Breastfeeding Support
and Promotion
Joan Younger Meek, MD, FAAP
AAP Section on Breastfeeding
Management of Breastfeeding
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Breastfeeding initiation
Recommended breastfeeding practices
Weight pattern
Hypoglycemia
Jaundice
Employment
Breastfeeding Promotion in Physicians’
Office Practices Curriculum
3 Key Educational Tools for Physicians to
Teach New Mothers
• Nutritional parameters
• Hand expression
• Latch and positioning
AAP Policy Statement
Recommended Breastfeeding Practices
• Initiate in the first hour.
• Keep newborn and
mother together in
recovery and after.
• Avoid unnecessary oral
suctioning.
• Avoid traumatic
procedures.
AAP Pediatrics 2012;129:e827-841.
Breastfeeding Initiation
• Skin-to-skin contact
– Promotes physiologic
stability
– Provides warmth
– Enhances feeding
opportunities
– Infant crawls to breast
and self-attaches
Photo © Joan Younger Meek, MD, FAAP
• Delay weights and measurements, vitamin K
and eye prophylaxis until after first feeding
• Knowledgeable breastfeeding advocate in
labor & delivery
AAP Policy Statement
Recommended Breastfeeding Practices:
• Avoid the routine use of supplements unless
there is a true medical indication and the
physician has ordered the supplement
• Avoid the use of pacifiers in healthy, term
infants, until breastfeeding is well established
(approximately 3-4 weeks of age)
Medical Indications for
Supplementation
• Very low birth weight or some premature infants
• Hypoglycemia that does not respond to
breastfeeding
• Severe maternal illness
• Inborn errors of metabolism
• Acute dehydration not responsive to routine
breastfeeding or excessive weight loss
• Maternal medication use incompatible with
breastfeeding
Academy of Breastfeeding Medicine Clinical Protocol #3: Hospital
guidelines for the use of supplementary feedings in the healthy
term breastfed neonate.(www.bfmed.org)
AAP Policy Statement
Feeding Pattern
• Encourage at least 8–12 feedings per day.
• Alternate the breast that is offered first.
• Allow infant to nurse on at least one side
until infant falls asleep or comes off the
breast to increase fat and calorie
consumption.
Infant Assessment
Infant Weight
• Weight Loss
– Average loss of about 6% over the first 3–4 days.
– Loss greater than 8-10% mandates careful evaluation
of breastfeeding.
• Weight Gain
– Begins with increase in mother’s milk production by at
least day 4–5.
– Expect gain of 15–30 g/day (1/2 to 1 oz per day)
through the first 2–3 months of life.
Infant Assessment
Poor Weight Gain
• Problem
– Inadequate milk supply or milk transfer.
• Solution
– Weigh infant, feed infant, weigh again.
– Evaluate infant at the breast.
– Correct latch and positioning.
– Improve milk production and transfer.
– Increase frequency and duration of
feeding.
Infant Assessment
Elimination Pattern
• Expect
– 4-6 pale or colorless voids/day by day 4
– 3-4 loose, yellow, curd-like stools after
most feedings by day 4, continuing
through the first month
• Constipation is unusual in the first month—
may indicate insufficient milk intake.
EVALUATE
• Infrequent stools are common after the first
month in the healthy breastfed infant.
Infant Assessment
Breastfeeding evaluation
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Proper positioning at the breast
Proper latch and lip closure
Sufficient areola in infant’s mouth
Tongue extends over lower gums
Adequate jaw excursion with suckling
Effective swallowing motion
Coordination of suck-swallow-breathe
AAP Policy Statement
Recommended Breastfeeding Practices
• Formal evaluation of breastfeeding
during the first 24–48 hours and again at
3–5 days of age
• Assess
– Infant weight
– General health
– Breastfeeding
– Jaundice
– Hydration
– Elimination pattern
AAP Policy Statement
Recommended Breastfeeding Practices
• Do not give water, juice, or solids in the first
6 months.
• Initiate iron supplements only if indicated
clinically in the first 6 months.
• Include iron-rich foods or supplements after
6 months of age.
• Supplement with 400 IU vitamin D daily.
• Provide fluoride after 6 months if household
water supply is deficient (< 0.3 ppm).
• Avoid cow’s milk before 12 months.
Maternal Trouble Signs
• Nipple pain
• Nipple trauma
Photo © Joan Meek, MD, FAAP
Neonatal Hypoglycemia
• No need to monitor asymptomatic low risk
infants for hypoglycemia
• Routine monitoring of healthy term infants
may harm the mother-infant breastfeeding
relationship
• Early, exclusive breastfeeding meets the
nutritional needs of healthy term infants and
will maintain adequate glucose levels
AAP; World Health Organization
Academy of Breastfeeding Medicine
Neonatal Hypoglycemia
• Routine supplementation of healthy, term
infants with water, glucose water or formula
is unnecessary and may interfere with
establishing normal breastfeeding and
normal metabolic compensatory
mechanisms.
• Healthy term infants should initiate
breastfeeding with 30-60 minutes of life and
continue feeding on demand.
AAP; World Health Organization;
Academy of Breastfeeding Medicine
Maternal Trouble Signs
• Engorgement
Photo © Joan Younger Meek, MD, FAAP
Jaundice and Breastfeeding
• Infants <38 weeks gestational age and
breastfed are at higher risk
• Systematic assessment of all infants before
discharge for the risk of severe
hyperbilirubinemia is warranted
• Provide parents with written and verbal
information about newborn jaundice
• Provide appropriate follow-up based on the
time of discharge and the risk assessment
AAP Subcommittee on Hyperbilirubinemia Clinical
Practice Guideline: Pediatrics 2004; 114: 297-316.
Management of
Hyperbilirubinemia
• Promote and support successful
breastfeeding
• Perform a systematic assessment before
discharge for the risk of severe
hyperbilirubinemia
• Provide early and focused follow-up based
on the risk assessment
AAP Subcommittee on Hyperbilirubinemia Clinical
Practice Guideline: Pediatrics 2004; 114: 297-316.
Primary Prevention of Jaundice
• Recommendation 1.0
– Clinicians should advise mothers to nurse their
infants at least 8 to 12 times per day for the first
several days.
• Recommendation 1.1
– The AAP recommends against routine
supplementation of nondehydrated breastfed
infants with water or dextrose water.
• “Supplementation with water or glucose water
will not prevent hyperbilirubinemia or decrease
total serum bilirubin levels.”
AAP Subcommittee on Hyperbilirubinemia Clinical
Practice Guideline: Pediatrics 2004; 114: 297-316.
Risk Assessment for Jaundice
before Discharge
• Recommendation 5.1
– Before discharge assess risk for severe
hyperbilirubinemia
• Every nursery should have formal protocol
• Essential for infants discharged before 72 hrs
• Best method: measure serum or
transcutaneous bilirubin in every infant before
discharge
• Plot on Bhutani curve (perform at same time as
metabolic blood sampling)
AAP Subcommittee on Hyperbilirubinemia Clinical
Practice Guideline: Pediatrics 2004; 114: 297-316.
AAP Clinical Practice Guideline
• Management of Hyperbilirubinemia in the
Newborn Infant 35 or More Weeks of
Gestation
Nomogram for designation of risk in 2840 well newborns at 36 or more weeks’
gestational age with birth weight of 2000 g or more or 35 or more weeks’ gestational
age and birth weight of 2500 g or more based on the hour-specific serum bilirubin
values.
AAP Subcommittee on Hyperbilirubinemia. Pediatrics.
2004;114:297–316
Management of Breastfeeding
Jaundice
Increase caloric intake
Increase breastfeeding
frequency to 10–12
feedings/day
Increase duration of
breastfeeding
Improve latch and
positioning
Provide supplements
only when medically
indicated
Enhances milk
production
and transfer
Decreased
enterohepatic
reabsorption
Increased stool
output
Lower serum
bilirubin
Breast Milk Jaundice
• Definition
– Begins after day of life 5–7
– Increased bilirubin reabsorption from
intestine
– Lasts several weeks to months
Breast Milk Jaundice
• Management
– Avoid interruption of breastfeeding in
healthy term babies.
– No routine indication for water or formula
supplementation.
– If bilirubin >20 mg/dL, consider
phototherapy.
– Rule out other causes of prolonged
jaundice.
Nursing Supplementation
Illustration by Tony LeTourneau
Milk Expression
• Wash hands before manual or hand
expression.
• Use a good-quality electric pump for regular
expression.
• Milk storage
– Chill as soon as possible.
– Refrigerate milk for up to 4 days.
– Freeze for longer storage.
Milk Expression
Photo © Jane Morton, MD, FAAP
Photo © Kay Hoover, MEd, IBCLC
Return to the Workplace or
School
• Continued breastfeeding is feasible and
desirable for mother and infant.
• Prepare ahead by discussing with the
employer or school personnel.
• Delay introduction of bottles until milk
supply well established at 3–4 weeks.
Employed Mother
Workplace support
• Breaks for
feeding/
expressing
• Private, clean
place to pump
• Refrigerator
or cooler with
ice packs to
store and transport
milk
Illustration by Tony LeTourneau
Adolescents and Breastfeeding
• Highly recommended for adolescent mothers
• Prenatal education and postpartum support
are essential
• Arrange with school personnel to express
milk at school or use on-site child care
program, if available
• Maintain healthy diet with adequate calories,
1,300 mg calcium per day, 15 mg iron, and a
daily multivitamin
Summary
• Breastfeeding is the preferred feeding for
almost all infants.
• Skin-to-skin contact should be initiated
immediately after delivery.
• Supplementation is rarely indicated and
interferes with successful lactation.
• Good breastfeeding technique can help to
minimize problems.
• Close follow-up in the early days and weeks
is essential for breastfeeding success.