Breastfeeding Success Kirsten E. Crowley, MD Edited May, 2005




Kirsten E. Crowley, MD

Edited May, 2005

The big push

American Academy of Pediatrics

“Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth.”


Infants should be breastfed for at least the first four months of life, and if possible 6 months

Healthy People 2010 Objective

Increase the number of mothers breastfeeding postpartum to 75%, at 6 months to 50%, and at 1 year to 25%

Benefits to the Baby

Protects against



 allergies

Provides species-specific nutrition and hormones

May enhance development and intelligence

Confers long term benefits

Protection against infection

The studies

In first year of life, incidence of diarrheal illness among breastfed infants was half that of formula-fed infants

Infants who were exclusively formula-fed had a 70% increase in their risk of developing an ear infection

Formula-fed infants were 17 times more likely to be admitted for pneumonia

More infection studies

Associated with a lower incidence of RSV infection during the first year of life

Relative risk of developing a UTI of 0.38 compared to formula-fed infants

In the NICU

Among babies born at more than 30 weeks, confirmed NEC was 20 times more common in formula-fed babies

The incidence of sepsis/meningitis are significantly reduced in human milk fed VLBW infants

Other illness

There is an inverse relationship between breastfeeding and morbidity

Breastfed infants have gastroesophageal reflux episodes of significantly shorter duration

Breastfeeding is protective against SIDS

Toddlers who were breastfed appear to be healthier

Protection against allergies

In allergic families, formula introduction in the first week of life and weaning at less than 4 months were associated with increased allergies later in life

Eczema was less common and milder

Breastmilk = 22%

Soymilk formula = 63%

 cow’s milk formula = 70%

Enhances development and intelligence

Controversial of course

Some studies have shown higher IQ and improved cognitive development in breastfed children

Psychomotor and social development may be improved as well

Long term benefits

Lower incidence of

 diabetes

 childhood cancer and breast cancer

May influence LDL concentration and mortality from ischemic heart disease

Decreased cavities

Better response to vaccines

Benefits to mom

Delays fertility due to lactational amenorrhea

Reduces risk of breast, uterine, ovarian, and endometrial cancer

Enhances emotional health

Decreases insulin requirements

Decreases osteoporosis

Promotes postpartum weight loss

Societal benefits

Encourages optimum child spacing

Improves vaccine effectiveness

Decreased expense of food (formula for one year is between $1160 and $3915)

Decreased medical expenses

1000 bottle-fed infants had 2033 excess office visits,

212 excess days in the hospital, and 609 more prescriptions = $459-$808 per family per year

Reduced absenteeism due to child illness

Protects the environment (bottles, packages, etc.)

So, how are we doing?

In 1998

64% of women initiated breastfeeding

29% were still breastfeeding at 6 months

16% were breastfeeding at one year

 highest rates in several generations

Rates still fall short of the Healthy People goals of 75% initiation, 50% at 6 months, and 25% at one year

U.S. breastfeeding rates are the second lowest of all industrialized nations

Who tends to breastfeed?

Most common among women who are

 college educated

 white

 married

 older than 30 years

 middle or higher income levels

More prevalent in the western regions of the country

What affects success?

Maternity hospital routines

 accuracy and timeliness of breastfeeding assistance are the most important

Birth weight and health of the newborn

Peer attitudes

Length of maternity leave

Employer’s willingness to make accommodations

Opinion of the child’s father

Aggressive marketing of formula

Promoting success

Women who are better informed regarding the benefits of breastfeeding and the breastfeeding process are more likely to initiate (and probably maintain) breastfeeding

An interesting study

Kistin et al.

First controlled trial of prenatal maternal counseling by MDs

Counseling increased the rate of initiation and duration of breastfeeding in a predominantly low-income, urban, African

American population

National Assessment of

Physicians’ Breast-feeding

Knowledge, Attitudes,

Training, and Experience

Freed, et al. JAMA.. 1995; 273(6): 472-476

Residents and practitioners in peds, FP, and OB/gyn were lacking in

Breastfeeding knowledge base

Ability to give appropriate advice

The role of the pediatrician

Promote and support

Become knowledgeable and skilled in physiology and clinical management

Provide education

Parents, Colleagues, Nurses, Residents

Become familiar with local resources

Develop and promote policy

Encourage insurance coverage

Promote breastfeeding friendly workplaces

Assessing for success

The input (milk transfer)

The output (urine & stool)

The ultimate (weight)

The intake

Goal is 8-12 feedings per day

Feedings should last 10-15 minutes when the baby is a newborn

Understand the cues

Sleep arousal

Increased alertness

Hand to mouth

Tongue or mouth movements

Crying (late stage of hunger)

The output


Before the milk is in: one void for each day of age

After the milk arrives: 6-8 times per day


Days 1-4: meconium

Day 4-4 weeks: 4 yellow, seedy BM per day

1-4 months: varies from one per feed to once a week

The ultimate judge:

The Weight

Initial loss

8-10% of birthweight

Return to birthweight

10-14 days

Aggressive intervention if not by 2 weeks

Rate of gain for full term babies

First 2 months = 30 grams per day

> 2 months = 20-30 grams per day

Assess the Latch!

Incorrect latch is one of the most common etiologies for poor weight gain

Observation of the mother - infant dyad is extremely important!

Correct latch


Mom holds breast back from areola and nipple with


Use manual stimulation to erect the nipple

Tickle the baby’s lips gently

Wait for baby to open mouth like a yawn

Center nipple quickly while pulling baby in close to the breast

Initial latch may be painful, but abates as nursing progresses

Correct latch


Tip of nose and chin touching breast

Tummy to tummy

Lips flanged over areola - fish lips

Gums bypass nipple and are over areola

(where the milk sinuses are)

Movement of facial and jaw muscles, ear wiggling

Look for suck-swallow patterns

Assessment of suck

Tongue comes over the gumline

Cupping of tongue at the lip

Feel up and down motion of the posterior tongue

Strength of suck

Nursing positions

Cradle hold

Mom upright in comfortable chair with pillows in the lap and feet supported

Tummy to tummy

Head in straight line

Ear, shoulder, and hips in straight line

Baby’s body at breast level (boppy pillow)

Baby’s head in crook of elbow

Baby’s back supported with forearm

Cup breast with free hand

Cradle hold

Boppy pillow

Nursing positions

Football hold

Mom in same position

Baby’s body and legs under mom’s arm

Head snugly in mom’s hand with neck grasped by thumb and pinky and head on palm and other fingers

Pillows under the baby (boppy)

Avoid flexing baby’s head too much

Football hold

Nursing positions:

Lying Down

Helpful after a cesarean section

Good for tired moms

Eases nighttime feedings early on if the dyad is cosleeping

Common problems

(and how to fix them)

Sore nipples

Discomfort at the beginning is OK

Improper position is the main cause

Can also be caused by infection or inappropriate nipple care


Position correctly

Begin feeding on least sore nipple

Frequent shorter feeds

Rub expressed milk onto nipple/areola

Air dry nipples

Pump if nipples are too painful


Occurs on the second to fourth days

Results from hormone changes that suddenly increase milk production

Temporary!!!: The supply becomes balanced within a few days


Nurse frequently, around the clock

Heat and massage before feeding

Express some milk if baby can’t latch

May be harmful to supply if not relieved


Bacterial breast infection

 caused by inadequate emptying of milk


 achy, flu-like

 breast pain, redness, tenderness fever/chills


Dicloxicillin 250 mg QID x 10 days

Keflex 500 mg QID x 10 days

Rest, fluids, pain meds, nurse often or pump after feeds, moist heat


Rapid development of extremely sore nipples, burning or itching, shooting pain

Look for deep pink areas on mom and thrush or diaper candidiasis in baby

Treat both mom and baby

Topical antifungal for both, oral nystatin

Wash anything in contact with baby’s mouth or breast

Breastfeeding jaundice

Exaggerated physiologic jaundice due to lack of food in GI tract and increased enterohepatic circulation

Usually occurs in second to third day


Increase feeding frequency

Mom should pump if baby is sleepy or poor feeder

Feed baby EMM or formula only

Use alternate feeding systems if necessary

Watch baby’s weight