breastfeeding - acmt · breastfeeding. a meta-analysis combining 45 studies published thru 2001...
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Breastfeeding
Anne Eglash, MD, FABM,* IBCLC,†Anne Montgomery, MD, FAAFP, FABM,* IBCLC,†
and Julie Wood, MD, FAAFP, FABM,* IBCLC†
ackgroundreastfeeding has always been the gold standard for infant feeding.hroughout recorded human history, populations knew that not breast-
eeding was associated with infant mortality, despite evidence that someopulations did not survive due to artificially feeding their young.1
During the turn of the 20th century, with the industrial revolution in fullwing, women left their children during the day to work in cities, andany children were artificially fed not only with cow’s milk, but with a
ew product: infant formula. With pasteurization and refrigeration, theery high mortality rate of artificially fed infants declined, such thatrtificial feeding became more popular. Eventually prescribed by physi-ians in the United States during most of the 20th century, artificialeeding was embraced as being more scientific and healthier thanreastfeeding. By 1972, less than 30% of infants were exclusivelyreastfed in the first week of life.2
While many physicians were prescribing formula for infant feeding, Laeche League emerged in the 1950s as a strong grass roots movementmong women in many countries, to re-establish infant feeding at thereast.2 Eventually, with increasing scientific evidence of the risks oformula feeding, and the incomparable benefits of breastfeeding, healthrganizations worldwide have published policy statements that affirm themportance of breastfeeding as well as risks of artificial feeding for allopulations around the world.3,4
urrent RecommendationsThe international infrastructure of breastfeeding policy was the Inno-
enti Declaration, established by policymakers at a meeting sponsored by
FABM: Fellow of the Academy of Breastfeeding Medicine.IBCLC: Certified by the International Board of Lactation Consultant Examiners.is Mon 2008;54:343-411
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HO and UNICEF in 1990.5 The Declaration set a number of criteriahat should be met by each government in order to increase breastfeedingates worldwide and therefore decrease infant mortality rates. Thiseclaration was adopted as the basis for international health policy on
nfant and young child feeding at the 44th World Health Assembly in991.The main features of the Declaration include:
) Every government should have a national breastfeeding committee.) Every facility providing maternity services shall practice the “10 Steps
to Successful Breastfeeding.” These 10 steps are procedures thatreduce barriers and empower women to successfully breastfeed theirinfants.
) Enforce the principles and aims of the International Code of Market-ing of Breast-Milk Substitutes. “The Code,” as it is usually referred to,is a set of recommendations to regulate the marketing of breastmilksubstitutes, bottles, and teats. Breastmilk substitutes should be avail-able when needed, but not promoted.6
) Every government shall enact legislation to protect the breastfeedingrights of every working woman.
The World Health Organization recommends that infants be exclusivelyreastfed for the first 6 months of life to achieve optimal growth,evelopment, and health. Thereafter, to meet their evolving nutritionalequirements, infants should receive nutritionally adequate and safeomplementary foods while breastfeeding continues for up to 2 years ofge or beyond.The American Academy of Pediatrics (AAP) and the American Acad-
my of Family Physicians also recommend exclusive breastfeeding forbout the first 6 months, followed by complementary foods at around 6onths, with the continuation of breastfeeding for at least 1 year and
eyond for as long as is mutually desired by the mother and child.3,4 TheAP policy statement emphasizes that there is no age limit at whichreastfeeding should terminate. No studies have shown psychologicalamage to children who breastfeed up to age 3 and beyond.3
Healthy People 2010, which is a national health promotion and diseaserevention initiative, includes an objective to increase breastfeeding ratesn the USA. Its 2010 target is for 75% of all mothers to initiatereastfeeding after birth, 50% continuing to breastfeed at 6 months with5% of those mothers exclusively breastfeeding until 6 months, and 25%
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reastfeeding RatesAccording to the 2004 Center for Disease Control National Immuniza-
ion Survey, approximately 73.8% of mothers in the USA initiatedreastfeeding, 41.5% were breastfeeding at 6 months, and 20.9% werereastfeeding at 1 year.Women who are older, have a higher education, and strong family
nd/or partner support are more likely to breastfeed. Adolescents are moreikely to breastfeed if their mothers did. Women who are married andomen with a higher income also have greater breastfeeding rates. In thenited States, there is a significant difference in breastfeeding prevalence
mong different ethnic groups. Hispanic women have the highest breast-eeding rates, followed by Caucasian women. Non-Hispanic Africanmerican women have the lowest breastfeeding rates in the USA.9
enefits of Breastfeeding
nfantBreastfed children do not share the same illness or mortality rates of
rtificially fed children, even in developed countries. There is evidenceor short- and long-term benefits of breastfeeding.Artificially fed infants have significantly higher rates of acute otitisedia, non-specific gastroenteritis, severe lower respiratory tract infec-
ions, atopic dermatitis, asthma, sudden infant death syndrome (SIDS),nd necrotizing enterocolitis.3
The immune system of newborns is immature, and the complex andlaborate anti-infective properties of breastmilk protect the young infantrom infection. In addition to immunoglobulins, human milk containsroteins such as lactoferrin, lysozyme and casein, lipids, oligosaccha-ides, enzymes, prostaglandins, growth factors, hormones, and cells thatork in many different ways to prevent infections and modulate the
mmune system. This natural immune protection is not available tortificially fed infants.10
These special properties of breastmilk also provide long-term protectionrom many diseases seen at higher rates in artificially fed infants,ncluding an increased risk of obesity, type 1 and 2 diabetes, andhildhood leukemia.11 The Agency for Healthcare Research and Quality,n its 2007 comprehensive literature review, found no definite relationshipetween breastfeeding and IQ performance; however, most studies hadignificant confounding variables not controlled for, particularly maternalntelligence.12
The World Health Organization concluded in their systematic review
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nd meta-analysis that adults breastfed as infants have a modest decreasen blood pressure and cholesterol compared with adults who neverreastfed.13 The AHRQ summarized that the risk of cardiovasculariseases and breastfeeding in infancy needs further investigation beforeccepting this association.
aternalBreastfeeding has been shown to improve pancreatic �-cell function inomen with a history of gestational diabetes.14 In a large prospective
tudy involving 2 cohorts of nurses totaling 150,000 subjects, there wasn inverse relationship between duration of breastfeeding and risk of type
diabetes among women without a history of gestational DM. Eachdditional year of breastfeeding was associated with a 4% (95% CI 1-9)educed risk of developing type 2 diabetes in the first cohort and a 12%95% CI 6-18) reduced risk in the second cohort.12,14
Breastfeeding did not appear to impact the risk of developing type 2iabetes among the nurses who had gestational diabetes.15
Studies show that breastfeeding for a short time or not at all isssociated with a higher risk of postpartum depression, although it isnclear how these are related. It is possible that women who haveymptoms of postpartum depression may wean the baby early or chooseot to breastfeed.12
The risks of ovarian and breast cancer are higher in women who do notreastfeed, and these risks are inversely associated with the duration ofreastfeeding. A meta-analysis combining 45 studies published thru 2001ith approximately 147,275 women calculated a 4.3% (95% CI 2.9-5.8)
eduction in breast cancer for every year of breastfeeding.16 Anothereta-analysis has shown a 28% decreased risk of breast cancer in womenho breastfeed longer than 12 months.17
AHRQ performed a meta-analysis on 9 studies that examined theelationship between ovarian cancer and breastfeeding. They found a 21%95% CI 9-32) reduction in the risk of ovarian cancer compared withomen who never breastfed.12
Breastfeeding is associated with a decrease in fertility, which improveshild spacing. This is particularly true when a woman is exclusivelyreastfeeding, meaning that the infant is not receiving any other food suchs formula or solids. A clinical algorithm, called the Lactation Amenor-hea Method (LAM), has been established. If a woman is amenorrheic,er baby is under 6 months of age, and she is fully breastfeeding hernfant, then she has a 1-2% chance of becoming pregnant at that time.18,19
nce she resumes menstruating, or if her baby is over 6 months, and/or
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he initiates other foods for the baby, the LAM method is no longerpplicable.
ocietalWomen who work outside the home have a shorter duration ofreastfeeding, and intentions to work full time are significantly associatedith lower rates of breastfeeding initiation and shorter duration.20,21
orking women who are faced with too many barriers to continuereastfeeding take off more sick days for their children as compared withomen who continue to breastfeed while back to work. Several studies
ndicate that support for lactation at work benefits individual families asell as employers. Supportive employers experience earlier return of
mployees from maternity leave, an enhanced public image as anmployer, decreased employee absenteeism, fewer health care costs, andess employee turnover.22-24 Among the top 100 mother-friendly compa-ies rated in Working Mother magazine 2007 for the USA, 98% haveactation support programs, as compared with 26% nationally (based on2007 survey of Society for Human Resource Management).25
Because breastfeeding babies and mothers are healthier, breastfeedingas been found to decrease health care costs for families, employers, andociety.26 One study found that infants breastfed for at least 3 monthsaved the health care payer more than $300 during the first year of life asompared with formula-fed infants, just for the diagnoses of otitis media,ower respiratory infections, and gastroenteritis.23,26
A 1999 Italian observational study studied the health care costs of 2nfant cohorts, 458 fully breastfed infants versus 362 not fully breastfednfants. The ambulatory health care costs for the fully breastfed groupere approximately 34.69 Euros per infant/year compared with 54.59uros for non-fully breastfed group, and 133.43 versus 254.03 Euros forospital care, respectively.27
natomy and Physiology of Breastfeeding
reast Anatomy (Fig 1)The glandular tissue of the breast is comprised of 15-20 lobes. Within
ach lobe are lobules with clusters of alveoli, like grapes on a vine, whichre lined with milk-producing cells called lactocytes. The alveoli passilk through ductules, which eventually drain into a more dominant duct
eading from each lobe to the nipple pore. Each alveolus is surrounded byyoepithelial cells, which contract in response to oxytocin released from
he posterior pituitary.28 The cells compress the alveoli, sending milk
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own the ductal system to be expelled by the breast. This is seen clinicallys a let-down, or milk-ejection reflex (Fig 2).The nipple has 4-18 openings, or pores. The nipple and areola contain
rectile tissue, allowing the nipple to elongate with infant feeding andumping. The areola is the darker pigmented area around the nipple andontains Montgomery glands, which are located circumferentially. Thesemall oil-producing glands provide lubrication and help prevent infectionf the skin.28,29
The mammary gland develops through five stages30: (1) Embryogene-is, (2) Pubertal development, (3) Development during pregnancy, (4)actation, and (5) Involution.Embryogenesis. During fetal development, the mammary bud can be
dentified at 18-19 weeks gestation. This epidermal tissue extends into theubepidermal mesenchyme. This is met by mesenchymal tissue thatxtends subdermally to form the fat-pad precursor. The fat-pad precursors invaded by ducts that branch out to form an immature mammary ductystem. These rudimentary breasts are present at birth in the connective
IG 1. Anatomy of the human breast. (Adapted with permission from Donna Geddes, PhD.vailable from: http://www.biochem.biomedchem.uwa.edu.au/Our_People/home_pages/cademic_staff/hartman/peter_hartmann/download.) (Color version of figure is availablenline.)
issue just posterior to the nipple. This tissue will often become swollen
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nd may secrete milk after birth, under maternal hormone influenceuring pregnancy.Pubertal Development. At puberty, the hypothalamus secretes gonado-
ropin-releasing hormone, which in turn stimulates anterior pituitaryelease of LH and FSH. Both LH and FSH stimulate ovarian productionf androgens, progesterone, and estrogen. Estrogen stimulates the growthf the mammary ducts into the mammary fat-pad, and progesteroneontributes to lobulo-alveolar development (Fig 3).The mature breast of a woman before her first pregnancy is divided into
obules which consist of terminal duct units. These terminal duct lobularnits consist of ducts with a few small branching ductules terminatingnto alveolar clusters, which are underdeveloped and quiescent untilregnancy.Pregnancy. The hormone changes of pregnancy stimulate full devel-pment of the breast tissue, and there is an overall increase in the ratio oflandular tissue to adipose tissue in the breast. The concentration oflandular tissue is greatest close to the nipple in the distal breast. Thesehanges are responsible for the breast growth and discomfort that womeneel during the first trimester. Progesterone, prolactin, and placental
IG 2. Lobules with a lobe of the breast. (Reprinted with permission from Hanne M. Jensen, MD:he Breast in 3 Dimensions: Fact and Fancy, 2005.) (Color version of figure is available online.)
actogen play central roles in the development and differentiation of
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landular tissue, particularly the alveoli. One small study measuring therowth of breast tissue during pregnancy found that breast growthorrelates with placental lactogen levels. Breast growth during pregnancymong the eight women in this study ranged from 12 to 227 mL.31
strogen is thought to stimulate elaboration of the ductal system (Fig 4).Lactation. Lactogenesis, defined by the onset of milk production and
ecretion, is divided into two stages32:Stage 1. The first stage of lactogenesis occurs during the second
rimester of pregnancy, when prolactin from the anterior pituitary glandtimulates the lactocytes to further develop and produce colostrum. Thisarly colostrum contains lactose, total proteins, and immunoglobulins.igh levels of circulating progesterone prevent milk production duringregnancy.Stage II. After birth of the infant and expulsion of the placenta, therogesterone level drops, ushering in the production of milk synthesis,nder the influence of the high prolactin level. Significant changes in thelveoli occur with a decrease in permeability between the lactocytes.ecause this decrease in permeability prevents movement of molecules
hrough the spaces between lactocytes and into the plasma, there is a
IG 3. The developing breast. (Reprinted with permission from Hanne M. Jensen, MD: Thereast in 3 Dimensions: Fact and Fancy, 2005.) (Color version of figure is available online.)
ecrease in sodium and chloride levels in colostrum, and an increase in
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actose and other mature milk components. Most women notice aelatively low volume secretion of colostrum the first 24-48 hours. Onverage, colostrum secretion is about 100 mL/day, and is high in IgA andactoferrin, two very important immunoprotective proteins. During therst 4 days postpartum, colostrum secretion rapidly evolves into transi-
ional milk, which is much greater in volume and contains mostomponents of mature milk. With this increase in milk volume, theoncentration of lactoferrin and IgA decreases approximately 10-fold.ncreased levels of �-lactalbumin, lactose, citrate, glucose, free phos-hate, and calcium are associated with increased milk volume. Transi-ional milk is defined by the continuum of changes that occur in milkomposition from colostrum immediately postpartum to mature milk bybout 10 days postpartum.32
Constituents of mature human milk can be broken into the followingategories; proteins, nonprotein nitrogens, carbohydrates such as lactosend oligosaccharides, lipids, vitamins, minerals, and cells. The mostariable constituent in human milk is fat, which can be influenced byuration of gestation, months postpartum, parity, breastmilk volume,iming during feeding, maternal diet, and maternal weight gain during
IG 4. A normal breast slice clusters of lobules, with their terminal ducts. A major duct is alsoresent. (Reprinted with permission from Hanne M. Jensen, MD: The Breast in 3 Dimensions:act and Fancy, 2005.) (Color version of figure is available online.)
regnancy.33,34
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Human milk proteins not only provide amino acids, but have diverseoles such as immunoprotection, carriage of vitamins and hormones, andnzymatic activity. The main carbohydrate is lactose, which is the secondajor constituent of breastmilk. Lipids provide the highest concentration
f calories in breastmilk, supplying 30-50 g/L.Vitamin content of breastmilk varies according to maternal vitaminutritional status. In general, if maternal vitamin status is sufficient,reastmilk vitamin levels are stable and do not vary in accordance withaternal intake.33
Delayed Lactation. The rapid increase in milk volume between 36 and20 hours postpartum is perceived by mothers as the “coming in” of theirilk. Multiparous women tend to have an earlier increase in milk volume
han primiparous women. Many factors have been associated with a delay inactogenesis,32 such as cesarean section, placental retention,35 obesity,36-38
rolonged second stage of labor, flat or inverted nipples,38 stressful delivery,nd diabetes.40 Women who experience a delay in lactogenesis may nototice a rapid increase in milk supply until approximately 6-10 daysostpartum (Table 1).Hormonal Regulation of Lactogenesis. A decrease in progesterone and
ontinued elevation of prolactin are required for lactogenesis to occur.he decrease in progesterone is accomplished by the removal of thelacenta postpartum. As milk volume increases, removal of milk ismportant to maintain lactogenesis.Prolactin is secreted by the anterior pituitary gland, and its secretion
rom the pituitary gland is partially regulated by the amount of nippletimulation that occurs during early lactation. In the absence of sucklingostpartum, prolactin levels will decrease to prepregnancy levels by 7ays.44 Prolactin stimulates the synthesis of milk by binding to membrane
ABLE 1. Factors associated with a delay in lactation
Cesarean section38,39
Prolonged second stage of labor38
Flat or inverted nipples38
Pacifier use38
Primiparity38,39
Diabetes40
Medications that inhibit prolactin and oxytocin (see Table 10)Retained placental fragments35
Obesity36-38
Inadequate frequency of nursing/pumping30,41
Maternal stress during delivery42,43
eceptors of the mammary epithelial cells. Although elevated prolactin
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evels are necessary for milk production in early lactation, the volume ofilk produced is not associated with prolactin levels.30 Prolactin secre-
ion is also under the inhibitory control of dopamine, produced in theypothalamus. Catecholamine levels in the hypothalamus influence do-amine levels, so medications and events which decrease catecholamineevels also decrease dopamine levels, thereby increasing prolactin lev-ls.44 Prolactin levels tend to be highest overnight, which is when mostomen will attest to having higher milk supplies. Prolactin levelsradually diminish over time postpartum despite continuing successfulreastfeeding. Approximately 6 months postpartum, the breastmilk sup-ly becomes more dependent on milk demand and removal than onrolactin levels; however, prolactin levels do remain above baseline untileaning occurs.30
Oxytocin is responsible for milk-ejection, or “let down.” Secreted byhe posterior pituitary, it acts by stimulating contraction of myoepithelialells which surround alveoli and ducts in the lactating breast. Theontraction of the myoepithelial cells enables milk transport and ejectionrom the breast. Several stimuli initiate the pulsatile oxytocin release as aeuroendocrine reflex, including tactile stimulation to the nipples andight, sound, or thought of the infant. Mothers commonly feel theiret-downs, perceived as a tingling, tight sensation. During a breastfeedingession, several let-downs may occur. Oxytocin release can be inhibitedy psychological stress, alcohol consumption in a dose-dependent man-er,29 and opioid use.32
he Breastfeeding-Friendly Physicians OfficeSeveral studies have demonstrated that health provider support ofreastfeeding is associated with an increased initiation and duration ofreastfeeding rates among the provider’s patients, especially if the healthrovider is trained in lactation.45 The Baby Friendly Hospital Initiativestablished evidence-based steps that a hospital can take to improveuccessful breastfeeding outcomes. These steps can be applied to theutpatient medical setting where families receive their ongoing care.It is recommended that a medical office develop a breastfeeding-
riendly policy in conjunction with the office staff. The policy couldnclude items such as not offering free formula gift packs, encouragingothers to breastfeed, and ensuring new families the opportunity to visitith a health care provider prenatally to discuss infant feeding.Breastfeeding women should be encouraged to breastfeed in the office.rivacy should be offered to mothers, but it should not be mandatory for
others to move to a separate place to breastfeed. Comfortable, support-M, June 2008 353
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ve chairs should be available, and a breastfeeding pillow with anntibacterial cover is a convenient item to offer breastfeeding mothers.he office should have positive visual messages encouraging breastfeed-
ng, as opposed to pictures and materials that demonstrate artificialeeding as the norm. Samples of formula, bottles, and nipples should note given to families as gift packs.46 The office should have communityreastfeeding resources available that list locations to purchase breastumps, phone numbers for support groups, classes, and names of lactationpecialists.The office clinical staff should have sufficient knowledge and triage
ools to manage phone calls about breastfeeding problems and concernsegarding medications and breastfeeding. Educational materials for fam-lies regarding breastfeeding issues, such as engorgement, human milktorage, sore nipples, latch, and low milk supply, should be availableTable 2).Discussing the topic of breastfeeding during well-woman exams can
ncrease a woman’s awareness of breastfeeding pre-pregnancy. Duringeview of the self-breast exam, women can be taught about the naturalunction of the breast, along with the maternal health benefits ofreastfeeding, particularly in regard to the decreased risk of breast cancer.Preteens and teens can also be taught about the natural function ofreasts, and why the breasts grow in puberty.
renatal EducationHealth provider encouragement of breastfeeding during antenatal careas been shown to increase the incidence of breastfeeding, particularlymong minority and single women.47
The United States Preventive Services Task Force found fair evidencehat educational programs combining breastfeeding education with be-avioral counseling, such as 30- to 90-minute breastfeeding classes run byactation consultants, are associated with increased breastfeeding initia-ion and continuation for up to 3 months postpartum.48
Many women make their decisions about infant feeding before theyecome pregnant, and the maternity care provider should discuss infanteeding with every pregnant woman. Not only should women be asked byhat method they plan to feed their newborn(s), but also encouraged to
hare their reasoning if not planning to breastfeed. Many women haveisguided beliefs about breastfeeding that can be remedied with appro-
riate counseling. Women and their partners should express understand-ng of the risks of artificial feeding for the infant and woman’s health.49
t is important to take into consideration the cultural beliefs of the woman
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nd her partner. Providing breastfeeding information for other familyembers such as grandparents can help provide breastfeeding support to
he expectant mother.Pregnant women and their partners should be encouraged to attend areastfeeding class that incorporates anatomy and physiology of breast-eeding, positioning and latch, normal frequency and duration of feedings,eneral breast care, how to assess whether the baby is feeding well, andecommendations on duration of breastfeeding.48
During prenatal care, it is recommended that the maternity care provideriscuss breast development and perform a breast exam in order to identifyed flags for the risk of insufficient milk postpartum. Women should besked whether they have noticed an increase in breast size and breast
ABLE 2. Breastfeeding-friendly physician office
ffice Staff ● Breastfeeding office policy.● Knowledgeable phone triage.● Sensitivity to breastfeeding women’s needs in the
office setting.● No free formula samples or other promotion of artificial
feeding.ffice Physical Plant ● Comfortable private place to nurse.
● Welcome atmosphere to nurse in the waiting room.● Positive visual messages about breastfeeding;
avoidance of artificial feeding messages.● Books available as resources for physicians and office
staff regarding maternal medications, management ofcommon problems.
ealth Care Providers ● Available prenatal visit to discuss infant feeding andcare with pediatric provider.
● Maternity care provider to discuss breastfeedingprenatally and perform a breast exam.
● Encourage a breastfeeding class prenatally.● Provide written or multimedia resources for patient
education.● See the baby within 1–2 days after discharge from the
hospital or birthing center, and continue frequent visitsuntil the baby is gaining weight adequately and motherappears confident.
● Observe a breastfeeding session.● Work in concert with lactation professionals in the
community, and provide information for othercommunity resources.
● Support breastfeeding mothers and babies whenconfronted with medical needs that may jeopardizebreastfeeding success (ie, medications, procedures).
● Address breastfeeding issues at well-child visits.
iscomfort during the first trimester. Lack of breast changes during
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regnancy may be associated with an insufficient milk supply postpartum.history of breast surgery, such as reduction or augmentation, and breast
rradiation also places the newborn at risk for insufficient milk. On exam,vidence of inverted nipples that will not evert with gentle pinching maylso increase the risk of insufficient milk transfer.50
ontraindications to BreastfeedingThere are very few contraindications to initiating or continuingreastfeeding. In the United States, maternal HIV infection is consid-red a contraindication to breastfeeding, since the HIV virus canpread through breastmilk. However, in countries where alternatives toreastfeeding are not available, safe, affordable, or sustainable,reastfeeding is recommended.7 Untreated maternal tuberculosis andctive herpes lesions on the breast also are contraindications toursing. Women who are treated with antimetabolites, chemotherapygents, or who have exposure to radioactive materials, includingiagnostic or therapeutic radioactive isotopes, should not nurse untilhese substances are cleared from the breastmilk. Infants who havealactosemia should not breastfeed.3,51
Active use of certain drugs of abuse, such as PCP, heroin, cocaine,nd methamphetamine, is generally contraindicated during breastfeed-ng.3 Because maternal–infant bonding is increased with breastfeed-ng, and bonding is very important to decrease the risk of infanteglect,52 each case involving a maternal history of substance abusehould be individually evaluated by the physician(s) of the mother andnfant, as well as social services, to determine the cost/benefit of
ABLE 3. Contraindications to breastfeeding
Maternal Substance Ingestion Maternal Illness Infant Illness
rugs of abuse:● Cocaine● Heroin● LSD● Methamphetamine● Marijuana● PCP● Inhalants
HIV infectionHTLV infectionUntreated maternal TB infectionActive herpes simplex lesions on
the breast
Galactosemia
aternal medication:● Radioactive isotope therapy● Antimetabolite therapy
(ie, cancer treatment)
reastfeeding (Table 3).
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etting Off to the Right Start for Healthy Termnfants
ospital RoutinesHospital practices surrounding labor and birth have been found to havereat impact on the success of breastfeeding initiation, Many policies androcedures developed in hospitals during the 20th century have not takennto account lactation physiology and neonatal needs in regard toreastfeeding. The World Health Organization and UNICEF recognizedhe barriers posed by hospital policies, and in 1989 published a set ofecommended guidelines titled “Protecting, Promoting, and Supportingreastfeeding: The Special Role of Maternity Care Practices.”53 From
his document emerged “The Ten Steps to Successful Breastfeeding”Table 4). As of August 2007, 61 hospitals and birth centers in the USAave been designated as “Baby-Friendly” by establishing education,olicies, and procedures to optimize their level of care for lactation.54
Healthy infants should have as little intervention as possible after theyeliver and should have immediate skin-to-skin contact with theirothers at least until after the first feeding has occurred (Fig 5). Infants
ave natural instincts to breastfeed and will often latch themselves ontohe breast if health care providers allow them the opportunity.55 Afterirth, encourage hospital staff to dry, stimulate, and assess the infant onhe mother’s abdomen. The baby may be covered with a blanket while
ABLE 4. Ten steps to successful breastfeeding
1. Have a written breastfeeding policy that is routinely communicated to all health carestaff.
2. Train all health care staff in skills necessary to implement this policy.3. Inform all pregnant women about the benefits and management of breastfeeding.4. Help mothers initiate breastfeeding within a half hour of birth.5. Show mothers how to breastfeed, and how to maintain lactation even if they should be
separated from their infants.6. Give newborn infants no food and drink other than breast milk, unless medically
indicated.7. Practise rooming-in; allow mothers and infants to remain together 24 hours a day.8. Encourage breastfeeding on demand.9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding
infants.0. Foster the establishment of breastfeeding support groups and refer mothers to them on
discharge from the hospital or clinic.
ource: The Baby Friendly Hospital Initiative USA; Available from: http://www.babyfriendlyusa.rg/eng/01.html.
kin-to-skin with the mother. The mother’s body temperature will adjust
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o the baby’s needs.56 Over-vigorous suctioning of the oral cavity andirway should be avoided to prevent later feeding aversion. Routinerocedures such as vitamin K injection, eye ointment, and routinemmunizations should be delayed until baby has completed the firsteeding.Mothers and babies should remain together and “room-in” the sameospital room throughout their hospital stay. While rooming-in, parentsill learn about their baby’s early feeding cues, such as rooting, placing
he hands to the mouth, and increased physical activity (Fig 6). Room-ng-in has been found to increase frequency of feeding as well as short-nd long-term success of breastfeeding.57 It is important to teach thatrying is a late sign of hunger, and it is often difficult to get the baby toatch on and feed once the baby is crying.Term breastfeeding newborns should ideally nurse 8-12 times a day.he frequency may vary with some feedings clustered together. Theaby may need to be awakened for feeds every 3 hours during the firstew weeks until he or she is gaining steadily and is back to birtheight.49 A baby may be gently stimulated by massage or changing
he diaper if she needs to be awakened to nurse. There should be no
IG 5. A mother holding an infant skin-to-skin immediately after birth. (Color version of figure isvailable online.)
ime limit at the breast. The baby should finish feeding on one breast
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nd then, if still exhibiting hunger cues, latch onto the other breast. Ifhe baby only nurses from one side, offer the other breast first at theext feeding. It is ideal to nurse equally from both breasts in a 24-houreriod. Parents frequently express concern about whether their baby isetting an adequate amount of breastmilk— especially first timearents or those who have fed with a bottle and are accustomed toitnessing the exact volume baby has consumed. All health careroviders should be aware of appropriate newborn elimination patternsn order to educate parents about signs of sufficient milk intake.58
ypically, on day 1 of life, a healthy term newborn will producepproximately 1 stool and 1 small urine. On day 2, 2 stools and 2rines are typical, and on day 3, a minimum of 3 stools and 3 urinesre expected. Beyond day 3 as the mother’s mature milk appears, ateast 6-8 wet diapers and 6-8 yellow, seedy stools are reassuring eachay. Many parents and health care providers find it helpful to have aeeding and voiding/stooling log available in the early postpartumays to assure proper nutrition and hydration of the infant59 (Table 5).Education of nurses, physicians, and other health care professionalsorking with the nursing couplet regarding the dynamics of breast-
eeding is imperative in order to assist the nursing couplet with
IG 6. A baby demonstrated an early feeding cue. (Color version of figure is available online.)
ppropriate positioning and latch. It is recommended that a health care
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rofessional, usually a nurse, observe a breastfeeding every shift whilen the hospital or birthing center. This will help to ensure properransfer of milk to the baby, and decrease the risk of sore nipples,racks, and breast infections.
ositioningTypically taught positioning of the baby involves holding the newborn
lose to the mother, with the ear, shoulder, and hip aligned, andummy-to-tummy with mother. The cradle hold involves supporting theead and upper body with a bent arm that is on the same side as the breasteing fed from. The other arm supports either the breast or the lower partf the baby’s body. With the cross-cradle hold, the mother supports theaby at the breast using the opposite arm to the breast by holding theosterior head just beneath the occiput, as well as the trunk and buttocksf the baby. The ipsilateral arm supports the breast. The cross-cradle holds a more common position when the baby is very small, very young,nd/or has a weakness in the upper body and neck. Commonly, a mothernd baby will each lie on their sides, facing each other, to nurse. A babyay also lie on top of a reclining mother in a vertical, oblique, or
orizontal manner. In whatever comfortable position the mother chooseso use, paying attention to infant alignment helps to ensure a deep latcho that the nipple is not traumatized and the baby can effectively transferilk (Figs 7–10).
atchOnce positioned in a way that is comfortable for mother and baby, theaby should be brought close to the breast. Often, the baby’s mouth willpen wide with tactile stimulation to the lower lip and chin from thereast. Once the baby’s mouth is open wide, the baby should be brought
ABLE 5. Signs of sufficient milk intake
Infant Mother
Audible swallowing heard during feeding ● Breasts are full before a feeding andAppears relaxed during feeding and softer after a feedingsatiated after feeding ● May notice let-down reflex duringHas awake, alert, calm times between feedingfeedingsNurses 8–12 times in a 24-hour periodDiapers are almost always wet, andseveral stools per day after milk “is in”Gains 20–30 g a day after day 3–5 of life
o the nipple/areolar complex in an asymmetric fashion, with the chin and
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ower lip first touching the areola. The upper mouth is then broughtorward over the nipple/areolar complex, in order to latch onto the breasts deeply as possible. It is helpful to think of the baby latching onto thereast in the same way an adult would try to take a big bite from a veryhick deli sandwich. Sometimes the nipple/areolar complex needs to beompressed with the free hand to enable the baby to attain a deep latch,rying to get as much areola into the baby’s mouth as possible (Figs 11nd 12).Alternatively, and likely much more naturally, the baby can be
nabled to self-latch to the breast. The baby should be placedkin-to-skin ventrally between the mother’s breasts, in an uprightosition, so that if the baby looks up, he will see his mother’s face.nce the baby is relaxed and hungry, the mother will observe aobbing and pecking behavior against her body, and the baby willttempt to throw himself laterally. The mother should continue toupport the baby, but also allow the baby to lead such lateralovement to the breast. As the baby reaches the nipple, the baby will
xtend his neck in a sniffing position, keeping his chin and lower lipgainst the breast in close proximity to the nipple, open his mouth
IG 8. A mother holding her baby in a cross-cradle hold, using the opposite arm from the breasto support the baby. (Color version of figure is available online.)
ide and latch onto the nipple/areolar complex.60
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uckingWhen the baby is actively nursing, the mother should feel that the babyas good suction, without a sense that the baby will easily detach.ucking is often described as nutritive, where the baby is receiving milknd swallowing accordingly, versus nonnutritive, when the baby is notctively receiving milk, so only has intermittent swallows. Mothershould be taught to look for the different types of sucking to gain annderstanding of when her let-down occurs, and when the baby may note actively feeding (nonnutritive sucking) at the breast. Sucking at thereast can be challenged by many factors, such as a very fast flow rate ofreastmilk, infant fatigue, illness or discomfort, breathing difficulties,ypotonia, a short lingual frenulum, gastroesophageal reflux, torticollis,left lip and palate, macroglossia, and other oromotor pathology.61
upplementationParents, and often health care providers, worry that breastfeeding babieseed supplementation in the first few days of life. There is a common
IG 9. A mother feeding her baby in a side-lying position. (Color version of figure is availablenline.)
erception that colostrum is not adequate in calories or volume. Healthy, term
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ewborns do not need supplementation unless medically indicated. A visualid, such as a walnut or large marble, to demonstrate for parents the small sizef the newborn’s stomach can be invaluable. Colostrum is calorie- androtein-dense, as well as rich in antibodies and other immune substrates,aking it the ideal food for a newborn.10 However, health care providersust adequately assess the positioning, latch, suck, and swallow to assure
IG 10. The football hold, where the baby is supported under mother’s arm. (Color version ofgure is available online.)
hat the breastfeeding infant is effective in obtaining colostrum58 (Table 6).
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Although a term healthy newborn should not need supplementation, theollowing are situations in which supplementation of mother’s milk isedically indicated.
xcessive Weight LossA normal infant should be gaining 20-30 g a day once mother’s milk is
in,” around day 3-5 postpartum. An 8-10% weight loss without evidencehat mother’s milk is increasing, or that the baby is starting to gain weight,s a reason to supplement the baby.62 Feedings should be witnessed tossess latch, suck, and swallow to assure milk transfer. A common reasonhat a healthy baby may not gain sufficient weight despite presence of aufficient milk supply is infant sleepiness. Breastfeeding is a much morective process of feeding than bottle feeding, and oftentimes newbornseed to be gently awakened to finish feeding.63 Infant sleepiness is easyo diagnose; parents will usually complain that the baby falls asleep earlyn the feeding and is hard to keep awake. Occasionally a sleepy baby mayeed supplementation, since excessive weight loss may lead to more
IG 11. A latch often seen on an older infant, with relaxed lips, face close to the breast, theorner of the mouth slightly pursed.
leepiness and inability to successfully breastfeed.
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nfant IllnessIll infants often do not breastfeed well due to weakness, suck dysfunc-
ion, or lack of appetite and may need supplementation. Unless pro-
IG 12. A latch typical of a newborn, with a wide open mouth, nose touching the breast, doublehin present. (Color version of figure is available online.)
ABLE 6. Medical reasons for supplementation in term, healthy infant
Infant Maternal
ypoglycemia, measured by serum glucose,after infant has had opportunity tobreastfeed.
nborn errors of metabolism.nability to feed at the breast due to
separation, illness, or congenitalanomaly.
linical evidence of dehydration.ncontrolled hyperbilirubinemia despiteoptimal breastfeeding.eight loss of greater than 8–10% withdelayed lactogenesis.
eed for additional nutrient intake in lowbirthweight infants.
Delayed lactogenesis with poor infantintake.
Unavailability of mother due to illnessor geographic separation.
Primary glandular insufficiency.Prior breast surgery or radiation.Medications/substances not
compatible with breastfeeding.Maternal illness contraindicating
breastfeeding.
oundly ill, the neonate should be allowed to breastfeed regularly, with
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upplementation offered after breastfeeding as needed. Typical illnesscenarios include hypoglycemia, hyperbilirubinemia with a bilirubinround 18 or above, acute dehydration, infection, hypotonia, anatomiceformities, and gastroesophageal reflux.64
aternal–Infant SeparationOccasionally a mother and baby may be separated if a mother or infantas to be transferred to another medical floor, another medical facility, orf the mother is too ill to feed the baby completely by breastmilk. Aother who is separated from her infant should be encouraged to pump
er breasts at least every 3 hours or 8-10 times a day to maintain her milkupply and to provide breastmilk for her baby. Hospital staff should beensitive to this need and should provide education and support for theother. In the first few days postpartum, it can be very difficult to express
ufficient colostrum for the baby using an electric breast pump, andanual expression has been demonstrated to be more effective.65 A
ursing baby typically will ingest more colostrum than what pumping canrovide, so often these babies need some supplementation.
aternal MedicationIn rare situations, the mother may need to take a medication that is
ontraindicated with breastfeeding. Usually medications that are new orf concern with breastfeeding can be substituted by medications that arenown to be safe with breastfeeding.
elayed or Insufficient LactogenesisSome mothers who are highly motivated to breastfeed will still haveifficulty with onset of lactogenesis, suboptimal breastfeeding, or poornfant weight gain. Dewey and coworkers investigated risk factors leadingo such difficulties and found factors associated with suboptimal breast-eeding early postpartum to include primiparity, cesarean section, flat ornverted nipples, the infant’s health at birth, supplementation withoutsing breastmilk in the first 48 hours, pacifier use, stage II of labor greaterhan 1 hour, maternal BMI greater than 27 kg/m2, and birth weight greaterhan 3600 g. Findings in the study also emphasized the importance oflose follow-up at 72-96 hours postpartum, given the risk of infantehydration in these cases.38
If supplementation is medically indicated, the preferred choice is toupplement with the mother’s expressed breast milk. If the baby is able toreastfeed, the mother should pump her breasts after nursing the baby.
nother option is pasteurized banked donor human milk from a milk bankM, June 2008 367
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hat follows the guidelines established by the Human Milk Bankingssociation of North America.66 Infant formula is a third choice for
upplementation. Glucose water or sterile water should never be used,ince they do not supply sufficient calories or protein to substitute forother’s milk. The method of supplementation, such as a cup, bottle,nger feeding, or a supplemental tube at the breast, should be individu-lized, ideally in consultation with a knowledgeable health professional,s all methods can interfere with the baby’s ability to nurse successfullyt the breast. Risks of supplementation include interfering with maternalilk supply, maternal discouragement, difficulty getting the baby back to
reast, and changes in bowel flora due to the use of formula.Cup Feeding (Fig 13). Cup feeding is considered a safe way to
IG 13. A medicine cup can be used to supplement a young infant. (Color version of figure isvailable online.)
upplement a baby and is used in several special care units for premature
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nfants. It may also be used for short-term supplementation of term infants.few studies have demonstrated fewer oxygen desaturations and lower heart
ates with cup feeding as compared with bottle feeding for premature infants,ossibly because of the slower rate of feeding that occurs with cupeeding.67,68 Cup feeding should be demonstrated to the parent by anowledgeable health professional. Usually a 30-mL medicine cup or shotlass is used, and the milk is allowed to touch the lower lip so that the babyill sip or lap the milk. Milk should not be poured into the baby’s mouth.Finger Feeding (Fig 14). Finger feeding is another short-term option
hat allows safe supplementation. An infant feeding tube or a butterflyeedle with the needle removed is attached to a syringe of milk, and theube is attached to a finger. When the baby sucks on the finger, the babyraws the milk from the syringe. It is safest to not push the syringe,llowing the baby to suck the milk at his own pace. Finger feeding allowshe infant to have more control over feeding as compared with a bottle.here is no evidence that finger feeding is preferred over bottle feeding in
erms of preserving feeding skills at the breast, but it may be a morecceptable form of supplementation by the baby as opposed to the bottle.Supplemental Tube at the Breast (Fig 15). A supplemental nursing
IG 14. Fingerfeeding. A feeding tube is attached to a syringe, and taped to a finger. (Colorersion of figure is available online.)
ube to be used at the breast can be purchased commercially, or a gastric
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eeding tube and syringe can be used, as described with finger feeding.he tip of the tube is situated at the nipple, and taped onto the breast.hen the baby attaches to the breast, the baby will also attach to and
IG 15. A supplemental nursing device used at the breast. The baby latches onto the breast andhe tube to receive supplementation while nursing. (Color version of figure is available online.)
eceive milk from the feeding tube. This technique is beneficial in cases
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here the milk supply is low, or the baby is weak and not very effectiveith sucking. Use of a supplemental tube at the breast may be limited by
ts cumbersome nature, lack of portability, and acceptance by the infant.Bottle Feeding. Bottle feeding remains the most common method of
upplementation for breastfeeding babies. Sucking from a bottle entailsifferent oromotor skills than breastfeeding, which can result in the babyecoming conditioned to the bottle and preferring the bottle overreastfeeding.63 Many babies, however, are able to nurse at the breast andottle feed with equal skill. For babies that need long-term supplemen-ation or when mothers return to work, bottle feeding is the most practicalethod to use.Pacifiers should not be offered until breastfeeding is well establishedithout difficulties and the baby demonstrates appropriate weight gain.henever a newborn shows an interest in suckling during the first few
ays postpartum, the baby should be put to the breast, and not given aacifier. This will help establish mother’s milk supply as soon as possible,nd ensure adequate nutrient intake by the newborn. One study hasemonstrated that pacifiers are associated with a decreased breastfeedinguration.69 Once breastfeeding is going well and the infant is gainingell, parents must also be counseled that, if electing to use a pacifier, it
hould be for non-nutritive sucking only and not a replacement forursing. They should be certain that the baby is not hungry beforeffering it.70
ospital DischargePrior to leaving the hospital or birthing center, it is important for parents
o express confidence of knowledge regarding several breastfeedingssues. Each mother should demonstrate competence with nursing, in-luding latching, identifying infant swallows and readiness to end aeeding, and identifying early feeding cues. Health care providers shoulde sure that parents understand the normal frequency and duration ofeedings of the newborn, as well as the number of expected stools and wetiapers indicating adequate hydration. Parents should know how to wakep a sleepy baby to assure an adequate number of feedings in the earlyewborn days.58,59 Mothers should also know that breast engorgementay occur on day 3-5 postpartum. They should be taught that frequent,
ffective feeding often prevents significant engorgement.71 However, ifhe breasts become too taut around the nipple–areolar complex for theaby to latch on well, she should manually express or use a pump toemove a small amount of milk from the breasts, making it easier for the
aby to latch on.M, June 2008 371
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Upon discharge, arrange to see the baby within 1-2 days in the office.f the baby demonstrates breastfeeding problems, neonatal jaundice, orxcessive weight loss, follow-up in 1 day is indicated. The baby should beollowed as an outpatient every 1-2 days until he/she demonstrates aeight gain of 20-30 g per day and mother expresses confidence
egarding infant feeding.59 It is also important to assess other breastfeed-ng problems, especially sore nipples, which should be evaluated imme-iately (see “Maternal Problems”). It is also not too early to address a planor the mother who may be returning to work and to share milk storagenformation. Provide parents with information on breastfeeding resourcesn the community. These may be the local La Leche League or hospitalreastfeeding support group, local lactation consultants, public andrivate health offices, and WIC. A breastfeeding hotline may also beelpful to new breastfeeding parents. If a local hotline is unavailable,onsider the National Breastfeeding Hotline (1-800-994-9662), providedy the Department of Health and Human Service’s Office on Women’sealth.
ommon Breastfeeding Problems: Neonatal
he Near Term Infant Not in the NICUInfants born during 35-37 weeks gestation require individualized
actation assistance. Often these babies do well enough to avoid aICU stay, room-in with mom, and are discharged at the same time as
heir mothers. However, they do tend to have a unique set of issuesequiring heightened awareness regarding breastfeeding. Near termnfants often have an uncoordinated suck and swallow due to lowuscle tone and neurologic immaturity. They are sleepier and are at
isk of not waking up when they are hungry and in need of calories andydration. Therefore, they have a higher risk of hypoglycemia, andecause of their relative immaturity, they have delayed hepaticilirubin excretion leading to jaundice. When working with the nearerm infant, consider an automatic lactation consult to help the motherstablish an adequate milk supply, and to optimize infant feeding athe breast— especially if the baby is a weak nurser. To be proactive inreventing excessive weight loss, dehydration, and jaundice, near termabies often need supplementation, ideally with mother’s own ex-ressed milk, after feeding at the breast.72 These babies also need verylose follow-up after discharge, usually within 24 hours after dis-
harge to monitor for the above problems.72 DM, June 2008
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eonatal Jaundice (Table 7)Jaundice, caused by elevated levels of serum bilirubin, affects manyewborns in the first week of life. One study demonstrated that 5-12% ofreastfed infants had bilirubin levels �15 mg/dL compared with 0.6–2%f infants who were fed formula.73 DeCarvalho and coworkers comparedhe amount of bilirubin in stool and serum on days 1 and 3 in breastfednd formula-fed infants. The decreased excretion of bilirubin in thereastfed infants’ stool and resultant elevation in serum bilirubin levels asompared with the formula-fed infants are likely due to the decreasedolume intake of colostrum versus formula. There was also less stoolutput among the breastfed infants in the first days, leading to lessilirubin excretion.74
Mild jaundice in the first week postpartum is considered physiologic,nd more recently, this slight hyperbilirubinemia has been recognized asossibly beneficial to the infant for its anti-oxidant properties.75
In order to prevent kernicterus and its long-term sequelae, all babieshould be assessed for severe, unconjugated hyperbilirubinemia prior toeaving the hospital or birthing center.3 One of the most common causesf non-physiologic jaundice in the breastfeeding infant is ineffectivereastfeeding with insufficient calorie intake. Appropriate interventionnvolving lactation assessment must be made to correct the feedingroblem and improve calorie intake. Breastfeeding does not need to benterrupted, but the infant may need to be supplemented. Appropriateupplementation includes expressed breastmilk, pasteurized donor humanilk, or infant formula. Water should not be given as a supplement. With
n increased calorie intake, infants will generally stool more, therebyecreasing their intrahepatic circulation and decreasing their bilirubin
ABLE 7. Risk factors for unconjugated hyperbilirubinemia in breastfed babies76,77
● Insufficient calorie intake● Blood group incompatability● Cephalohematoma● Hemolysis● Infant illness● Gestational age less than 38 weeks● East Asian race● Family history of jaundice● Infant macrosomia of a diabetic mother● Breastmilk jaundice● Congenital thyroid deficiency
evel.
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Other risk factors for severe unconjugated hyperbilirubinemia includelood group incompatibilities, infant illness such as infection or sepsis,rematurity, cepahalohematoma or other bruising, East Asian race, familyistory of jaundice, or infant macrosomia of a diabetic mother. Jaundiceppearing less than 24 hours is never physiologic, and etiology must beromptly evaluated.76 Breastmilk jaundice is an extension of physiologicnconjugated hyperbilirubinemia beyond the first week of life. It is alsoaused by increased bilirubin reabsorption from the intestine. Usually, theotal bilirubin will be greater than 12 mg/dL but less than 20 mg/dL.irect bilirubin will be normal as will liver enzymes. Other causes of
aundice must be ruled out. If a term baby is greater than 5 days old,eeding, stooling, and gaining weight well, and the bilirubin is remainingess than 20 mg/dL, no treatment is needed. There is no special treatmentequired for breastmilk jaundice for stable bilirubin levels less than 18g/dL in healthy near term infants 35-37 weeks or a 38-week infant with
ther risk factors for jaundice. There is no indication for interruption ofreastfeeding or routine supplementation in any of these cases. Becausereastmilk jaundice is a diagnosis of exclusion, it is important to followilirubin levels until they are decreasing. Breastmilk jaundice may take upo 3 months to resolve. If bilirubin rises above 18-20 mg/dL, phototherapyhould be initiated. If phototherapy does not adequately reduce theilirubin level, then it is advisable to interrupt breastfeeding for 24 hoursnd feed the baby with an elemental formula while the mother pumps andaves her milk.76
ypoglycemiaThe definition of hypoglycemia in the newborn remains variable and
ometimes controversial based on gestational age, weight, type ofeasurement, and whether symptomatic or asymptomatic. It is well
stablished that healthy, term, breastfeeding, appropriate-for-gestational-ge infants do not need routine monitoring of blood glucose as this cannterfere with breastfeeding and does not appear to improve outcomes.ven in the presence of a single low glucose reading, the health carerovider should consider whether the infant is symptomatic, feeding well,r has other risk factors. Newborns at highest risk of hypoglycemianclude: small for gestational age (�10th percentile), large for gestationalge (�90th percentile), a discordant smaller twin, infant of a gestationaliabetic mother, low birth weight �2500 g, post asphyxia, erythroblas-osis fetalis, polycythemia, cold stress/hypothermia, sepsis, respiratoryistress, endocrine abnormalities, or inborn errors of metabolism. In
ddition to being cognizant of the risk factors for hypoglycemia, encour-74 DM, June 2008
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ging frequent breastfeeding by continuous maternal–infant contact helpso prevent hypoglycemia by promoting normal physiology.78
nsufficient Weight GainAny infant who has lost more than 10% of birth weight, who has not
egained his birth weight by 2 weeks of age, or who has an unexplainedeight loss or failure to gain properly must be evaluated immediately for
nsufficient weight gain. The infant should be gaining 20-30 g per daynce the mother’s milk is “in” by day 3-5 postpartum.79 Insufficienteight gain may occur because (1) the infant is not feeding effectively,
2) the infant has a higher than expected calorie need, or (3) mother hasn insufficient milk supply.Infant Factors for Slow Infant Weight Gain. Infant risk factors foroor or sluggish feeding behavior include prematurity, congenital andcquired infections, trisomy 21, gastroesophageal reflux disease, congen-tal anomalies (particularly of the mouth and throat), congenital heartisease, cystic fibrosis, neurologic conditions, suck incoordination, ahort lingual frenulum, or excessive sleepiness.64 More rarely, somenfants may also have a higher than expected caloric need, or are volumeestricted and unable to obtain sufficient calorie intake with a givenolume of breastmilk. These problems are diagnosed based on infantistory, physical exam, and observation of a feed. It is important for arained health care professional to determine whether adequate milkransfer is occurring. The infant may have a poor latch, inadequateucking due to weakness, or suck and swallow may be uncoordinated.re- and postfeeding weight assessments may help to determine adequacyf milk transfer. Ineffective feeding may lead to low maternal prolactinevels and incomplete breast emptying, leading to a decreased milkupply.32 Treating the underlying medical problem of the infant will oftenelp or remedy the insufficient infant feeding.Maternal Factors for Slow Infant Weight Gain. Many situationsredispose to a low milk supply, including maternal–infant separation,uch that the baby is not able to feed often enough: use of a nipple shield,aternal hormone imbalances, insufficient glandular tissue, a history of
reast surgery, medication or substance use, and maternal illness, eithercute or chronic (see “Maternal Health Problems: Low Milk Supply”).A careful history and physical examination of the mother and baby
hould be performed, as well as observation of a breastfeeding session. Its important to ask about the duration and frequency of feeding, infantehavior at the breast such as shortness of breath or sleepiness, and
atterns of stool and urine output. Inquire whether the mother has anyM, June 2008 375
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oncerns about how breastfeeding is going or if she is having any pain,edness, or other concerns regarding her breasts, or any history ofedication use, breast surgery, or lack of breast fullness postpartum.erform a complete examination of the infant, with attention to the mouthnd sucking reflex, followed by observation of a feeding session. Whilehe baby is breastfeeding, attention should be paid to the positioning,uck, swallow, and oral–motor coordination. A breast exam may also bendicated.64
Once the underlying cause for the poor weight gain is identified andorrected, the infant may begin to gain in an appropriate or an acceleratedanner. Careful observation of intake and weights should continue until
he expected growth pattern is achieved. In some situations, supplemen-ation may need to be given with expressed mother’s milk, donor humanilk, or formula. Care should be given to individualize the method of
upplementation with a cup, finger feeding, supplemental system at thereast, or a bottle. This decision may require consultation with a lactationonsultant. Most babies can continue to breastfeed in addition to receivingxtra calories from supplementation.62,72
ommon Breastfeeding Problems: Maternal
ngorgementDuring Lactogenesis II, approximately 2-5 days after delivery, milkroduction increases. At this time, there is increased blood flow to thereasts accompanied by interstitial edema. Breasts normally become fullnd warm. Excessive engorgement with pain and edema may be pre-ented by (1) avoiding excessive intravenous fluids and oxytocin in thentrapartum period, (2) frequent and complete emptying of the breast inhe early neonatal period, and (3) continued frequent nursing during theeriod of Lactogenesis II.80
Ideally, breastfeeding will begin within an hour of birth. Babies may noturse well the first postpartum day if labor analgesia has been used.other and baby should be kept together and should spend as much time
kin-to-skin as possible. Most healthy term babies will begin nursing wellithin 24 hours. After the first 24 hours, if the baby is not makingrogress toward latching well or if the mother and baby are separated,other should be assisted with expression of milk to assure adequate
rainage of the breast to prevent or ameliorate engorgement. If mothernd baby are separated right after birth and nursing will not be startingromptly due to infant illness, the mother can be assisted to begin milk
xpression as soon as she is stable after the delivery.7076 DM, June 2008
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In more troubling cases, women may develop bilateral breast redness,iscomfort, and low grade fever. Sometimes the area around the nippleecomes firm and less compressible, which may make it difficult for theaby to latch on deeply and effectively to the breast, potentially causingipple trauma and poor milk transfer. Mothers should be taught to handxpress some milk to soften the areola, making it easier for the baby toatch on appropriately.81 Engorgement can be relieved by frequent breastmptying and/or nursing and cool compresses. Some recommend chilledreen cabbage leaves placed directly against the breast tissue under thera,82 although a systematic review of studies for breast engorgementound cabbage leaves, oxytocin, cold packs, and ultrasound therapy to beo better than placebo in relieving engorgement.83 Unrelieved engorge-ent may lead to decreased milk supply and other complications, such as
ipple damage and mastitis.
igantomastiaThis rare condition occurs in about 1/100,000 women. The etiology is
hought to be hormonal. It may mimic severe engorgement when it occursn the early postpartum period. It consists of severe, often painfulnlargement of both breasts. It usually develops during pregnancy butay occur in the postpartum period. The pain can be extreme, and in
evere cases, necrosis of the breast skin can occur. Although it usuallyesolves postpartum, it can recur with subsequent pregnancies. Treatmentor severe or recurrent cases usually involves bilateral subcutaneousastectomies.84,85
ore Nipples (Table 8)Sore nipples are one of the most common reasons for prematureeaning, and probably the most common reason women do not continueursing past the first few weeks.86,87 Most women experience transientipple soreness while the baby is latching on during the first week or two.owever, nipple damage is never normal and there should be no nippleain between feedings or once milk is flowing during a feeding. Manyothers think sore nipples are to be expected; however, it is important to
ducate mothers prenatally and in the early postpartum period thatersistent sore nipples, and especially nipple damage, are not normal andhould prompt her to seek assistance.The most common precipitating cause of sore nipples is incorrect
atch88 (Fig 16). Mothers should be assisted with obtaining a correct latchrom the very first feed. If nipples are sore, a knowledgeable professional
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ABLE 8. Causes of sore nipples
echanical/Trauma● Improper positioning● Incorrect latch● Suck disorganization● Ankyloglossia● Infant biting● Pump trauma
nfectious● Candida of nipples● Bacterial infections
X ImpetigoX MastitisX Intraductal
● Herpes simplex/zosterermatoses
● Atopic dermatitis● Irritant dermatitis● Allergic dermatitis● Psoriasis
ormonal● Menstrual cycle● Pregnancy
asospasm● Primary, due to Raynaud syndrome
● Secondary, due to trauma, infectionIG 16. Sore nipple. This mother sustained nursing trauma to her nipple from inappropriate latch
nd suckling. (Color version of figure is available online.)78 DM, June 2008
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eeded corrections. Infant ankyloglossia (“tongue-tie”) may also contrib-te to nipple soreness, due to the difficulty the baby may have withatching deeply onto the breast (see “Getting Off to the Right Start”).nce latch and positioning problems have been identified and corrected,
he underlying cause of persistent sore nipples must be identified. Theifferential diagnosis of persistent sore nipples includes bacterial infec-ion, yeast infection, dermatitis or other primary skin disorders, Raynaudhenomenon of the nipples, nipple trauma, and hormonal factors such aseturn of the menstrual cycle or pregnancy.Persistent sore nipples may be due to infection. Any break in the skinf the nipple may harbor a bacterial infection, usually due to Staphylo-occus aureus. Nipple wounds should be cultured if possible. Superficialipple impetigo may be treated with topical mupirocin 2% ointment orral antibiotics suitable to treat a S. aureus infection. Oral antibiotics maye more effective than topical antibiotics, and should definitely beonsidered if there is any tenderness of the areola or underlying breastissue or other evidence of deeper infection.89 Mothers should bebserved closely for development of acute mastitis, with symptoms ofever, myalgias, and breast redness and swelling. Continued breastfeedinghould be encouraged if at all possible. If the nipples are too sore for theother to feed the baby at the breast, she should be assisted to maintain
actation via hand or pump expression, and her milk may be fed to heraby.Yeast infections of the nipple are common, especially when there is
oncomitant oral thrush or candida diaper dermatitis in the baby. Aaternal vaginal yeast infection can also predispose to this condition. The
ipples look bright red, shiny, and are very tender and sometimes pruritic.ain with a nipple yeast infection often presents as a burning prickly pain
n the nipples, with possible deep, shooting pain radiating into thereasts.90 Both mother’s nipples and baby’s mouth should be treated ifither shows signs of yeast. Treatments may include topical nystatin qidtopical cream to mother’s nipples and oral suspension for the baby),opical 1% Gentian violet painted every 2 or 3 days for 3 doses in theaby’s mouth and on mother’s nipples, or oral fluconazole for mother andhe baby for 7-10 days. Breast pads should be changed frequently, andny bottle nipples or pacifiers should be sterilized regularly. Yeastnfections, however, are often over diagnosed and treated, sometimes overhe phone, without thorough evaluation. Most true isolated yeast infec-ions are superficial nipple dermatoses. Deep breast pain and anyersistent breast pain should be carefully evaluated since the infecting
rganism is more likely to be Staphylococcus than Candida.91 Breast milkM, June 2008 379
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ultures can be falsely negative because the lactoferrin in breastmilkuppresses growth of pathogenic organisms. Special culture techniquesre being studied to improve the reliability of breastmilk cultures, such asdding iron to culture media to bind lactoferrin.90
Atopic dermatitis, contact dermatitis, psoriasis, and other dermatosesay present on the nipple.92 Women who have a history of skin disorders
re particularly at risk for nipple dermatoses. Possible allergens orrritants should be identified and eliminated. These may include newetergents used to launder the bras, creams used on the nipples, or traumarom pumping. Topical corticosteroids such as triamcinolone 0.1%, eitherream or ointment, may be used. It is best to avoid fluorinated and higherotency topical steroids if possible, although these may be used short termf needed to adequately treat the condition. Although absorption of theteroid by the infant is minimal, the nipple may be cleansed with aaterless moisturizing cleanser prior to a feeding. Bacterial and yeast
uperinfection is possible, especially if there are breaks in the skin. Nippleultures may aid in diagnosis.The differential diagnosis for nipple dermatitis includes Paget’s diseasef the nipple. Paget’s disease is a rare cancerous condition that mimicsermatitis or may appear as a yeast infection, with itching, burning,edness, and scaling of the nipple and areola. There may be a bloodyischarge and the nipple may be flattened against the breast. Biopsy of thereola should be considered for recalcitrant cases of nipple dermatitis toid in definitive diagnosis of the dermatitis and to rule out malignancy.93
Vasospasm of the nipple (Raynaud phenomenon) usually presents asurning or sharp, shooting pain following a feeding or at other times thathe nipple is subjected to temperature change, such as showering orwimming. The pain is accompanied by color changes of the nipple fromale/white to blue/purple to red. This can be primary, especially inomen with a prior history of Raynaud syndrome or autoimmune disease,ut most commonly it is secondary to nipple trauma or infection. If it isprimary problem, the pain will only occur when nipple color changes
re present, and during exposure to cold as well as during or after nursing.f the Raynaud symptoms stem from the presence of an infection orermatitis, the nipples and/or breasts will hurt even when there are noolor changes of the nipple. The vasospasm may be treated successfullyith immediate warmth, such as a heating pad or warm moist cloth,
pplied to the breast and nipple immediately after nursing. Avoiding nipplexposure to cold and emotional stress has also been recommended.94
owever, the first treatment is to identify and treat the underlying cause.
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ore severe or persistent cases of vasospasm can be treated with calciumhannel blockers such as extended release nifedipine.95
If mothers have persistent sore nipples or nipple damage, the infanthould be examined for evidence of ankyloglossia or tongue-tie. Whileost tongue-tied babies can bottle feed without much difficulty, anky-
oglossia has been shown to have an effect on the duration of breastfeed-ng. If there is evidence of a shortened lingual frenulum and a breast-eeding problem related to this, such as sore nipples, poor latch, ornsufficient milk transfer, clipping of the frenulum is indicated. In thearly weeks, when the frenulum is thin and translucent, this is a simpleffice procedure that does not require anesthesia. When there is a thickerbrous or muscular frenulum, referral to an oral surgeon or otolaryngol-gist may be required.96
Sore nipples that occur several months postpartum may result fromormonal changes with the menstrual cycle, trauma from infant biting orulling, or pump trauma. Pregnancy may also cause sore nipples, andhould be considered in amenorrheic women without any other clearause of nipple soreness.
lugged DuctsPlugged ducts may present as tender lumps in the breast that are not
ssociated with redness or fever. These often occur during periods ofrregular nursing when the breast is not being fully emptied. Commonituations include when mothers return to work, longer durations of infantleep at night, or maternal separation from the infant for other reasons.ometimes mechanical factors, such as underwire bras or other restrictivelothing, can contribute to poor breast drainage. Plugs may also occur inbreast subjected to previous surgery with disruption of ducts. Ductal
egments that are completely unable to drain will eventually involute andtop producing milk. Maternal stress, fatigue, and poor fluid intake maylso contribute to frequency of plugging. Frequent nursing or pumping,ointing the baby’s nose toward the lump while nursing, and gentlyassaging the lump during feeds can help with drainage. Recurrent
lugged ducts may also indicate a low-grade bacterial infection in theilk ducts, particularly if the breasts feel sore with deep throbbing.91
ersistent plugged ducts can lead to acute mastitis with fever and breastedness. Some women have found that reducing dairy fat intake or addingecithin supplements reduces plugging. As with other breast lumps, aresumed plugged duct requires further evaluation if it persists for morehan a few days. A recurrent plugged duct in the same area without prior
reast surgery should also be evaluated for a possible obstructing lesion.97M, June 2008 381
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astitisClinical mastitis occurs quite frequently among lactating women, with
n incidence varying from 2.5% to 27%, depending on the population.98
Mastitis represents a localized interstitial infection in the breast, mostommonly due to S. aureus, although other pathogens may includetaphylococcus epidermitis, Streptococcus, or other bacteria.99 It mayresent as a localized red, tender area of one breast and usually isssociated with systemic symptoms such as fever, myalgias, and lassi-ude, which may even precede the distinct breast symptoms. If fever is notresent, the first intervention may be rest, fluids, frequent moist heat, andrequent drainage of the affected breast. When fever is present, or whenreast symptoms have been present for 24 hours, treatment with annti-staphylococcal antibiotic is recommended. Milk should be cultured ifossible, although commonly will not reveal the causative organismecause of the antibacterial properties of human milk. Treatment shouldontinue for 10-14 days. Common regimens include dicloxacillin 500 mgtimes a day, cephalexin 500 mg 4 times a day, or clindamycin 300 mgtimes a day, and these are compatible with breastfeeding unless the babyas a medication allergy.100 If symptoms do not begin to respond within2 hours with dicloxacillin or cephalexin, consider changing to clinda-ycin since methacillin-resistant S. aureus infections do occur.101 Moist
eat should be continued as often as possible, and breastfeeding shouldontinue since breast drainage is imperative and best accomplished by theaby. If breastfeeding is not possible or too uncomfortable, the breastust be drained regularly using hand expression or a pump.In some women, deep breast pain may persist after the acute mastitis
ymptoms resolve. This may indicate a low-grade persistent intraductalacterial infection. These cases may respond to prolonged courses (4-6eeks) of anti-staphylococcal antibiotics. Macrolide antibiotics may bearticularly useful in these cases.102
reast AbscessA breast abscess may complicate mastitis in 5-10% of cases. Aersistent tender lump with and often without fever may indicate theevelopment of an abscess. The possibility of a deep abscess should alsoe considered in cases of persistent deep breast pain with breast fullnessr firmness. The diagnosis can be confirmed by ultrasound. Abscessesequire incision and drainage; this may be accomplished surgically.103
ome abscesses may be drained with a needle via ultrasound guidance,104
lthough a follow-up ultrasound should be performed a few days later to
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onfirm resolution with repeat drainage if needed. The fluid from thebscess should be cultured, and the mother should be maintained on annti-staphylococcal antibiotic until the lesion and pain resolve. Coverageor methicillin-resistant staphylococcus should be considered, especiallyn areas where it is common in the community.101,105 Breastfeeding onhe affected side may continue as long as the incision is away from theipple, and there is no purulent material in the breastmilk. Breastmilk inhe surgical wound does not compromise healing. Even if feeding fromhe affected breast is difficult, the mother should be encouraged toontinue to nurse on the opposite breast and to resume nursing on theffected side as it heals.85,100
reast Masses and Breast CancerAll persistent breast masses need to be explained, including those thatccur in breastfeeding women. A lump that is not tender or red is notikely to be infection. Any lump that persists after treatment for infectionlso needs to be investigated. The first step in evaluation of a breast lumpn a lactating woman is ultrasound. Nontender fluid-filled lumps are mostommonly galactoceles; these can be observed or may be drained witheedle aspiration under ultrasound guidance if necessary.103
Solid masses in lactating women require tissue diagnosis.50 A fineeedle aspiration (FNA) is an appropriate initial procedure; however, aegative FNA does not entirely rule out cancer. Women with a negativeiopsy should be followed closely if they choose not to have open biopsy.arger, more concerning, persistent masses and those with equivocalNAs should be biopsied. Ideally, the biopsy incision should be madeway from the nipple and in a radial rather than circumferential fashiono avoid disrupting ducts. Breastfeeding can continue, and women shouldot be expected to wean before a breast biopsy is performed. Milk fistulasccasionally develop after breast surgery in the incision, but these willesolve spontaneously and do not require intervention.Mammograms may be performed in lactating women; however, thereasts will appear quite dense, increasing the risk for false-negativeesting. The woman should feed the baby just prior to mammography tompty the breasts as much as possible. The mammogram should be ready a radiologist with experience reading mammograms of lactatingreasts. A negative mammogram in a lactating woman with a persistentreast lump does not negate the need for biopsy.50 For women at risk forreast cancer, breast cancer screening should proceed as recommendeduring lactation.106 MRI may be an alternative way to evaluate lactating
reasts.107M, June 2008 383
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The diagnosis of breast cancer will generally require weaning sinceost premenopausal women with breast cancer undergo radiation and
hemotherapy. Mothers should be counseled and supported as they makehese treatment decisions, especially if faced with weaning a very youngaby. Many mothers find it emotionally difficult to wean in order toroceed with breast cancer treatment. Referral to a local donor humanilk bank may be helpful for women seeking resources for pasteurized
onor human milk.Breast cancer survivors who become pregnant should be encouraged toreastfeed. A history of breast surgery and radiation may affect milkupply. Mothers who have undergone mastectomy but no radiation to theemaining breast can often develop a full supply for one infant. Someesearchers believe that breastfeeding after breast cancer will have arotective effect on the contralateral breast.108
aternal MedicationsMost medications can be used safely during lactation, or a safe alternativeedication can be found. Although almost all medications can be found in
race amounts in breast milk, medications may be used by lactating motherss long as they do not cause significant adverse effects in the infants. Therere certain general principles that can help the health professional chooseppropriate medications for lactating women (Table 9).In order for a maternal medication to reach the infant, it must pass from
he maternal plasma into the breast milk, be ingested by the infant, and bebsorbed by the infant. Medications can do this by passive diffusion or byctive transport. Small molecules, like ethanol, pass easily into milk, suchhat the level in breastmilk equals the maternal blood level. Medicationshat are very large, such as insulin, generally do not pass into milkecause they cannot cross from the plasma through the mammary alveolarells into the milk. If a medication is highly protein bound, a smallermount of free medication will be available to transfer into the milk.
ABLE 9. Medication characteristics that aid or reduce transfer of drugs to the breastfeeding baby
More Likely to Pass into Milk/Baby: Less Likely to Pass into Milk/Baby:
mall molecule, eg, ethanol Large molecule, eg, heparinow protein binding High protein bindingipid soluble Water solubleong half-life Short half-lifective metabolites that pass into milk Not absorbed from infant gut
edications that are highly lipid soluble can generally pass more easily
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nto milk than those that are not; this means that most drugs that can reachhe mother’s central nervous system will be found in breastmilk.109
Medications that can safely be given to infants can be prescribed toactating mothers. This includes, for example, most common antibioticsnd analgesics. However, some medications that are contraindicated inabies can be given to lactating women because the medication may notass through into breastmilk or may not be absorbed by the infant. A goodxample is tetracycline, which is bound to the calcium in breastmilk, suchhat it is not absorbed by the infant. Other medications that are notbsorbed by the infant GI tract include those parenterally administrated,uch as the antibody infliximab, and therefore are generally consideredafe.Some medications that might be “safe” for the baby can decreaseaternal milk supply, so should be avoided or given with caution,
specially in the neonatal period when the breastmilk supply is beingstablished (Table 10). Hormonal contraceptives, especially those con-aining estrogen, may significantly decrease the milk supply at any timeuring the lactational period. Other medications that have been shown toecrease milk supply include pseudoephedrine, nicotine, alcohol, narcoticnalgesics in high doses, and bromocriptine.Very few medications are contraindicated in breastfeeding. These
nclude chemotherapeutic agents, some radioisotopes, and drugs ofbuse.110,111
Other drugs are considered to be “of concern” when given to lactatingomen. This group comprises most CNS-active medications, including
edatives (especially those with long half-lives), antidepressants, anti-nxiety agents, and anti-psychotics. Other specific medications of concernnclude acebutolol, 5-acetylsalycilic acid, atenolol, aspirin, clemastine,
ABLE 10. Medications/substances that may reduce milk supply132
Hormonal ContraceptivesX Progestogens in the first week and possibly laterX Estrogen-containing contraceptives at any time, of most concern in first 4–6 monthsDecongestantsX PseudoephedrineNicotineAlcoholNarcotic analgesics in high dosesBromocriptine/CabergolineClomiphene
rgotamine, lithium, phenindione, phenobarbital, primidone, and sul-
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asalazine. These medications should be used only when no acceptablelternatives exist for mother’s therapy, and baby should be monitoredlosely for side effects.110
Excessive use of alcohol should be avoided by breastfeeding women;owever, women who choose to occasionally consume small amountsf alcohol may continue to breastfeed. Alcohol diffuses easily betweenlasma and breastmilk, and plasma and milk concentrations arepproximately equal. Alcohol is cleared from the milk as it clears fromhe plasma. To minimize exposure, a mother should feed the baby justefore consuming an alcoholic beverage. Allowing at least 2 to 2.5ours per drink (1 oz alcohol, 4 oz wine, 12 oz beer) after consumptionefore resuming nursing will allow clearance of the alcohol from theother’s plasma and milk. Excessive alcohol use at around five drinksill impair the let-down reflex and decrease maternal milk supply.111
Most narcotic analgesics can safely be given in low doses toreastfeeding mothers, and in fact women may find breastfeedingore manageable in the early newborn period if their pain is
dequately controlled, especially after cesarean delivery. However,nfants whose mothers are receiving narcotic analgesics should beonitored closely for sedation.111 A small number of mothers rapidlyetabolize codeine to morphine; their infants can show disproportion-
te sedation.112
Postpartum depression is common, and many breastfeeding mothers arereated for postpartum depression with medications. There are knownisks to infant neurodevelopment from maternal depression,113 as well asnown risks to babies from not breastfeeding. These known risks must beeighed against the theoretical risk of exposure of breastfeeding infants
o small amounts of medication in breast milk. In general, the best choicef antidepressant medication is one that has worked well for the mothern the past, since adequate treatment of maternal depression is likely toesult in the best outcome for the baby.Paroxitene, sertraline, citalopram, and escitaolpram are shorter-actingSRI antidepressants that are found in very low levels in breast milk andave not been measurable in infant serum; these drugs should be the drugsf first choice for maternal depression requiring drug treatment.114
luoxetine is a longer-acting SSRI, which should be used with cautionnd in low doses in breastfeeding women. Fluoxetine use has beenssociated with infant side effects, such as colic, fussiness, and drowsi-ess.111 Cognitive-behavioral therapy (CBT) is effective for mild tooderate depression and should also be offered. Effective CBT may
llow avoidance or minimization of medication exposure. Breastfeeding
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utcomes different than the mother’s expectations may exacerbate de-ression, and mothers who wean before they are ready to may have anncreased risk of depression.115
Several resources are available to assist clinicians in choosing medica-ions for breastfeeding mothers and counseling mothers about medica-ions they are taking (Table 11).
nsufficient Milk Supply (Table 12)Nearly all mothers can make enough milk for their babies if breastfeed-
ng is well-supported. Many mothers perceive that their milk supply is notdequate.116 This can be addressed through education about the normaleeding patterns of nursing infants, including the wide variety of nursingstyles” and the occurrence of growth spurts. When the infant is notrowing adequately, careful assessment of milk production, milk transfer,nd the health of the baby will lead to identification of the underlyingroblem. Interventions should support the breastfeeding couplet whiledentifying and addressing the underlying cause(s) of the insufficient milk
ABLE 11. Resources for medications in lactation
he National Library of Medicine’s Drugs and Lactation Database (LactMed)http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACTA peer-reviewed and fully referenced database of drugs to which breastfeeding mothers
may be exposed.Among the data included are maternal and infant levels of drugs, possible effects on
breastfed infants and on lactation, and alternate drugs to consider.merican Academy of Pediatrics, Committee on Drugs. The transfer of drugs and otherhemicals into human milk. Pediatrics 2001;108:776.Committee opinion updated every several years. Lists drugs as “compatible with
breastfeeding,” “of concern,” and “contraindicated.”edications in Mother’s Milk (11th edition), 2006. Thomas Hale, PhDBook published and updated approximately annually by Hale Publishing, available at
http://www.ibreastfeeding.com and other sources. Palm download and online versionalso available.
Frequently updated listing of a large number of medications including lactationpharmacology with milk and infant levels when known, and alternative medications.
onprescription Drugs for the Breastfeeding Mother, 2007. Frank Nice RPh, DPA, CPHP.Published by Hale Publishing, designed as a companion to Medications in Mother’s Milk.Description of 1400 nonprescription drugs and their relative risk to the breastfeeding
mother.rugs in Pregnancy and Lacation (7th edition), 2005. Gerald Briggs, B. Pharm, Rogerreeman, MD, Sumner Yaffee, MD.Published by Lippincott, Williams, and Wilcott.Textbook discussing drug pharmacology in pregnancy and lactation. Most useful for
pregnancy, contains pharmacology information for many drugs in lactation.
upply.
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nadequate Milk TransferOne of the most common causes of an insufficient milk supply is the
ack of demand for milk by the infant, resulting in a gradual decrease inilk production, and possibly alveolar tissue involution. Babies who haveweak latch or suck may not take as much milk as they need to grow.his results in poor infant growth, and what appears to be a poor milkupply. Sometimes it can be very hard to determine which is the primaryroblem. There are many common infant conditions that lead to insuffi-ient breast emptying with resultant low milk supply (see “Commoneonatal Breastfeeding Problems”). Insufficient weight gain may occur
arly on after birth, with the infant not gaining back to birthweight in theppropriate time. It may also be seen later postpartum between 2 and 6onths, in situations such as neurological or metabolic conditions of the
aby, or infant gastroesophageal reflux.When newborns are ill or when they require treatment for jaundice,
xtra care should be taken to assist mothers in establishing and maintain-ng milk supply. Milk expression should begin as soon as possible if it islear that the baby will not be able to nurse well at breast, and at leastithin 24 hours of birth if mother and baby are separated.Most cases of inadequate milk supply are secondary to poor feeding and
ABLE 12. Causes of insufficient milk supply
Maternal● Inadequate glandular development● Obesity● Polycystic Ovarian Syndrome● Sheehan’s Syndrome● Retained placental fragments● Hyper- or hypothyroidism● Maternal medications● Breast surgery, esp. breast reduction
Infant● Inadequate milk transfer leading to decreased production● Prematurity, including near-term● Infant illness● Trisomy 21● Cleft lip or palate● Other anatomic or neurologic abnormalities leading to decreased suck● Severe jaundice
Related to perinatal or breastfeeding management● Mother—infant separation after birth● Supplemental feedings when not medically indicated● Inappropriate use of nipple shields and pacifiers
espond to supportive interventions. If the baby is latching and suckling
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ell, the first intervention is to increase frequency of nursing to at leastvery 2 hours in the daytime and every 3 hours at night. For babies whore not suckling well, this can be augmented with pumping at this samerequency, ideally with a hospital-grade double-electric pump. Babyhould feed at the breast, and the feeding should be followed by pumping.he baby can be supplemented with the expressed breast milk (seerevious section on supplementation of the infant). If the mother cannotxpress a sufficient amount of milk after nursing the baby, the babyhould be supplemented with either pasteurized donor human milk ornfant formula. Maximizing skin-to-skin contact, avoiding nipple shields,nd making sure mother is getting adequate rest and taking in adequateutrition and hydration can also help. It is crucial to ensure adequatealorie intake of the baby. Severe cases of poor feeding can lead toypernatremic dehydration, which is a medical emergency. In manyases, an otherwise healthy infant will become stronger and more efficientt the breast with proper nutrition and growth. Over time, the increasedemand for milk by pumping the breasts after feeding will often increasehe maternal breastmilk supply in cases where the mother has the abilityo have an adequate supply.64
nsufficient Glandular DevelopmentVery few women are anatomically unable to produce enough milk for
heir infants. Some women have abnormal breasts that do not containufficient glandular tissue to make milk.117 These breasts often have aubular shape and are widely spaced. These women may notice minimalreast changes during pregnancy and lack of fullness of the breasts in therst 3-10 days postpartum.118 In most cases, women with insufficientlandular development respond modestly to galactogogues and usually doot develop a full supply for a growing infant. These women may benefitrom using a supplemental nursing system at the breast in order to keephe baby at the breast for complete feeding, rather than having toupplement the baby after the baby nurses.
olycystic Ovarian SyndromePolycystic Ovarian Syndrome (PCOS), also called hyperandrogenic
hronic anovulation syndrome, includes symptoms such as amenorrhea/ligomenorrhea, hirsutism, obesity, infertility, acne, ovarian cysts, andvidence of the metabolic syndrome including elevated lipids and insulinesistance or overt diabetes. Women with this syndrome seem to haveathologic interference with mammogenesis, lactogenesis, and galacto-
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uring adolescence. They tend to have limited breast growth duringregnancy and delayed lactogenesis II. All of these may lead to a lowilk supply. Treatment with metformin may ameliorate some of these
ssues; however, many of these women have difficulty developing a fullilk supply especially if adolescent breast development has been af-
ected. Some will respond to treatment with galactogogues. Optimizingeight and management of symptoms prior to pregnancy may help.119
istory of Breast SurgeryWomen who have had breast reduction surgery can have insufficient
issue remaining to fully support an infant, although they often have aartial supply of milk and some mothers will have a full supply of milk.f the nipple was transplanted during breast reduction surgery, ducts anderves may have been disrupted such that there is decreased nippleensation. Because nipple sensation provides feedback for prolactin andxytocin secretion, there may be some inhibition of milk let-down, andnsufficient milk production due to an inadequate prolactin level.120
Although breast augmentation surgery usually does not inhibit breast-eeding, particularly if it does not involve a periareolar incision, theoman may have had hypoplastic breasts prior to surgery.121 Any breast
urgery can affect milk supply and should be considered a risk factor fornsufficient milk.117
ormonal FactorsSince it is the delivery of the placenta and decrease in serum proges-
erone concentration that leads to lactogenesis II, retained placentalragments can lead to delayed or diminished lactogenesis II and low milkupply and should be suspected, especially in a woman who is havingeavier than expected or prolonged vaginal bleeding postpartum. Evenhen there is no excess bleeding postpartum, retained placental fragments
an be present, or there can be placenta increta with placenta tissueetained in the uterine wall. This can be evaluated by ultrasound or MRI.ven several weeks postpartum, treatment of retained placental fragmentsan lead to resumption of milk production.122
Sheehan’s syndrome usually occurs as the result of a massive postpar-um hemorrhage leading to ischemic pituitary necrosis. It may rarely beeen after a normal delivery without severe hemorrhage. Failure ofostpartum lactation and failure to resume postpartum menses are theost common presenting symptoms. Although Sheehan’s syndrome is
ery rare with modern maternity care and the availability of blood
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others who have had significant postpartum hemorrhages, particularly ifhey have symptoms of other pituitary hormone deficiencies, should bevaluated for Sheehan’s syndrome through hormonal testing and possiblymaging of the sella. Women may still be able to breastfeed with hormoneeplacement treatment, although they will likely need to supplement. Thisan be done at the breast with a supplemental system. If they also lackosterior pituitary hormones, Oxytocin nasal spray can be used to assistith let-down.100,123
Maternal thyroid disease is suspected to affect milk supply, althoughhere are no human studies done to support the possibility that hyperthy-oidism and hypothyroidism affect lactation. Rat studies suggest thatypothyroidism decreases oxytocin release and pup growth, and hyper-hyroidism may lead to mammary involution.124,125 Since postpartumhyroid disease is very common, women should be checked for abnormalhyroid levels and treated if appropriate. Common medical treatments foroth hypo- and hyperthyroidism are compatible with breastfeeding.yperthyroidism due to postpartum thyroiditis is usually self-limiting.efinitive treatment for Graves disease with radioactive iodine wouldeed to wait until after weaning, although suppressive therapy or surgicalhyroidectomy could be done during lactation.100,126
aternal ObesityObesity (BMI � 30) affects breastfeeding initiation and duration.auses appear to be multifactorial with both psychosocial and physio-
ogical components. There are higher rates of obesity among groups ofomen who are less likely to breastfeed. Obese women may haveroblems with self-esteem, body comfort, and self-efficacy that mayiminish their interest in or ability to pursue breastfeeding. However,hysiologic issues may also be important. Mechanical difficulties such asositioning and latching infants to large breasts can be challenging in theewborn period. Obese women also demonstrate a delay in lactogenesisI, with a lower prolactin response to nursing 48 hours after delivery. It isnclear whether this is due to differences in maternal hormones, such aseptin,estradiol, insulin, and progesterone, or due to poor infant sucklingdentified in infants of obese mothers.38 Obese mothers should be givenntensive lactation support in the early postpartum period and should beollowed closely for insufficient lactation.37
hildbirth InterventionsChildbirth interventions can affect milk supply. Maternal labor narcot-
cs and epidural analgesia/anesthesia may affect infant suckling and cause
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delay in lactogenesis II. Cesarean section deliveries may be associatedith a delay in breastfeeding initiation, probably through mother–baby
eparation as well as the increased use of analgesics in the postpartumeriod. Mothers and babies with a wide range of birth experiences canuccessfully breastfeed if adequately supported. Extra time skin-to-skin inhe early perinatal period and the avoidance of supplemental feedings inhe neonatal period unless medically indicated can assist in establishinghe breastfeeding relationship.127
Optimal early breastfeeding management for the mother and newbornromotes an adequate milk supply. Early, frequent nursing with room-ng-in in the hospital helps the mother learn her baby’s feeding cues.abies demonstrate lip movements, bring their hands to their mouths, andecome alert when they are ready to feed. When babies are separatedrom their mothers, these early cues are often missed and they reach a latetage of hunger, which is crying. Pacifier use in the early newborn period,eeding the baby on a schedule rather than on cue, and other hospitaloutines that interfere with establishment of breastfeeding can impair theevelopment of an optimal milk supply.70
aternal MedicationsMaternal medications can decrease milk supply. Combination oral
ontraceptives should not be used during the first 4-6 months of lactationecause the estrogen component may suppress milk supply.128 Even aftermonths, some women may notice a drop in their milk supply with an
strogen-containing contraceptive. Progestin-only contraceptives haveot been associated with decreased supply in population studies, butnecdotal reports of decreased supply, particularly with depomedroxypro-esterone acetate, remain concerning. Progestogens given in the first feways postpartum could theoretically interfere with lactogenesis II.129 Theanufacturers do not recommend using them until after 6 weeks
ostpartum.Other maternal medications may also decrease the milk supply (see
Maternal Medications”). Women who experience a decrease in milkupply from medication often can increase their supplies by stopping theffending medication and increase milk demand by nursing and/orxpressing more often. Occasionally short-term use of galactogogues areeeded.
alactogoguesTreatment with a galactogogue may be considered to augment the
aternal supply if other supportive measures are also in place. Options92 DM, June 2008
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nclude herbal supplements and prescription medications. Mother’s Milkea made by Traditional Medicinals is an herbal tea with no significantide effects; it may be helpful in mild cases of low milk supply.Fenugreek (Trigonella Foenum–graecum), a member of the pea family,
s the most commonly recommended herbal galactogogue. The Food andrug Administration (FDA) lists fenugreek as “Possibly Safe” when used
n medicinal amounts. A few preliminary studies have found fenugreekffective in increasing milk supply.130,131
Most fenugreek capsules made of crushed fenugreek seeds are 580-610g, and the typical dose is two to three capsules three times a day.Fenugreek is a common spice used in India and the Middle East, andecause it is used as a flavoring agent in imitation maple syrup, womenho use it as a galactogogue notice a maple-syrup odor to their breastmilk
nd other body secretions. It can also cause hypoglycemia in largemounts. Fenugreek has been observed to worsen asthma symptoms, andan cause allergic reactions including nasal congestion, wheezing, facialngioedema, and shock. Because fenugreek is in the Fabaceae plantamily, it would be wise to avoid fenugreek in cases of known allergy tother Fabaceae plants, such as soybeans, peanuts, and green peas.Other herbs used as galactogogues for which no randomized clinical
rials exist include goats rue, blessed thistle, milk thistle, anise, basil, andarshmallow, among others.Prescription medications used as galactogogues include metoclopro-ide and domperidone. Both of these medications increase milk supply
ver 1-2 weeks. These medications are dopamine antagonists thatncrease the prolactin level, and are primarily used as prokinetics for GIotility disorders. Metoclopromide is usually dosed at 10 mg 3-4 timesday, and the usual domperidone dose is 20 mg 3-4 times a day.etoclopromide use is limited by its central nervous system side effects
f fatigue, dizziness, tardive dyskinesia, and seizures, and should bevoided in women with a history of depression. It should not be used inomen with significant psychiatric histories, seizure disorders, or somether neurologic disorders. Domperidone is much better tolerated since itoes not cross through the blood brain barrier, preventing neurologic sideffects. Domperidone is not currently FDA-approved in the United States.lthough the FDA has restricted its use and its importation to the USA,
t may be available from compounding pharmacies in the United States.omperidone has been used commonly and successfully as a galactogue
n countries such as Canada, Australia, New Zealand, and England.132
Pharmacologic galactogogues should generally be used for 2-3 weeks
hile other issues regarding breastfeeding support and problems areM, June 2008 393
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ddressed. If the milk supply responds to the galactogogue and otherreastfeeding issues have been resolved, the medication may then beapered. If the milk supply drops after withdrawal of the galactogogue,estarting the medication is acceptable; however, there are no long-termtudies on efficacy or safety.133
eturning to WorkMany mothers return to work soon after the birth of a baby. Approxi-ately 53% of mothers in the USA of children under 1 year of age pursue
aid employment.134 Mothers in a variety of work settings have success-ully combined working and breastfeeding. A mother should be encour-ged to plan her back-to-work strategy with breastfeeding in the work-lace in order to provide a smooth transition back to work. Her health carerovider should provide anticipatory guidance in the form of advocacy,nformation on milk expression and milk storage, and educationalesources on breastfeeding while back to work.Educating employers about the advantages of breastfeeding in the worklace can help mothers maintain lactation when back to work. Parents ofreastfed babies lose less work time due to infant illness. Mothers whond their employers supportive of breastfeeding may be more loyal andore likely to return to work after childbirth.135
A mother should be encouraged to take the longest maternity leaveossible, as it is important to avoid prolonged separation from the babyntil breastfeeding is well established and breastfeeding problems areesolved. Maternity leaves of at least 14 weeks are encouraged by thenternational Labor Organization.136 The USA Family Medical Leave ActFMLA) allows for 12 weeks of unpaid leave for the birth of a baby formployees in qualifying positions. For many women, however, theconomic realities of their lives will preclude long leaves. Helpingomen establish breastfeeding in whatever time they have before
eturning to work is essential. If available and feasible, part-time workan be a strategy to protect breastfeeding for many mothers. Returning toork on a Thursday rather than a Monday can allow for a short “workeek” the first week back.Factors that support breastfeeding success in the workplace includen-site daycare, time to pump at work in a clean, available location,mployer support, flexible work schedule, and family support.137 Allow-ng the mother to bring her child to work may also promote continuedursing. Nursing the baby even once during the mother’s lunch break can
acilitate breastfeeding.94 DM, June 2008
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Most mothers will need to express milk for their babies when they areeparated at work. Generally, a mother should plan to express milk asften as the baby would nurse, or at least every 4 hours. The mother of aery young baby may need to express milk even more often to avoid theiscomfort of over-full breasts and leaking. An electric double-pumpystem usually maximizes milk expression in the shortest amount of time,uch that the mother can complete her milk expression during a 15- to0-minute break. For employees without a private office, pumping can beone in a clean restroom, break room, or conference room. Employershould be encouraged to set up lactation rooms when they employ severalomen of child-bearing age.135
Many mothers express and store breast milk in advance of their returno work. A woman returning to work should be advised that her milkupply may decrease during the work week and increase when nursing theaby full-time on nonwork days. Having a reserve supply of breastmilk inhe freezer can provide peace of mind for and lessen stress on the workingother.Some women find “reverse cycle nursing” to be a useful strategy,here babies naturally adopt a pattern of nursing more frequently in
he evening, night, and early morning when they are with theirothers. The babies sleep more and eat less during the work day.138
f a mother is able to delay her return to work until the baby is olderhan 6 months and taking solid foods, less breastmilk may be neededhen mother is at work.For women who are unable or unwilling to express milk when at work,artial breastfeeding is beneficial and should be encouraged.12 Mostorking women can maintain a substantial milk supply if they feed theaby four times a day, for example, in the morning, after work, atedtime, and once during the night.
xpressing and Storing BreastmilkSeveral options are available for expressing breast milk and depend on
he specific needs of the mother. Generally, a mother needs to empty herreasts as often as the baby feeds. Most women who need to express milkver a long period of time will choose a double electric pump. Mothersumping for premature infants or trying to increase their milk supply havereatest success with a hospital-grade pump.139 Double electric pumpsave been shown to extract a similar amount of milk to what a full-term
aby ingests at a single nursing.140 These pumps also can raise theM, June 2008 395
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rolactin to the level observed with nursing.141 Mothers with a well-stablished milk supply often choose a standard retail double pumpystem to maintain the milk supply at work. Mothers who only need toxpress milk occasionally may choose a hand pump or may do well withand expression.Women who are trying to increase their milk supply can pump after theaby feeds to increase breast stimulation and more thoroughly empty thereast, encouraging increased production. Women will generally need toump at least six to eight times per day if they are not feeding the babyt the breast, and will continue to make milk as long as they continue toump. All breastfeeding women should learn how to manually expressilk for times that they unexpectedly need to express milk and do not
ave access to a pump.Freshly expressed human milk should be refrigerated as soon asossible but may be kept at room temperature up to 6 hours. Mothersan safely store their milk in an insulated cooler with ice packs for upo 24 hours, making expression feasible for women who do not haveccess to a refrigerator at work. Fresh milk may be refrigerated for 5-8ays. Previously frozen milk thawed in the refrigerator may be keptor up to 24 hours. Milk may be frozen for up to 2 weeks in the freezerompartment of a refrigerator–freezer with a common door, 3-6onths in a refrigerator–freezer with separate doors, and 6-12 months
n a separate deep freeze at 0 degrees Fahrenheit. Milk should be keptn the bottom or back of the freezer away from the door. Milk may betored in glass or hard plastic containers. Plastic bags specificallyesigned for milk storage may be used for short-term storage only,ince there is greater risk of milk contamination in plastic bags. Milkhould be stored in small aliquots that can be individually thawed forse to avoid waste since any thawed milk that is left over after aeeding should be discarded. Milk should be thawed in warm water orvernight in the refrigerator. Milk should never be heated in aicrowave as this can denature proteins and cause hot spots142,143
Table 13).
nticipatory Guidance of Breastfeeding atell-Child Visits
Well-child exams offer opportunities to provide ongoing support,ducation, and encouragement of breastfeeding to families. Because
reastfeeding is the gold standard for infant feeding and is central to the96 DM, June 2008
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ealth of mothers and infants, it is as important of a topic as otherutrition and safety issues.144
eeding FrequencyParents often express frustration that their newborn infants breastfeed asften as every 1.5 to 2 hours. During the first month of life, these feedingsay be somewhat slow because of infant sleepiness, especially if the babyas born �37 weeks gestation. These early feedings may also be
lustered, particularly in the evening, such that the baby may nurseonstantly for 2-3 hours at a time. Parents should also anticipate “growthpurts,” which tend to occur at around 3 and 6 weeks of age for healthyerm infants. “Growth spurts” are recognized as 2- to 3-day episodes ofery frequent feeding, such as every hour, and associated with a mildncrease in fussiness and decrease in stooling. It is important for parentso recognize that this short-term change in behavior is not due to annsufficient milk supply.Feeding frequency will gradually decrease during the first 6 months, and
fficiency of feeding will improve, such that the baby may be eating every-3 hours during the first 4 months of life, and every 3-5 hours by 4onths of age. By 4 months, the baby may nurse for only 5-10 minutes,
urning his attention quickly to another activity. By 9 months of age,nfants are often nursing for short periods 4-6 times a day.
tool FrequencyInfants have a strong gastro-colic reflex at birth, and often stool with
ach feeding. This reflex usually diminishes by 1 month of age, at whichoint stooling frequency widely varies. It may be normal for a breastfednfant to stool anywhere from once a week to 5 times a day. If stooling
ABLE 13. Milk storage guidelines142,143
Storage Location TemperatureStorageDuration
resh milk, Countertop Room 4–6 hoursresh milk, Refrigerator 35–40°F 5–8 daysreviously frozen milk, thawed in refrigerator 35–40°F 24 hoursreezer section of refrigerator—freezer with common door 5°F 2 weeksreezer section of refrigerator—freezer with separate door 0°F 3–6 monthstand-alone deep freeze �4°F 6–12 months
ppears very infrequent, the infant should be weighed to make sure that
M, June 2008 397
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nterval weight gain is appropriate. By 4 months of age, breastfedabies typically stool once a day or less. As long as the baby issymptomatic, and eats and gains weight well, there is no reason tontervene.
erceived Milk SupplyBreastfeeding mothers typically experience some degree of engorge-ent during the first 3-6 days postpartum, and will feel quite full if the
aby has not eaten for a few hours. By 2-4 weeks postpartum, thereastmilk supply becomes much more closely matched to the infantemand, such that engorgement becomes less of a problem, unless thenfant drastically changes his feeding schedule. The hormone prolactinontinues to play a significant role in milk production until approximately-6 months postpartum, when prolactin levels decline. Milk productionhen becomes predominately autocrine, meaning that the milk supply isess influenced by prolactin, and more by the demand of milk removal.32
omen often notice less breast fullness at around 4-6 months postpartum,ith substantial improvement in breast leakage between feedings.
eething and BitingMothers often will express concern about whether their nursing infantsill bite when they begin to teeth at around 3-4 months of age. Certainly
ome babies will clench down onto the nipple or bite at times, but rarelyoes significant nipple trauma occur.When an infant is actively nursing and swallowing, his tongue is
xtended beyond the lower gum line. The baby is not able to clamp downnto the nipple when the tongue is extended. As the baby finishes feeding,nd milk is no longer flowing, the baby may retract his tongue and suckleonnutritively, such as on a pacifier. This is the time when biting mayccur. Mothers can identify this behavior and take the baby off the breasthen feeding is finished. This nonnutritive sucking may also occur while
he baby is sleeping at the breast, so taking the baby off the breast whenleeping will prevent clenching or biting onto the nipple.Sometimes older babies will bite to gain mother’s attention. The mother
hould try to extinguish this behavior by showing a startled or negativeesponse. The nursing baby should be offered praise when he is at thereast and not biting.145
ighttime FeedingSleeping through the night is not necessarily expected from infants
uring the first year of life. Night time awakening during the first 398 DM, June 2008
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onths of age is often related to the need to feed,146 but there are manyther reasons why breastfed infants wake up in the middle of the night.esides hunger, infants may be experiencing illness, discomfort, insecu-
ity, and/or fear. Infants as individuals have varying sleep patterns andighttime needs, and nighttime rituals and expectations vary greatlyetween families and cultures. Breastfeeding is often used by families asway to calm and resettle an upset infant in the middle of the night.
amilies frequently turn to their pediatric provider for advice on whetherreastfeeding should be offered, or if other resettling maneuvers shoulde used, such as swaddling, holding, or walking. The advice given mustake into account the cultural beliefs of the family, their parenting style,nd the specific nighttime concerns that they have. For example, somearents prefer to cosleep with the infant, and are only concerned about therequent feeding at night. Other parents may not be concerned about therequent feeding , but worry about their inability to keep the baby out ofheir bed. So far there is no evidence that giving solids to infants under 6onths of age improves their sleep performance. One study showed no
ifference in sleep duration when infants were given rice cereal in aottle.147
omplementary FoodsThe WHO recommends exclusive breastfeeding until 6 months of age,ith the addition of complementary foods and continued breastfeedingntil 2 years of age and beyond. Feeding complementary foods before 6onths can displace breastmilk, and does not offer any growth advan-
ages over exclusive breastfeeding.148,149 The risk for diarrhea in disad-antaged populations is 2- to 13-fold higher when complementary foodsre started before 6 months of age. Exclusive breastfeeding for 6 monthslso decreases the maternal risk of fertility by increasing the likelihood ofactational amenorrhea, and accelerates maternal weight loss.150
Iron concentration in breastmilk is sufficient for healthy term infantsntil 6 months, after which infants need other sources of iron, whichormally can be provided in complementary foods such as meats, oats,pinach, stewed dried fruits, and iron-fortified baby cereals.Infants should be fed complementary foods at least 2-3 times a day, that
re pureed or mashed until about 8-9 months, at which point they oftenave the ability to feed themselves soft foods. Infants will continue toreastfeed at least 4-6 times a day beyond 6 months of age until they aren a full adult diet by 1 year of age. After 1 year, breastfeeding frequencyaries among infants, and depends on toddler and maternal interest/
reference and toddler intake of complementary foods.148M, June 2008 399
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utritional Supplements for Breastfeeding InfantsInfants at risk for iron deficiency with exclusive breastfeeding for 6onths include those born preterm less than 37 weeks gestation, small-
or-gestational-age, or born to a mother with low prenatal stores of iron,s well as those at risk for poor iron stores at or after birth. These babiesre likely to need supplementation with iron drops before 6 months ofge.148
Routine vitamin D supplementation of 200 units a day is recommendedy the American Academy of Pediatrics, based on several cases of ricketsound largely among babies of color, over the last 30 years. The mainource of vitamin D for humans is the sun, but because of the risk of skinancer over time, it is recommended that infants not be exposed to directunlight without protection such as sunscreen or shade. Lack of sunxposure thereby limits an infant’s absorption of vitamin D naturally.nfants with dark skin absorb less vitamin D from the sun compared tohose with light skin. Breastmilk is known to have little vitamin D, unlesshe maternal vitamin D level is high enough to provide sufficient vitamin
in the breastmilk. Current guidelines on vitamin D supplementation inreastfeeding women do not support the high doses of maternal vitamin
supplementation required to provide enough vitamin D in breastmilk.itamin D supplementation is available for infants in drop form.151
Oral fluoride supplementation is recommended at 6 months of age andeyond for all infants and children who do not have regular access torinking water that has at least 0.3 ppm of fluoride.152
eaningThere is no age at which it is medically indicated to stop nursing.3
hildren who breastfeed beyond the age of 1 year continue to receiveignificant calories, essential fatty acids, and micronutrients. Breastfeed-ng beyond 1 year of age also significantly protects children fromehydration, since breastfeeding will usually increase during times ofllness. Evidence suggests dose-related benefits of breastfeeding. A recenteta-analysis determined that, for each additional year of breastfeeding,omen have a 4-12% decreased risk of type 2 diabetes mellitus and a.3% decreased risk of breast cancer. The risk of ovarian cancer isecreased by 21% with at least 12 months of breastfeeding. Infants enjoy4% risk reduction of being overweight as an adult with each month of
reastfeeding.12
Women may turn to their physicians for advice on weaning. Women
hould be encouraged to wean their babies when they feel the time is00 DM, June 2008
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ight, and not because of perceived societal expectations. Women mayeed counseling on how to balance pressures from various familyembers and friends about when to wean.There are many ways to wean a child. Weaning can be gradual, partial,
brupt, or child-lead. If a mother decides to wean an infant, graduallyncreasing the interval between feedings will help prevent engorgementnd the risk of plugged ducts and infection. Alternatively, the mother canbruptly stop nursing the baby and use a breast pump to drain her breasts,radually increasing the time interval between pumpings until her milkupply appears insignificant. Bottles for young infants or cups for oldernfants and toddlers can be offered instead of the breast. Women whotruggle with an oversupply of milk will take a longer time to weanompared with women who do not overproduce milk.Weaning children over the age of 1 can be more challenging, particu-
arly if the child is still very interested in nursing. It is helpful to talk withhe mother about why she would like to wean, whether she would like toartially or totally wean, and what kind of weaning strategies may workor her child. Some negotiation with the child may be necessary,epending on the developmental stage of the child. Toddlers may adjustasily to changes in routine, such as having a babysitter put the toddlerown for a nap rather than mother nursing the toddler to sleep. Olderhildren may need explanations and bargaining to break out of a nursingoutine.Many mothers are relieved to learn that they don’t need to totally wean
heir children until both mother and child are ready. Partially nursing,uch as before naps, bedtime, and/or in the morning, can alleviate somef the stress that comes from a frequently nursing toddler or olderhild.153
onclusionEvidence from the latter half of the 20th century confirms thatreastfeeding is the nutritional standard for infants against which allther forms of nutrition should be measured. With proper educationnd support from one’s family, community, and health care providers,he vast majority of women can succeed in breastfeeding their babies.ealth care providers should inform each mother of the risks to herealth with artificial feeding, and inform parents of the increasedealth risks of artificial feeding for the infant. Health care providersan encourage and protect breastfeeding by providing families withnformation and local resources needed for breastfeeding success, not
nly during the prenatal and early postpartum period, but also inM, June 2008 401
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reparation for returning to work and at well-child visits. An under-tanding of lactational anatomy and physiology is necessary forhysicians to appropriately manage breastfeeding problems, and tonderstand how some hospital routines and medical decisions canegatively impact breastfeeding success. Most common infant andaternal health problems should not preclude breastfeeding, butothers and infants will need support from knowledgeable health care
rofessionals and board-certified lactation consultants. There are manyducational resources (Table 14) available to physicians for ongoingearning in the field of breastfeeding medicine.
REFERENCES1. Fildes V. The culture and biology of breastfeeding: an historial review of Western
Europe. In: Stuart-Macadam P, Dettwyler KA, editors. Breastfeeding Biocultural
ABLE 14. Physician education resources
ORGANIZATIONS
he Academy of Breastfeeding Medicinehttp://www.bfmed.orgA multidisciplinary worldwide physician organization dedicated to physician education on
breastfeeding.he American Academy of Pediatrics Section on Breastfeedinghttp://www.aap.org/breastfeeding/New%20SOBr.cfmA special interest group for AAP members, offering networking and educational resources
regarding breastfeeding.he International Lactation Consultant Associationhttp://www.ilca.orgA worldwide organization of lactation consultants, providing ongoing education,
resources, and networking for breastfeeding specialists. Their Web site provides a listof educational courses available.
a Leche League International Medical Associateshttp://www.llli.org/MAP.html?m�0,2,1A program for physicians within La Leche League providing educational resources for
physicians and their patients.
JOURNALS
reastfeeding MedicineThe official journal of the Academy of Breastfeeding Medicinehttp://www.liebertpub.com/publication.aspx?pub_id�173&crit�breastfeeding
ournal of Human LactationThe official journal of the International Lactation Consultant Associationhttp://jhl.sagepub.com/
nternational Breastfeeding JournalAn open-access peer-reviewed electronic journalhttp://www.internationalbreastfeedingjournal.com/
Perspectives. New York, NY: Walter de Gruyter, 1995. p. 101-26.
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2. Apple RD. Mothers & Medicine: A Social History of Infant Feeding 1890-1950.Madison, WI: University of Wisconsin Press, 1987. p. 4-53.
3. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and theuse of human milk. Pediatrics 2005;115:496-506.
4. The American Academy of Family Physicians. Breastfeeding Position Paper2001. Available from: http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html. Accessed December 26, 2007.
5. World Health Organization/UNICEF. The Innocenti Declaration, adopted byparticipants at the WHO/UNICEF policymakers’ meeting on “Breastfeeding in the1990s: A Global Initiative.” Spedale degli Innocenti, Florence, Italy, August 1,1990. Available from: http://www.unicef.org/programme/breastfeeding/innocenti.htm. Accessed December 26, 2007.
6. World Health Organization. The International Code of Marketing of Breast-MilkSubstitutes 1981. Available from: http://www.who.int/nutrition/publications/code_english.pdf. Accessed December 26, 2007.
7. World Health Organization, UNICEF. Global Strategy for Infant and Young ChildFeeding 2003. Available from: http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/gs_iycf.pdf. Accessed December 26, 2007.
8. Centers for Disease Control and Prevention and Health Resources and ServicesAdministration. Healthy People 2010, 2005. Available from: http://www.healthypeople.gov/document/html/volume2/16mich.htm#_Toc4946996596. Ac-cessed December 26, 2007.
9. The Center for Disease Control. National Immunization Survey September 2006.Available from: http://www.cdc.gov/breastfeeding/data/NIS_data/data_2004.htm.Accessed December 26, 2007.
10. Hanson L. The role of breastfeeding in the defense of the infant. In: Hale T,Hartmann PE, editors. Textbook of Human Lactation (1st ed). Amarillo, TX: HalePublishing, 2007. p. 159-92.
11. Hamosh M. Bioactive factors in human milk. Pediatr Clin North Am2001;48(2):69-86.
12. Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant HealthOutcomes in Developed Countries. Evidence Report/Technology Assessment No.153 (Prepared by Tufts-New England Medical Center Evidence-based PracticeCenter, under Contract No. 290-02-0022). AHRQ Publication No. 07-E007.Rockville, MD: Agency for Healthcare Research and Quality, April 2007.
13. Horta BL, Bahl R, Martines JC, et al. Evidence on the long term effects ofbreastfeeding; Systematic Reviews and Meta-Analyses Department of Child andAdolescent Health and Development, World Health Organization 2007.Available from: http://www.who.int/child-adolescent-health/publications/NUTRITION/ISBN_92_4_159523_0.htm. Accessed December 26, 2007.
14. Stuebe AM, Rich-Edwards JW, Willett WC, et al. Duration of lactation andincidence of type 2 diabetes. JAMA 2005;294(20):2601-10.
15. McManus RM, Cunningham I, Watson A, et al. Beta-cell function and visceral fatin lactating women with a history of gestational diabetes. Metabolism2001;50(6):715-9.
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studies in 30 countries, including 50302 women with breast cancer and 96973women without the disease. Lancet 2002;360(9328):187-95.
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19. Labbok M, Nichols-Johnson V, Valdes-Anderson V, et al. Contraception duringbreastfeeding protocol #13, February 2005. Available from: http://www.bfmed.org/index.asp?menuID�139&firstlevelmenuID�139. Accessed December 26, 2007.
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38. Dewey KG, Nommsen-Rivers LA, Heinig MJ, et al. Risk factors for suboptimalinfant breastfeeding behavior, delayed onset of lactation, and excess neonatalweight loss. Pediatrics 2003;112:607-19.
39. Chapman DJ, Perez-Escamilla R. Identification of risk factors for delayed onset oflactation. J Am Diet Assoc 1999;99:450-4.
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