Breastfeeding

Breastfeeding

Breastfeeding Anne Eglash, MD, FABM,* IBCLC,† Anne Montgomery, MD, FAAFP, FABM,* IBCLC,† and Julie Wood, MD, FAAFP, FABM,* IBCLC† Background Breastfee...

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Breastfeeding Anne Eglash, MD, FABM,* IBCLC,† Anne Montgomery, MD, FAAFP, FABM,* IBCLC,† and Julie Wood, MD, FAAFP, FABM,* IBCLC† Background Breastfeeding has always been the gold standard for infant feeding. Throughout recorded human history, populations knew that not breastfeeding was associated with infant mortality, despite evidence that some populations did not survive due to artificially feeding their young.1 During the turn of the 20th century, with the industrial revolution in full swing, women left their children during the day to work in cities, and many children were artificially fed not only with cow’s milk, but with a new product: infant formula. With pasteurization and refrigeration, the very high mortality rate of artificially fed infants declined, such that artificial feeding became more popular. Eventually prescribed by physicians in the United States during most of the 20th century, artificial feeding was embraced as being more scientific and healthier than breastfeeding. By 1972, less than 30% of infants were exclusively breastfed in the first week of life.2 While many physicians were prescribing formula for infant feeding, La Leche League emerged in the 1950s as a strong grass roots movement among women in many countries, to re-establish infant feeding at the breast.2 Eventually, with increasing scientific evidence of the risks of formula feeding, and the incomparable benefits of breastfeeding, health organizations worldwide have published policy statements that affirm the importance of breastfeeding as well as risks of artificial feeding for all populations around the world.3,4

Current Recommendations The international infrastructure of breastfeeding policy was the Innocenti 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. Dis Mon 2008;54:343-411 0011-5029/2008 $34.00 ⫹ 0 doi:10.1016/j.disamonth.2008.03.001 DM, June 2008

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WHO and UNICEF in 1990.5 The Declaration set a number of criteria that should be met by each government in order to increase breastfeeding rates worldwide and therefore decrease infant mortality rates. This Declaration was adopted as the basis for international health policy on infant and young child feeding at the 44th World Health Assembly in 1991. The main features of the Declaration include: 1) Every government should have a national breastfeeding committee. 2) Every facility providing maternity services shall practice the “10 Steps to Successful Breastfeeding.” These 10 steps are procedures that reduce barriers and empower women to successfully breastfeed their infants. 3) Enforce the principles and aims of the International Code of Marketing of Breast-Milk Substitutes. “The Code,” as it is usually referred to, is a set of recommendations to regulate the marketing of breastmilk substitutes, bottles, and teats. Breastmilk substitutes should be available when needed, but not promoted.6 4) Every government shall enact legislation to protect the breastfeeding rights of every working woman. The World Health Organization recommends that infants be exclusively breastfed for the first 6 months of life to achieve optimal growth, development, and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to 2 years of age or beyond. The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians also recommend exclusive breastfeeding for about the first 6 months, followed by complementary foods at around 6 months, with the continuation of breastfeeding for at least 1 year and beyond for as long as is mutually desired by the mother and child.3,4 The AAP policy statement emphasizes that there is no age limit at which breastfeeding should terminate. No studies have shown psychological damage to children who breastfeed up to age 3 and beyond.3 Healthy People 2010, which is a national health promotion and disease prevention initiative, includes an objective to increase breastfeeding rates in the USA. Its 2010 target is for 75% of all mothers to initiate breastfeeding after birth, 50% continuing to breastfeed at 6 months with 25% of those mothers exclusively breastfeeding until 6 months, and 25% of mothers breastfeeding at 1 year.8 344

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Breastfeeding Rates According to the 2004 Center for Disease Control National Immunization Survey, approximately 73.8% of mothers in the USA initiated breastfeeding, 41.5% were breastfeeding at 6 months, and 20.9% were breastfeeding at 1 year. Women who are older, have a higher education, and strong family and/or partner support are more likely to breastfeed. Adolescents are more likely to breastfeed if their mothers did. Women who are married and women with a higher income also have greater breastfeeding rates. In the United States, there is a significant difference in breastfeeding prevalence among different ethnic groups. Hispanic women have the highest breastfeeding rates, followed by Caucasian women. Non-Hispanic African American women have the lowest breastfeeding rates in the USA.9

Benefits of Breastfeeding Infant Breastfed children do not share the same illness or mortality rates of artificially fed children, even in developed countries. There is evidence for short- and long-term benefits of breastfeeding. Artificially fed infants have significantly higher rates of acute otitis media, non-specific gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, asthma, sudden infant death syndrome (SIDS), and necrotizing enterocolitis.3 The immune system of newborns is immature, and the complex and elaborate anti-infective properties of breastmilk protect the young infant from infection. In addition to immunoglobulins, human milk contains proteins such as lactoferrin, lysozyme and casein, lipids, oligosaccharides, enzymes, prostaglandins, growth factors, hormones, and cells that work in many different ways to prevent infections and modulate the immune system. This natural immune protection is not available to artificially fed infants.10 These special properties of breastmilk also provide long-term protection from many diseases seen at higher rates in artificially fed infants, including an increased risk of obesity, type 1 and 2 diabetes, and childhood leukemia.11 The Agency for Healthcare Research and Quality, in its 2007 comprehensive literature review, found no definite relationship between breastfeeding and IQ performance; however, most studies had significant confounding variables not controlled for, particularly maternal intelligence.12 The World Health Organization concluded in their systematic review DM, June 2008

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and meta-analysis that adults breastfed as infants have a modest decrease in blood pressure and cholesterol compared with adults who never breastfed.13 The AHRQ summarized that the risk of cardiovascular diseases and breastfeeding in infancy needs further investigation before accepting this association.

Maternal Breastfeeding has been shown to improve pancreatic ␤-cell function in women with a history of gestational diabetes.14 In a large prospective study involving 2 cohorts of nurses totaling 150,000 subjects, there was an inverse relationship between duration of breastfeeding and risk of type 2 diabetes among women without a history of gestational DM. Each additional year of breastfeeding was associated with a 4% (95% CI 1-9) reduced 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 2 diabetes among the nurses who had gestational diabetes.15 Studies show that breastfeeding for a short time or not at all is associated with a higher risk of postpartum depression, although it is unclear how these are related. It is possible that women who have symptoms of postpartum depression may wean the baby early or choose not to breastfeed.12 The risks of ovarian and breast cancer are higher in women who do not breastfeed, and these risks are inversely associated with the duration of breastfeeding. A meta-analysis combining 45 studies published thru 2001 with approximately 147,275 women calculated a 4.3% (95% CI 2.9-5.8) reduction in breast cancer for every year of breastfeeding.16 Another meta-analysis has shown a 28% decreased risk of breast cancer in women who breastfeed longer than 12 months.17 AHRQ performed a meta-analysis on 9 studies that examined the relationship between ovarian cancer and breastfeeding. They found a 21% (95% CI 9-32) reduction in the risk of ovarian cancer compared with women who never breastfed.12 Breastfeeding is associated with a decrease in fertility, which improves child spacing. This is particularly true when a woman is exclusively breastfeeding, meaning that the infant is not receiving any other food such as formula or solids. A clinical algorithm, called the Lactation Amenorrhea Method (LAM), has been established. If a woman is amenorrheic, her baby is under 6 months of age, and she is fully breastfeeding her infant, then she has a 1-2% chance of becoming pregnant at that time.18,19 Once she resumes menstruating, or if her baby is over 6 months, and/or 346

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she initiates other foods for the baby, the LAM method is no longer applicable.

Societal Women who work outside the home have a shorter duration of breastfeeding, and intentions to work full time are significantly associated with lower rates of breastfeeding initiation and shorter duration.20,21 Working women who are faced with too many barriers to continue breastfeeding take off more sick days for their children as compared with women who continue to breastfeed while back to work. Several studies indicate that support for lactation at work benefits individual families as well as employers. Supportive employers experience earlier return of employees from maternity leave, an enhanced public image as an employer, decreased employee absenteeism, fewer health care costs, and less employee turnover.22-24 Among the top 100 mother-friendly companies rated in Working Mother magazine 2007 for the USA, 98% have lactation support programs, as compared with 26% nationally (based on a 2007 survey of Society for Human Resource Management).25 Because breastfeeding babies and mothers are healthier, breastfeeding has been found to decrease health care costs for families, employers, and society.26 One study found that infants breastfed for at least 3 months saved the health care payer more than $300 during the first year of life as compared with formula-fed infants, just for the diagnoses of otitis media, lower respiratory infections, and gastroenteritis.23,26 A 1999 Italian observational study studied the health care costs of 2 infant cohorts, 458 fully breastfed infants versus 362 not fully breastfed infants. The ambulatory health care costs for the fully breastfed group were approximately 34.69 Euros per infant/year compared with 54.59 Euros for non-fully breastfed group, and 133.43 versus 254.03 Euros for hospital care, respectively.27

Anatomy and Physiology of Breastfeeding Breast Anatomy (Fig 1) The glandular tissue of the breast is comprised of 15-20 lobes. Within each lobe are lobules with clusters of alveoli, like grapes on a vine, which are lined with milk-producing cells called lactocytes. The alveoli pass milk through ductules, which eventually drain into a more dominant duct leading from each lobe to the nipple pore. Each alveolus is surrounded by myoepithelial cells, which contract in response to oxytocin released from the posterior pituitary.28 The cells compress the alveoli, sending milk DM, June 2008

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FIG 1. Anatomy of the human breast. (Adapted with permission from Donna Geddes, PhD. Available from: http://www.biochem.biomedchem.uwa.edu.au/Our_People/home_pages/ academic_staff/hartman/peter_hartmann/download.) (Color version of figure is available online.)

down the ductal system to be expelled by the breast. This is seen clinically as a let-down, or milk-ejection reflex (Fig 2). The nipple has 4-18 openings, or pores. The nipple and areola contain erectile tissue, allowing the nipple to elongate with infant feeding and pumping. The areola is the darker pigmented area around the nipple and contains Montgomery glands, which are located circumferentially. These small oil-producing glands provide lubrication and help prevent infection of the skin.28,29 The mammary gland develops through five stages30: (1) Embryogenesis, (2) Pubertal development, (3) Development during pregnancy, (4) Lactation, and (5) Involution. Embryogenesis. During fetal development, the mammary bud can be identified at 18-19 weeks gestation. This epidermal tissue extends into the subepidermal mesenchyme. This is met by mesenchymal tissue that extends subdermally to form the fat-pad precursor. The fat-pad precursor is invaded by ducts that branch out to form an immature mammary duct system. These rudimentary breasts are present at birth in the connective tissue just posterior to the nipple. This tissue will often become swollen 348

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FIG 2. Lobules with a lobe of the breast. (Reprinted with permission from Hanne M. Jensen, MD: The Breast in 3 Dimensions: Fact and Fancy, 2005.) (Color version of figure is available online.)

and may secrete milk after birth, under maternal hormone influence during pregnancy. Pubertal Development. At puberty, the hypothalamus secretes gonadotropin-releasing hormone, which in turn stimulates anterior pituitary release of LH and FSH. Both LH and FSH stimulate ovarian production of androgens, progesterone, and estrogen. Estrogen stimulates the growth of the mammary ducts into the mammary fat-pad, and progesterone contributes to lobulo-alveolar development (Fig 3). The mature breast of a woman before her first pregnancy is divided into lobules which consist of terminal duct units. These terminal duct lobular units consist of ducts with a few small branching ductules terminating into alveolar clusters, which are underdeveloped and quiescent until pregnancy. Pregnancy. The hormone changes of pregnancy stimulate full development of the breast tissue, and there is an overall increase in the ratio of glandular tissue to adipose tissue in the breast. The concentration of glandular tissue is greatest close to the nipple in the distal breast. These changes are responsible for the breast growth and discomfort that women feel during the first trimester. Progesterone, prolactin, and placental lactogen play central roles in the development and differentiation of DM, June 2008

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FIG 3. The developing breast. (Reprinted with permission from Hanne M. Jensen, MD: The Breast in 3 Dimensions: Fact and Fancy, 2005.) (Color version of figure is available online.)

glandular tissue, particularly the alveoli. One small study measuring the growth of breast tissue during pregnancy found that breast growth correlates with placental lactogen levels. Breast growth during pregnancy among the eight women in this study ranged from 12 to 227 mL.31 Estrogen is thought to stimulate elaboration of the ductal system (Fig 4). Lactation. Lactogenesis, defined by the onset of milk production and secretion, is divided into two stages32: Stage 1. The first stage of lactogenesis occurs during the second trimester of pregnancy, when prolactin from the anterior pituitary gland stimulates the lactocytes to further develop and produce colostrum. This early colostrum contains lactose, total proteins, and immunoglobulins. High levels of circulating progesterone prevent milk production during pregnancy. Stage II. After birth of the infant and expulsion of the placenta, the progesterone level drops, ushering in the production of milk synthesis, under the influence of the high prolactin level. Significant changes in the alveoli occur with a decrease in permeability between the lactocytes. Because this decrease in permeability prevents movement of molecules through the spaces between lactocytes and into the plasma, there is a decrease in sodium and chloride levels in colostrum, and an increase in 350

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FIG 4. A normal breast slice clusters of lobules, with their terminal ducts. A major duct is also present. (Reprinted with permission from Hanne M. Jensen, MD: The Breast in 3 Dimensions: Fact and Fancy, 2005.) (Color version of figure is available online.)

lactose and other mature milk components. Most women notice a relatively low volume secretion of colostrum the first 24-48 hours. On average, colostrum secretion is about 100 mL/day, and is high in IgA and lactoferrin, two very important immunoprotective proteins. During the first 4 days postpartum, colostrum secretion rapidly evolves into transitional milk, which is much greater in volume and contains most components of mature milk. With this increase in milk volume, the concentration of lactoferrin and IgA decreases approximately 10-fold. Increased levels of ␣-lactalbumin, lactose, citrate, glucose, free phosphate, and calcium are associated with increased milk volume. Transitional milk is defined by the continuum of changes that occur in milk composition from colostrum immediately postpartum to mature milk by about 10 days postpartum.32 Constituents of mature human milk can be broken into the following categories; proteins, nonprotein nitrogens, carbohydrates such as lactose and oligosaccharides, lipids, vitamins, minerals, and cells. The most variable constituent in human milk is fat, which can be influenced by duration of gestation, months postpartum, parity, breastmilk volume, timing during feeding, maternal diet, and maternal weight gain during pregnancy.33,34 DM, June 2008

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TABLE 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

Human milk proteins not only provide amino acids, but have diverse roles such as immunoprotection, carriage of vitamins and hormones, and enzymatic activity. The main carbohydrate is lactose, which is the second major constituent of breastmilk. Lipids provide the highest concentration of calories in breastmilk, supplying 30-50 g/L. Vitamin content of breastmilk varies according to maternal vitamin nutritional status. In general, if maternal vitamin status is sufficient, breastmilk vitamin levels are stable and do not vary in accordance with maternal intake.33 Delayed Lactation. The rapid increase in milk volume between 36 and 120 hours postpartum is perceived by mothers as the “coming in” of their milk. Multiparous women tend to have an earlier increase in milk volume than primiparous women. Many factors have been associated with a delay in lactogenesis,32 such as cesarean section, placental retention,35 obesity,36-38 prolonged second stage of labor, flat or inverted nipples,38 stressful delivery, and diabetes.40 Women who experience a delay in lactogenesis may not notice a rapid increase in milk supply until approximately 6-10 days postpartum (Table 1). Hormonal Regulation of Lactogenesis. A decrease in progesterone and continued elevation of prolactin are required for lactogenesis to occur. The decrease in progesterone is accomplished by the removal of the placenta postpartum. As milk volume increases, removal of milk is important to maintain lactogenesis. Prolactin is secreted by the anterior pituitary gland, and its secretion from the pituitary gland is partially regulated by the amount of nipple stimulation that occurs during early lactation. In the absence of suckling postpartum, prolactin levels will decrease to prepregnancy levels by 7 days.44 Prolactin stimulates the synthesis of milk by binding to membrane receptors of the mammary epithelial cells. Although elevated prolactin 352

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levels are necessary for milk production in early lactation, the volume of milk produced is not associated with prolactin levels.30 Prolactin secretion is also under the inhibitory control of dopamine, produced in the hypothalamus. Catecholamine levels in the hypothalamus influence dopamine levels, so medications and events which decrease catecholamine levels also decrease dopamine levels, thereby increasing prolactin levels.44 Prolactin levels tend to be highest overnight, which is when most women will attest to having higher milk supplies. Prolactin levels gradually diminish over time postpartum despite continuing successful breastfeeding. Approximately 6 months postpartum, the breastmilk supply becomes more dependent on milk demand and removal than on prolactin levels; however, prolactin levels do remain above baseline until weaning occurs.30 Oxytocin is responsible for milk-ejection, or “let down.” Secreted by the posterior pituitary, it acts by stimulating contraction of myoepithelial cells which surround alveoli and ducts in the lactating breast. The contraction of the myoepithelial cells enables milk transport and ejection from the breast. Several stimuli initiate the pulsatile oxytocin release as a neuroendocrine reflex, including tactile stimulation to the nipples and sight, sound, or thought of the infant. Mothers commonly feel their let-downs, perceived as a tingling, tight sensation. During a breastfeeding session, several let-downs may occur. Oxytocin release can be inhibited by psychological stress, alcohol consumption in a dose-dependent manner,29 and opioid use.32

The Breastfeeding-Friendly Physicians Office Several studies have demonstrated that health provider support of breastfeeding is associated with an increased initiation and duration of breastfeeding rates among the provider’s patients, especially if the health provider is trained in lactation.45 The Baby Friendly Hospital Initiative established evidence-based steps that a hospital can take to improve successful breastfeeding outcomes. These steps can be applied to the outpatient medical setting where families receive their ongoing care. It is recommended that a medical office develop a breastfeedingfriendly policy in conjunction with the office staff. The policy could include items such as not offering free formula gift packs, encouraging mothers to breastfeed, and ensuring new families the opportunity to visit with a health care provider prenatally to discuss infant feeding. Breastfeeding women should be encouraged to breastfeed in the office. Privacy should be offered to mothers, but it should not be mandatory for mothers to move to a separate place to breastfeed. Comfortable, supportDM, June 2008

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ive chairs should be available, and a breastfeeding pillow with an antibacterial cover is a convenient item to offer breastfeeding mothers. The office should have positive visual messages encouraging breastfeeding, as opposed to pictures and materials that demonstrate artificial feeding as the norm. Samples of formula, bottles, and nipples should not be given to families as gift packs.46 The office should have community breastfeeding resources available that list locations to purchase breast pumps, phone numbers for support groups, classes, and names of lactation specialists. The office clinical staff should have sufficient knowledge and triage tools to manage phone calls about breastfeeding problems and concerns regarding medications and breastfeeding. Educational materials for families regarding breastfeeding issues, such as engorgement, human milk storage, sore nipples, latch, and low milk supply, should be available (Table 2). Discussing the topic of breastfeeding during well-woman exams can increase a woman’s awareness of breastfeeding pre-pregnancy. During review of the self-breast exam, women can be taught about the natural function of the breast, along with the maternal health benefits of breastfeeding, particularly in regard to the decreased risk of breast cancer. Preteens and teens can also be taught about the natural function of breasts, and why the breasts grow in puberty.

Prenatal Education Health provider encouragement of breastfeeding during antenatal care has been shown to increase the incidence of breastfeeding, particularly among minority and single women.47 The United States Preventive Services Task Force found fair evidence that educational programs combining breastfeeding education with behavioral counseling, such as 30- to 90-minute breastfeeding classes run by lactation consultants, are associated with increased breastfeeding initiation and continuation for up to 3 months postpartum.48 Many women make their decisions about infant feeding before they become pregnant, and the maternity care provider should discuss infant feeding with every pregnant woman. Not only should women be asked by what method they plan to feed their newborn(s), but also encouraged to share their reasoning if not planning to breastfeed. Many women have misguided beliefs about breastfeeding that can be remedied with appropriate counseling. Women and their partners should express understanding of the risks of artificial feeding for the infant and woman’s health.49 It is important to take into consideration the cultural beliefs of the woman 354

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TABLE 2. Breastfeeding-friendly physician office Office Staff

Office Physical Plant

Health Care Providers

● 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. ● 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 of common problems. ● Available prenatal visit to discuss infant feeding and care with pediatric provider. ● Maternity care provider to discuss breastfeeding prenatally 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 visits until the baby is gaining weight adequately and mother appears confident. ● Observe a breastfeeding session. ● Work in concert with lactation professionals in the community, and provide information for other community resources. ● Support breastfeeding mothers and babies when confronted with medical needs that may jeopardize breastfeeding success (ie, medications, procedures). ● Address breastfeeding issues at well-child visits.

and her partner. Providing breastfeeding information for other family members such as grandparents can help provide breastfeeding support to the expectant mother. Pregnant women and their partners should be encouraged to attend a breastfeeding class that incorporates anatomy and physiology of breastfeeding, positioning and latch, normal frequency and duration of feedings, general breast care, how to assess whether the baby is feeding well, and recommendations on duration of breastfeeding.48 During prenatal care, it is recommended that the maternity care provider discuss breast development and perform a breast exam in order to identify red flags for the risk of insufficient milk postpartum. Women should be asked whether they have noticed an increase in breast size and breast discomfort during the first trimester. Lack of breast changes during DM, June 2008

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TABLE 3. Contraindications to breastfeeding Maternal Substance Ingestion

Maternal Illness

Infant Illness

Drugs of abuse: ● Cocaine ● Heroin ● LSD ● Methamphetamine ● Marijuana ● PCP ● Inhalants Maternal medication: ● Radioactive isotope therapy ● Antimetabolite therapy (ie, cancer treatment)

HIV infection HTLV infection Untreated maternal TB infection Active herpes simplex lesions on the breast

Galactosemia

pregnancy may be associated with an insufficient milk supply postpartum. A history of breast surgery, such as reduction or augmentation, and breast irradiation also places the newborn at risk for insufficient milk. On exam, evidence of inverted nipples that will not evert with gentle pinching may also increase the risk of insufficient milk transfer.50

Contraindications to Breastfeeding There are very few contraindications to initiating or continuing breastfeeding. In the United States, maternal HIV infection is considered a contraindication to breastfeeding, since the HIV virus can spread through breastmilk. However, in countries where alternatives to breastfeeding are not available, safe, affordable, or sustainable, breastfeeding is recommended.7 Untreated maternal tuberculosis and active herpes lesions on the breast also are contraindications to nursing. Women who are treated with antimetabolites, chemotherapy agents, or who have exposure to radioactive materials, including diagnostic or therapeutic radioactive isotopes, should not nurse until these substances are cleared from the breastmilk. Infants who have galactosemia should not breastfeed.3,51 Active use of certain drugs of abuse, such as PCP, heroin, cocaine, and methamphetamine, is generally contraindicated during breastfeeding.3 Because maternal–infant bonding is increased with breastfeeding, and bonding is very important to decrease the risk of infant neglect,52 each case involving a maternal history of substance abuse should be individually evaluated by the physician(s) of the mother and infant, as well as social services, to determine the cost/benefit of breastfeeding (Table 3). 356

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TABLE 4. Ten steps to successful breastfeeding 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 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. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. Source: The Baby Friendly Hospital Initiative USA; Available from: http://www.babyfriendlyusa. org/eng/01.html.

Getting Off to the Right Start for Healthy Term Infants Hospital Routines Hospital practices surrounding labor and birth have been found to have great impact on the success of breastfeeding initiation, Many policies and procedures developed in hospitals during the 20th century have not taken into account lactation physiology and neonatal needs in regard to breastfeeding. The World Health Organization and UNICEF recognized the barriers posed by hospital policies, and in 1989 published a set of recommended guidelines titled “Protecting, Promoting, and Supporting Breastfeeding: The Special Role of Maternity Care Practices.”53 From this document emerged “The Ten Steps to Successful Breastfeeding” (Table 4). As of August 2007, 61 hospitals and birth centers in the USA have been designated as “Baby-Friendly” by establishing education, policies, and procedures to optimize their level of care for lactation.54 Healthy infants should have as little intervention as possible after they deliver and should have immediate skin-to-skin contact with their mothers at least until after the first feeding has occurred (Fig 5). Infants have natural instincts to breastfeed and will often latch themselves onto the breast if health care providers allow them the opportunity.55 After birth, encourage hospital staff to dry, stimulate, and assess the infant on the mother’s abdomen. The baby may be covered with a blanket while skin-to-skin with the mother. The mother’s body temperature will adjust DM, June 2008

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FIG 5. A mother holding an infant skin-to-skin immediately after birth. (Color version of figure is available online.)

to the baby’s needs.56 Over-vigorous suctioning of the oral cavity and airway should be avoided to prevent later feeding aversion. Routine procedures such as vitamin K injection, eye ointment, and routine immunizations should be delayed until baby has completed the first feeding. Mothers and babies should remain together and “room-in” the same hospital room throughout their hospital stay. While rooming-in, parents will learn about their baby’s early feeding cues, such as rooting, placing the hands to the mouth, and increased physical activity (Fig 6). Rooming-in has been found to increase frequency of feeding as well as shortand long-term success of breastfeeding.57 It is important to teach that crying is a late sign of hunger, and it is often difficult to get the baby to latch on and feed once the baby is crying. Term breastfeeding newborns should ideally nurse 8-12 times a day. The frequency may vary with some feedings clustered together. The baby may need to be awakened for feeds every 3 hours during the first few weeks until he or she is gaining steadily and is back to birth weight.49 A baby may be gently stimulated by massage or changing the diaper if she needs to be awakened to nurse. There should be no time limit at the breast. The baby should finish feeding on one breast 358

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FIG 6. A baby demonstrated an early feeding cue. (Color version of figure is available online.)

and then, if still exhibiting hunger cues, latch onto the other breast. If the baby only nurses from one side, offer the other breast first at the next feeding. It is ideal to nurse equally from both breasts in a 24-hour period. Parents frequently express concern about whether their baby is getting an adequate amount of breastmilk— especially first time parents or those who have fed with a bottle and are accustomed to witnessing the exact volume baby has consumed. All health care providers should be aware of appropriate newborn elimination patterns in order to educate parents about signs of sufficient milk intake.58 Typically, on day 1 of life, a healthy term newborn will produce approximately 1 stool and 1 small urine. On day 2, 2 stools and 2 urines are typical, and on day 3, a minimum of 3 stools and 3 urines are expected. Beyond day 3 as the mother’s mature milk appears, at least 6-8 wet diapers and 6-8 yellow, seedy stools are reassuring each day. Many parents and health care providers find it helpful to have a feeding and voiding/stooling log available in the early postpartum days to assure proper nutrition and hydration of the infant59 (Table 5). Education of nurses, physicians, and other health care professionals working with the nursing couplet regarding the dynamics of breastfeeding is imperative in order to assist the nursing couplet with appropriate positioning and latch. It is recommended that a health care DM, June 2008

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TABLE 5. Signs of sufficient milk intake Infant

Mother

● Audible swallowing heard during feeding ● Appears relaxed during feeding and satiated after feeding ● Has awake, alert, calm times between feedings ● Nurses 8–12 times in a 24-hour period ● Diapers are almost always wet, and several stools per day after milk “is in” ● Gains 20–30 g a day after day 3–5 of life

● Breasts are full before a feeding and softer after a feeding ● May notice let-down reflex during feeding

professional, usually a nurse, observe a breastfeeding every shift while in the hospital or birthing center. This will help to ensure proper transfer of milk to the baby, and decrease the risk of sore nipples, cracks, and breast infections.

Positioning Typically taught positioning of the baby involves holding the newborn close to the mother, with the ear, shoulder, and hip aligned, and tummy-to-tummy with mother. The cradle hold involves supporting the head and upper body with a bent arm that is on the same side as the breast being fed from. The other arm supports either the breast or the lower part of the baby’s body. With the cross-cradle hold, the mother supports the baby at the breast using the opposite arm to the breast by holding the posterior head just beneath the occiput, as well as the trunk and buttocks of the baby. The ipsilateral arm supports the breast. The cross-cradle hold is a more common position when the baby is very small, very young, and/or has a weakness in the upper body and neck. Commonly, a mother and baby will each lie on their sides, facing each other, to nurse. A baby may also lie on top of a reclining mother in a vertical, oblique, or horizontal manner. In whatever comfortable position the mother chooses to use, paying attention to infant alignment helps to ensure a deep latch so that the nipple is not traumatized and the baby can effectively transfer milk (Figs 7–10).

Latch Once positioned in a way that is comfortable for mother and baby, the baby should be brought close to the breast. Often, the baby’s mouth will open wide with tactile stimulation to the lower lip and chin from the breast. Once the baby’s mouth is open wide, the baby should be brought to the nipple/areolar complex in an asymmetric fashion, with the chin and 360

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FIG 7. A mother holding her baby in the cradle hold, using the arm on the same side as the breast to support the baby. (Color version of figure is available online.)

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FIG 8. A mother holding her baby in a cross-cradle hold, using the opposite arm from the breast to support the baby. (Color version of figure is available online.)

lower lip first touching the areola. The upper mouth is then brought forward over the nipple/areolar complex, in order to latch onto the breast as deeply as possible. It is helpful to think of the baby latching onto the breast in the same way an adult would try to take a big bite from a very thick deli sandwich. Sometimes the nipple/areolar complex needs to be compressed with the free hand to enable the baby to attain a deep latch, trying to get as much areola into the baby’s mouth as possible (Figs 11 and 12). Alternatively, and likely much more naturally, the baby can be enabled to self-latch to the breast. The baby should be placed skin-to-skin ventrally between the mother’s breasts, in an upright position, so that if the baby looks up, he will see his mother’s face. Once the baby is relaxed and hungry, the mother will observe a bobbing and pecking behavior against her body, and the baby will attempt to throw himself laterally. The mother should continue to support the baby, but also allow the baby to lead such lateral movement to the breast. As the baby reaches the nipple, the baby will extend his neck in a sniffing position, keeping his chin and lower lip against the breast in close proximity to the nipple, open his mouth wide and latch onto the nipple/areolar complex.60 362

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FIG 9. A mother feeding her baby in a side-lying position. (Color version of figure is available online.)

Sucking When the baby is actively nursing, the mother should feel that the baby has good suction, without a sense that the baby will easily detach. Sucking is often described as nutritive, where the baby is receiving milk and swallowing accordingly, versus nonnutritive, when the baby is not actively receiving milk, so only has intermittent swallows. Mothers should be taught to look for the different types of sucking to gain an understanding of when her let-down occurs, and when the baby may not be actively feeding (nonnutritive sucking) at the breast. Sucking at the breast can be challenged by many factors, such as a very fast flow rate of breastmilk, infant fatigue, illness or discomfort, breathing difficulties, hypotonia, a short lingual frenulum, gastroesophageal reflux, torticollis, cleft lip and palate, macroglossia, and other oromotor pathology.61

Supplementation Parents, and often health care providers, worry that breastfeeding babies need supplementation in the first few days of life. There is a common perception that colostrum is not adequate in calories or volume. Healthy, term DM, June 2008

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FIG 10. The football hold, where the baby is supported under mother’s arm. (Color version of figure is available online.)

newborns do not need supplementation unless medically indicated. A visual aid, such as a walnut or large marble, to demonstrate for parents the small size of the newborn’s stomach can be invaluable. Colostrum is calorie- and protein-dense, as well as rich in antibodies and other immune substrates, making it the ideal food for a newborn.10 However, health care providers must adequately assess the positioning, latch, suck, and swallow to assure that the breastfeeding infant is effective in obtaining colostrum58 (Table 6). 364

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FIG 11. A latch often seen on an older infant, with relaxed lips, face close to the breast, the corner of the mouth slightly pursed.

Although a term healthy newborn should not need supplementation, the following are situations in which supplementation of mother’s milk is medically indicated.

Excessive Weight Loss A 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 evidence that mother’s milk is increasing, or that the baby is starting to gain weight, is a reason to supplement the baby.62 Feedings should be witnessed to assess latch, suck, and swallow to assure milk transfer. A common reason that a healthy baby may not gain sufficient weight despite presence of a sufficient milk supply is infant sleepiness. Breastfeeding is a much more active process of feeding than bottle feeding, and oftentimes newborns need to be gently awakened to finish feeding.63 Infant sleepiness is easy to diagnose; parents will usually complain that the baby falls asleep early in the feeding and is hard to keep awake. Occasionally a sleepy baby may need supplementation, since excessive weight loss may lead to more sleepiness and inability to successfully breastfeed. DM, June 2008

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FIG 12. A latch typical of a newborn, with a wide open mouth, nose touching the breast, double chin present. (Color version of figure is available online.)

TABLE 6. Medical reasons for supplementation in term, healthy infant Infant

Maternal

Hypoglycemia, measured by serum glucose, after infant has had opportunity to breastfeed. Inborn errors of metabolism. Inability to feed at the breast due to separation, illness, or congenital anomaly. Clinical evidence of dehydration. Uncontrolled hyperbilirubinemia despite optimal breastfeeding. Weight loss of greater than 8 –10% with delayed lactogenesis. Need for additional nutrient intake in low birthweight infants.

Delayed lactogenesis with poor infant intake. Unavailability of mother due to illness or geographic separation. Primary glandular insufficiency. Prior breast surgery or radiation. Medications/substances not compatible with breastfeeding. Maternal illness contraindicating breastfeeding.

Infant Illness Ill infants often do not breastfeed well due to weakness, suck dysfunction, or lack of appetite and may need supplementation. Unless profoundly ill, the neonate should be allowed to breastfeed regularly, with 366

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supplementation offered after breastfeeding as needed. Typical illness scenarios include hypoglycemia, hyperbilirubinemia with a bilirubin around 18 or above, acute dehydration, infection, hypotonia, anatomic deformities, and gastroesophageal reflux.64

Maternal–Infant Separation Occasionally a mother and baby may be separated if a mother or infant has to be transferred to another medical floor, another medical facility, or if the mother is too ill to feed the baby completely by breastmilk. A mother who is separated from her infant should be encouraged to pump her breasts at least every 3 hours or 8-10 times a day to maintain her milk supply and to provide breastmilk for her baby. Hospital staff should be sensitive to this need and should provide education and support for the mother. In the first few days postpartum, it can be very difficult to express sufficient colostrum for the baby using an electric breast pump, and manual expression has been demonstrated to be more effective.65 A nursing baby typically will ingest more colostrum than what pumping can provide, so often these babies need some supplementation.

Maternal Medication In rare situations, the mother may need to take a medication that is contraindicated with breastfeeding. Usually medications that are new or of concern with breastfeeding can be substituted by medications that are known to be safe with breastfeeding.

Delayed or Insufficient Lactogenesis Some mothers who are highly motivated to breastfeed will still have difficulty with onset of lactogenesis, suboptimal breastfeeding, or poor infant weight gain. Dewey and coworkers investigated risk factors leading to such difficulties and found factors associated with suboptimal breastfeeding early postpartum to include primiparity, cesarean section, flat or inverted nipples, the infant’s health at birth, supplementation without using breastmilk in the first 48 hours, pacifier use, stage II of labor greater than 1 hour, maternal BMI greater than 27 kg/m2, and birth weight greater than 3600 g. Findings in the study also emphasized the importance of close follow-up at 72-96 hours postpartum, given the risk of infant dehydration in these cases.38 If supplementation is medically indicated, the preferred choice is to supplement with the mother’s expressed breast milk. If the baby is able to breastfeed, the mother should pump her breasts after nursing the baby. Another option is pasteurized banked donor human milk from a milk bank DM, June 2008

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FIG 13. A medicine cup can be used to supplement a young infant. (Color version of figure is available online.)

that follows the guidelines established by the Human Milk Banking Association of North America.66 Infant formula is a third choice for supplementation. Glucose water or sterile water should never be used, since they do not supply sufficient calories or protein to substitute for mother’s milk. The method of supplementation, such as a cup, bottle, finger feeding, or a supplemental tube at the breast, should be individualized, ideally in consultation with a knowledgeable health professional, as all methods can interfere with the baby’s ability to nurse successfully at the breast. Risks of supplementation include interfering with maternal milk supply, maternal discouragement, difficulty getting the baby back to breast, and changes in bowel flora due to the use of formula. Cup Feeding (Fig 13). Cup feeding is considered a safe way to supplement a baby and is used in several special care units for premature 368

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FIG 14. Fingerfeeding. A feeding tube is attached to a syringe, and taped to a finger. (Color version of figure is available online.)

infants. It may also be used for short-term supplementation of term infants. A few studies have demonstrated fewer oxygen desaturations and lower heart rates with cup feeding as compared with bottle feeding for premature infants, possibly because of the slower rate of feeding that occurs with cup feeding.67,68 Cup feeding should be demonstrated to the parent by a knowledgeable health professional. Usually a 30-mL medicine cup or shot glass is used, and the milk is allowed to touch the lower lip so that the baby will 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 that allows safe supplementation. An infant feeding tube or a butterfly needle with the needle removed is attached to a syringe of milk, and the tube is attached to a finger. When the baby sucks on the finger, the baby draws the milk from the syringe. It is safest to not push the syringe, allowing the baby to suck the milk at his own pace. Finger feeding allows the infant to have more control over feeding as compared with a bottle. There is no evidence that finger feeding is preferred over bottle feeding in terms of preserving feeding skills at the breast, but it may be a more acceptable form of supplementation by the baby as opposed to the bottle. Supplemental Tube at the Breast (Fig 15). A supplemental nursing tube to be used at the breast can be purchased commercially, or a gastric DM, June 2008

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FIG 15. A supplemental nursing device used at the breast. The baby latches onto the breast and the tube to receive supplementation while nursing. (Color version of figure is available online.)

feeding tube and syringe can be used, as described with finger feeding. The tip of the tube is situated at the nipple, and taped onto the breast. When the baby attaches to the breast, the baby will also attach to and receive milk from the feeding tube. This technique is beneficial in cases 370

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where the milk supply is low, or the baby is weak and not very effective with sucking. Use of a supplemental tube at the breast may be limited by its cumbersome nature, lack of portability, and acceptance by the infant. Bottle Feeding. Bottle feeding remains the most common method of supplementation for breastfeeding babies. Sucking from a bottle entails different oromotor skills than breastfeeding, which can result in the baby becoming conditioned to the bottle and preferring the bottle over breastfeeding.63 Many babies, however, are able to nurse at the breast and bottle feed with equal skill. For babies that need long-term supplementation or when mothers return to work, bottle feeding is the most practical method to use. Pacifiers should not be offered until breastfeeding is well established without difficulties and the baby demonstrates appropriate weight gain. Whenever a newborn shows an interest in suckling during the first few days postpartum, the baby should be put to the breast, and not given a pacifier. This will help establish mother’s milk supply as soon as possible, and ensure adequate nutrient intake by the newborn. One study has demonstrated that pacifiers are associated with a decreased breastfeeding duration.69 Once breastfeeding is going well and the infant is gaining well, parents must also be counseled that, if electing to use a pacifier, it should be for non-nutritive sucking only and not a replacement for nursing. They should be certain that the baby is not hungry before offering it.70

Hospital Discharge Prior to leaving the hospital or birthing center, it is important for parents to express confidence of knowledge regarding several breastfeeding issues. Each mother should demonstrate competence with nursing, including latching, identifying infant swallows and readiness to end a feeding, and identifying early feeding cues. Health care providers should be sure that parents understand the normal frequency and duration of feedings of the newborn, as well as the number of expected stools and wet diapers indicating adequate hydration. Parents should know how to wake up a sleepy baby to assure an adequate number of feedings in the early newborn days.58,59 Mothers should also know that breast engorgement may occur on day 3-5 postpartum. They should be taught that frequent, effective feeding often prevents significant engorgement.71 However, if the breasts become too taut around the nipple–areolar complex for the baby to latch on well, she should manually express or use a pump to remove a small amount of milk from the breasts, making it easier for the baby to latch on. DM, June 2008

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Upon discharge, arrange to see the baby within 1-2 days in the office. If the baby demonstrates breastfeeding problems, neonatal jaundice, or excessive weight loss, follow-up in 1 day is indicated. The baby should be followed as an outpatient every 1-2 days until he/she demonstrates a weight gain of 20-30 g per day and mother expresses confidence regarding infant feeding.59 It is also important to assess other breastfeeding problems, especially sore nipples, which should be evaluated immediately (see “Maternal Problems”). It is also not too early to address a plan for the mother who may be returning to work and to share milk storage information. Provide parents with information on breastfeeding resources in the community. These may be the local La Leche League or hospital breastfeeding support group, local lactation consultants, public and private health offices, and WIC. A breastfeeding hotline may also be helpful to new breastfeeding parents. If a local hotline is unavailable, consider the National Breastfeeding Hotline (1-800-994-9662), provided by the Department of Health and Human Service’s Office on Women’s Health.

Common Breastfeeding Problems: Neonatal The Near Term Infant Not in the NICU Infants born during 35-37 weeks gestation require individualized lactation assistance. Often these babies do well enough to avoid a NICU stay, room-in with mom, and are discharged at the same time as their mothers. However, they do tend to have a unique set of issues requiring heightened awareness regarding breastfeeding. Near term infants often have an uncoordinated suck and swallow due to low muscle tone and neurologic immaturity. They are sleepier and are at risk of not waking up when they are hungry and in need of calories and hydration. Therefore, they have a higher risk of hypoglycemia, and because of their relative immaturity, they have delayed hepatic bilirubin excretion leading to jaundice. When working with the near term infant, consider an automatic lactation consult to help the mother establish an adequate milk supply, and to optimize infant feeding at the breast— especially if the baby is a weak nurser. To be proactive in preventing excessive weight loss, dehydration, and jaundice, near term babies often need supplementation, ideally with mother’s own expressed milk, after feeding at the breast.72 These babies also need very close follow-up after discharge, usually within 24 hours after discharge to monitor for the above problems. 372

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TABLE 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

Neonatal Jaundice (Table 7) Jaundice, caused by elevated levels of serum bilirubin, affects many newborns in the first week of life. One study demonstrated that 5-12% of breastfed infants had bilirubin levels ⬎15 mg/dL compared with 0.6 –2% of infants who were fed formula.73 DeCarvalho and coworkers compared the amount of bilirubin in stool and serum on days 1 and 3 in breastfed and formula-fed infants. The decreased excretion of bilirubin in the breastfed infants’ stool and resultant elevation in serum bilirubin levels as compared with the formula-fed infants are likely due to the decreased volume intake of colostrum versus formula. There was also less stool output among the breastfed infants in the first days, leading to less bilirubin excretion.74 Mild jaundice in the first week postpartum is considered physiologic, and more recently, this slight hyperbilirubinemia has been recognized as possibly beneficial to the infant for its anti-oxidant properties.75 In order to prevent kernicterus and its long-term sequelae, all babies should be assessed for severe, unconjugated hyperbilirubinemia prior to leaving the hospital or birthing center.3 One of the most common causes of non-physiologic jaundice in the breastfeeding infant is ineffective breastfeeding with insufficient calorie intake. Appropriate intervention involving lactation assessment must be made to correct the feeding problem and improve calorie intake. Breastfeeding does not need to be interrupted, but the infant may need to be supplemented. Appropriate supplementation includes expressed breastmilk, pasteurized donor human milk, or infant formula. Water should not be given as a supplement. With an increased calorie intake, infants will generally stool more, thereby decreasing their intrahepatic circulation and decreasing their bilirubin level. DM, June 2008

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Other risk factors for severe unconjugated hyperbilirubinemia include blood group incompatibilities, infant illness such as infection or sepsis, prematurity, cepahalohematoma or other bruising, East Asian race, family history of jaundice, or infant macrosomia of a diabetic mother. Jaundice appearing less than 24 hours is never physiologic, and etiology must be promptly evaluated.76 Breastmilk jaundice is an extension of physiologic unconjugated hyperbilirubinemia beyond the first week of life. It is also caused by increased bilirubin reabsorption from the intestine. Usually, the total bilirubin will be greater than 12 mg/dL but less than 20 mg/dL. Direct bilirubin will be normal as will liver enzymes. Other causes of jaundice must be ruled out. If a term baby is greater than 5 days old, feeding, stooling, and gaining weight well, and the bilirubin is remaining less than 20 mg/dL, no treatment is needed. There is no special treatment required for breastmilk jaundice for stable bilirubin levels less than 18 mg/dL in healthy near term infants 35-37 weeks or a 38-week infant with other risk factors for jaundice. There is no indication for interruption of breastfeeding or routine supplementation in any of these cases. Because breastmilk jaundice is a diagnosis of exclusion, it is important to follow bilirubin levels until they are decreasing. Breastmilk jaundice may take up to 3 months to resolve. If bilirubin rises above 18-20 mg/dL, phototherapy should be initiated. If phototherapy does not adequately reduce the bilirubin level, then it is advisable to interrupt breastfeeding for 24 hours and feed the baby with an elemental formula while the mother pumps and saves her milk.76

Hypoglycemia The definition of hypoglycemia in the newborn remains variable and sometimes controversial based on gestational age, weight, type of measurement, and whether symptomatic or asymptomatic. It is well established that healthy, term, breastfeeding, appropriate-for-gestationalage infants do not need routine monitoring of blood glucose as this can interfere with breastfeeding and does not appear to improve outcomes. Even in the presence of a single low glucose reading, the health care provider should consider whether the infant is symptomatic, feeding well, or has other risk factors. Newborns at highest risk of hypoglycemia include: small for gestational age (⬍10th percentile), large for gestational age (⬎90th percentile), a discordant smaller twin, infant of a gestational diabetic mother, low birth weight ⬍2500 g, post asphyxia, erythroblastosis fetalis, polycythemia, cold stress/hypothermia, sepsis, respiratory distress, endocrine abnormalities, or inborn errors of metabolism. In addition to being cognizant of the risk factors for hypoglycemia, encour374

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aging frequent breastfeeding by continuous maternal–infant contact helps to prevent hypoglycemia by promoting normal physiology.78

Insufficient Weight Gain Any infant who has lost more than 10% of birth weight, who has not regained his birth weight by 2 weeks of age, or who has an unexplained weight loss or failure to gain properly must be evaluated immediately for insufficient weight gain. The infant should be gaining 20-30 g per day once the mother’s milk is “in” by day 3-5 postpartum.79 Insufficient weight gain may occur because (1) the infant is not feeding effectively, (2) the infant has a higher than expected calorie need, or (3) mother has an insufficient milk supply. Infant Factors for Slow Infant Weight Gain. Infant risk factors for poor or sluggish feeding behavior include prematurity, congenital and acquired infections, trisomy 21, gastroesophageal reflux disease, congenital anomalies (particularly of the mouth and throat), congenital heart disease, cystic fibrosis, neurologic conditions, suck incoordination, a short lingual frenulum, or excessive sleepiness.64 More rarely, some infants may also have a higher than expected caloric need, or are volume restricted and unable to obtain sufficient calorie intake with a given volume of breastmilk. These problems are diagnosed based on infant history, physical exam, and observation of a feed. It is important for a trained health care professional to determine whether adequate milk transfer is occurring. The infant may have a poor latch, inadequate sucking due to weakness, or suck and swallow may be uncoordinated. Pre- and postfeeding weight assessments may help to determine adequacy of milk transfer. Ineffective feeding may lead to low maternal prolactin levels and incomplete breast emptying, leading to a decreased milk supply.32 Treating the underlying medical problem of the infant will often help or remedy the insufficient infant feeding. Maternal Factors for Slow Infant Weight Gain. Many situations predispose to a low milk supply, including maternal–infant separation, such that the baby is not able to feed often enough: use of a nipple shield, maternal hormone imbalances, insufficient glandular tissue, a history of breast surgery, medication or substance use, and maternal illness, either acute or chronic (see “Maternal Health Problems: Low Milk Supply”). A careful history and physical examination of the mother and baby should be performed, as well as observation of a breastfeeding session. It is important to ask about the duration and frequency of feeding, infant behavior at the breast such as shortness of breath or sleepiness, and patterns of stool and urine output. Inquire whether the mother has any DM, June 2008

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concerns about how breastfeeding is going or if she is having any pain, redness, or other concerns regarding her breasts, or any history of medication use, breast surgery, or lack of breast fullness postpartum. Perform a complete examination of the infant, with attention to the mouth and sucking reflex, followed by observation of a feeding session. While the baby is breastfeeding, attention should be paid to the positioning, suck, swallow, and oral–motor coordination. A breast exam may also be indicated.64 Once the underlying cause for the poor weight gain is identified and corrected, the infant may begin to gain in an appropriate or an accelerated manner. Careful observation of intake and weights should continue until the expected growth pattern is achieved. In some situations, supplementation may need to be given with expressed mother’s milk, donor human milk, or formula. Care should be given to individualize the method of supplementation with a cup, finger feeding, supplemental system at the breast, or a bottle. This decision may require consultation with a lactation consultant. Most babies can continue to breastfeed in addition to receiving extra calories from supplementation.62,72

Common Breastfeeding Problems: Maternal Engorgement During Lactogenesis II, approximately 2-5 days after delivery, milk production increases. At this time, there is increased blood flow to the breasts accompanied by interstitial edema. Breasts normally become full and warm. Excessive engorgement with pain and edema may be prevented by (1) avoiding excessive intravenous fluids and oxytocin in the intrapartum period, (2) frequent and complete emptying of the breast in the early neonatal period, and (3) continued frequent nursing during the period of Lactogenesis II.80 Ideally, breastfeeding will begin within an hour of birth. Babies may not nurse well the first postpartum day if labor analgesia has been used. Mother and baby should be kept together and should spend as much time skin-to-skin as possible. Most healthy term babies will begin nursing well within 24 hours. After the first 24 hours, if the baby is not making progress toward latching well or if the mother and baby are separated, mother should be assisted with expression of milk to assure adequate drainage of the breast to prevent or ameliorate engorgement. If mother and baby are separated right after birth and nursing will not be starting promptly due to infant illness, the mother can be assisted to begin milk expression as soon as she is stable after the delivery.70 376

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In more troubling cases, women may develop bilateral breast redness, discomfort, and low grade fever. Sometimes the area around the nipple becomes firm and less compressible, which may make it difficult for the baby to latch on deeply and effectively to the breast, potentially causing nipple trauma and poor milk transfer. Mothers should be taught to hand express some milk to soften the areola, making it easier for the baby to latch on appropriately.81 Engorgement can be relieved by frequent breast emptying and/or nursing and cool compresses. Some recommend chilled green cabbage leaves placed directly against the breast tissue under the bra,82 although a systematic review of studies for breast engorgement found cabbage leaves, oxytocin, cold packs, and ultrasound therapy to be no better than placebo in relieving engorgement.83 Unrelieved engorgement may lead to decreased milk supply and other complications, such as nipple damage and mastitis.

Gigantomastia This rare condition occurs in about 1/100,000 women. The etiology is thought to be hormonal. It may mimic severe engorgement when it occurs in the early postpartum period. It consists of severe, often painful enlargement of both breasts. It usually develops during pregnancy but may occur in the postpartum period. The pain can be extreme, and in severe cases, necrosis of the breast skin can occur. Although it usually resolves postpartum, it can recur with subsequent pregnancies. Treatment for severe or recurrent cases usually involves bilateral subcutaneous mastectomies.84,85

Sore Nipples (Table 8) Sore nipples are one of the most common reasons for premature weaning, and probably the most common reason women do not continue nursing past the first few weeks.86,87 Most women experience transient nipple soreness while the baby is latching on during the first week or two. However, nipple damage is never normal and there should be no nipple pain between feedings or once milk is flowing during a feeding. Many mothers think sore nipples are to be expected; however, it is important to educate mothers prenatally and in the early postpartum period that persistent sore nipples, and especially nipple damage, are not normal and should prompt her to seek assistance. The most common precipitating cause of sore nipples is incorrect latch88 (Fig 16). Mothers should be assisted with obtaining a correct latch from the very first feed. If nipples are sore, a knowledgeable professional should observe latch and positioning and assist the mother to make any DM, June 2008

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TABLE 8. Causes of sore nipples Mechanical/Trauma

● ● ● ● ● ●

Infectious

● Candida of nipples ● Bacterial infections X Impetigo X Mastitis X Intraductal ● Herpes simplex/zoster

Dermatoses

● ● ● ●

Hormonal

● Menstrual cycle ● Pregnancy

Vasospasm

● Primary, due to Raynaud syndrome ● Secondary, due to trauma, infection

Improper positioning Incorrect latch Suck disorganization Ankyloglossia Infant biting Pump trauma

Atopic dermatitis Irritant dermatitis Allergic dermatitis Psoriasis

FIG 16. Sore nipple. This mother sustained nursing trauma to her nipple from inappropriate latch and suckling. (Color version of figure is available online.) 378

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needed corrections. Infant ankyloglossia (“tongue-tie”) may also contribute to nipple soreness, due to the difficulty the baby may have with latching deeply onto the breast (see “Getting Off to the Right Start”). Once latch and positioning problems have been identified and corrected, the underlying cause of persistent sore nipples must be identified. The differential diagnosis of persistent sore nipples includes bacterial infection, yeast infection, dermatitis or other primary skin disorders, Raynaud phenomenon of the nipples, nipple trauma, and hormonal factors such as return of the menstrual cycle or pregnancy. Persistent sore nipples may be due to infection. Any break in the skin of the nipple may harbor a bacterial infection, usually due to Staphylococcus aureus. Nipple wounds should be cultured if possible. Superficial nipple impetigo may be treated with topical mupirocin 2% ointment or oral antibiotics suitable to treat a S. aureus infection. Oral antibiotics may be more effective than topical antibiotics, and should definitely be considered if there is any tenderness of the areola or underlying breast tissue or other evidence of deeper infection.89 Mothers should be observed closely for development of acute mastitis, with symptoms of fever, myalgias, and breast redness and swelling. Continued breastfeeding should be encouraged if at all possible. If the nipples are too sore for the mother to feed the baby at the breast, she should be assisted to maintain lactation via hand or pump expression, and her milk may be fed to her baby. Yeast infections of the nipple are common, especially when there is concomitant oral thrush or candida diaper dermatitis in the baby. A maternal vaginal yeast infection can also predispose to this condition. The nipples look bright red, shiny, and are very tender and sometimes pruritic. Pain with a nipple yeast infection often presents as a burning prickly pain in the nipples, with possible deep, shooting pain radiating into the breasts.90 Both mother’s nipples and baby’s mouth should be treated if either shows signs of yeast. Treatments may include topical nystatin qid (topical cream to mother’s nipples and oral suspension for the baby), topical 1% Gentian violet painted every 2 or 3 days for 3 doses in the baby’s mouth and on mother’s nipples, or oral fluconazole for mother and the baby for 7-10 days. Breast pads should be changed frequently, and any bottle nipples or pacifiers should be sterilized regularly. Yeast infections, however, are often over diagnosed and treated, sometimes over the phone, without thorough evaluation. Most true isolated yeast infections are superficial nipple dermatoses. Deep breast pain and any persistent breast pain should be carefully evaluated since the infecting organism is more likely to be Staphylococcus than Candida.91 Breast milk DM, June 2008

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cultures can be falsely negative because the lactoferrin in breastmilk suppresses growth of pathogenic organisms. Special culture techniques are being studied to improve the reliability of breastmilk cultures, such as adding iron to culture media to bind lactoferrin.90 Atopic dermatitis, contact dermatitis, psoriasis, and other dermatoses may present on the nipple.92 Women who have a history of skin disorders are particularly at risk for nipple dermatoses. Possible allergens or irritants should be identified and eliminated. These may include new detergents used to launder the bras, creams used on the nipples, or trauma from pumping. Topical corticosteroids such as triamcinolone 0.1%, either cream or ointment, may be used. It is best to avoid fluorinated and higher potency topical steroids if possible, although these may be used short term if needed to adequately treat the condition. Although absorption of the steroid by the infant is minimal, the nipple may be cleansed with a waterless moisturizing cleanser prior to a feeding. Bacterial and yeast superinfection is possible, especially if there are breaks in the skin. Nipple cultures may aid in diagnosis. The differential diagnosis for nipple dermatitis includes Paget’s disease of the nipple. Paget’s disease is a rare cancerous condition that mimics dermatitis or may appear as a yeast infection, with itching, burning, redness, and scaling of the nipple and areola. There may be a bloody discharge and the nipple may be flattened against the breast. Biopsy of the areola should be considered for recalcitrant cases of nipple dermatitis to aid in definitive diagnosis of the dermatitis and to rule out malignancy.93 Vasospasm of the nipple (Raynaud phenomenon) usually presents as burning or sharp, shooting pain following a feeding or at other times that the nipple is subjected to temperature change, such as showering or swimming. The pain is accompanied by color changes of the nipple from pale/white to blue/purple to red. This can be primary, especially in women with a prior history of Raynaud syndrome or autoimmune disease, but most commonly it is secondary to nipple trauma or infection. If it is a primary problem, the pain will only occur when nipple color changes are present, and during exposure to cold as well as during or after nursing. If the Raynaud symptoms stem from the presence of an infection or dermatitis, the nipples and/or breasts will hurt even when there are no color changes of the nipple. The vasospasm may be treated successfully with immediate warmth, such as a heating pad or warm moist cloth, applied to the breast and nipple immediately after nursing. Avoiding nipple exposure to cold and emotional stress has also been recommended.94 However, the first treatment is to identify and treat the underlying cause. 380

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More severe or persistent cases of vasospasm can be treated with calcium channel blockers such as extended release nifedipine.95 If mothers have persistent sore nipples or nipple damage, the infant should be examined for evidence of ankyloglossia or tongue-tie. While most tongue-tied babies can bottle feed without much difficulty, ankyloglossia has been shown to have an effect on the duration of breastfeeding. If there is evidence of a shortened lingual frenulum and a breastfeeding problem related to this, such as sore nipples, poor latch, or insufficient milk transfer, clipping of the frenulum is indicated. In the early weeks, when the frenulum is thin and translucent, this is a simple office procedure that does not require anesthesia. When there is a thicker fibrous or muscular frenulum, referral to an oral surgeon or otolaryngologist may be required.96 Sore nipples that occur several months postpartum may result from hormonal changes with the menstrual cycle, trauma from infant biting or pulling, or pump trauma. Pregnancy may also cause sore nipples, and should be considered in amenorrheic women without any other clear cause of nipple soreness.

Plugged Ducts Plugged ducts may present as tender lumps in the breast that are not associated with redness or fever. These often occur during periods of irregular nursing when the breast is not being fully emptied. Common situations include when mothers return to work, longer durations of infant sleep at night, or maternal separation from the infant for other reasons. Sometimes mechanical factors, such as underwire bras or other restrictive clothing, can contribute to poor breast drainage. Plugs may also occur in a breast subjected to previous surgery with disruption of ducts. Ductal segments that are completely unable to drain will eventually involute and stop producing milk. Maternal stress, fatigue, and poor fluid intake may also contribute to frequency of plugging. Frequent nursing or pumping, pointing the baby’s nose toward the lump while nursing, and gently massaging the lump during feeds can help with drainage. Recurrent plugged ducts may also indicate a low-grade bacterial infection in the milk ducts, particularly if the breasts feel sore with deep throbbing.91 Persistent plugged ducts can lead to acute mastitis with fever and breast redness. Some women have found that reducing dairy fat intake or adding lecithin supplements reduces plugging. As with other breast lumps, a presumed plugged duct requires further evaluation if it persists for more than a few days. A recurrent plugged duct in the same area without prior breast surgery should also be evaluated for a possible obstructing lesion.97 DM, June 2008

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Mastitis Clinical mastitis occurs quite frequently among lactating women, with an incidence varying from 2.5% to 27%, depending on the population.98 Mastitis represents a localized interstitial infection in the breast, most commonly due to S. aureus, although other pathogens may include Staphylococcus epidermitis, Streptococcus, or other bacteria.99 It may present as a localized red, tender area of one breast and usually is associated with systemic symptoms such as fever, myalgias, and lassitude, which may even precede the distinct breast symptoms. If fever is not present, the first intervention may be rest, fluids, frequent moist heat, and frequent drainage of the affected breast. When fever is present, or when breast symptoms have been present for 24 hours, treatment with an anti-staphylococcal antibiotic is recommended. Milk should be cultured if possible, although commonly will not reveal the causative organism because of the antibacterial properties of human milk. Treatment should continue for 10-14 days. Common regimens include dicloxacillin 500 mg 4 times a day, cephalexin 500 mg 4 times a day, or clindamycin 300 mg 4 times a day, and these are compatible with breastfeeding unless the baby has a medication allergy.100 If symptoms do not begin to respond within 72 hours with dicloxacillin or cephalexin, consider changing to clindamycin since methacillin-resistant S. aureus infections do occur.101 Moist heat should be continued as often as possible, and breastfeeding should continue since breast drainage is imperative and best accomplished by the baby. If breastfeeding is not possible or too uncomfortable, the breast must be drained regularly using hand expression or a pump. In some women, deep breast pain may persist after the acute mastitis symptoms resolve. This may indicate a low-grade persistent intraductal bacterial infection. These cases may respond to prolonged courses (4-6 weeks) of anti-staphylococcal antibiotics. Macrolide antibiotics may be particularly useful in these cases.102

Breast Abscess A breast abscess may complicate mastitis in 5-10% of cases. A persistent tender lump with and often without fever may indicate the development of an abscess. The possibility of a deep abscess should also be considered in cases of persistent deep breast pain with breast fullness or firmness. The diagnosis can be confirmed by ultrasound. Abscesses require incision and drainage; this may be accomplished surgically.103 Some abscesses may be drained with a needle via ultrasound guidance,104 although a follow-up ultrasound should be performed a few days later to 382

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confirm resolution with repeat drainage if needed. The fluid from the abscess should be cultured, and the mother should be maintained on an anti-staphylococcal antibiotic until the lesion and pain resolve. Coverage for methicillin-resistant staphylococcus should be considered, especially in areas where it is common in the community.101,105 Breastfeeding on the affected side may continue as long as the incision is away from the nipple, and there is no purulent material in the breastmilk. Breastmilk in the surgical wound does not compromise healing. Even if feeding from the affected breast is difficult, the mother should be encouraged to continue to nurse on the opposite breast and to resume nursing on the affected side as it heals.85,100

Breast Masses and Breast Cancer All persistent breast masses need to be explained, including those that occur in breastfeeding women. A lump that is not tender or red is not likely to be infection. Any lump that persists after treatment for infection also needs to be investigated. The first step in evaluation of a breast lump in a lactating woman is ultrasound. Nontender fluid-filled lumps are most commonly galactoceles; these can be observed or may be drained with needle aspiration under ultrasound guidance if necessary.103 Solid masses in lactating women require tissue diagnosis.50 A fine needle aspiration (FNA) is an appropriate initial procedure; however, a negative FNA does not entirely rule out cancer. Women with a negative biopsy should be followed closely if they choose not to have open biopsy. Larger, more concerning, persistent masses and those with equivocal FNAs should be biopsied. Ideally, the biopsy incision should be made away from the nipple and in a radial rather than circumferential fashion to avoid disrupting ducts. Breastfeeding can continue, and women should not be expected to wean before a breast biopsy is performed. Milk fistulas occasionally develop after breast surgery in the incision, but these will resolve spontaneously and do not require intervention. Mammograms may be performed in lactating women; however, the breasts will appear quite dense, increasing the risk for false-negative testing. The woman should feed the baby just prior to mammography to empty the breasts as much as possible. The mammogram should be read by a radiologist with experience reading mammograms of lactating breasts. A negative mammogram in a lactating woman with a persistent breast lump does not negate the need for biopsy.50 For women at risk for breast cancer, breast cancer screening should proceed as recommended during lactation.106 MRI may be an alternative way to evaluate lactating breasts.107 DM, June 2008

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TABLE 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:

Small molecule, eg, ethanol Low protein binding Lipid soluble Long half-life Active metabolites that pass into milk

Large molecule, eg, heparin High protein binding Water soluble Short half-life Not absorbed from infant gut

The diagnosis of breast cancer will generally require weaning since most premenopausal women with breast cancer undergo radiation and chemotherapy. Mothers should be counseled and supported as they make these treatment decisions, especially if faced with weaning a very young baby. Many mothers find it emotionally difficult to wean in order to proceed with breast cancer treatment. Referral to a local donor human milk bank may be helpful for women seeking resources for pasteurized donor human milk. Breast cancer survivors who become pregnant should be encouraged to breastfeed. A history of breast surgery and radiation may affect milk supply. Mothers who have undergone mastectomy but no radiation to the remaining breast can often develop a full supply for one infant. Some researchers believe that breastfeeding after breast cancer will have a protective effect on the contralateral breast.108

Maternal Medications Most medications can be used safely during lactation, or a safe alternative medication can be found. Although almost all medications can be found in trace amounts in breast milk, medications may be used by lactating mothers as long as they do not cause significant adverse effects in the infants. There are certain general principles that can help the health professional choose appropriate medications for lactating women (Table 9). In order for a maternal medication to reach the infant, it must pass from the maternal plasma into the breast milk, be ingested by the infant, and be absorbed by the infant. Medications can do this by passive diffusion or by active transport. Small molecules, like ethanol, pass easily into milk, such that the level in breastmilk equals the maternal blood level. Medications that are very large, such as insulin, generally do not pass into milk because they cannot cross from the plasma through the mammary alveolar cells into the milk. If a medication is highly protein bound, a smaller amount of free medication will be available to transfer into the milk. Medications that are highly lipid soluble can generally pass more easily 384

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TABLE 10. Medications/substances that may reduce milk supply132 ● Hormonal Contraceptives X Progestogens in the first week and possibly later X Estrogen-containing contraceptives at any time, of most concern in first 4 – 6 months ● Decongestants X Pseudoephedrine ● Nicotine ● Alcohol ● Narcotic analgesics in high doses ● Bromocriptine/Cabergoline ● Clomiphene

into milk than those that are not; this means that most drugs that can reach the mother’s central nervous system will be found in breastmilk.109 Medications that can safely be given to infants can be prescribed to lactating mothers. This includes, for example, most common antibiotics and analgesics. However, some medications that are contraindicated in babies can be given to lactating women because the medication may not pass through into breastmilk or may not be absorbed by the infant. A good example is tetracycline, which is bound to the calcium in breastmilk, such that it is not absorbed by the infant. Other medications that are not absorbed by the infant GI tract include those parenterally administrated, such as the antibody infliximab, and therefore are generally considered safe. Some medications that might be “safe” for the baby can decrease maternal milk supply, so should be avoided or given with caution, especially in the neonatal period when the breastmilk supply is being established (Table 10). Hormonal contraceptives, especially those containing estrogen, may significantly decrease the milk supply at any time during the lactational period. Other medications that have been shown to decrease milk supply include pseudoephedrine, nicotine, alcohol, narcotic analgesics in high doses, and bromocriptine. Very few medications are contraindicated in breastfeeding. These include chemotherapeutic agents, some radioisotopes, and drugs of abuse.110,111 Other drugs are considered to be “of concern” when given to lactating women. This group comprises most CNS-active medications, including sedatives (especially those with long half-lives), antidepressants, antianxiety agents, and anti-psychotics. Other specific medications of concern include acebutolol, 5-acetylsalycilic acid, atenolol, aspirin, clemastine, ergotamine, lithium, phenindione, phenobarbital, primidone, and sulDM, June 2008

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fasalazine. These medications should be used only when no acceptable alternatives exist for mother’s therapy, and baby should be monitored closely for side effects.110 Excessive use of alcohol should be avoided by breastfeeding women; however, women who choose to occasionally consume small amounts of alcohol may continue to breastfeed. Alcohol diffuses easily between plasma and breastmilk, and plasma and milk concentrations are approximately equal. Alcohol is cleared from the milk as it clears from the plasma. To minimize exposure, a mother should feed the baby just before consuming an alcoholic beverage. Allowing at least 2 to 2.5 hours per drink (1 oz alcohol, 4 oz wine, 12 oz beer) after consumption before resuming nursing will allow clearance of the alcohol from the mother’s plasma and milk. Excessive alcohol use at around five drinks will impair the let-down reflex and decrease maternal milk supply.111 Most narcotic analgesics can safely be given in low doses to breastfeeding mothers, and in fact women may find breastfeeding more manageable in the early newborn period if their pain is adequately controlled, especially after cesarean delivery. However, infants whose mothers are receiving narcotic analgesics should be monitored closely for sedation.111 A small number of mothers rapidly metabolize codeine to morphine; their infants can show disproportionate sedation.112 Postpartum depression is common, and many breastfeeding mothers are treated for postpartum depression with medications. There are known risks to infant neurodevelopment from maternal depression,113 as well as known risks to babies from not breastfeeding. These known risks must be weighed against the theoretical risk of exposure of breastfeeding infants to small amounts of medication in breast milk. In general, the best choice of antidepressant medication is one that has worked well for the mother in the past, since adequate treatment of maternal depression is likely to result in the best outcome for the baby. Paroxitene, sertraline, citalopram, and escitaolpram are shorter-acting SSRI antidepressants that are found in very low levels in breast milk and have not been measurable in infant serum; these drugs should be the drugs of first choice for maternal depression requiring drug treatment.114 Fluoxetine is a longer-acting SSRI, which should be used with caution and in low doses in breastfeeding women. Fluoxetine use has been associated with infant side effects, such as colic, fussiness, and drowsiness.111 Cognitive-behavioral therapy (CBT) is effective for mild to moderate depression and should also be offered. Effective CBT may allow avoidance or minimization of medication exposure. Breastfeeding 386

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TABLE 11. Resources for medications in lactation The National Library of Medicine’s Drugs and Lactation Database (LactMed) http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT A 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. American Academy of Pediatrics, Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics 2001;108:776. Committee opinion updated every several years. Lists drugs as “compatible with breastfeeding,” “of concern,” and “contraindicated.” Medications in Mother’s Milk (11th edition), 2006. Thomas Hale, PhD Book published and updated approximately annually by Hale Publishing, available at http://www.ibreastfeeding.com and other sources. Palm download and online version also available. Frequently updated listing of a large number of medications including lactation pharmacology with milk and infant levels when known, and alternative medications. Nonprescription 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. Drugs in Pregnancy and Lacation (7th edition), 2005. Gerald Briggs, B. Pharm, Roger Freeman, 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.

outcomes different than the mother’s expectations may exacerbate depression, and mothers who wean before they are ready to may have an increased risk of depression.115 Several resources are available to assist clinicians in choosing medications for breastfeeding mothers and counseling mothers about medications they are taking (Table 11).

Insufficient Milk Supply (Table 12) Nearly all mothers can make enough milk for their babies if breastfeeding is well-supported. Many mothers perceive that their milk supply is not adequate.116 This can be addressed through education about the normal feeding patterns of nursing infants, including the wide variety of nursing “styles” and the occurrence of growth spurts. When the infant is not growing adequately, careful assessment of milk production, milk transfer, and the health of the baby will lead to identification of the underlying problem. Interventions should support the breastfeeding couplet while identifying and addressing the underlying cause(s) of the insufficient milk supply. DM, June 2008

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TABLE 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

Inadequate Milk Transfer One of the most common causes of an insufficient milk supply is the lack of demand for milk by the infant, resulting in a gradual decrease in milk production, and possibly alveolar tissue involution. Babies who have a weak latch or suck may not take as much milk as they need to grow. This results in poor infant growth, and what appears to be a poor milk supply. Sometimes it can be very hard to determine which is the primary problem. There are many common infant conditions that lead to insufficient breast emptying with resultant low milk supply (see “Common Neonatal Breastfeeding Problems”). Insufficient weight gain may occur early on after birth, with the infant not gaining back to birthweight in the appropriate time. It may also be seen later postpartum between 2 and 6 months, in situations such as neurological or metabolic conditions of the baby, or infant gastroesophageal reflux. When newborns are ill or when they require treatment for jaundice, extra care should be taken to assist mothers in establishing and maintaining milk supply. Milk expression should begin as soon as possible if it is clear that the baby will not be able to nurse well at breast, and at least within 24 hours of birth if mother and baby are separated. Most cases of inadequate milk supply are secondary to poor feeding and respond to supportive interventions. If the baby is latching and suckling 388

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well, the first intervention is to increase frequency of nursing to at least every 2 hours in the daytime and every 3 hours at night. For babies who are not suckling well, this can be augmented with pumping at this same frequency, ideally with a hospital-grade double-electric pump. Baby should feed at the breast, and the feeding should be followed by pumping. The baby can be supplemented with the expressed breast milk (see previous section on supplementation of the infant). If the mother cannot express a sufficient amount of milk after nursing the baby, the baby should be supplemented with either pasteurized donor human milk or infant formula. Maximizing skin-to-skin contact, avoiding nipple shields, and making sure mother is getting adequate rest and taking in adequate nutrition and hydration can also help. It is crucial to ensure adequate calorie intake of the baby. Severe cases of poor feeding can lead to hypernatremic dehydration, which is a medical emergency. In many cases, an otherwise healthy infant will become stronger and more efficient at the breast with proper nutrition and growth. Over time, the increased demand for milk by pumping the breasts after feeding will often increase the maternal breastmilk supply in cases where the mother has the ability to have an adequate supply.64

Insufficient Glandular Development Very few women are anatomically unable to produce enough milk for their infants. Some women have abnormal breasts that do not contain sufficient glandular tissue to make milk.117 These breasts often have a tubular shape and are widely spaced. These women may notice minimal breast changes during pregnancy and lack of fullness of the breasts in the first 3-10 days postpartum.118 In most cases, women with insufficient glandular development respond modestly to galactogogues and usually do not develop a full supply for a growing infant. These women may benefit from using a supplemental nursing system at the breast in order to keep the baby at the breast for complete feeding, rather than having to supplement the baby after the baby nurses.

Polycystic Ovarian Syndrome Polycystic Ovarian Syndrome (PCOS), also called hyperandrogenic chronic anovulation syndrome, includes symptoms such as amenorrhea/ oligomenorrhea, hirsutism, obesity, infertility, acne, ovarian cysts, and evidence of the metabolic syndrome including elevated lipids and insulin resistance or overt diabetes. Women with this syndrome seem to have pathologic interference with mammogenesis, lactogenesis, and galactopoesis. With early onset, they may have decreased breast development DM, June 2008

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during adolescence. They tend to have limited breast growth during pregnancy and delayed lactogenesis II. All of these may lead to a low milk supply. Treatment with metformin may ameliorate some of these issues; however, many of these women have difficulty developing a full milk supply especially if adolescent breast development has been affected. Some will respond to treatment with galactogogues. Optimizing weight and management of symptoms prior to pregnancy may help.119

History of Breast Surgery Women who have had breast reduction surgery can have insufficient tissue remaining to fully support an infant, although they often have a partial supply of milk and some mothers will have a full supply of milk. If the nipple was transplanted during breast reduction surgery, ducts and nerves may have been disrupted such that there is decreased nipple sensation. Because nipple sensation provides feedback for prolactin and oxytocin secretion, there may be some inhibition of milk let-down, and insufficient milk production due to an inadequate prolactin level.120 Although breast augmentation surgery usually does not inhibit breastfeeding, particularly if it does not involve a periareolar incision, the woman may have had hypoplastic breasts prior to surgery.121 Any breast surgery can affect milk supply and should be considered a risk factor for insufficient milk.117

Hormonal Factors Since it is the delivery of the placenta and decrease in serum progesterone concentration that leads to lactogenesis II, retained placental fragments can lead to delayed or diminished lactogenesis II and low milk supply and should be suspected, especially in a woman who is having heavier than expected or prolonged vaginal bleeding postpartum. Even when there is no excess bleeding postpartum, retained placental fragments can be present, or there can be placenta increta with placenta tissue retained in the uterine wall. This can be evaluated by ultrasound or MRI. Even several weeks postpartum, treatment of retained placental fragments can lead to resumption of milk production.122 Sheehan’s syndrome usually occurs as the result of a massive postpartum hemorrhage leading to ischemic pituitary necrosis. It may rarely be seen after a normal delivery without severe hemorrhage. Failure of postpartum lactation and failure to resume postpartum menses are the most common presenting symptoms. Although Sheehan’s syndrome is very rare with modern maternity care and the availability of blood transfusions, it may occur more commonly in the developing world. 390

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Mothers who have had significant postpartum hemorrhages, particularly if they have symptoms of other pituitary hormone deficiencies, should be evaluated for Sheehan’s syndrome through hormonal testing and possibly imaging of the sella. Women may still be able to breastfeed with hormone replacement treatment, although they will likely need to supplement. This can be done at the breast with a supplemental system. If they also lack posterior pituitary hormones, Oxytocin nasal spray can be used to assist with let-down.100,123 Maternal thyroid disease is suspected to affect milk supply, although there are no human studies done to support the possibility that hyperthyroidism and hypothyroidism affect lactation. Rat studies suggest that hypothyroidism decreases oxytocin release and pup growth, and hyperthyroidism may lead to mammary involution.124,125 Since postpartum thyroid disease is very common, women should be checked for abnormal thyroid levels and treated if appropriate. Common medical treatments for both hypo- and hyperthyroidism are compatible with breastfeeding. Hyperthyroidism due to postpartum thyroiditis is usually self-limiting. Definitive treatment for Graves disease with radioactive iodine would need to wait until after weaning, although suppressive therapy or surgical thyroidectomy could be done during lactation.100,126

Maternal Obesity Obesity (BMI ⱖ 30) affects breastfeeding initiation and duration. Causes appear to be multifactorial with both psychosocial and physiological components. There are higher rates of obesity among groups of women who are less likely to breastfeed. Obese women may have problems with self-esteem, body comfort, and self-efficacy that may diminish their interest in or ability to pursue breastfeeding. However, physiologic issues may also be important. Mechanical difficulties such as positioning and latching infants to large breasts can be challenging in the newborn period. Obese women also demonstrate a delay in lactogenesis II, with a lower prolactin response to nursing 48 hours after delivery. It is unclear whether this is due to differences in maternal hormones, such as leptin,estradiol, insulin, and progesterone, or due to poor infant suckling identified in infants of obese mothers.38 Obese mothers should be given intensive lactation support in the early postpartum period and should be followed closely for insufficient lactation.37

Childbirth Interventions Childbirth interventions can affect milk supply. Maternal labor narcotics and epidural analgesia/anesthesia may affect infant suckling and cause DM, June 2008

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a delay in lactogenesis II. Cesarean section deliveries may be associated with a delay in breastfeeding initiation, probably through mother– baby separation as well as the increased use of analgesics in the postpartum period. Mothers and babies with a wide range of birth experiences can successfully breastfeed if adequately supported. Extra time skin-to-skin in the early perinatal period and the avoidance of supplemental feedings in the neonatal period unless medically indicated can assist in establishing the breastfeeding relationship.127 Optimal early breastfeeding management for the mother and newborn promotes an adequate milk supply. Early, frequent nursing with rooming-in in the hospital helps the mother learn her baby’s feeding cues. Babies demonstrate lip movements, bring their hands to their mouths, and become alert when they are ready to feed. When babies are separated from their mothers, these early cues are often missed and they reach a late stage of hunger, which is crying. Pacifier use in the early newborn period, feeding the baby on a schedule rather than on cue, and other hospital routines that interfere with establishment of breastfeeding can impair the development of an optimal milk supply.70

Maternal Medications Maternal medications can decrease milk supply. Combination oral contraceptives should not be used during the first 4-6 months of lactation because the estrogen component may suppress milk supply.128 Even after 6 months, some women may notice a drop in their milk supply with an estrogen-containing contraceptive. Progestin-only contraceptives have not been associated with decreased supply in population studies, but anecdotal reports of decreased supply, particularly with depomedroxyprogesterone acetate, remain concerning. Progestogens given in the first few days postpartum could theoretically interfere with lactogenesis II.129 The manufacturers do not recommend using them until after 6 weeks postpartum. Other maternal medications may also decrease the milk supply (see “Maternal Medications”). Women who experience a decrease in milk supply from medication often can increase their supplies by stopping the offending medication and increase milk demand by nursing and/or expressing more often. Occasionally short-term use of galactogogues are needed.

Galactogogues Treatment with a galactogogue may be considered to augment the maternal supply if other supportive measures are also in place. Options 392

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include herbal supplements and prescription medications. Mother’s Milk Tea made by Traditional Medicinals is an herbal tea with no significant side effects; it may be helpful in mild cases of low milk supply. Fenugreek (Trigonella Foenum– graecum), a member of the pea family, is the most commonly recommended herbal galactogogue. The Food and Drug Administration (FDA) lists fenugreek as “Possibly Safe” when used in medicinal amounts. A few preliminary studies have found fenugreek effective in increasing milk supply.130,131 Most fenugreek capsules made of crushed fenugreek seeds are 580-610 mg, 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, and because it is used as a flavoring agent in imitation maple syrup, women who use it as a galactogogue notice a maple-syrup odor to their breastmilk and other body secretions. It can also cause hypoglycemia in large amounts. Fenugreek has been observed to worsen asthma symptoms, and can cause allergic reactions including nasal congestion, wheezing, facial angioedema, and shock. Because fenugreek is in the Fabaceae plant family, it would be wise to avoid fenugreek in cases of known allergy to other Fabaceae plants, such as soybeans, peanuts, and green peas. Other herbs used as galactogogues for which no randomized clinical trials exist include goats rue, blessed thistle, milk thistle, anise, basil, and marshmallow, among others. Prescription medications used as galactogogues include metoclopromide and domperidone. Both of these medications increase milk supply over 1-2 weeks. These medications are dopamine antagonists that increase the prolactin level, and are primarily used as prokinetics for GI motility disorders. Metoclopromide is usually dosed at 10 mg 3-4 times a day, and the usual domperidone dose is 20 mg 3-4 times a day. Metoclopromide use is limited by its central nervous system side effects of fatigue, dizziness, tardive dyskinesia, and seizures, and should be avoided in women with a history of depression. It should not be used in women with significant psychiatric histories, seizure disorders, or some other neurologic disorders. Domperidone is much better tolerated since it does not cross through the blood brain barrier, preventing neurologic side effects. Domperidone is not currently FDA-approved in the United States. Although the FDA has restricted its use and its importation to the USA, it may be available from compounding pharmacies in the United States. Domperidone has been used commonly and successfully as a galactogue in countries such as Canada, Australia, New Zealand, and England.132 Pharmacologic galactogogues should generally be used for 2-3 weeks while other issues regarding breastfeeding support and problems are DM, June 2008

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addressed. If the milk supply responds to the galactogogue and other breastfeeding issues have been resolved, the medication may then be tapered. If the milk supply drops after withdrawal of the galactogogue, restarting the medication is acceptable; however, there are no long-term studies on efficacy or safety.133

Returning to Work Many mothers return to work soon after the birth of a baby. Approximately 53% of mothers in the USA of children under 1 year of age pursue paid employment.134 Mothers in a variety of work settings have successfully combined working and breastfeeding. A mother should be encouraged to plan her back-to-work strategy with breastfeeding in the workplace in order to provide a smooth transition back to work. Her health care provider should provide anticipatory guidance in the form of advocacy, information on milk expression and milk storage, and educational resources on breastfeeding while back to work. Educating employers about the advantages of breastfeeding in the work place can help mothers maintain lactation when back to work. Parents of breastfed babies lose less work time due to infant illness. Mothers who find their employers supportive of breastfeeding may be more loyal and more likely to return to work after childbirth.135 A mother should be encouraged to take the longest maternity leave possible, as it is important to avoid prolonged separation from the baby until breastfeeding is well established and breastfeeding problems are resolved. Maternity leaves of at least 14 weeks are encouraged by the International Labor Organization.136 The USA Family Medical Leave Act (FMLA) allows for 12 weeks of unpaid leave for the birth of a baby for employees in qualifying positions. For many women, however, the economic realities of their lives will preclude long leaves. Helping women establish breastfeeding in whatever time they have before returning to work is essential. If available and feasible, part-time work can be a strategy to protect breastfeeding for many mothers. Returning to work on a Thursday rather than a Monday can allow for a short “work week” the first week back. Factors that support breastfeeding success in the workplace include on-site daycare, time to pump at work in a clean, available location, employer support, flexible work schedule, and family support.137 Allowing the mother to bring her child to work may also promote continued nursing. Nursing the baby even once during the mother’s lunch break can facilitate breastfeeding. 394

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Most mothers will need to express milk for their babies when they are separated at work. Generally, a mother should plan to express milk as often as the baby would nurse, or at least every 4 hours. The mother of a very young baby may need to express milk even more often to avoid the discomfort of over-full breasts and leaking. An electric double-pump system usually maximizes milk expression in the shortest amount of time, such that the mother can complete her milk expression during a 15- to 20-minute break. For employees without a private office, pumping can be done in a clean restroom, break room, or conference room. Employers should be encouraged to set up lactation rooms when they employ several women of child-bearing age.135 Many mothers express and store breast milk in advance of their return to work. A woman returning to work should be advised that her milk supply may decrease during the work week and increase when nursing the baby full-time on nonwork days. Having a reserve supply of breastmilk in the freezer can provide peace of mind for and lessen stress on the working mother. Some women find “reverse cycle nursing” to be a useful strategy, where babies naturally adopt a pattern of nursing more frequently in the evening, night, and early morning when they are with their mothers. The babies sleep more and eat less during the work day.138 If a mother is able to delay her return to work until the baby is older than 6 months and taking solid foods, less breastmilk may be needed when mother is at work. For women who are unable or unwilling to express milk when at work, partial breastfeeding is beneficial and should be encouraged.12 Most working women can maintain a substantial milk supply if they feed the baby four times a day, for example, in the morning, after work, at bedtime, and once during the night.

Expressing and Storing Breastmilk Several options are available for expressing breast milk and depend on the specific needs of the mother. Generally, a mother needs to empty her breasts as often as the baby feeds. Most women who need to express milk over a long period of time will choose a double electric pump. Mothers pumping for premature infants or trying to increase their milk supply have greatest success with a hospital-grade pump.139 Double electric pumps have been shown to extract a similar amount of milk to what a full-term baby ingests at a single nursing.140 These pumps also can raise the DM, June 2008

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prolactin to the level observed with nursing.141 Mothers with a wellestablished milk supply often choose a standard retail double pump system to maintain the milk supply at work. Mothers who only need to express milk occasionally may choose a hand pump or may do well with hand expression. Women who are trying to increase their milk supply can pump after the baby feeds to increase breast stimulation and more thoroughly empty the breast, encouraging increased production. Women will generally need to pump at least six to eight times per day if they are not feeding the baby at the breast, and will continue to make milk as long as they continue to pump. All breastfeeding women should learn how to manually express milk for times that they unexpectedly need to express milk and do not have access to a pump. Freshly expressed human milk should be refrigerated as soon as possible but may be kept at room temperature up to 6 hours. Mothers can safely store their milk in an insulated cooler with ice packs for up to 24 hours, making expression feasible for women who do not have access to a refrigerator at work. Fresh milk may be refrigerated for 5-8 days. Previously frozen milk thawed in the refrigerator may be kept for up to 24 hours. Milk may be frozen for up to 2 weeks in the freezer compartment of a refrigerator–freezer with a common door, 3-6 months in a refrigerator–freezer with separate doors, and 6-12 months in a separate deep freeze at 0 degrees Fahrenheit. Milk should be kept in the bottom or back of the freezer away from the door. Milk may be stored in glass or hard plastic containers. Plastic bags specifically designed for milk storage may be used for short-term storage only, since there is greater risk of milk contamination in plastic bags. Milk should be stored in small aliquots that can be individually thawed for use to avoid waste since any thawed milk that is left over after a feeding should be discarded. Milk should be thawed in warm water or overnight in the refrigerator. Milk should never be heated in a microwave as this can denature proteins and cause hot spots142,143 (Table 13).

Anticipatory Guidance of Breastfeeding at Well-Child Visits Well-child exams offer opportunities to provide ongoing support, education, and encouragement of breastfeeding to families. Because breastfeeding is the gold standard for infant feeding and is central to the 396

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TABLE 13. Milk storage guidelines142,143 Storage Location

Temperature

Storage Duration

Fresh milk, Countertop Fresh milk, Refrigerator Previously frozen milk, thawed in refrigerator Freezer section of refrigerator—freezer with common door Freezer section of refrigerator—freezer with separate door Stand-alone deep freeze

Room 35–40°F 35–40°F 5°F 0°F ⫺4°F

4–6 hours 5–8 days 24 hours 2 weeks 3–6 months 6–12 months

health of mothers and infants, it is as important of a topic as other nutrition and safety issues.144

Feeding Frequency Parents often express frustration that their newborn infants breastfeed as often as every 1.5 to 2 hours. During the first month of life, these feedings may be somewhat slow because of infant sleepiness, especially if the baby was born ⬍37 weeks gestation. These early feedings may also be clustered, particularly in the evening, such that the baby may nurse constantly for 2-3 hours at a time. Parents should also anticipate “growth spurts,” which tend to occur at around 3 and 6 weeks of age for healthy term infants. “Growth spurts” are recognized as 2- to 3-day episodes of very frequent feeding, such as every hour, and associated with a mild increase in fussiness and decrease in stooling. It is important for parents to recognize that this short-term change in behavior is not due to an insufficient milk supply. Feeding frequency will gradually decrease during the first 6 months, and efficiency of feeding will improve, such that the baby may be eating every 2-3 hours during the first 4 months of life, and every 3-5 hours by 4 months of age. By 4 months, the baby may nurse for only 5-10 minutes, turning his attention quickly to another activity. By 9 months of age, infants are often nursing for short periods 4-6 times a day.

Stool Frequency Infants have a strong gastro-colic reflex at birth, and often stool with each feeding. This reflex usually diminishes by 1 month of age, at which point stooling frequency widely varies. It may be normal for a breastfed infant to stool anywhere from once a week to 5 times a day. If stooling appears very infrequent, the infant should be weighed to make sure that DM, June 2008

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interval weight gain is appropriate. By 4 months of age, breastfed babies typically stool once a day or less. As long as the baby is asymptomatic, and eats and gains weight well, there is no reason to intervene.

Perceived Milk Supply Breastfeeding mothers typically experience some degree of engorgement during the first 3-6 days postpartum, and will feel quite full if the baby has not eaten for a few hours. By 2-4 weeks postpartum, the breastmilk supply becomes much more closely matched to the infant demand, such that engorgement becomes less of a problem, unless the infant drastically changes his feeding schedule. The hormone prolactin continues to play a significant role in milk production until approximately 4-6 months postpartum, when prolactin levels decline. Milk production then becomes predominately autocrine, meaning that the milk supply is less influenced by prolactin, and more by the demand of milk removal.32 Women often notice less breast fullness at around 4-6 months postpartum, with substantial improvement in breast leakage between feedings.

Teething and Biting Mothers often will express concern about whether their nursing infants will bite when they begin to teeth at around 3-4 months of age. Certainly some babies will clench down onto the nipple or bite at times, but rarely does significant nipple trauma occur. When an infant is actively nursing and swallowing, his tongue is extended beyond the lower gum line. The baby is not able to clamp down onto the nipple when the tongue is extended. As the baby finishes feeding, and milk is no longer flowing, the baby may retract his tongue and suckle nonnutritively, such as on a pacifier. This is the time when biting may occur. Mothers can identify this behavior and take the baby off the breast when feeding is finished. This nonnutritive sucking may also occur while the baby is sleeping at the breast, so taking the baby off the breast when sleeping will prevent clenching or biting onto the nipple. Sometimes older babies will bite to gain mother’s attention. The mother should try to extinguish this behavior by showing a startled or negative response. The nursing baby should be offered praise when he is at the breast and not biting.145

Nighttime Feeding Sleeping through the night is not necessarily expected from infants during the first year of life. Night time awakening during the first 3 398

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months of age is often related to the need to feed,146 but there are many other reasons why breastfed infants wake up in the middle of the night. Besides hunger, infants may be experiencing illness, discomfort, insecurity, and/or fear. Infants as individuals have varying sleep patterns and nighttime needs, and nighttime rituals and expectations vary greatly between families and cultures. Breastfeeding is often used by families as a way to calm and resettle an upset infant in the middle of the night. Families frequently turn to their pediatric provider for advice on whether breastfeeding should be offered, or if other resettling maneuvers should be used, such as swaddling, holding, or walking. The advice given must take into account the cultural beliefs of the family, their parenting style, and the specific nighttime concerns that they have. For example, some parents prefer to cosleep with the infant, and are only concerned about the frequent feeding at night. Other parents may not be concerned about the frequent feeding , but worry about their inability to keep the baby out of their bed. So far there is no evidence that giving solids to infants under 6 months of age improves their sleep performance. One study showed no difference in sleep duration when infants were given rice cereal in a bottle.147

Complementary Foods The WHO recommends exclusive breastfeeding until 6 months of age, with the addition of complementary foods and continued breastfeeding until 2 years of age and beyond. Feeding complementary foods before 6 months can displace breastmilk, and does not offer any growth advantages over exclusive breastfeeding.148,149 The risk for diarrhea in disadvantaged populations is 2- to 13-fold higher when complementary foods are started before 6 months of age. Exclusive breastfeeding for 6 months also decreases the maternal risk of fertility by increasing the likelihood of lactational amenorrhea, and accelerates maternal weight loss.150 Iron concentration in breastmilk is sufficient for healthy term infants until 6 months, after which infants need other sources of iron, which normally can be provided in complementary foods such as meats, oats, spinach, stewed dried fruits, and iron-fortified baby cereals. Infants should be fed complementary foods at least 2-3 times a day, that are pureed or mashed until about 8-9 months, at which point they often have the ability to feed themselves soft foods. Infants will continue to breastfeed at least 4-6 times a day beyond 6 months of age until they are on a full adult diet by 1 year of age. After 1 year, breastfeeding frequency varies among infants, and depends on toddler and maternal interest/ preference and toddler intake of complementary foods.148 DM, June 2008

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Nutritional Supplements for Breastfeeding Infants Infants at risk for iron deficiency with exclusive breastfeeding for 6 months include those born preterm less than 37 weeks gestation, smallfor-gestational-age, or born to a mother with low prenatal stores of iron, as well as those at risk for poor iron stores at or after birth. These babies are likely to need supplementation with iron drops before 6 months of age.148 Routine vitamin D supplementation of 200 units a day is recommended by the American Academy of Pediatrics, based on several cases of rickets found largely among babies of color, over the last 30 years. The main source of vitamin D for humans is the sun, but because of the risk of skin cancer over time, it is recommended that infants not be exposed to direct sunlight without protection such as sunscreen or shade. Lack of sun exposure thereby limits an infant’s absorption of vitamin D naturally. Infants with dark skin absorb less vitamin D from the sun compared to those with light skin. Breastmilk is known to have little vitamin D, unless the maternal vitamin D level is high enough to provide sufficient vitamin D in the breastmilk. Current guidelines on vitamin D supplementation in breastfeeding women do not support the high doses of maternal vitamin D supplementation required to provide enough vitamin D in breastmilk. Vitamin D supplementation is available for infants in drop form.151 Oral fluoride supplementation is recommended at 6 months of age and beyond for all infants and children who do not have regular access to drinking water that has at least 0.3 ppm of fluoride.152

Weaning There is no age at which it is medically indicated to stop nursing.3 Children who breastfeed beyond the age of 1 year continue to receive significant calories, essential fatty acids, and micronutrients. Breastfeeding beyond 1 year of age also significantly protects children from dehydration, since breastfeeding will usually increase during times of illness. Evidence suggests dose-related benefits of breastfeeding. A recent meta-analysis determined that, for each additional year of breastfeeding, women have a 4-12% decreased risk of type 2 diabetes mellitus and a 4.3% decreased risk of breast cancer. The risk of ovarian cancer is decreased by 21% with at least 12 months of breastfeeding. Infants enjoy a 4% risk reduction of being overweight as an adult with each month of breastfeeding.12 Women may turn to their physicians for advice on weaning. Women should be encouraged to wean their babies when they feel the time is 400

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right, and not because of perceived societal expectations. Women may need counseling on how to balance pressures from various family members and friends about when to wean. There are many ways to wean a child. Weaning can be gradual, partial, abrupt, or child-lead. If a mother decides to wean an infant, gradually increasing the interval between feedings will help prevent engorgement and the risk of plugged ducts and infection. Alternatively, the mother can abruptly stop nursing the baby and use a breast pump to drain her breasts, gradually increasing the time interval between pumpings until her milk supply appears insignificant. Bottles for young infants or cups for older infants and toddlers can be offered instead of the breast. Women who struggle with an oversupply of milk will take a longer time to wean compared with women who do not overproduce milk. Weaning children over the age of 1 can be more challenging, particularly if the child is still very interested in nursing. It is helpful to talk with the mother about why she would like to wean, whether she would like to partially or totally wean, and what kind of weaning strategies may work for her child. Some negotiation with the child may be necessary, depending on the developmental stage of the child. Toddlers may adjust easily to changes in routine, such as having a babysitter put the toddler down for a nap rather than mother nursing the toddler to sleep. Older children may need explanations and bargaining to break out of a nursing routine. Many mothers are relieved to learn that they don’t need to totally wean their children until both mother and child are ready. Partially nursing, such as before naps, bedtime, and/or in the morning, can alleviate some of the stress that comes from a frequently nursing toddler or older child.153

Conclusion Evidence from the latter half of the 20th century confirms that breastfeeding is the nutritional standard for infants against which all other forms of nutrition should be measured. With proper education and support from one’s family, community, and health care providers, the vast majority of women can succeed in breastfeeding their babies. Health care providers should inform each mother of the risks to her health with artificial feeding, and inform parents of the increased health risks of artificial feeding for the infant. Health care providers can encourage and protect breastfeeding by providing families with information and local resources needed for breastfeeding success, not only during the prenatal and early postpartum period, but also in DM, June 2008

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TABLE 14. Physician education resources ORGANIZATIONS The Academy of Breastfeeding Medicine http://www.bfmed.org A multidisciplinary worldwide physician organization dedicated to physician education on breastfeeding. The American Academy of Pediatrics Section on Breastfeeding http://www.aap.org/breastfeeding/New%20SOBr.cfm A special interest group for AAP members, offering networking and educational resources regarding breastfeeding. The International Lactation Consultant Association http://www.ilca.org A worldwide organization of lactation consultants, providing ongoing education, resources, and networking for breastfeeding specialists. Their Web site provides a list of educational courses available. La Leche League International Medical Associates http://www.llli.org/MAP.html?m⫽0,2,1 A program for physicians within La Leche League providing educational resources for physicians and their patients. JOURNALS Breastfeeding Medicine The official journal of the Academy of Breastfeeding Medicine http://www.liebertpub.com/publication.aspx?pub_id⫽173&crit⫽breastfeeding Journal of Human Lactation The official journal of the International Lactation Consultant Association http://jhl.sagepub.com/ International Breastfeeding Journal An open-access peer-reviewed electronic journal http://www.internationalbreastfeedingjournal.com/

preparation for returning to work and at well-child visits. An understanding of lactational anatomy and physiology is necessary for physicians to appropriately manage breastfeeding problems, and to understand how some hospital routines and medical decisions can negatively impact breastfeeding success. Most common infant and maternal health problems should not preclude breastfeeding, but mothers and infants will need support from knowledgeable health care professionals and board-certified lactation consultants. There are many educational resources (Table 14) available to physicians for ongoing learning in the field of breastfeeding medicine.

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