Kirsten E. Crowley, MD
Edited May, 2005

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American Academy of Pediatrics
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“Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth.”
WHO and UNICEF
 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%

 Protects against
 Infection
 Illness
 allergies
 Provides species-specific nutrition and hormones
 May enhance development and intelligence
 Confers long term benefits

 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

 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

 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

 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%

 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

 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

 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

 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.)

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In 1998
 64% of women initiated breastfeeding
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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

 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

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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

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

 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

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

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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

 The input (milk transfer)
 The output (urine & stool)
 The ultimate (weight)

 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)

 Urine
 Before the milk is in: one void for each day of age
 After the milk arrives: 6-8 times per day
 Stool
 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

 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

 Incorrect latch is one of the most common etiologies for poor weight gain
 Observation of the mother - infant dyad is extremely important!

 Mother
 Mom holds breast back from areola and nipple with
C-hold
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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

 Baby
 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

 Tongue comes over the gumline
 Cupping of tongue at the lip
 Feel up and down motion of the posterior tongue
 Strength of suck

 Cradle hold
 Mom upright in comfortable chair with pillows in the lap and feet supported
 Tummy to tummy
 Head in straight line
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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

 Football hold
 Mom in same position
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Baby’s body and legs under mom’s arm
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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)
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Avoid flexing baby’s head too much

 Helpful after a cesarean section
 Good for tired moms
 Eases nighttime feedings early on if the dyad is cosleeping

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Discomfort at the beginning is OK
Improper position is the main cause
Can also be caused by infection or inappropriate nipple care
Treatment
 Position correctly
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Begin feeding on least sore nipple
Frequent shorter feeds
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Rub expressed milk onto nipple/areola
Air dry nipples
 Pump if nipples are too painful

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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
Treatment
 Nurse frequently, around the clock
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Heat and massage before feeding
Express some milk if baby can’t latch
May be harmful to supply if not relieved

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Bacterial breast infection
 caused by inadequate emptying of milk
Symptoms
 achy, flu-like
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 breast pain, redness, tenderness fever/chills
Treatment
 Dicloxicillin 250 mg QID x 10 days
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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
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Wash anything in contact with baby’s mouth or breast

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Exaggerated physiologic jaundice due to lack of food in GI tract and increased enterohepatic circulation
Usually occurs in second to third day
Treatment
 Increase feeding frequency
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Mom should pump if baby is sleepy or poor feeder
Feed baby EMM or formula only
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Use alternate feeding systems if necessary
Watch baby’s weight