Breastfeeding – Advance Practice Nurse Pharmacology Credit
This course is intended to provide the information necessary for a healthcare professional to be able to instruct a woman on the benefits and mechanics of breastfeeding.
By the end of this activity, the learner will be able to:
- Discuss the benefits of breastfeeding
- Describe national, international and professional mandates to improve breastfeeding rates
- Describe potential barriers to breastfeeding
- Describe the physiology of lactation and contraindications to breastfeeding
- Identify what healthcare professionals can do to support breastfeeding
- Describe techniques for successful breastfeeding that are based on current research
Breastmilk is the ideal nutrition for infants. After a decline in breastfeeding in the mid-20th Century, US breastfeeding rates are gradually improving—the result of both consumer demand and professional mandates. Current recommendations are for exclusive breastfeeding through the first six months of life, with the addition of complementary solid foods at about six months of age and continued breastfeeding until at least one year of age.
These recommendations were formalized by the American Academy of Pediatrics (AAP) when it first published the statement “Breastfeeding and the Use of Human Milk,” in 1997. Since then it has been revised and reasserted twice, most recently in 2012. The 2012 document contains the strongest recommendation yet, stating “Research and practice in the 5 years since publication of the last AAP policy statement have reinforced the conclusion that breastfeeding and the use of human milk confer unique nutritional and non-nutritional benefits to the infant and the mother and, in turn, optimize infant, child, and adult health as well as child growth and development. Recently, published evidence-based studies have confirmed and quantitated the risks of not breastfeeding. Thus, infant feeding should not be considered as a lifestyle choice but rather as a basic health issue” (Section on Breastfeeding/American Academy of Pediatrics, 2012).
Breastfeeding rates are reported as the National Breastfeeding Report Card, a part of the National Immunization Study. These data show that breastfeeding initiation (or ever-breastfed) has improved, with national averages around 81%. From there, however, the numbers drop off significantly, with few women persisting to breastfeed the recommended year or more. Even fewer are exclusively breastfeeding for any duration. There is significant racial disparity in breastfeeding initiation, duration, and exclusivity. Black mothers are far less likely to breastfeed than Caucasian, Hispanic, or Asian mothers (Centers for Disease Control, 2016).
A recent evaluation of the CDC/USDA Infant Feeding Practices Survey revealed that 60% of breastfeeding mothers in the United States do not meet their own goals (Infant Feeding Practices Survey, 2009).
Breastmilk: The Gold Standard
The advantages of breastfeeding include health, nutritional, immunologic, developmental, psychological, social, economic, environmental benefits, and enhanced cognitive development.
Breastfed infants have reduced incidence or severity of:
- Lower respiratory infections
- Necrotizing entercolisits
- Allergy and eczema
- Celiac Disease
- Inflammatory Bowl Disease
- Leukemia and Lymphoma
Breastfeeding also promotes the health of the breastfeeding mother. It protects against:
- Postpartum blood loss and hemorrhage
- Type II Diabetes
- Cardiovascular disease
- Breast cancer
- Ovarian cancer
And may also help with:
- the spacing of pregnancies
- return to pre-pregnancy weight
In a public health context, communities benefit when there is less infectious disease among children since children spread illness to others. Reduced illness overall in a community provides protection for individuals who have compromised immune systems or otherwise vulnerable individuals.
Economic benefits to breastfeeding abound. Infant formula can cost $1500 or more for a family. The family must also provide for the cost of bottles and nipples and the cleaning of these supplies. While breastfed babies may receive some bottles, especially as mothers return to work, there can be significant savings on these items if mothers feed their infants at breast while they are together. The reduction in illness in breastfed infants can also save money. A single gastroenteritis averted must certainly save a family the cost of diapers, not to mention missed work for the parents who cannot send the child to daycare.
A study published in 2010 detailed the economic costs of our nation’s low breastfeeding rates by noting the cost analysis of all pediatric illnesses that are reduced or prevented by breastfeeding and the nation’s breastfeeding rates (Bartrick, MD, MSca & Reinhold, 2010). The authors concluded that if 90% of mothers in the United States breastfed exclusively for six months, there would be a savings of $13 billion a year and that more than 900 deaths, mostly of infants, would be prevented. The savings do not include the loss of work among parents of ill children or the adult deaths that occur as a result of diseases acquired in childhood.
Mandates & Recommendations
The AAP recommends exclusive breastfeeding for about six months, with continuation of breastfeeding for one year or longer as mutually desired by mother and infant, a recommendation concurred to by the WHO and the Institute of Medicine (Section on Breastfeeding/American Academy of Pediatrics, 2012;Infant Feeding Practices Survey, 2009). The important talking points of the AAP’s policy include the following:
- Human milk is the preferred feeding for all infants, including premature and sick newborns, with rare exceptions. The ultimate decision on feeding of the infant is the mother’s. Pediatricians should provide parents with complete, current information on the benefits and methods of breastfeeding to ensure that the feeding decision is a fully informed one. When direct breastfeeding is not possible, expressed human milk, fortified when necessary for the premature infant, should be provided. Before advising against breastfeeding or recommending premature weaning, the practitioner should weigh thoughtfully the benefits of breastfeeding against the risks of not receiving human milk.
- Breastfeeding should begin as soon as possible after birth, usually within the first hour. Except under special circumstances, the newborn infant should remain with the mother throughout the recovery period. Procedures that may interfere with breastfeeding or traumatize the infant should be avoided or minimized.
- Newborns should be nursed whenever they show signs of hunger, such as increased alertness or activity, mouthing, or rooting. Crying is a late indicator of hunger. Newborns should be nursed approximately 8 to 12 times every 24 hours until satiety, usually 10 to 15 minutes on each breast. In the early weeks after birth, low-demand or difficult-to-read babies should be aroused to feed if 4 hours have elapsed since the last nursing. Appropriate initiation of breastfeeding is facilitated by continuous rooming-in. Formal evaluation of breastfeeding performance should be undertaken by trained observers and fully documented in the record during the first 24 to 48 hours after delivery and again at the early follow-up visit, which should occur 48 to 72 hours after discharge. Maternal recording of the time of each breastfeeding and its duration, as well as voids and stools during the early days of breastfeeding in the hospital and at home facilitates the evaluation process greatly.
- No supplements (water, glucose water, formula, and so forth) should be given to breastfeeding newborns unless a medical indication exists. With sound breastfeeding knowledge and practices, supplements are rarely needed. Supplements and pacifiers should be avoided whenever possible and, if used at all, only after breastfeeding is well established.
- When discharged less than 48 hours after delivery, all breastfeeding mothers and their newborns should be seen by a pediatrician or other knowledgeable healthcare practitioner when the newborn is 2 to 4 days of age. In addition to determination of infant weight and general health assessment, breastfeeding should be observed and evaluated for evidence of successful breastfeeding behavior. The infant should be assessed for jaundice, adequate hydration, and age-appropriate elimination patterns (at least six urinations per day and three to four stools per day) by 5 to 7 days of age. All newborns should be seen by one month of age.
- Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first six months after birth. Infants weaned before 12 months of age should not receive cow’s milk feedings but should receive iron-fortified infant formula. Gradual introduction of iron-enriched solid foods in the second half of the first year should complement the breast milk diet. It is recommended that breastfeeding continues for at least 12 months, and thereafter for as long as mutually desired.
- Many women are found to be Vitamin D deficient. Breastfed infants may require Vitamin D supplementation daily since Vitamin D in breastmilk is not sufficient to prevent rickets in some children. While sunlight is a potential source of Vitamin D, concerns about burns and later skin cancer as a result of sun exposure are sufficient to revise the recommendation to exclude allowing infants sun exposure as a method to increase their Vitamin D. One study suggests that mothers may have sufficient Vitamin D if they take Vitamin D Supplementation in the amount of6400 IU/day. Fluoride supplementation may be recommended by the child’s healthcare provider after six months of age, dependent upon the child’s intake of water and the family’s water source.
- Should hospitalization of the breastfeeding mother or infant be necessary, every effort should be made to maintain breastfeeding, preferably directly, or by pumping the breasts and feeding expressed breast milk, if necessary.
Healthy People 2020
Healthy People 2020 is an initiative of the US Department of Health and Human Services. The project sets national objectives for specific health promotion and disease prevention activities. Benchmarks for success are identified. Data is collected to observe the impact of these prevention activities. Breastfeeding Objectives in Healthy People 2010 were revised to take into account the improvement in rates.
In recognition of the need to increase exclusivity and duration more effectively, new objectives were added to address hospital practices and return to work—two of the most common issues cited by women for early cessation of breastfeeding.
Surgeon General’s Call to Action to Support Breastfeeding
In January 2011, US Surgeon General Regina Benjamin released the Surgeon General’s Call to Action to Support Breastfeeding (US Department of Health and Human Services, 2011). The report details the obstacles breastfeeding women encounter, including:
- Lack of experience or understanding in family members of how best to support
- Not enough opportunity to communicate with other breastfeeding mothers
- Lack of up-to-date instruction and information from health care professionals
- Hospital Practices that make it difficult to get started with successful breastfeeding
- Lack of accommodation to breastfeed or express breastmilk in the workplace
The report details the evidence to support a multifaceted approach to breastfeeding promotion, including recommendations for health care personnel, family members, and employers.
Joint Commission Perinatal Core Measure Set for Exclusive Breastfeeding
The Joint Commission is the agency that accredits most US hospitals. In 2009, the Joint Commission’s new Perinatal Care Core Measure Set was published. It includes exclusive breastfeeding. While hospitals voluntarily participate in the core measure set at this writing, it will become mandatory for maternity hospitals with 1100 births per year.
Compliance requires that hospitals provide documentation that the newborn was exclusively fed breastmilk during the entire hospitalization. Exclusive breast milk feeding is defined by the Joint Commission as newborn receiving only breastmilk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines. The US Breastfeeding Committee has published a document that is designed to assist hospitals in the Implementation of the Exclusive Breastfeeding Perinatal Core Measure (United States Breastfeeding Committee, 2010).
A national initiative directed by Michelle Obama to reduce pediatric obesity and overweight, Let’s Move (LetsMove.gov) began its work with a comprehensive report to the President listing all activities which can contribute to reducing this national crisis. Among the recommendations for action were the following which addresses the importance of breastfeeding to lifelong healthy weight:
- Recommendation 1.3: Hospitals and health care providers should use maternity care practices that empower new mothers to breastfeed, such as the Baby-Friendly hospital standards.
- Recommendation 1.4: Health care providers and insurance companies should provide information to pregnant women and new mothers on breastfeeding, including the availability of educational classes, and connect pregnant women and new mothers to breastfeeding support programs to help them make an informed infant feeding decision.
- Recommendation 1.5: Local health departments and community-based organizations, working with health care providers, insurance companies, and others should develop peer support pro- grams that empower pregnant women and mothers to get the help and support they need from other mothers who have breastfed.
- Recommendation 1.6: Early childhood settings should support breastfeeding.
The document specifies the following Benchmark of Success: An increase In breastfeeding rates.
Unicef/World Health Organization
Unicef/WHO According to the World Health Organization (WHO) and UNICEF about 1 million babies die every year because they were not breastfed. Many more millions suffer from infectious diseases and malnutrition, never reaching their full potential because they were bottle-fed (World Health Organization, 2013). Aggressive marketing of infant formula is in direct conflict with the directives of the WHO and UNICEF, which jointly adopted the International Code of Marketing of Breast milk Substitutes in 1981. The code has ten main provisions:
- No advertising of breast milk substitutes should be done.
- No free samples of breast milk substitutes should be given to mothers.
- No promotion of products through healthcare facilities should be done.
- There should be no company-appointed “nurses” to “advise” mothers.
- No gifts or personal samples should be given to health workers.
- No words or pictures idealizing artificial feeding, including pictures of infants, should be on the labels of the products.
- Information to health workers should be scientific and factual.
- All information on artificial feeding, including the labels, should explain the benefits of breastfeeding and the costs and hazards associated with artificial feeding.
- Unsuitable products, such as sweetened condensed milk, should not be promoted for babies.
- All products should be of high quality and take into account the climatic and storage conditions of the country where they are used.
Baby Friendly Hospital Initiative
Baby Friendly Hospital Initiative: The Infant-Friendly Hospital Initiative (BFHI) was launched by the World Health Organization and the United Nations Children’s Fund (UNICEF) in 1991 to improve breastfeeding rates. The initiative helps hospitals and birthing centers create an environment that is conducive to breastfeeding if they comply with the following ten steps to successful breastfeeding:
- There must be a written breastfeeding policy that is routinely communicated to all heathcare staff.
- The facility must train all healthcare staff in skills necessary to implement the breastfeeding policy.
- Educate all pregnant women about he benefits and management of breastfeeding.
- Help mothers start breastfeeding with in a hour of birth.
- Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.
- Give newborns only breast milk, unless other feedings are medically indicated.
- Allow mothers and infants to remain together at all times.
- Encourage breastfeeding on demand.
- No artificial teats, pacifiers, dummies, or soothers should be given to breastfeeding infants
- Refer mothers to breastfeeding support groups on discharge from the hospital or birthing center.
Facilities that wish to achieve Baby Friendly Designation must work through the 4-D Pathway (Discovery, Development, Dissemination, Designation) which includes removing formula marketing from the facility and demonstrate all of the above (Baby Friendly USA, 2012).
Barriers to Breastfeeding
Despite federal mandates and overwhelming medical evidence, women still struggle with a series of barriers as they set about breastfeeding their infants. It is important that health care providers are aware of these and work to minimize their impact on mothers who are attempting to breastfeed.
Among the most frequently encountered barrier is lack of support from the mother’s family and immediate community. Lack of support by the family may be because the woman’s family members didn’t breastfeed themselves or attempted to and didn’t persist for one reason or another. Family members may not value breastfeeding because they do not understand the health benefits or because they want to help the mother feed the baby. Cultural issues, including strong feelings about uncovering one’s body in public to feed the baby, may contribute to making a mother feel very conflicted about the choice to breastfeed.
Healthcare providers who are not appropriately educated to assist breastfeeding families also represent a barrier to breastfeeding. During pregnancy, mothers may not receive adequate information about feeding choices to make a truly informed decision if their healthcare providers who are ill-equipped to answer questions about breastfeeding. Once the baby has arrived, mothers may struggle to persist with breastfeeding if healthcare providers are not able to assist her with difficulties. Additionally, failure to understand the physiology of lactation can lead providers to give a parent the wrong advice and potentially damage the mother’s ability to breastfeed (for example: if a nurse offers to keep the baby in the nursery for the night and give the baby a bottle so that the mother can sleep).
A woman’s employment status and employer can also impact the mother’s perception of her ability to breastfeed. Early return to employment or return to a setting without opportunity and hygienic places to pump milk is potential deterrents to mothers who wish to breastfeed. They may feel that time is so short that they need not even initiate breastfeeding. Conventional wisdom that women need to begin bottles early to “make sure” the baby will take a bottle may derail early breastfeeding efforts.
The larger community may provoke concerns among women who choose to breastfeed. Negative or perceived negative opinions from those at church and school, and strangers in public places like libraries, malls, and restaurants, among other places, may also serve as a source of intimidation to a breastfeeding mother or may prompt her to choose bottle feeding when she is out of the house.
Hospital practices can have a serious impact on the family and their breastfeeding success. Among the common health care practices that may reduce the success of breastfeeding mothers are the separation of the mother and infant in the hospital, use of pacifiers, supplemental feedings without medical reason, short hospital stays, and formula discharge bags. As you may note, these are the same issues that are addressed in the Baby Friendly Hospital Initiative.
Medical Challenges are not unusual in the early days of breastfeeding. Most commonly women are dealing with sore nipples and engorgement. These are typically related to poor nursing management in the early newborn period, but may be present despite best care practices. Real or perceived low milk supply, oversupply, and breast infections are also possible during lactation.
It may be said that breastfeeding is economical, but it would be a mistake to imply to parents that it is free. Certainly, if things go well, it can be very inexpensive to breastfeed, but if there are problems or if the mother is returning to work and must pump there are costs to consider. These include the cost of lactation consultants, office visits for weight checks, pumps and supplies and the assorted paraphernalia that are marketed to new mothers and fathers. Increasingly, insurance companies are covering breast pumps and may even send one to the family prior to delivery.
The marketing of breastmilk substitutes (or artificial baby formula) is a significant barrier to successful breastfeeding. Formula companies spend a great deal of money selling their products as “most like breastmilk” and making sure that parents recognize their company names. Companies give free growth charts, crib cards, diaper bags, and even How to Breastfeed books to hospitals to pass on to new parents. Many parents even receive formula samples in the mail. While many new parents are glad to have this freebie on the shelf, it is an unethical practice by the formula company, promoting name recognition and good will to the family about their product. Health care professionals must avoid any potential conflict of interest by refusing gifts, food and continuing education units that are sponsored by formula companies. It is not unethical to hear a formula representative’s “pitch” but the health care provider should balance this with personal research about the various formulas offered.
Health Care Professional’s Role
- Remain current! Like any area of healthcare, the body of knowledge regarding breastfeeding, the unique qualities of breastmilk and the ways to care for patients who are experiencing problems are dynamic and under frequent study. It is imperative that health care providers are knowledgeable about the evidence that informs the care we provide.
- Know your resources
- Professional Lactation Support-Health care professionals who have special training in lactation are an important resource to lactating women and health care providers. The International Board Certified Lactation Consultant (IBCLC) is the most rigorous preparation, with emphasis on education and contact with breastfeeding families before one can sit for the certification exam. Other professionals who have completed additional training may be CLC (Certified Lactation Counselor), generally a two day course requirement.
- Mother to Mother Support is a great resource for mothers, whether they are having problems or not. Contact with others who have similar age babies is helpful to women as they settle into their new role of parenting. La Leche League, founded in 1956 when US breastfeeding rates were as low as 20%, is one such resource. The LLL has groups all over, including in international locales. Social media has allowed these groups to grow and thrive. Mothers can bond first online and then make meetings when they are able.
- WIC (Women Infants & Children Supplemental Nutrition program) is a federal initiative to ensure that pregnant women and young children receive adequate nutrition. Breastfeeding promotion is a priority in the WIC program. WIC Benefits include food coupons for food support for the breastfeeding mothers, lactation consultants and peer counselors to provide support to breastfeeding mothers.
- Online support for breastfeeding mothers is increasingly available. Get to know the available sites and steer new mothers to those that are easy to navigate and offer evidence-based care.
- Affordable Care Act
- Requires coverage for lactation support
- Coverage for pumps and other lactation supplies
- Support for Mothers Returning to Work
When a woman becomes pregnant, her body starts to prepare for breastfeeding. During the fourth or fifth month, her body is capable of producing milk. The first milk is called colostrum. The woman produces colostrum for several days after delivery then as breastmilk “comes in” or surges in volume the milk transitions to a lighter color.
During pregnancy, the women’s body increases its production of prolactin. This hormone stimulates the cells in breast tissue to make milk. The amount of prolactin also increases when a mother nurses the infant. The size of breasts is not a factor in how much milk a woman makes. The infant’s nursing controls the milk production. The more the infant nurses and more specifically the better the infant drains the breast, the more milk the mother makes.
Oxytocin and Prolactin are the two main hormones associated with lactation. Oxytocin and Prolactin are influenced by several factors, including stress, time of day, and the infant (crying, sucking, etc.). Breastfeeding should be started shortly after delivery; when the placenta separates, prolactin levels rise, and the milk-producing process is started. The colostrum is thicker and more yellow than breast milk and lasts about 2 to 4 days. Although the process is started with the separation of the placenta, sucking is required to produce and sustain milk supply. The new mother’s temperature usually rises slightly, and she may become quite emotional at just about the time that her breasts start feeling full and firm; signaling that the “milk is in.” While milk production is accomplished primarily through Prolactin, milk ejection (or let-down) is accomplished through oxytocin.
Oxytocin could be described as the “great sensation” hormone. Oxytocin produces the intense pain of contractions and the intense pleasure of milk letting down. This sensation described as a “tingling” or “sensual” feeling by some mothers, varies in intensity from woman to woman and from day to day, just like contractions. It is important for the woman to understand that these sensations are very normal and that allowing herself to relax helps milk ejection just the way it helps contractions. Conversely, fatigue, stress, and a sense of fear or shame inhibit the milk ejection reflex. Poor let-down may result in inadequate milk supply to the newborn, but more frequently, a decrease in prolactin caused by inadequate sucking and stimulation to the breast is the likely cause.
A lactating mother’s body is always making milk, with her breasts functioning, in part, as storage. Supply is regulated by demand, i.e., when the breast receives more stimulation, more milk is produced. The emptier the breast, the faster the body makes milk to replace it; the fuller the breast, the more milk production slows down. Milk production is related to feeding frequency and efficient drainage. The milk supply declines when feedings are infrequent or restricted. The best plan is for new mothers to understand that the establishment of a good supply for their baby depends upon early, frequent and effective removal of milk from the breast.
This concept of supply and demand seems simple enough, but inaccurate or incomplete recommendations often upset the natural symbiosis of supply and demand. During the last few decades, well-intentioned hospital nurses have encouraged to send their infants to the nursery, allowing their mothers to sleep through the night. Research studies have shown, however, that mothers do not identify night feedings as a source of fatigue. Mothers should get up with babies for night feedings and can adjust by having adequate opportunities to nap instead of entertaining visitors. Prolactin levels, which are higher during lactation, contribute to feelings of drowsiness. Therefore, the mother should have naps and round-the-clock stimulation to her breasts to promote an adequate supply of milk a few days later when she is home from the hospital.
The mother should be warned that there will be times when the infant’s demand seems as though it is greater than her supply, most notably when he is experiencing a “growth spurt.” Unlike the teenage boy who suddenly grows out of his trousers, nothing visibly happens during infant growth spurts. This “growth spurt” is actually a need for increased calories and typically occurs around two weeks, six weeks and 12 weeks of age. During this time, the mother should nurse as frequently as the infant demands; sometimes every hour. Within 72 hours the milk supply, due to increased stimulation, will increase to meet the infant’s demand adequately. The mother may be tempted to supplement with formula but doing so will interfere with her ability to meet the infant’s increased need.
Oxytocin is another hormone that increases during pregnancy. It causes tiny muscles cells in the breast to contract and squeeze milk down the milk ducts to the nipples. This process is called the letdown reflex and occurs each time the mother nurses an infant.
Contraindications to Breastfeeding
Few contraindications to breastfeeding exist. Women who live in developed countries and are infected with human immunodeficiency virus (HIV) or human T-lymphotropic virus type I (HTLV-I) should not breastfeed. Policy considerations may change over time as research in areas of the world demonstrate that breastfeeding did not increase HIV transmission in infants, but more studies are needed.
Infants born to women who have active untreated tuberculosis should not breastfeed. In addition, women who are undergoing chemotherapy or receiving antimetabolites or radioactive treatments should not breastfeed.
Galactosemia, an inborn error of metabolism, is an absolute contraindication to breastfeeding. Infants with this disorder are unable to utilize galactose, a component of the lactose sugar in human milk. Accumulation of galactose leads to adverse consequences, including failure to thrive, liver dysfunction, cataracts, and mental retardation. Breastfeeding is not contraindicated with other inborn errors of metabolism such as phenylketonuria, but infants should be monitored closely for their blood phenylalanine levels.
Women who use street drugs should not be encouraged to breastfeed, but women who are undergoing a Methadone treatment program are encouraged to breastfeed to reduce the effects of drug withdrawal in the infant.
An Approach to Lactation Support
Women begin their breastfeeding journey amid all of the barriers described earlier. Health care providers would do best to assume NOTHING when offering support. As with any patient care, it is vital to be alert to the culture of the family and ask questions which clarify the family’s plans to feed their baby. In general, offering support to help the family meet their own breastfeeding goals is both empowering and non-threatening. Remain positive and non-judgmental. Make recommendations from the existing evidence and use personal anecdotes sparingly
Lactation Support: The newborn
LaLeche League International is a worldwide organization that helps families learn about breastfeeding. They make the following recommendations for optimal positioning during breastfeeding (LaLeche League, 2013).
The mother should position herself comfortably. Pillows, back support, and/or a footrest may be helpful but are not required. The infant should be positioned close to the mother, with his hips flexed, so that he does not have to turn his head to reach the breast. His mouth and nose should be facing the nipple. If possible, a helper can hand the infant to the mother once she is comfortable. If the infant is crying, it may be helpful to allow the baby to suck on a finger briefly to calm prior to trying to attach. Support the breast so it is not pressing on the infant’s chin. The infant’s chin should drive into the breast. Attach or latch infant onto the breast. Encourage him to open his mouth wide and pull him close by supporting his back (rather than the back of his head) so that his chin drives into the breast. His nose will be touching the breast. The mother’s hand should form a support for the infant’s neck. If pain is felt, detach the infant gently and try again. These steps may need to be frequently repeated during the early weeks. The mother and infant will find a technique that works for them after some practice.
There are specific positions suggested by the La Leche League. These are the following:
Clutch or football position
Laid-back or biologic nurturing position
No supplements/pacifiers/nipple confusion
Pacifiers and artificial teats are not recommended for newborns who are learning to breastfeed. Breast and bottle feeding require different oral-motor skills, and rubber nipples provide more stimuli that babies may imprint upon instead of the softer breast. As a result, some babies develop nipple confusion and apply inappropriate sucking techniques to the breast when they switch between breast and bottle. More importantly, families who employ pacifiers may be missing feeding cues. Newborns who are rooting need to go to the breast. Frequent feedings bring the milk in and help the baby maintain normal homeostasis and temperature.
One breast or two?
In the first weeks, many mothers offer both breasts at each feeding to help establish the milk supply. It may not be necessary to use both breasts at each feeding once the milk is in. It is more important to let the infant empty the breast. Women who have abundant supply may find that the baby is well sated after feeding from just one side.
How to know if the baby is getting enough
When a mother breastfeeds early and often, 10-12 times a day (and sometimes more) in the first two weeks, milk production is greater, the infant gains more weight, and the mother continues breastfeeding for a longer period. Newborns need to feed every 2-3 hours at a minimum, but it isn’t usual to see “cluster feeds” during which the infant may feed every hour for 2-3 hours and then sleep well for a longer period. Feedings usually take about 20 minutes but may be 35-40 minutes and more. When the infant begins to receive milk, his jaw will be working all the way back to his ear. His temples will wiggle, and you can hear him swallowing (LaLeche League, 2008). As an infant becomes full, sucking slows down. Infants will let go of the nipple when they are full. If the mother needs to release the nipple before the infant lets go, gently place a finger in the infant’s mouth, between his gums to release suction.
The mother should watch the number of wet diapers and bowel movements at first to assure the infant is getting enough milk. With colostrum, an infant will wet only one or two diapers per day. After the third postpartum day, infants with adequate intake should begin to have 6-8 wet diapers per day. Fewer than six wet diapers, dark yellow or orange urine, or brick-red urate crystals in the diaper are signs of inadequate intake and should be reported to the physician. Clearance of meconium is precipitated by copious milk intake. Infants who are successfully nursing should clear meconium and have transitional stools within approximately three days of birth. After day four, the majority of infants have four or more stools per day, although fewer can be normal.
A well-nourished infant will be alert and active, appear healthy, and have good color and firm skin. The infant should gain at least 4-7 ounces per week and will be growing in length and head circumference (American Academy of Pediatrics, 2012).
During pregnancy, the breast typically grows in size. Normal routine for hygiene is all that is necessary. No special creams or lotions and no alcohol should be applied to the breasts. There is no need to “toughen up” the breasts and nipples prior to breastfeeding. Nursing bras purchased during pregnancy may be too small to accommodate breast changes after delivery. There is no medical reason to wear bras either before or after delivery. Many women feel most comfortable with a supportive bra, but one is not required.
Many breastfeeding mothers leak milk, especially in the early months. Leaking can occur between feedings or on one side while nursing on the other. Absorbent padding can be used to catch the flow. A towel or cotton diaper can be used. Disposal nursing pads or reusable cotton pads are available to wear in the bra (LaLeche League, 2008). Plastic backed nursing pads should not be used, because they hold moisture close to the nipple and do not allow for air-flow.
Maternal Diet during Breastfeeding
Maternal diet during lactation affects the flavor and odor of the milk, thus introducing the infant to sensory aspects of foods that may be consumed later in life.
Breastfeeding mothers should eat a well-balanced diet. There are no foods that should be avoided during breastfeeding, unless the mother notices that the infant reacts negatively to something she has eaten. Consumption of alcohol should be avoided. Caffeine should be avoided or restricted.
Maternal problems in the newborn period
During early breastfeeding, sore nipples are a frequent complaint. The nipples will probably be tender the first few days after breastfeeding is started, but if it persists, the mother should seek a lactation expert consultation. Proper positioning and assuring that the infant is latched on correctly can prevent or eliminate many cases of sore or cracked nipples. Saline soaks, or the application of green tea bags (after steeping in boiling water and allowing to cool slightly) may reduce sore nipple pain.
Engorged, full, hard breasts are a common complication in the first week of breastfeeding and tend to occur when the milk is not being regularly removed. It can be uncomfortable, and make it hard for the infant to latch on. Hand-expressing milk or using a breast pump can help you relieve or prevent engorgement. During the early days of breastfeeding, this may occur if the infant is not breastfeeding about every 2 hours. Some relief can be attained by applying a cold, wet cloth to the breast. Advise parents to dampen hand towels and keep them in the fridge. These can then be wrapped around the breast anywhere that is hard and swollen. Use the cold towels up to 10 minutes of every hour until the swelling goes down. Some women alternate the cold compresses with warm showers. Engorgement is a temporary condition that passes the initial inflammation is reduced, and milk is regularly removed from the breast.
Lactation Support: After the newborn stage
Milk supply is dependent on both hormonal input and the demand for milk requested by the infant. The best way to ensure good supply is for the mother to breastfeed on demand and pump her breasts while away from the infant to mimic that demand.
If one breast becomes swollen, sore and has reddened areas, it may be an indication of a blocked milk duct or infection, called mastitis. A fever of greater than 101 and flu-like symptoms may also be present. The mother’s primary care provider should be consulted. Occasionally, women can avoid antibiotics if the symptoms are mild and have a duration of less than 24 hours by resting, consuming plenty of fluids and ensuring that the breasts are well-drained regularly. A mother should not stop breastfeeding while she has mastitis. Doing so may increase the severity of the infection. The infection will not spread in the mother’s milk, and her provider should use an antibiotic that is compatible with breastfeeding. Occasionally, a lactating woman may develop a breast abscess, generally characterized by an intensely painful large lump that is very red on the surface of the breast. If an abscess is suspected, she must be seen immediately by her primary care provider. An ultrasound will be needed to diagnose the abscess, and it may require drainage, hopefully by needle aspiration so that it heals quickly.
Most, but not all, therapeutic drugs are compatible with breastfeeding. In general, the decision to use medications while breastfeeding should reflect a consideration of the relative risks and benefits to both mother and child. For example, most antidepressants are only present in small amounts in breastmilk and very little is detectable in infant serum. The mother who finds herself in need of the antidepressant can benefit greatly from it and can be reassured that her infant is at very low risk. The nurse should check the available references and provide the family with the most current recommendations and the studies, if any, to support them.
It is not appropriate to encourage mothers to “pump and dump” after most procedures, even if general anesthesia is required. The same is true for dental procedures, most radiological exams, including those with contrast. The breastfeeding mother can request a list of the drugs that will be used in procedures in advance and ask clinic staff (often the pediatric office as the mother’s provider is reticent to make decisions about what goes into the baby) to check the available sources so that she knows how to proceed. In time, healthcare providers in all areas will become aware of the resources and will utilize these rather than create stress for a breastfeeding mother. In the event that a new agent is added and has not yet been researched, “pump and save” is a far better plan, allowing the mother time to do the research at a later time and, if the agent is safe (as is most often the case), avoiding waste of precious breastmilk.
Tom Hale, RPH, Ph.D., is a clinical pharmacologist, Professor at the Texas Tech University School of Medicine. He has extensively studied the safety of medications for use while breastfeeding. As a result, he has authored the very popular Medications and Mothers Milk and maintains the Infant Risk Center Website (http://www.infantrisk.com). The National Library of Medicine also maintains a searchable database of drugs and lactation, Lactmed (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT). There is now a cell phone application for Lactmed and others are likely to follow soon. Health care providers who counsel lactating women should become familiar with these resources and help mothers to check medications for their implications for breastfeeding.
Poor weight gain/supply concerns
When a breastfed infant does not gain well, it is imperative that health care providers work to strike a balance between giving the baby adequate nourishment and working to increase the mother’s supply. Supplemental feeds may be necessary, but also help the mother to commence pumping to support her supply so that she can work toward providing all the breastmilk her infant requires for good growth. Failure to thrive and insufficient milk are complex problems that typically require collaboration between the primary care providers and certified lactation consultants (IBCLCs). When healthcare providers suggest supplemental feedings for infants, it is important to advise the mother to pump her breasts regularly as well. Pumping is especially important if the infant does not drain the breasts well. She must try to simulate the work of the baby with pumping. Advising a “triple feeding” plan-feed the baby at the breast, offer supplement, and pump the breasts will help support breastfeeding until the family can get in to see an IBCLC and the problems can be sorted out.
Return to work/being away from the baby
Keeping the mother and infant together is the best way to support regular breastfeeding. However, this is not always possible, especially if the mother works outside the home.
Breastmilk should be expressed when a mother is separated from the infant for an extended time. Expressing breatmilk while apart avoids engorgement and decreased milk supply. Save expressed milk in a clean glass or polypropylene container, then cool and refrigerate or freeze. The expressed milk can be fed to the infant by bottle, or an infant formula can be used in the mother’s absence.
Milk can be expressed by hand, or by using a breast pump. Good handwashing is important anytime milk is expressed. A pump should be used carefully to avoid damaging the nipples. It should be positioned according to the directions, and only gentle pumping should be done. There are several sizes of breast shields available for pumps. Correct sizing of the breast shield will help the mother to pump comfortably and to express the most milk.
Some mothers may find that hand expression is easy and sufficient for their requirements. To express milk manually put a container under the breast and massage the breast gently toward the nipple. Place a thumb about 1 inch back from the tip of the nipple, and the first finger is placed opposite. Press back toward the chest; gently press the areola between the thumb and finger; then release. Do this in a rhythmic motion until the milk flows or squirts out. Rotate the thumb and finger around the areola to get milk from several positions.
Mothers should be counseled to always wash hands before expressing or handling breast milk. Studies measuring optimal containers used for milk storage concluded that glass and hard plastic (polypropylene) are the recommended choices for milk storage. Guidelines for the duration of milk storage are based on factors including the preservation of nutritional and non-nutritional factors and minimal bacterial contamination.
- Frozen milk can be stored for at least six months (avoid storing milk on the door or in the front of the freezer).
- Fresh milk can be stored in the refrigerator for 72 hours optimally, and for 5-8 days under very clean conditions.
- Thawed/fortified milk can be kept for 24 hours.
- Milk at room temperature can be kept for 4 hours optimally, and for 6-8 hours under very clean conditions.
There are no clear recommendations at present about the safety of refreezing mother’s milk. Milk that has been thawed and is left over after a feeding should be discarded if not used up within 1-2 hours. Do not save milk from a used bottle for use at another feeding. It is suggested that parents chill fresh milk prior to adding it to already frozen milk. Thaw the milk in a refrigerator or a warm bowl of water. Do not use a microwave to heat bottles, because they do not heat evenly and excessive heat can destroy important proteins and vitamins in the milk (Clinical Protocol Number #8: Human Milk Storage Information for Home Use for Healthy Full Term Infants, 2010).
Many nursing mothers dread the appearance of teeth because they assume that the child will soon begin biting and end the nursing relationship. In fact, when a child bites at the breast he is not breastfeeding, likely having forgotten where he is and perhaps trying to soothe sore gums. Most children can be taught that biting is not acceptable. If the baby bites, the mother should respond quickly and firmly. A strong “NO!” and stern face, removal of the child from the lap and the mother walking away for a period of even less than a minute will communicate that biting ends a feeding session.
An infant who is truly ready to wean will usually do so gradually, over a period of weeks or months. If an infant has been breastfeeding well and suddenly refuses to nurse, it is probably what is called a nursing strike. Most nursing strikes are over within two to four days. They happen for many reasons. The best plan is to work through the strike with persistence and patience. Try not to take it personally. Seek out a quiet, dim room and avoid unnecessary stimulation.
Breastfeeding mothers who are with their infants full time and nurse on demand typically do not have a menses for several months. Nursing tends to postpone fertility, though it is not recommended that breastfeeding women assume that they cannot get pregnant while nursing.
Caution should be exercised when taking hormonal contraceptives. Some, not all, women find that use of a birth control pill, shot or IUD can reduce their milk supply. Hormonal contraceptive is an area that requires more study.
The normal age for weaning for the human species is between 3 and 4 years of age. It is unusual in our culture for mothers to breastfeed that long but if they choose to do so, their healthcare providers should support them. It is best if women can wean their infants gradually. The first step to weaning may be to adopt a “Don’t offer, don’t refuse” policy. As breastfeeding becomes more rare, the child may wean without argument. Medical and familyemergencies that necessitate abrupt weaning are traumatizing to mothers and infants alike and may require expert management and counseling for optimal adjustment.
Premature and seriously ill babies are able to breastfeed. The mother’s own milk is considered best for preterm infants. Given the often protracted period between birth and breastfeeding for most preterm newborns, a number of challenges for mothers and neonatal intensive care unit nurses in establishing lactation, providing mother’s milk and achieving breastfeeding preterm infants are many including the following:
- Initiating and maintaining milk supply without the stimulation of the infant at the breast
- Transition from gavage to feeding at the breast
- Quantifying milk transfer (how much did they infant get?)
Premature breast milk is a dynamic fluid, composed of macro and micronutrients especially suited to meet the needs of the preterm infant. The presence of other cellular components such as enzymes, immune factors and cytokines, set breast milk apart from commercial infant formulas in their unique function and effect on the developing neonatal gut and infant immune responses. Because of these human milk components, the early small volume feedings administered to the preterm infant could be considered medicinal in nature. Colostrum is more concentrated in specific immune factors and as such provides a protective coating to the vulnerable gastrointestinal tract of the preterm newborn.
If the infant is not able to nurse, at first, the mother can collect breast milk to be fed to the infant. Procurement of small amounts of colostrum can be labor intensive and requires the coordinated efforts of the mother and nursing staff in the postpartum and neonatal areas in the early days following delivery. Early and frequent hand expression followed by the use of an efficient, comfortable mechanical pump in the early days post birth can provide effective nipple stimulation to promote high levels of circulating hormones responsible for adequate milk production and ejection. Reduced milk production can lead to frustration and formula supplements. Teaching mothers hand expression, beginning that work in the delivery room and providing easy access to hospital-grade breast pumps and adequate instruction related to mechanical milk expression to mothers separated from their infants would increase the likelihood of successful lactation outcomes.
Breastfeeding after Breast Surgery
The choice to breastfeed after breast surgery (augmentation or breast reduction) may require advice from a knowledgeable health care professional to avoid common misunderstandings by mothers and healthcare providers. Mothers are often told that they will not be able to breastfeed with a history of breast surgery. Quite possibly breastfeeding was not a priority to the woman at the time of the surgery and as such the topic was not addressed. Breast surgery can interfere with milk production. Incisions can sever ducts, interrupt blood flow, or sever the lateral cutaneous branch of the fourth intercostal nerve which may result in the loss of hormonal response to suckling and reduce milk production. Disruption of milk ducts and scar tissue may predispose women to plugged ducts, mastitis or galactocele formation.
It is clear that breastfeeding is affected by reduction surgeries, but it doesn’t mean that a woman who has undergone the procedure will not be able to breastfeed. It is possible for severed ducts to repair over time and if adequate lactation tissue is present, a woman may be able to lactate and breastfeed normally. For some mothers, a previous reduction will necessitate supplementation with donated human milk or formula. These mothers are often frustrated with the lack of adequate instruction given to them to make breastfeeding to work. They are often treated with an “all” or “nothing” attitude by misinformed health care providers. The care of a provider with IBCLC (International Board Certified Lactation Consultant) credentials would be very appropriate for a mother who wishes to breastfeed after breast reduction.
The best plan is one that provides the mother with the care and information she requires to initiate breastfeeding and stimulate her supply to its potential. Frequent evaluation of the infant’s weight and ability to transfer milk from the breast is of high importance. As with any breastfed infant, the parents should be given information as to how to evaluate good feeding and swallowing and for the output (wet and soiled diaper) expectations. It may be helpful to introduce pumping after feedings to stimulate the breasts further and provide the mother with the best opportunity to establish good supply.
Breast augmentation surgery may not interfere with breastfeeding. Typically the implant is placed beneath the chest muscle, and there is little, if any, impact on the ducts. When obtaining the history of the mother’s breast surgery, providers should ask about the surgery and specifically if there was a change in the placement of the nipple, as this would signal severing of ducts and may negatively impact lactation and breastfeeding. Some women who have undergone breast augmentation surgery experience greater than usual engorgement as the milk surges.
The Hospitalized Breastfeeding Family: Their needs
Readmission after going home as a newborn is a stressful occurrence for the parents of a newborn. The most common reason for readmission is neonatal jaundice. Jaundice occurs when the newborn’s bilirubin rises. Jaundice is common in newborns because their livers are not yet mature enough to clear circulating bilirubin as red blood cells are broken down. The bilirubin must be cleared by the gut, so infants who are not feeding well are more at risk for high bilirubin levels. Jaundice creates significant pressure for the breastfeeding mother who perceives her milk as inadequate to keep her infant healthy. Among the interventions that may assist the breastfeeding family when they are readmitted for any reason after delivery:
- Lactation Consult immediately
- Provide mother with pump if indicated
- Encourage mother to stay and breastfeed as she would at home
- Stay positive
- Emphasize the early problems do not necessarily mean that things will not work out
Older infants may be admitted for any number of issues. It is a natural part of the admission history to discern the family’s feeding plans for their child. Asking specific questions about the infant’s diet and feeding times will assist the nursing staff to develop a nutrition plan that provides as much continuity as possible for the family while the infant is hospitalized. It is imperative that nursing staff respects the family’s breastfeeding relationship and encourages rooming-in for the breastfeeding mother while the infant is hospitalized. Admitting staff should document nature of infant feeding well so that subsequent shifts are aware of family needs. If feeding is a part of the concern, nursing staff should facilitate a lactation consult.
When a breastfeeding mother is admitted to the hospital for any reason, nursing staff should find out nature of mom’s breastfeeding relationship and document this for use by subsequent shifts. Have pump available for times mom cannot nurse while hospitalized and order a Lactation consult if needed.
Occasionally supplementation is required for the health of the infant. If supplementation is required, the mother’s milk should be the first choice if available. After that, pasteurized donor milk and as a final option, formula is recommended for infant supplementation. If mother’s milk is not available or the milk is insufficient for infant growth, families can be counseled that formula can be added to the infant diet, possibly just temporarily. Among Lactation Consultants, it is said that Rule Number One is “Feed the Baby!” and Rule Number Two is “Support Mother’s Milk Supply!” The baby may need a few “doses” of artificial baby formula when there is insufficient milk to make sure the baby is stooling and gaining weight normally. However, it is imperative that nursing staff facilitate the mother in breastfeeding and pumping to increase the mother’s supply so that once the crisis is past, the baby will return to full breastfeeding with ample volume of breastmilk available.
In most situations, breastfeeding is the best option for an infant. Each nurse, whether interacting with new mothers in the hospital or in the community, can significantly affect the breastfeeding experience of mothers in their care. Helping behaviors include being physically present when mothers are learning early breastfeeding skills, teaching practical techniques (positioning, latch), helping mothers anticipate problems and how to solve them and valuing the act of breastfeeding. Hindering behaviors include indifference to breastfeeding, intrusive or rough handling of the mother’s breasts or infant, being too rushed to spend time with the mother, not listening to the mother’s concerns, providing conflicting advice and provision of formula as a quick fix to early challenges. Evidence-based lactation care and services can have a lifetime effect on the health of the mothers and infants entrusted to nursing care. Healthcare professionals play a key role in helping mothers to understand this concept and in supporting their decision to breastfeed.
Case Study #1
Malcolm is a 3-day old infant, born to parents Ryan and Jen after an uneventful pregnancy. The delivery was vaginal after a 20 hour labor. At today’s visit, Malcolm’s weight is 7# 3 oz, or 93% of his birthweight. He is noted to be quite jaundiced, especially in the face with some jaundice extending to the nipple line on his chest. Parents report he is breastfeeding “all the time” and that he has had five wet diapers and two stools in the past 24 hours. The last stool was a light brown color. Jen’s breasts are warm and very tense. Jen and Ryan are concerned that Malcolm is not getting enough. They are feeling pressured by the grandparents who would like to offer him a bottle. Jen is weepy and exhausted. At this visit, breastfeeding was observed and the baby was observed to be swallowing with each suck. Jen reports that latch is comfortable.
Parents were advised that Malcolm is well and that breastfeeding is progressing as expected. Malcolm’s frequent feedings are establishing supply, and he is taking in good volume, evidenced by his diaper output. Parents can expect increasing stooling and gradual change of stool color to a bright yellow. Jaundice should clear with stooling increase but will be followed closely—a weight and jaundice check in 24-48 hours. Parents offered reassurance that feedings will get easier and baby will rest better as milk supply is well-established. Strategies for helping mom to get a little extra rest discussed, as well as ideas for ways to help grandparents feel useful while still avoiding bottles and supplements.
Case Study # 2
Suzanne is a 31-year-old mother of 3-month-old Veronica. Suzanne is scheduled to have her gall bladder removed next week by laparoscopy. Her surgeon has suggested that she will need to “pump and dump” her breastmilk for 24 hours after surgery. Suzanne contacts her pediatric office to determine if this is necessary. She has a list of the medications that will be used in anesthesia. The nurse checks each of these against searchable databases and provides Suzanne with the information that these agents are quickly out of her system after surgery and that the breastmilk will not be impacted by the anesthesia medications. The nurse further advises Suzanne that should she receive something unanticipated in surgery, she can “pump and save” her milk and call to check on whether there will be any problem offering the milk to the baby.