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 biologic 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.

A. Promote hospital policies that support exclusive breastfeeding and nonseparation of mother and infant during hospital stay, beginning with immediate skin-to-skin contact after birth.

B. Encourage frequent feeding (8 to 12 feeds per 24 hours) in response to early infant cues.

C. When direct breastfeeding is not possible, instruct mother to hand express and/or pump to promote milk production.

D. Supplements to breast milk (i.e., water or formula) should not be given unless medically indicated.

E. Breastfeeding should be well established (about 2 weeks postbirth) before pacifiers are used.

F. Complementary foods should be introduced around 6 months with continued breastfeeding up to and beyond the first year.

G. Oral vitamin D drops (400 IU daily) should be given to the infant beginning within the first few days of age.

H. Supplemental fluoride should not be provided during the first 6 months of age.

A. Prenatal period. During pregnancy, all mothers should receive the following:

1. Information on the benefits of breastfeeding for mothers and infants

2. General information on the importance of exclusive breastfeeding during the maternity hospital stay in order to lay the foundation for adequate milk production

B. Early postpartum period. Prior to hospital discharge, all mothers should receive the following:

1. Breastfeeding assessment by a maternal-child nurse or lactation specialist

2. General breastfeeding information about the following:

a. Basic positioning of infant to allow correct infant attachment at the breast

b. Minimum anticipated feeding frequency (8 times/24-hour period)

c. Expected physiologically appropriate small colostrum intakes (about 15 to 20 mL in first 24 hours)

d. Infant signs of hunger and adequacy of milk intake

e. Common breast conditions experienced during early breastfeeding and basic management strategies

f. Postdischarge referral sources for breastfeeding support

C. All breastfeeding infants should be seen by a pediatrician or other health care provider within 1 to 3 days after discharge from the birth hospital to ensure appropriate milk intake, assessed by weight change from birth weight and urine and stool output. By 3 to 5 days of age, the infant should have yellow, seedy stools (˜3/day) and no more meconium stools and at least six wet diapers per day. A validated nomogram for assessing newborn weight loss can be accessed at http://www.newbornweight.org/.

1. 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.

2. Expect a return to birth weight by 12 to 14 days of age and a continued rate of growth of at least ½ oz/day during the first month.

3. 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.

a. The ability of infant to transfer milk at breast can be measured by weighing the infant before and after feeding using the following guidelines:

i. Weighing the diapered infant before and immediately after the feeding (without changing the diaper)

ii. 1 g infant weight gain equals 1 mL milk intake

4. If milk transfer is inadequate, supplementation (preferably with expressed breast milk) may be indicated.

5. Instructing the mother to express her milk with a mechanical breast pump following or in place of a feeding will allow additional breast stimulation to increase milk production.

A. 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.

B. 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., eczema, bacterial, fungal infection). Management includes (i) assessment of infant positioning and latch-on 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.

C. Engorgement is a severe form of increased breast fullness that usually presents on day 3 to 5 postpartum signaling the onset of copious milk production. Engorgement may be caused by inadequate and/or infrequent breast stimulation resulting in swollen, hard breasts that are warm to the touch. The infant may have difficulty latching on to the breast until the engorgement is resolved. Treatment includes (i) application of warm, moist heat to the breast alternating with cold compresses to relieve edema of the breast tissue, (ii) gentle hand expression of milk to soften areola to facilitate infant attachment to the breast, (iii) gentle massage of the breast during feeding and/or milk expression, and (iv) mild analgesic (acetaminophen) or antiinflammatory (naproxen) for pain relief and/or reduction of inflammation.

D. Plugged ducts usually present as a palpable lump or area of the breast that does not soften during a feeding or pumping session. It may be the result of an ill-fitting bra, tight, constricting clothing, or a missed or delayed feeding/pumping. Treatment includes (i) frequent feedings/pumpings beginning with the affected breast, (ii) application of moist heat and breast massage before and during feeding, and (iii) positioning infant during feeding to locate the chin toward the affected area to allow for maximum application of suction pressure to facilitate breast emptying.

E. Mastitis is an inflammatory and/or infectious breast condition—usually affecting only one breast. Signs and symptoms include rapid onset of fatigue, body aches, headache, fever, and tender, reddened breast area. Treatment includes (i) continued breastfeeding on affected and unaffected breasts, (ii) frequent and efficient milk removal—using an electric breast pump when necessary (it is not necessary to discard expressed breast milk), (iii) appropriate antibiotics for a sufficient period (10 to 14 days), and (iv) comfort measures to relieve breast discomfort and general malaise (i.e., analgesics, moist heat/massage to breast).

V. SPECIAL SITUATIONS. Certain conditions in the infant, mother, or both may indicate specific strategies that require a delay and/or modification of the normal breastfeeding relationship. Whenever breastfeeding is delayed or suspended for a period of time, frequent breast emptying with an electric breast pump is recommended to ensure maintenance of lactation.

1. Hyperbilirubinemia is not a contraindication to breastfeeding. Special attention should be given to ensuring infant is breastfeeding effectively in order to enhance gut motility and facilitate bilirubin excretion. In rare instances of severe hyperbilirubinemia, breastfeeding may be interrupted temporarily for a short period of time.

2. Congenital anomalies may require special management.

a. Craniofacial anomalies (i.e., cleft lip/palate, Pierre Robin) present challenges to the infant’s ability to latch effectively to the breast. Modified positioning and special devices (i.e., obturator, nipple shield) may be utilized to achieve an effective latch.

b. Cardiac or respiratory conditions may require fluid restriction and special attention to pacing of feeds to minimize fatigue during feeding.

c. Restrictive lingual frenulum (ankyloglossia/tongue tie) may interfere with the infant’s ability to effectively breastfeed. The inability of the infant to extend the tongue over the lower gum line and lift the tongue to compress the underlying breast tissue may compromise effective milk transfer. Frenulotomy is often the treatment of choice.