the recommended time period and overlaps with when difficulties first start. 

Whether the first week, or when there is a new challenge, “Access to All” includes providing timely care.  There are not enough lactation consultants available to provide everyone with immediate access, and patients have limited time, barriers to transportations, and varying recovery from delivery. 

Let’s make that first visit count by having breastfeeding support integrated into the routine first outpatient primary care visit.