Breastfeeding
Nancy Hurst
I. RATIONALE FOR BREASTFEEDING.
Breastfeeding enhances maternal involvement, interaction, and bonding; provides species-specific nutrients to support normal infant growth; provides nonnutrient growth factors, immune factors, hormones, and other bioactive components that can act as biological signals; and can decrease the incidence and severity of infectious diseases, enhance neurodevelopment, decrease the incidence of childhood obesity and some chronic illnesses, and decrease the incidence and severity of atopic disease. Breastfeeding is beneficial for the mother’s health because it increases maternal metabolism; has maternal contraceptive effects with exclusive, frequent breastfeeding; is associated with decreased incidence of maternal premenopausal breast cancer and osteoporosis; and imparts community benefits by decreasing health care costs and economic savings related to commercial infant formula expenses.
II. RECOMMENDATIONS ON BREASTFEEDING FOR HEALTHY TERM INFANTS INCLUDE THE FOLLOWING GENERAL PRINCIPLES
Exclusive breastfeeding for the first 6 months
When direct breastfeeding is not possible, expressed breast milk should be provided
Place infants skin to skin with their mothers immediately after birth and encourage frequent feedings (8—12 feeds/24-hour period)
Supplements (i.e., water or formula) should not be given unless medically indicated
Breastfeeding should be well established before pacifiers are used
Complementary foods should be introduced around 6 months with continued breastfeeding up to and beyond the first year
Oral vitamin D drops (400 IU/daily) should be given to the infant beginning within the first few days of age
Supplemental fluoride should not be provided during the first 6 months of age
III. MANAGEMENT AND SUPPORT ARE NEEDED FOR SUCCESSFUL BREASTFEEDING
Early postpartum period. Prior to hospital discharge, all mothers should receive:
Breastfeeding assessment by a lactation and/or nurse specialist
General breastfeeding information about:
Basic positioning of infant to allow correct infant attachment at the breast
Minimum anticipated feeding frequency (eight times/24-hour period)
Expected physiologically appropriate small colostrum intakes (about 15-20 mL in first 24 hours).
Infant signs of hunger and adequacy of milk intake
Common breast conditions experienced during early breastfeeding and basic management strategies
Proper referral sources when indicated
All breastfeeding infants should be seen by a pediatrician or other health care provider at 3 to 5 days of age to ensure that the infant has stopped losing weight and lost no more than 8 to 10% birth weight; has yellow, seedy stools (approximately 3/d)—no more meconium stools; and has at least six wet diapers per day.
At 3 to 5 days postdelivery, the mother should experience some breast fullness, and notice some dripping of milk from opposite breast during breastfeeding; demonstrate ability to latch infant to breast; understand infant signs of hunger and satiety; understand expectations and treatment of minor breast/nipple conditions.
Expect a return to birth weight by 12 to 14 days of age and a continued rate of growth of at least 1/2 ounce per day during the first month.
If infant growth is inadequate, after ruling out any underlying health conditions in the infant, breastfeeding assessment should include adequacy of infant attachment to the breast; presence or absence of signs of normal lactogenesis (i.e., breast fullness, leaking); and maternal history of conditions (i.e., endocrine, breast surgery) that may affect lactation.
The ability of infant to transfer milk at breast can be measured by weighing the infant before and after feeding using the following guidelines:
Weighing the diapered infant before and immediately after the feeding (without changing the diaper)
1 g infant weight gain equals 1 mL milk intake
If milk transfer is inadequate, supplementation (preferably with expressed breast milk) may be indicated.
Instructing the mother to express her milk with a mechanical breast pump following feeding will allow additional breast stimulation to increase milk production.
IV. MANAGEMENT OF BREASTFEEDING PROBLEMS
Sore, tender nipples. Most mothers will experience some degree of nipple soreness most likely a result of hormonal changes and increased friction caused by the infant’s sucking action. A common description of this soreness includes an intense onset at the initial latch-on with a rapid subsiding of discomfort as milk flow increases. Nipple tenderness should diminish during the first few weeks until no discomfort is experienced during breastfeeding. Purified lanolin and/or expressed breast milk applied sparingly to the nipples following feedings may hasten this process.
Traumatized, painful nipples (may include bleeding, blisters, cracks). Nipple discomfort associated with breastfeeding that does not follow the scenario described previously requires immediate attention to determine cause and develop appropriate treatment modalities. Possible causes include ineffective, poor latch-on to breast; improper infant sucking technique; removing infant from breast without first breaking suction; and underlying nipple condition or infection (i.e., yeast, eczema). Management includes (i) assessment of infant positioning and latchon with correction of improper techniques. Ensure that mother can duplicate
positioning technique and experiences relief with adjusted latch-on. (ii) Diagnose any underlying nipple condition and prescribe appropriate treatment. (iii) In cases of severely traumatized nipples, temporary cessation of breastfeeding may be indicated to allow for healing. It is important to instruct the mother to maintain lactation with mechanical/hand expression until direct breastfeeding is resumed.
