The Decision to Breastfeed

Women make the decision to breastfeed before becoming pregnant, or early in the first trimester—often before their first prenatal visit. The influence of the primary care clinician on the decision to breastfeed is strong. In a 2001 study of 1229 women, Lu and colleagues found that prenatal encouragement to breastfeed was most influential for women from population groups that were least likely to breastfeed. Prenatal encouragement from a physician was associated with a more than 3-fold increase in breastfeeding initiation among low-income, young, and less educated women; with a 5-fold increase among black women, and by a nearly 11-fold increase among single women. Guise and colleagues conducted a meta-analysis of 30 randomized, controlled trials and 5 systematic reviews, and found that prenatal education was among the most important potential interventions for increasing breastfeeding initiation and duration.

As discussed in greater detail later in this review, implementation of the BFHI Ten Steps can lead to much higher breastfeeding rates. Step 3 of the BFHI states that all pregnant women should be informed of the benefits of breastfeeding. A Cochrane review concluded that the most effective type of prenatal education is a repeated, needs-based, clinician and patient dyadic informal education that occurs as a part of routine care. In a 2008 systematic review, Chung and colleagues studied the outcomes of structured breastfeeding education, and concluded that for every 3 to 5 women who attend a prenatal education program, 1 more woman will initiate and continue breastfeeding for up to 3 months. A smaller, but very recent, study indicates that training women prenatally about normal infant feeding cues can increase breastfeeding duration.

Many municipalities and some regions and nations have undertaken awareness and advertising campaigns such that women of childbearing age (and those who support them) are informed of the extensive health benefits of breastfeeding. Fig. 1 shows some examples of print advertising from around the globe. The effectiveness of such campaigns has been mixed. The extensive United States breastfeeding awareness campaign of 2005–2006 did seem to improve public sentiment about breastfeeding, but a causal link with improved breastfeeding rates cannot be determined from a mass intervention of this kind.

Two breastfeeding promotion campaigns. (A) A New Zealand campaign aims to normalize out-of-the-house breastfeeding and links breastfeeding with positive futures for the infants pictured. (B) One of the images from the U.S. AdCouncil 2005–2006 campaign that emphasized the health risks of formula feeding—this one about the link between not breastfeeding and childhood obesity.

([ A ] Copyright © New Zealand Ministry of Health. Available at: www.breastfeeding.org.nz . [ B ] From US Department of Health and Human Services, National Breastfeeding Campaign. Available at: http://womenshealth.gov/breastfeeding/government-in-action/national-breastfeeding-campaign/ .)

The Prenatal Visit, Community Supports

Many pediatricians offer prenatal visits to prospective parents. In addition to reviewing the workings of the office practice, this visit presents a great opportunity to provide anticipatory guidance about a choice that likely affects overall maternal and child health more than any of the other decisions that have to be made for the newborn around the time of delivery. Although pediatricians do not provide prenatal care, their influence may be able to work in a similar manner to the primary care counseling described if they encounter soon-to-be mothers during pregnancy. Unfortunately, the role of the pediatric prenatal visit specifically on breastfeeding initiation and duration has not been subject to study. Other prenatal preparation available to prospective breastfeeding women include informative books, classes, text messaging services (Text4Baby), lay support networks (La Leche League), and breastfeeding services provided by the Women, Infants and Children (WIC) program.

Of the aforementioned breastfeeding support services, those provided by WIC have been subject to the most study. Since 2008, WIC food packages have been changed such that women who are breastfeeding receive a substantially bigger and more nutritious food package. The first study of the impact of this food package change on breastfeeding outcomes was published in 2012, and found that more mothers are now receiving the full breastfeeding food package (without formula), but the overall breastfeeding initiation rate in the WIC population has not been impacted by the change.

Anticipating Probable Perinatal Medical Issues

Although the BFHI Ten Steps address the care of the healthy term newborn, not every birth of a baby is low risk and after 38 completed weeks of gestation. Although some medical issues arise acutely at delivery, there are others that can be anticipated during pregnancy, and the detrimental effects of these medical issues on breastfeeding can be mitigated with good preparation. For a woman with a history of preterm birth and/or ongoing preterm labor, there can be some degree of planning for how to achieve successful breastfeeding in the preterm neonate. A full review of breastfeeding the preterm infant is beyond the scope of this article, but is discussed by Underwood and colleagues elsewhere in this issue. Families that are anticipating a possible preterm delivery, however, can become familiar with the lactation support services at the hospital with the newborn intensive care unit where the infant will likely be born. They can familiarize themselves with techniques and services helpful for supplying milk for preterm infants, including pasteurized donor human milk, pumping, and hand expression.

Mothers with gestational or preexisting diabetes mellitus can anticipate a high likelihood of neonatal hypoglycemia after delivery. The first intervention for mild to moderate hypoglycemia in a newborn is often enteral supplementation with infant formula, often delivered via bottle and standard nipple; however, the breastfed infant with mild hypoglycemia can first be put directly to breast for a feed of colostrum. If there is an ineffective latch, the infant can be fed with colostrum that has been expressed by hand ( Fig. 2 ).

Devices for medically necessary supplementation. ( A ) A spoon is very useful for colostrum, because it can be held under the breast by an assistant for hand expression. It is perfect for collecting 1 or 2 teaspoons—the typical amount of colostrum expressed in the first 48 hours. Expressed colostrum can be fed to the infant right from the spoon, without loss of milk in collecting materials. ( B ) Feeding cups are the most common method for supplemental feeds worldwide, and the only bottle alternative subject to rigorous research methods. ( C ) A dropper is most useful for smaller amounts of early milk. It can be inserted on the inside of the cheek and given slowly, shown here while the newborn sucks on the mother’s finger. ( D ) Supplemental nursing system allows for supplementation either via finger, as pictured here, or directly at the breast. The small tube is taped to the areola, and the infant takes both tube and areola into his mouth simultaneously. The main advantage is continued stimulation of nipple and pituitary–mammary axis during supplementation. Disadvantages include expense, difficulty with cleaning in places where water is scarce, and lack of rigorous study of its efficacy. The mother in this picture had significant nipple erosions, and was therefore supplementing via fingerfeeding. Gloves are not necessary; they were used here owing to the mother’s long fingernails.

([ B ] Data from Howard CR, Howard FM, Lanphear B, et al. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics 2003;111:511–8.)

Avoiding formula supplementation preserves the health benefits of early, exclusive breastfeeding and may assist with better development of a full maternal milk supply. Some advocate the use of pasteurized human donor milk for any supplementation of the breastfed newborn; this approach is controversial, because the supply of this expensive resource is quite limited, and may ethically need to be reserved for preterm neonates.

The Decision to Breastfeed

Women make the decision to breastfeed before becoming pregnant, or early in the first trimester—often before their first prenatal visit. The influence of the primary care clinician on the decision to breastfeed is strong. In a 2001 study of 1229 women, Lu and colleagues found that prenatal encouragement to breastfeed was most influential for women from population groups that were least likely to breastfeed. Prenatal encouragement from a physician was associated with a more than 3-fold increase in breastfeeding initiation among low-income, young, and less educated women; with a 5-fold increase among black women, and by a nearly 11-fold increase among single women. Guise and colleagues conducted a meta-analysis of 30 randomized, controlled trials and 5 systematic reviews, and found that prenatal education was among the most important potential interventions for increasing breastfeeding initiation and duration.

As discussed in greater detail later in this review, implementation of the BFHI Ten Steps can lead to much higher breastfeeding rates. Step 3 of the BFHI states that all pregnant women should be informed of the benefits of breastfeeding. A Cochrane review concluded that the most effective type of prenatal education is a repeated, needs-based, clinician and patient dyadic informal education that occurs as a part of routine care. In a 2008 systematic review, Chung and colleagues studied the outcomes of structured breastfeeding education, and concluded that for every 3 to 5 women who attend a prenatal education program, 1 more woman will initiate and continue breastfeeding for up to 3 months. A smaller, but very recent, study indicates that training women prenatally about normal infant feeding cues can increase breastfeeding duration.

Many municipalities and some regions and nations have undertaken awareness and advertising campaigns such that women of childbearing age (and those who support them) are informed of the extensive health benefits of breastfeeding. Fig. 1 shows some examples of print advertising from around the globe. The effectiveness of such campaigns has been mixed. The extensive United States breastfeeding awareness campaign of 2005–2006 did seem to improve public sentiment about breastfeeding, but a causal link with improved breastfeeding rates cannot be determined from a mass intervention of this kind.

Two breastfeeding promotion campaigns. (A) A New Zealand campaign aims to normalize out-of-the-house breastfeeding and links breastfeeding with positive futures for the infants pictured. (B) One of the images from the U.S. AdCouncil 2005–2006 campaign that emphasized the health risks of formula feeding—this one about the link between not breastfeeding and childhood obesity.

([ A ] Copyright © New Zealand Ministry of Health. Available at: www.breastfeeding.org.nz . [ B ] From US Department of Health and Human Services, National Breastfeeding Campaign. Available at: http://womenshealth.gov/breastfeeding/government-in-action/national-breastfeeding-campaign/ .)

The Prenatal Visit, Community Supports

Many pediatricians offer prenatal visits to prospective parents. In addition to reviewing the workings of the office practice, this visit presents a great opportunity to provide anticipatory guidance about a choice that likely affects overall maternal and child health more than any of the other decisions that have to be made for the newborn around the time of delivery. Although pediatricians do not provide prenatal care, their influence may be able to work in a similar manner to the primary care counseling described if they encounter soon-to-be mothers during pregnancy. Unfortunately, the role of the pediatric prenatal visit specifically on breastfeeding initiation and duration has not been subject to study. Other prenatal preparation available to prospective breastfeeding women include informative books, classes, text messaging services (Text4Baby), lay support networks (La Leche League), and breastfeeding services provided by the Women, Infants and Children (WIC) program.

Of the aforementioned breastfeeding support services, those provided by WIC have been subject to the most study. Since 2008, WIC food packages have been changed such that women who are breastfeeding receive a substantially bigger and more nutritious food package. The first study of the impact of this food package change on breastfeeding outcomes was published in 2012, and found that more mothers are now receiving the full breastfeeding food package (without formula), but the overall breastfeeding initiation rate in the WIC population has not been impacted by the change.

Anticipating Probable Perinatal Medical Issues

Although the BFHI Ten Steps address the care of the healthy term newborn, not every birth of a baby is low risk and after 38 completed weeks of gestation. Although some medical issues arise acutely at delivery, there are others that can be anticipated during pregnancy, and the detrimental effects of these medical issues on breastfeeding can be mitigated with good preparation. For a woman with a history of preterm birth and/or ongoing preterm labor, there can be some degree of planning for how to achieve successful breastfeeding in the preterm neonate. A full review of breastfeeding the preterm infant is beyond the scope of this article, but is discussed by Underwood and colleagues elsewhere in this issue. Families that are anticipating a possible preterm delivery, however, can become familiar with the lactation support services at the hospital with the newborn intensive care unit where the infant will likely be born. They can familiarize themselves with techniques and services helpful for supplying milk for preterm infants, including pasteurized donor human milk, pumping, and hand expression.

Mothers with gestational or preexisting diabetes mellitus can anticipate a high likelihood of neonatal hypoglycemia after delivery. The first intervention for mild to moderate hypoglycemia in a newborn is often enteral supplementation with infant formula, often delivered via bottle and standard nipple; however, the breastfed infant with mild hypoglycemia can first be put directly to breast for a feed of colostrum. If there is an ineffective latch, the infant can be fed with colostrum that has been expressed by hand ( Fig. 2 ).

Devices for medically necessary supplementation. ( A ) A spoon is very useful for colostrum, because it can be held under the breast by an assistant for hand expression. It is perfect for collecting 1 or 2 teaspoons—the typical amount of colostrum expressed in the first 48 hours. Expressed colostrum can be fed to the infant right from the spoon, without loss of milk in collecting materials. ( B ) Feeding cups are the most common method for supplemental feeds worldwide, and the only bottle alternative subject to rigorous research methods. ( C ) A dropper is most useful for smaller amounts of early milk. It can be inserted on the inside of the cheek and given slowly, shown here while the newborn sucks on the mother’s finger. ( D ) Supplemental nursing system allows for supplementation either via finger, as pictured here, or directly at the breast. The small tube is taped to the areola, and the infant takes both tube and areola into his mouth simultaneously. The main advantage is continued stimulation of nipple and pituitary–mammary axis during supplementation. Disadvantages include expense, difficulty with cleaning in places where water is scarce, and lack of rigorous study of its efficacy. The mother in this picture had significant nipple erosions, and was therefore supplementing via fingerfeeding. Gloves are not necessary; they were used here owing to the mother’s long fingernails.

([ B ] Data from Howard CR, Howard FM, Lanphear B, et al. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics 2003;111:511–8.)

Avoiding formula supplementation preserves the health benefits of early, exclusive breastfeeding and may assist with better development of a full maternal milk supply. Some advocate the use of pasteurized human donor milk for any supplementation of the breastfed newborn; this approach is controversial, because the supply of this expensive resource is quite limited, and may ethically need to be reserved for preterm neonates.

The Importance of Skin-to-Skin Contact

Immediately after delivery, the placement of the newborn skin-to-skin on his or her mother’s chest has immense positive effects both on newborn physiologic parameters, and on numerous metrics of breastfeeding success ( Fig. 3 ). In a 2012 systematic review, Moore and colleagues demonstrated that skin-to-skin contact in the immediate post-delivery period improves physiologic transition in the newborn, increases the success of the first breastfeed, and leads to more effective breastfeeding. More babies that had been placed skin-to-skin continued to breastfeed through 1–4 months, compared with those receiving standard care.

The ideal place for a newborn—skin-to-skin with his mother.

Smaller studies of skin-to-skin contact have shown direct changes in infant behavior. Preterm infants exposed to their mother’s milk odor—a natural byproduct of skin-to-skin care—suckle for longer periods of time at each feeding, and consume more milk at each feeding when they reach 35 weeks post-conceptional age. In a study of 72 infants randomized to skin-to-skin contact versus isolation, the majority of those who were left in contact breastfed in the first hour. Whenever the first breastfeed occurred, 63% in the contact group had an effective sucking technique, whereas only 21% in the control group (left in isolation) demonstrated good breastfeeding skills at the first feed.

The First Breastfeed

Once in skin-to-skin contact with their mother, many infants find their own way to the breast and begin to feed without significant assistance. A dramatic example of this can be seen in the WHO/United Nations Children’s Fund (UNICEF)–sponsored video “The Breast Crawl,” in which a newborn girl finds the breast and begins to suckle without any assistance from her mother or from other adult observers ( Fig. 4 , video link). An early first breastfeed seems to help with increased milk supply in the first days of life, earlier passage of meconium, and a greater likelihood of continued breastfeeding. Conversely, delay in the first feed can lead to issues of poor milk supply and to greater odds of discontinuing breastfeeding.

Still frames from the UNICEF “Breast crawl” video. View at: http://www.breastcrawl.org/video.htm .

( Courtesy of UNICEF India; with permission. Available at: http://breastcrawl.org/video.shtml .)

Newborn Procedures

To align hospital policies with the clear benefits of early skin-to-skin contact and early breastfeeding, nurseries may find they need to alter the timing of routine newborn procedures. Unless a newborn is of significantly low birth weight (<1800–2000 g), is born at less than 34 weeks gestational age, or has signs and symptoms of illness requiring a transfer to a special care nursery, weighing of the infant can be deferred until after a few hours of skin-to-skin time. The only medically necessary reason to weigh a late preterm or term newborn immediately after delivery would be to administer correct dosages of weight-based medications or intravenous fluids—interventions that are not necessary for well-appearing neonates in this gestational age range.

The efficacy of the newborn dose of hepatitis B vaccine in preventing silent vertical hepatitis transmission is optimized when it is administered as close to delivery as possible. Parenteral vitamin K is the most effective form of phytonadione for preventing both early and late hemorrhagic disease of the newborn. Both of these injections can be delivered while the newborn is skin-to-skin and/or breastfeeding, because both skin-to-skin contact and breastfeeding have been demonstrated to diminish pain responses in the newborn. Newborns who require blood sampling for asymptomatic hypoglycemia may also have these heel lances done while they remain skin-to-skin.

Erythromycin eye ointment for prevention of opthalmia neonatorum need not be applied immediately after delivery. No study has examined the outcomes of differential timing of application, but waiting for an hour or 2 of skin-to-skin time before application should not have adverse effects from a microbiological perspective.

Normal Breastfeeding Patterns in the First Days

If new parents or extended family of the newborn, or the nursery medical, nursing, and other hospital staff are unfamiliar with normal breastfeeding patterns, this can be detrimental for the establishment of successful breastfeeding. The American Academy of Pediatrics (AAP), Academy of Breastfeeding Medicine (ABM), American Academy of Family Physicians, American College of Obstetricians and Gynecologists, WHO/UNICEF, and the U.S. Surgeon General all recommend 6 months of exclusive breastfeeding, because of the particular health benefits of breast milk as the only enteral intake (also discussed in detail by Dieterich and colleagues elsewhere in this issue). Many new families, however, are more familiar with the patterns of formula-fed infants, who generally consume higher volumes with less frequency than is normative for breastfed infants. In addition, because milk consumption with breastfeeding is not “seen” and not easily “measured,” many families worry that the “baby is not getting enough”; these families need particular reassurance from medical professionals.

Normal breastfeeding patterns during the first week of life, including timing, volume, and related output, are summarized in Table 1 . During the first 24 hours, a significant subset of newborns does not have a good latch. Most neonates have some effective latch and suckle by 48 hours of life, and supplementation for poor feeding not associated with significant illness in the mother or infant is not necessary in the first 2 days. If there is poor feeding with weight loss of greater than 7%, supplementation can be considered. Weight loss of 7% alone, however, in the absence of poor feeding, is not an indication for supplementation. We should take great care to reassure mothers that lack of effective feeding for the first day or so is quite normal, because medically unnecessary supplementation undermines maternal confidence in the ability to breastfeed and has an adverse effect on breastfeeding outcomes.

The first day can be a slower day for feeding, with many newborns having a long period of sleep after the first hour or two after they are born. Many infants only feed 4–6 feeds in the first 24 hours, although others will feed more frequently than this even during their first day. By day 2, feeding frequency typically increases to 8–12 times in each 24-hour period, but is generally not spaced at even intervals. Lower volumes of early milk (colostrum) then transition to mature milk (lactogenesis II), with higher volumes any time between 24 and 120 hours after delivery. Urine and stool output increase each day. A good rule of thumb for measuring sufficient intake in the first week is 1 urine and 1 stool for each day of life.

Certain physiologic cues can be useful to reassure families and the care team that breastfeeding is going well. Normal patterns of intake and output are a first good measure. The sensation of uterine cramping during feeding can reassure that the hypothalamic–pituitary–mammary gland axis is intact and that oxytocin release during suckling are occurring. Strong, early cramping is more common in multiparous women than in primiparous women; many in the latter category do not feel significant cramping for the first few days. At the onset of lactogenesis II, many but not all lactating women feel a sense of fullness in their breasts that diminishes after an effective breastfeed. Many women experience the feeling of “let-down” at the beginning of a breastfeed. This tingling sensation of milk flowing forward is caused by oxytocin release, but it can be absent in the first few days after delivery.

Step 1: Have a Written Breastfeeding Policy That Is Communicated to All Health Care Staff

There are models for ideal hospital breastfeeding policies from both the AAP and the ABM. The goal of a written policy should be to have breastfeeding supportive procedures that are consistent with the Ten Steps of the BFHI. Policies provide a written resource available at all hours of the day and night for hospital staff; they can foster consistency in language and practice, and can help to set budgetary priorities. Written breastfeeding policies are associated with increases in breastfeeding initiation and higher rates of breastfeeding continuation at 2 weeks. Better outcomes are seen at hospitals that have more comprehensive policies; the ABM and AAP model policies incorporate a sufficient level of detail.

Step 2: Train All Health Care Staff in Skills Necessary to Implement This Policy

The BFHI requires that nursing staff members who care for the mother–newborn dyad complete 20 hours of formal breastfeeding training, 3 hours of which must be clinical. Any physicians caring for 1 or both members of the couplet must complete 3 hours of continuing medical education. Resources for nurse and physician training are listed in Boxes 1 and 2 . The prior requirement of 18 hours of nurse training had been shown to increase rates of exclusive breastfeeding, likely because the bedside caregivers obtained increased skills to help mothers, and are not as likely to resort to formula supplementation to solve breastfeeding problems.

Box 1

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