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TREATMENT
GENERAL MEASURES
- Breastfeeding initiation
- Initiate breastfeeding immediately after birth, ideally placing the infant on mother's chest skin-to-skin IN FIRST HOUR (1,6)[A].
- Mother placed in a comfortable position, usually sitting or leaning back, with baby on chest allowing baby to move toward breast.
- As baby opens wide, bring baby close, tucking baby in "belly to belly."Ł Line baby's nose to nipple, baby tilts its head back with wide open mouth, bring baby close as baby latches to ensure baby's gum takes in more of the areola.
- Baby's lips are flanged, rounded cheeks, no clicking or popping sounds and abscense of nipple pain when latched.
- Feed baby on demand. Room-in and watch for hunger cues and cluster feeding.
- Feed 2 to 8 times for first 24 hours and 8 to 15 times per 24 hours, feeding 10 or more minutes, emptying and alternating breasts.
- Observation of a nursing session by an experienced physician, nurse, or lactation consultant
- Avoid supplementation with formula or water unless medically indicated.
- Contraindications to breastfeeding are few (WHO) (1).
- Maternal HIV (in industrialized world) or human T-cell leukemia virus (HTLV) infection
- Active untreated tuberculosis
- Active herpes simplex virus (HSV) lesions on the breast*
- Substances of abuse without evaluation and review medications that will pass into human milk
- Infants with galactosemia or maple syrup urine disease should not be fed with breast milk. Infants with phenylketonuria may be fed breast milk under close observation.
- Mothers who develop varicella 5 days before through 2 days after delivery*
- Mothers acutely infected with influenza H1N1 until afebrile*
- Maternal hepatitis is NOT a contraindication.
- *Expressed milk can be used.
ISSUES FOR REFERRAL
- Refer to trained physician, nurse, or IBCLC lactation consultant for inpatient and/or outpatient teaching.
- Frequent follow-up if having problems with latching, sore nipples, breast pain, or inadequate milk production.
COMPLEMENTARY & ALTERNATIVE MEDICINE
Galactagogues (7)[C] á
- Metoclopramide, domperidone, oxytocin, fenugreek, goat's rue, and milk thistle have mixed results in improving milk production but efficacy and safety data are lacking in literature.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
See mother and baby within a few days of hospital discharge, especially if first time breastfeeding. á
- Risk factors for suboptimal initiation
- Breast surgery, especially reduction surgery, prior to pregnancy may disrupt breast milk production in the future.
- Severe postpartum hemorrhage may lead to Sheehan syndrome, which is associated with difficulty breastfeeding due to poor milk production.
- Other factors: delivery mode, duration of labor, gestational age, maternal infection, parity, culture, mother-baby separation, maternal anxiety, artificial nipple, and nonbreast milk fluids.
Patient Monitoring
- Monitor infant's weight, behavior, and output closely.
- Supplementation with infant formula is recommended only if infant has lost ≥8-10% of birth weight or signs of dehydration such as decreased urine output.
- Supplementation without persistent breast stimulation with frequent feedings or breast pump use will decrease milk production and decrease breastfeeding success.
DIET
- For mothers:
- Drink plenty of fluids: 8 glasses of liquid a day
- Breastfeeding mothers require ~500 more calories a day than prepregnancy needs (1).
- Gassy foods can cause baby to be fussy.
- Limit caffeine to 300 mg/day.
- Alcohol should be avoided. 1 to 2 drinks/week of alcohol may be okay, but mothers should avoid nursing 2 to 3 hours after a drink. <2% of alcohol is passed to baby via breast milk.
- Continue prenatal vitamin supplements.
- For infants:
- In 2008, the AAP increased its recommended daily intake of vitamin D for infants from 200 to 400 IU. For exclusively breastfed babies, this will require taking a vitamin supplement, such as Poly-Vi-Sol or Vi-Daylin vitamin drops, 0.5 mL/day, beginning in the first few days of life (1).
- In 2010, the AAP recommended adding supplementation for breastfed infants with oral iron 1 mg/kg/day beginning at age 4 months.
- Preterm infants fed by human milk should receive an iron supplement of 2 mg/kg/day by 1 month of age, and this should be continued until the infant is weaned to iron-fortified formula or begins eating complementary foods that supply the 2 mg/kg of iron.
- Fluoride supplement is unnecessary until 6 months of age (1).
PATIENT EDUCATION
- Primary care-initiated interventions and support measures to normalize breastfeeding have been shown to be successful with respect to child and maternal health outcomes (8).
- U.S. Preventive Services Task Force (USPSTF) recommends structured breastfeeding education and behavioral counseling programs to promote breastfeeding.
- Regular promotion of the advantages of breastfeeding/risks of not breastfeeding (6)[A]
- Emphasize importance of exclusive breastfeeding for first 4 weeks of life to allow adequate buildup of sufficient milk supply.
- Milk usually transitions to mature milk about postpartum day 3 to 5.
- Frequent nursing (8-12 feedings per 24 hours by day 2)
- Baby should have 6 to 8 wet diapers/day and 3 to 4 bowel movements/day by day 6 to 8.
- Signs of adequate nursing
- Baby feeding on demand.
- Proper latching and positioning, nipples intact.
- Hard breasts become soft after feeding.
- Baby satisfied; appropriate weight gain (average 1 oz/day in first few months)
- Weaning
- Solid food may be introduced at 6 months with continuation of breastfeeding.
- Mothers returning to work/school should be introduced to alternative feeding methods 1 to 2 weeks prior. Initiate pumping to supply expressed breastmilk.
- Family planning
- Lactational amenorrhea method (LAM): Breastfeeding may be used as effective birth control option if (i) infant is <6 months old, (ii) infant is exclusively breastfeeding, and (iii) mother is amenorrheic.
- Other options include barrier methods, implants, Depo-Provera, PO contraception, and intrauterine devices (IUDs). ACOG recommends that progesterone-only pills be used 2 to 3 weeks postpartum, and that Depo-Provera, IUDs, combined OCPs, and Implanon can be used 6 weeks postpartum. However, ACOG recommends delaying use of combined OCPs until after 6 weeks postpartum when lactation is well established.
COMPLICATIONS
- Breast milk jaundice should be considered if jaundice persists for >1 week in an otherwise healthy, well-hydrated newborn. It peaks at 10 to 14 days.
- Plugged duct
- Mother is well except for sore lump in one or both breasts and is without fever.
- Use moist, hot packs on lump prior to, and during, nursing; more frequent nursing on affected side.
- Mastitis (see topic "Mastitis"Ł)
- Sore lump in one or both breasts plus fever and/or redness on skin overlying lump
- Use moist, hot packs on lump prior to, and during, nursing.
- Antibiotics covering for Staphylococcus aureus (most common organism)
- Other possible sources of fever should be ruled out, that is, endometritis and pyelonephritis.
- Mother should get increased rest; use acetaminophen (Tylenol) PRN.
- Fever should resolve within 48 hours or consider changing antibiotics. Lump should resolve. If it continues, an abscess may be present, requiring surgical drainage.
- Milk supply inadequate
- Check infant weight gain.
- Review signs of adequate supply; technique, frequency, and duration of nursing.
- Check to see if mother has been supplementing with formula, thereby decreasing her own milk production.
- Sore nipples
- Check technique and improve latch-on.
- Baby should be taken off the breast by breaking the suction with a finger in the mouth.
- Air-dry nipples after each nursing and/or coat with expressed breast milk.
- Use lanolin cream to help in healing.
- Do not wash nipples with soap and water.
- Check for signs of thrush in baby and on mother's nipple. If affected, treat both.
- Check for evidence of ankyloglossia (tongue tie) in the infant. Correction of ankyloglossia leads to decreased nipple soreness and improved breastfeeding.
- Nipple bleb due to improper positioning. Moist heat and improve latching techniques.
- Flat or inverted nipples
- When stimulated, inverted nipples will retract inward, flat nipples remain flat; check for this on initial prenatal physical.
- Nipple shells, a doughnut-shaped insert, can be worn inside the bra during the last month of pregnancy to force the nipple gently through the center opening of the shell.
- Engorgement
- Develops after milk first comes in (day 3 or 4 postpartum), resolves within a day or 2
- Signs are warm, hard, sore breasts.
- To resolve, offer baby more frequent nursing; breastfeed long enough to empty breasts.
REFERENCES
11 Johnston áM, Landers áS, Noble áL, et al. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841.22 Ip áS, Chung áM, Raman áG, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Rockville, MD: Agency for Health Care Research and Quality; 2007.33 Centers for Disease Control and Prevention. Breastfeeding Report Card-United States, 2014. Atlanta, GA: Centers for Disease Control and Prevention; 2014. http://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf. Accessed 2014.44 Sinusas áK, Gagliardi áA. Initial management of breastfeeding. Am Fam Physician. 2001;64(6):981-988.55 Centers for Disease Control and Prevention. Breastfeeding Vaccinations. Atlanta, GA: Centers for Disease Control and Prevention; 2010. http://www.cdc.gov/breastfeeding/recommendations/vaccinations.htm. Accessed 2014.66 American College of Obstetricians and Gynecologists Women's Health Care Physicians; Committee on Health Care for Underserved Women. Committee Opinion No. 570: breastfeeding in underserved women: increasing initiation and continuation of breastfeeding. Obstet Gynecol. 2013;122(2, Pt 1):423-428.77 Foranish áAB, Yancey áAM, Barnes áKN, et al. The use of galactogogues in the breastfeeding mother. Ann Pharmacother. 2012;46(10):1392-1404.88 Chantry áCJ, Eglash áA, Labbok áM. Position on breastfeeding. Breastfeed Med. 2008;3(4):267-270.
ADDITIONAL READING
- American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Breastfeeding Handbook for Physicians. Elk Grove Village, IL: American Academy of Pediatrics; 2006.
- Casey áCF, Slawson áDC, Neal áLR. Vitamin D supplementation in infants, children, and adolescents. Am Fam Physician. 2010;81(6):745-748.
- Philipp áBL, Bunik áM, Chantry áCJ, et al. ABM Clinical Protocol #7: Model Breastfeeding Policy (Revision 2010). Breastfeed Med. 2010;5(4):173-177.
- Wagner áCL, Greer áFR, Bhatia áJJ, et al. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008;122(5):1142-1152.
- Websites/Books:
- Baby Friendly USA at www.babyfriendly.org
- La Leche League at www.llli.org
- World Health Organization, United Nations Childrens Fund. Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. A Joint WHO/UNICEF Statement. Geneva, Switzerland: World Health Organization; 1989. http://www.unicef.org/newsline/tenstps.htm.
CODES
ICD10
Z39.1 Encounter for care and examination of lactating mother á
ICD9
V24.1 Postpartum care and examination of lactating mother á
SNOMED
69840006 normal breast feeding (finding) á
CLINICAL PEARLS
- Women who do not receive support are at risk for shorter durations of breastfeeding (8).
- Breast milk is the optimal food for infants, with myriad health benefits for mothers and children.
- USPSTF recommends regular, structured education during pregnancy to promote breastfeeding.
- Vitamin D and iron supplementation should begin at birth and 4 months of age, respectively, for exclusively breastfed infants.