Breastfeeding Recommendations

Major health professional organizations, including the National Association of Pediatric Nurse Practitioners (2007), the American Academy of Pediatrics (AAP) (2005), the American Academy of Family Physicians (AAFP) (2008), and the American Dietetic Association (ADA) (James and Lessen 2009) recommend breastfeeding exclusively for the first 6 months of life, then breastfeeding combined with other nutrients for at least the first year.

Proposed breastfeeding goals for Healthy People 2020 reaffirm those from the Healthy People 2010 document: 75% of mothers will initiate breastfeeding in the neonatal period; 50% will be breastfeeding at 6 months, and 25% at 1 year of age (U.S. Department of Health and Human Services [USDHHS], 2009). Breastfeeding rates have increased in the U.S. (Table 11-1), and three out of four new mothers initiate breastfeeding, meeting one of the Healthy People goals. Exclusive breastfeeding until 3 to 6 months and continued breastfeeding from 6 to 12 months still fall short of desired goals, however (Centers for Disease Control and Prevention [CDC], 2010). In 2011, the U. S. Department of Health and Human Services issued a report entitled The Surgeon General’s Call to Action to Support Breastfeeding (2011). Twenty actions were identified to support breastfeeding and include:

TABLE 11-1 Healthy People 2010 Objectives: Initiation and Duration of Breastfeeding for Children Born in 2007

Providers can make a major contribution to breastfeeding’s success by supporting these actions.

Hospital-Based Support

Benefits of Breastfeeding

With rare exception, breast milk is the ideal food for a human infant. Each mammalian species provides milk uniquely suited to its offspring, and milk from the human breast is no exception. It is a living fluid rich in vitamins, minerals, fat, proteins (including immunoglobulins and antibodies), and carbohydrates (especially lactose). It contains enzymes and cellular components, including macrophages and lymphocytes, in addition to many other constituents that offer ideal support for growth and maturation of the human infant. As the infant grows and develops, the properties of the breast milk change. The sequence of colostrum, transitional milk, and mature milk meets the changing nutritional needs of the newborn and infant. Thus the milk of a mother of a 9-month-old has different concentrations of fat, protein, and carbohydrate and different physical properties, such as pH, when compared with the milk of the mother of a newborn or 1-month-old. In addition, some of the constituent properties in the milk are different from one time of day to another.

In addition to providing optimal nutrition for growth and development, breastfeeding confers many short- and long-term health benefits to infants. A review of studies examining the effect of breastfeeding on infant health indicates a lower risk of nonspecific gastroenteritis, necrotizing enterocolitis, acute otitis media, severe lower respiratory tract infections, asthma, atopic dermatitis, type 1 and type 2 diabetes, obesity, sudden infant death syndrome (SIDS), and childhood leukemia in breastfed infants (Ip et al, 2009).

In the short term, studies show that breastfed babies have added protection against bacterial, viral, and protozoal illnesses during infancy. Human-milk glycans and immunoglobulins appear to inhibit pathogens from adhering to intestinal mucosa, replicating, and causing disease (Correa et al, 2006). Oligosaccharides in breast milk also support the growth of the infantis strain of Bifidobacterium longum in the intestine of the breastfed infant, while suppressing pathological bacteria such as Escherichia coli, Clostridium, and Enterococcus (Marcobal et al, 2010; Zivkovic et al, 2011). Breastfeeding also appears to reduce the incidence of fever after immunization (Pisacane et al, 2010).

The long-term benefits of breastfeeding for 6 months may include a decreased incidence of atopic diseases and an association with lower rates of asthma in young children (Greer et al, 2008). Breastfeeding may also be protective against obesity, has been associated with lower cholesterol in adults (Owen et al, 2008; Singhal, 2010), and may be protective against type 1 and type 2 diabetes in youth (Mayer-Davis et al, 2008).

Initiating breastfeeding is crucial; the infant enjoys health benefits with every day of breastfeeding. Maintaining breastfeeding is also crucial; there is evidence, for example, that infants who are breastfed for 6 months have less risk for infection than those breastfed for 4 months (Chantry et al, 2006). However, exclusive, prolonged breastfeeding may actually contribute to health problems. Pesonen and associates found that infants exclusively breastfed for 9 months or longer had an increased incidence of atopic dermatitis and food hypersensitivity in childhood (Pesonen et al, 2006). Complementary foods should be added to the infant diet by 6 months of age (see Chapter 10). Breastfeeding provides important nutritional and health-related benefits and should be continued to at least 1 year.

There are also benefits for the mother that include more rapid return to her nonpregnant state; establishment of the strong bond associated with successful nursing; decreased risk for breast cancer (De Silva et al, 2010) and ovarian cancer, especially if the lastborn child is breastfed (Titus-Ernstoff et al, 2010); decreased risk for metabolic syndrome (Gunderson et al, 2010); and a variety of other conditions (Stuebe and Schwarz, 2010).

Breastfeeding also provides an economic incentive as a free and plentiful source of excellent infant nutrition. The cost of formula and other necessary supplies easily exceeds $1000 to $1200 each year.

Contraindications to Breastfeeding

In addition to all the beneficial nutrients that are provided to the infant during breastfeeding, certain infections and many drugs or medications can be passed to the infant via breast milk. Although rare, contraindications to breastfeeding occur in some of these situations. In addition, a small number of infant conditions also preclude breastfeeding. Contraindications to breastfeeding include the following:

Characteristics of Human Milk

Anatomy and Physiology

Pregnancy brings about the final stage of mammogenesis—growth and differentiation of the mammary gland and development of the structures to support breast milk production. Estrogen, progesterone, placental lactogen, and prolactin all play a role in mammogenesis. By approximately 20 weeks the breast is capable of milk production. The actual production of breast milk is triggered by the fall in progesterone concentration after birth of the baby. Placental retention inhibits milk production because of the presence of progesterone and other hormones.

Suckling by the infant is essential to establish and maintain lactation. The amount of milk produced depends on stimulation of the breast, removal of milk from the breast, and release of hormones. The concept of “supply and demand” is an important one for providers and parents to understand. Suckling stimulates the hypothalamus to decrease prolactin-inhibiting factor and permits release of prolactin by the anterior pituitary, which leads to a rise in the level of prolactin. Prolactin levels are directly proportional to the level of suckling by the infant and are more important to initiating than maintaining lactation. The hypothalamus also stimulates the synthesis and release of oxytocin by the posterior pituitary (Fig. 11-1). Oxytocin reacts with receptors in the myoepithelial cells of the milk ducts to initiate a contracting action that results in forcing milk down the ducts. This action increases milk pressure called the letdown reflex or milk ejection reflex. Oxytocin also aids in maternal uterine involution.

FIGURE 11-1 Neuroendocrine loop.

Under the influence of the hormones mentioned previously, the mammary gland undergoes a dramatic change with an increase in size and rapid growth of the lobuloalveolar tissue. The alveoli are the sites of milk production and combine in numbers of 10 to 100 to form lobuli: 20 to 40 lobuli combine into lobes, and 15 to 25 lobes empty into a lactiferous duct. The ducts transport the milk to the nipple (Fig. 11-2).

FIGURE 11-2 Anatomy of the lactating breast.

(Modified from Medela AG, 2006; Ramsay et al: Anatomy of the lactating human breast redefined with ultrasound imaging, J Anatomy, 2005.)

The nipple and surrounding areola serve as a visual and tactile target to assist with latch-on. The size and shape of the woman’s breast and areola vary greatly. Fortunately the size of the breast is not a predictor of breast milk volume. Women with very small breasts can successfully breastfeed. The provider should be alert, however, for the occasional presence of insufficient glandular tissue, which is characterized by the absence of breast changes associated with pregnancy, a unilaterally underdeveloped breast, or conical-shaped breasts.

The size, shape, and position of the nipple also vary among women. The nipple may be everted (protuberant from the breast), flat, or inverted. It is not always possible to detect an inverted nipple by observation only. The “pinch test” may be needed to identify nipples that invert with tactile stimulation to the areola. To do the pinch test, place the thumb and forefinger on opposite sides of the areola about 1 to 1.5 inches back from the nipple-areolar junction. Gently compress as though bringing the two fingers together, causing the nipple to become more everted or inverted. This assessment should be conducted prenatally on every patient (Fig. 11-3). Management of inverted nipples is discussed later in this chapter.

FIGURE 11-3 Pinch test.

Despite the complexity of the anatomical and physiological processes, the great news is that breastfeeding can proceed for the mother and the baby with little or no awareness on their part of these considerations.

Assessment of the Breastfeeding Dyad

Prenatal assessment focuses on maternal expectations for breastfeeding; knowledge about breastfeeding, especially techniques for getting off to a good start; and identification of any contraindications to breastfeeding. A nipple evaluation should be completed. All pregnant women should be assessed, not just primigravidas. In the early postpartum period, assessment focuses on the transition to breastfeeding and should include close observation of a feeding. In addition, signs of progress for successful breastfeeding should be reviewed, and the names and phone numbers of contact persons should be given to mothers for follow-up or questions.