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Breastfeeding
Angelia Leipelt, BA, IBCLC, ICCE, CLE
Ronald G. Chambers Jr., MD, FAAFP
image BASICS
  • Breastfeeding is the natural process of feeding infant human milk directly from the breast.
  • Breast milk is the preferred nutritional source and the normal and physiologic way to feed all newborns and infants.
  • The American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), WHO, and other medical organizations recommend exclusive breastfeeding for 6 months, with continuation of breastfeeding for ≥ 1 year as desired by the mother and infant (1)[A].
DESCRIPTION
  • Maternal benefits (as compared with mothers who do not breastfeed) include the following (2):
    • Rapid involution/decreased postpartum bleeding (due to oxytocin release)
    • Association of decreased risk of postpartum depression and increased bonding
    • Associated postpartum weight loss
    • Decreased risk of breast cancer
    • Association of decreased risk of premenopausal ovarian cancer
    • Decreased risk of type 2 diabetes, hypertension, hyperlipidemia, rheumatoid arthritis and cardiovascular disease
    • Decreased risk of prematurity due to child spacing
    • Convenience and economic savings
  • Infant benefits (as compared with children who are formula-fed) include the following (1,2):
    • Ideal food: easily digestible, nutrients well absorbed, less constipation
    • Lower rates of virtually all infections via maternal antibody protection
      • Fewer respiratory and GI infections
      • Decreased incidence of otitis media
      • Decreased risk of bacterial meningitis, pneumonia, and sepsis
      • Decreased incidence of necrotizing enterocolitis
    • Decreased incidence of obesity and type 1 and 2 diabetes
    • Decreased incidence of allergies, clinical asthma, and atopic dermatitis in childhood
    • Decreased risk of developing celiac disease and inflammatory bowel disease
    • Decreased risk of childhood leukemia
    • Decreased risk of sudden infant death syndrome (SIDS) and decreased mortality
    • Higher intelligence scores and better neurodevel-opmental outcomes
    • Increased attachment between mother and baby
    • Decreased child abuse
EPIDEMIOLOGY
Incidence
  • According to the most recent breastfeeding scorecard, United States breastfeeding rates are on the rise. Based on the CDC, in 2014: any breastfeeding: 79.2% (however, differs among different sociode-mographic and culture) (3)
  • Breastfeeding at 6 months: 49.4%
  • Breastfeeding at 12 months: 26.7%
  • Exclusive breastfeeding at 3 months: 40.7%
  • Exclusive breastfeeding at 6 months: 18.8%
ETIOLOGY AND PATHOPHYSIOLOGY
The overarching mechanism of milk production is based on supply and demand.
  • Stimulation of areola causes secretion of oxytocin.
  • Oxytocin is responsible for let-down reflex when myoepithelial cells contract and milk is ejected into milk ducts (4).
  • Sucking stimulates secretion of prolactin, which triggers milk production.
  • Endocrine/metabolic: Cystic fibrosis, diabetes, galactosemia, phenylketonuria, and thyroid dysfunction may cause delayed lactation or decreased milk.
GENERAL PREVENTION
  • Most vaccinations can be given to breastfeeding mothers. The CDC recommends that the diphtheria-tetanus-acellular pertussis, hepatitis B, inactivated influenza virus (as opposed to live attenuated), measles-mumps-rubella (MMR), and inactivated polio and varicella vaccines can be given. The CDC recommends avoiding the yellow fever or smallpox vaccine in breastfeeding mothers (5).
  • The inactivated influenza virus is preferred to the live attenuated virus in women with infants' age 6 to 23 months, regardless of whether these infants are being breastfed (5).
image DIAGNOSIS
PHYSICAL EXAM
Examine breasts, ideally during pregnancy, looking for scars, lumps, or inverted nipples. Confirm history of infertility, breast pathology, and previous breastfeeding problems.
image TREATMENT
GENERAL MEASURES
  • Breastfeeding initiation
    • Initiate breastfeeding immediately after birth, ideally placing the infant on mother's chest, skin-to-skin, IN FIRST HOUR (1,6)[A].
    • Mother placed in a comfortable position, usually sitting or leaning back, with baby on chest allowing baby to move toward breast.
    • As baby opens wide, bring baby close, tucking baby in “belly to belly.” Line baby's nose to nipple, baby tilts its head back with wide open mouth, bring baby close as baby latches to ensure baby's gum takes in more of the areola.
    • Baby's lips are flanged, rounded cheeks, no clicking or popping sounds and abscense of nipple pain when latched.
    • Feed baby on demand. Room-in and watch for hunger cues and cluster feeding.
    • Feed 2 to 8 times for first 24 hours and 8 to 15 times per 24 hours, feeding 10 or more minutes, emptying and alternating breasts.
    • Observation of a nursing session by an experienced physician, nurse, or lactation consultant
    • Avoid supplementation with formula or water unless medically indicated.
    • Contraindications to breastfeeding are few (WHO) (1).
      • Maternal HIV (in industrialized world) or human T-cell leukemia virus (HTLV) infection
      • Active untreated tuberculosis
      • Active herpes simplex virus (HSV) lesions on the breast*
      • Substances of abuse without evaluation and review medications that will pass into human milk
      • Infants with galactosemia or maple syrup urine disease should not be fed with breast milk. Infants with phenylketonuria may be fed breast milk under close observation.
      • Mothers who develop varicella 5 days before through 2 days after delivery*
      • Mothers acutely infected with influenza H1N1 until afebrile*
      • Maternal hepatitis is NOT a contraindication.
      • *Expressed milk can be used.
ISSUES FOR REFERRAL
  • Refer to trained physician, nurse, or IBCLC lactation consultant for inpatient and/or outpatient teaching.
  • Frequent follow-up if having problems with latching, sore nipples, breast pain, or inadequate milk production.
COMPLEMENTARY & ALTERNATIVE MEDICINE
Galactagogues (7)[C]
  • Metoclopramide, domperidone, oxytocin, fenugreek, goat's rue, and milk thistle have mixed results in improving milk production but efficacy and safety data are lacking in literature.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
See mother and baby within a few days of hospital discharge, especially if first time breastfeeding.
  • Risk factors for suboptimal initiation
    • Breast surgery, especially reduction surgery, prior to pregnancy may disrupt breast milk production in the future.
    • Severe postpartum hemorrhage may lead to Sheehan syndrome, which is associated with difficulty breastfeeding due to poor milk production.
    • Other factors: delivery mode, duration of labor, gestational age, maternal infection, parity, culture, mother-baby separation, maternal anxiety, artificial nipple, and nonbreast milk fluids.
Patient Monitoring
  • Monitor infant's weight, behavior, and output closely.
  • Supplementation with infant formula is recommended only if infant has lost ≥8-10% of birth weight or signs of dehydration such as decreased urine output.
  • Supplementation without persistent breast stimulation with frequent feedings or breast pump use will decrease milk production and decrease breastfeeding success.
DIET
  • For mothers:
    • Drink plenty of fluids: 8 glasses of liquid a day
    • Breastfeeding mothers require ˜500 more calories a day than prepregnancy needs (1).
    • Gassy foods can cause baby to be fussy.
    • P.141

    • Limit caffeine to 300 mg/day.
    • Alcohol should be avoided. 1 to 2 drinks/week of alcohol may be okay, but mothers should avoid nursing 2 to 3 hours after a drink. <2% of alcohol is passed to baby via breast milk.
  • Continue prenatal vitamin supplements.
  • For infants:
    • In 2008, the AAP increased its recommended daily intake of vitamin D for infants from 200 to 400 IU. For exclusively breastfed babies, this will require taking a vitamin supplement, such as Poly-Vi-Sol or Vi-Daylin vitamin drops, 0.5 mL/day, beginning in the first few days of life (1).
    • In 2010, the AAP recommended adding supplementation for breastfed infants with oral iron 1 mg/kg/day beginning at age 4 months.
      • Preterm infants fed by human milk should receive an iron supplement of 2 mg/kg/day by 1 month of age, and this should be continued until the infant is weaned to iron-fortified formula or begins eating complementary foods that supply the 2 mg/kg of iron.
      • Fluoride supplement is unnecessary until 6 months of age (1).
PATIENT EDUCATION
  • Primary care-initiated interventions and support measures to normalize breastfeeding have been shown to be successful with respect to child and maternal health outcomes (8).
    • U.S. Preventive Services Task Force (USPSTF) recommends structured breastfeeding education and behavioral counseling programs to promote breastfeeding.
      • Regular promotion of the advantages of breastfeeding/risks of not breastfeeding (6)[A]
      • Emphasize importance of exclusive breastfeeding for first 4 weeks of life to allow adequate buildup of sufficient milk supply.
  • Milk usually transitions to mature milk about postpartum day 3 to 5.
  • Frequent nursing (8-12 feedings per 24 hours by day 2)
  • Baby should have 6 to 8 wet diapers/day and 3 to 4 bowel movements/day by day 6 to 8.
  • Signs of adequate nursing
    • Baby feeding on demand.
    • Proper latching and positioning, nipples intact.
    • Hard breasts become soft after feeding.
    • Baby satisfied; appropriate weight gain (average 1 oz/day in first few months)
  • Weaning
    • Solid food may be introduced at 6 months with continuation of breastfeeding.
    • Mothers returning to work/school should be introduced to alternative feeding methods 1 to 2 weeks prior. Initiate pumping to supply expressed breastmilk.
  • Family planning
    • Lactational amenorrhea method (LAM): Breastfeeding may be used as effective birth control option if (i) infant is <6 months old, (ii) infant is exclusively breastfeeding, and (iii) mother is amenorrheic.
    • Other options include barrier methods, implants, Depo-Provera, PO contraception, and intrauterine devices (IUDs). ACOG recommends that progesterone-only pills be used 2 to 3 weeks postpartum, and that Depo-Provera, IUDs, combined OCPs, and Implanon can be used 6 weeks postpartum. However, ACOG recommends delaying use of combined OCPs until after 6 weeks postpartum when lactation is well established.
REFERENCES
1. Johnston M, Landers S, Noble L, et al. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841.
2. Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Rockville, MD: Agency for Health Care Research and Quality; 2007.
3. Centers for Disease Control and Prevention. Breastfeeding Report Card—United States, 2014. Atlanta, GA: Centers for Disease Control and Prevention; 2014. http://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf. Accessed 2014.
4. Sinusas K, Gagliardi A. Initial management of breastfeeding. Am Fam Physician. 2001;64(6):981-988.
5. Centers for Disease Control and Prevention. Breastfeeding Vaccinations. Atlanta, GA: Centers for Disease Control and Prevention; 2010. http://www.cdc.gov/breastfeeding/recommendations/vaccinations.htm. Accessed 2014.
6. American College of Obstetricians and Gynecologists Women's Health Care Physicians; Committee on Health Care for Underserved Women. Committee Opinion No. 570: breastfeeding in underserved women: increasing initiation and continuation of breastfeeding. Obstet Gynecol. 2013;122(2, Pt 1):423-428.
7. Foranish AB, Yancey AM, Barnes KN, et al. The use of galactogogues in the breastfeeding mother. Ann Pharmacother. 2012;46(10):1392-1404.
8. Chantry CJ, Eglash A, Labbok M. Position on breastfeeding. Breastfeed Med. 2008;3(4):267-270.
Additional Reading
  • American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Breastfeeding Handbook for Physicians. Elk Grove Village, IL: American Academy of Pediatrics; 2006.
  • Casey CF, Slawson DC, Neal LR. Vitamin D supplementation in infants, children, and adolescents. Am Fam Physician. 2010;81(6):745-748.
  • Philipp BL, Bunik M, Chantry CJ, et al. ABM Clinical Protocol #7: Model Breastfeeding Policy (Revision 2010). Breastfeed Med. 2010;5(4):173-177.
  • Wagner CL, Greer FR, Bhatia JJ, et al. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008;122(5):1142-1152.
  • Websites/Books:
    • Baby Friendly USA at www.babyfriendly.org
    • La Leche League at www.llli.org
    • World Health Organization, United Nations Children's Fund. Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. A Joint WHO/UNICEF Statement. Geneva, Switzerland: World Health Organization; 1989. http://www.unicef.org/newsline/tenstps.htm.
Codes
ICD10
Z39.1 Encounter for care and examination of lactating mother
Clinical Pearls
  • Women who do not receive support are at risk for shorter durations of breastfeeding (8).
  • Breast milk is the optimal food for infants, with myriad health benefits for mothers and children.
  • USPSTF recommends regular, structured education during pregnancy to promote breastfeeding.
  • Vitamin D and iron supplementation should begin at birth and 4 months of age, respectively, for exclusively breastfed infants.