Basics
Description
Breast milk is recognized as the optimal nutrition for infants by the American Academy of Pediatrics (AAP), the World Health Organization (WHO), the Surgeon General, and all major medical groups. �
Physiology
- Breast milk production
- Lactogenesis I: Milk production begins around 16 weeks prenatally.
- Lactogenesis II: onset of copious milk secretion around 2-3 days after vaginal delivery. Under hormonal control initiated by the expulsion of placenta and decrease in progesterone levels
- Lactogenesis III: Mature milk production (maintenance) depends on autocrine (local) control. The amount of milk removed influences milk volume. If milk is not removed, a protein (feedback inhibitor of lactation) accumulates and inhibits prolactin release.
- Prolactin is released from the anterior pituitary in response to nipple stimulation and triggers milk secretion into the lumen of breast alveoli.
- Oxytocin is released from the posterior pituitary gland, causing ejection of milk into the breast ducts (milk ejection reflex).
- Let-down can be triggered by physical stimulation of the breast or by mental stimulation such as hearing a baby cry.
- Composition
- Largely independent of maternal diet, except for fatty acids and water-soluble vitamins
- Colostrum contains high levels of secretory immunoglobulin A for immune protection. Lactoferrin stimulates meconium passage and promotes colonization with protective lactobacillus bifidus.
- High whey-to-casein ratio
- Milk changes within a feed and throughout the day. Hindmilk and milk at night contains higher fat and calories.
- Risks of not breastfeeding:
- For child: increases risk of postneonatal death; gastroenteritis, necrotizing enterocolitis for preterm infants, lower respiratory infections, acute otitis media, bacterial meningitis, obesity, sudden infant death syndrome (SIDS), asthma, leukemia, and type II diabetes
- For mother: increases risk of ovarian and breast cancer, cardiovascular disease, and postpartum hemorrhage. Loss of benefit of lactational amenorrhea and child spacing
- For family: increased expenditures, more workdays lost to care for ill child
- For society: increases environmental impact and costs at least $13 billion annually related to an increase in childhood diseases
Epidemiology
Prevalence
- 79% of infants in the United States initiate breastfeeding, according to 2013 data from the Centers for Disease Control and Prevention.
- At 3 months, 41% breastfed exclusively.
- At 6 months, 49% breastfed, 16% exclusively
- At 12 months, 27% breastfed.
- Racial and economic disparities in breastfeeding exist; lower rates among African American women and women living in poverty
Risk Factors
- Contraindications to breastfeeding:
- Infant with classic galactosemia
- Maternal conditions:
- HIV (in industrialized countries)
- Illicit drug use
- Active, untreated tuberculosis
- Herpes simplex virus lesions on breast
- HTLV-I- or HTLV-II-positive
- Exposure to radioactive material, while there is radioactivity in the milk
- Use of some medications, such as cytotoxic drugs
- Infant conditions that may interfere with breastfeeding:
- Prematurity
- Low birth weight
- Hypotonia
- Cleft lip or palate
- Ankyloglossia (tongue-tie)
- Maternal conditions that may interfere with breastfeeding:
- History of breast surgery
- Abnormal breast shape (glandular insufficiency)
- Inverted nipples
- Medications that inhibit lactation
- Endocrine: infertility, hypothyroidism, polycystic ovary, retained placenta, Sheehan syndrome, obesity
- Common reasons cited for early termination of breastfeeding:
- Perceived insufficient milk supply
- Poor latch
- Sore nipples
- Returning to work or school
Diagnosis
History
- Experience breastfeeding previous children
- Prior breast surgery
- Breast enlargement during pregnancy
- Frequency and duration of feedings
- Feed > 8-12 times a day in the 1st few weeks of life, with no more than 4 hours between feedings.
- Newborns typically need > 8-10 minutes of active suckling to "empty"� a breast.
- Signs of adequate milk intake:
- Adequate hydration: 1 wet diaper for each day of life until milk "comes in"� around day 4 of life; then ≥ 6 wet diapers per 24 hours
- Adequate nutrition: stool changes from meconium to transitional to yellow seedy by 4th day of life. Infant typically has > 3-4 yellow stools/24 h in the first month. Stool pattern often changes at 1 month, and infant may only stool every 3-7 days.
- Infant may lose up to 8% of birth weight until milk "comes in"� around day 4 or 5.
- Infant should gain 15-30 g/day and be back to birth weight by 10-14 days.
- The WHO growth charts better represent typical growth of breastfed infants.
- Breast/nipple pain: Women may experience discomfort at first, but breastfeeding should not hurt. The most common cause of pain is poor latch. Other causes include candidal infection of the nipple, or mastitis.
Physical Exam
- Direct observation of a feeding is crucial:
- Examine the infant's oropharynx for thrush, ankyloglossia, or anatomic abnormalities.
- Examine the mother's breasts for scars (prior surgery), nipple inversion, erythema (possible candida), or cracking (poor latch).
- Infant feeding cues: Rooting, lip smacking, and sucking are early signs of hunger; crying is a late sign.
- The mother should be positioned comfortably and not have to bend down.
- Two types of infant positioning:
- Infant-led: The mother is semireclined in bed with the infant's head at breast height. The infant initiates the latch.
- Mother-led:
- Cross-cradle: easy visualization of latch. Mother holds her baby with the arm opposite the breast she is using, holds the back of the baby's neck, and brings the baby to breast height. Her other hand supports and compresses her breast. The infant should be in a straight line with ear, shoulder, and hip aligned.
- Other positions include cradle, football, and sidelying.
- For an effective latch, the mother touches the infant's nose or upper lip to her nipple and waits until the infant opens wide. She brings the infant to her breast. She may compress her breast with her thumb by the infant's nose parallel to upper lip.
- Evaluating the latch: Lips should be everted and mouth wide open approaching a 180 degrees angle. As much as possible of the areola is in the infant's mouth. More of the areola shows above the infant's mouth than below. The mother's nipple should not be distorted after the infant suckles.
- Signs of good milk transfer: Infant relaxed and breasts less full after nursing, infant has deep movement of the jaw and sucks/swallows/breathes rhythmically, milk visible in infant's mouth.
Diagnostic Tests & Interpretation
Lab
- Total/direct bilirubin level, if clinically indicated
- Electrolytes (especially sodium) in infant, if there is concern for dehydration
Treatment
Medication
- Vitamin D, 400 IU/24 h orally for all infants starting at the first visit if not given at hospital discharge, even if supplementing with formula
- The AAP Section on Breastfeeding recommends starting iron-rich complementary foods at 6 months, whereas the AAP Committee on Nutrition recommends elemental iron, 1 mg/kg/day, from age 4 months until iron-rich food is introduced. Elemental iron at 2 mg/kg/day starting by age 1 month is recommended for preterm infants.
- Thrush or candidal infection of the nipples requires simultaneous treatment of both mother and infant with a topical antifungal agent and thorough washing of all artificial nipples. Treatment options include nystatin or oral fluconazole for resistant cases.
- Most maternal medications are compatible with breastfeeding. Mothers should not breastfeed if using illicit or cytotoxic drugs, or radioactive compounds until cleared from the mother's milk. Choose medications with short half-lives, high protein binding, low oral bioavailability, high molecular weight, and low lipid solubility. Refer to databases such as the National Library of Medicine's LactMed.
Additional Therapies
General Measures
- Cracked nipples should be treated by correcting the latch. Women can apply breast milk or purified lanolin. Keep nipples dry.
- Engorgement can be relieved by frequent and effective feeding or pumping, breast massaging, and applying cool compresses.
- Clogged milk ducts may be treated with warm compresses, frequent emptying of the breast, massaging the area, and varying feeding positions.
- Pumping may help with inverted nipples. A nipple shield can be tried if inverted nipples cause trouble latching. Prolonged nipple shield use is controversial, as concerns exist regarding their impact on milk supply; thus their use should be limited to a short period of time (~1 month).
- Mastitis can be treated with antibiotics, frequent and effective feeding and maternal rest.
- Infants with ankyloglossia that affects latch or impedes milk transfer should be referred for frenotomy.
Complementary & Alternative Therapies
- Herbs traditionally used to try to increase milk supply (galactagogues) include the following:
- Fenugreek (Trigonella foenum-graecum): taken as tea or capsules. May be effective; probably safe in moderate doses
- Milk thistle (Silybum marianum): usually taken as a tea; increased milk supply in one study (no available safety data support use)
Inpatient Considerations
If a breastfed infant is hospitalized, encourage continued breastfeeding if possible. If the infant is not able to breastfeed, provide a hospital-grade double electric pump and encourage pumping at least 8 times/24 h. �
Follow-up Recommendations
Patient Monitoring
- In general, 2-3 days after hospital discharge. Weight check, physical exam, and observation of feeding
- Close follow-up 1-2 days later if concern about milk intake or jaundice then as needed
- At age 2-3 weeks: weight check and breastfeeding support
- Patient education: Mother should be assisted with latch and positioning and should know signs/symptoms of adequate milk intake (urine output, stooling), dehydration, and illness.
Diet
- For the infant:
- Except for vitamin D, no food or fluid other than breast milk is needed for the first 6 months of life.
- After 6 months, iron-rich foods and other complementary foods may be introduced.
- For the mother:
- ~500 kcal/day are used for breastfeeding.
- Women should avoid breastfeeding for at least 2 hours after alcohol consumption.
- If infant has G6PD deficiency, mother should avoid fava beans and certain medications.
Complications
- Infant
- Hyperbilirubinemia
- Dehydration/hypernatremia
- Mother
- Engorgement
- Clogged milk duct
- Mastitis
- Candidal nipple infection
- Cracked nipples
Additional Reading
- The Academy of Breastfeeding Medicine protocols: http://www.bfmed.org/Resources/Protocols.aspx
- Bartick �M, Reinhold �A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010;125(5):e1048-e1056. �[View Abstract]
- Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841.
- Kramer �MS, Kakuma �R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2009;(1).
- LactMed, National Institutes of Health: http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?
- La Leche League International: www.lalecheleague.org
- Office on Women's Health, U.S. Department of Health and Human Services: www.womenshealth.gov/breastfeeding
- U.S. Department of Health and Human Services. The Surgeon General's Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011. http://www.surgeongeneral.gov/library/calls/breastfeeding/calltoactiontosupportbreastfeeding.pdf. Accessed March 1, 2015.
Codes
ICD09
- 779.31 Feeding problems in newborn
- 750.0 Tongue tie
- 779.34 Failure to thrive in newborn
ICD10
- P92.5 Neonatal difficulty in feeding at breast
- Q38.1 Ankyloglossia
- P92.6 Failure to thrive in newborn
SNOMED
- 240301009 Breast-feeding problem in the newborn (finding)
- 67787004 tongue tie (disorder)
- 433476000 failure to thrive in infant (disorder)
- 206568009 Difficulty in feeding at breast (finding)
FAQ
- Q: How do I know if my baby is getting enough milk?
- A: Look for signs of effective feeding as described earlier. Your baby should suck deeply and rhythmically during a feeding, seem satisfied after a feeding, and gain approximately 15-30 g/day. A baby's elimination pattern may be variable, but, in general, most adequately breastfed infants will have 4 or more stools a day by 4 days of life.
- Q: How do I alleviate breast pain with nursing?
- A: Most pain is due to poor latch. Ensure deep latch. Compress the breast and make sure the baby takes as much of the areola as possible. If stinging occurs throughout nursing, consider candidal infection. Seek advice from a lactation expert if pain does not improve.
- Q: How can I increase my milk supply?
- A: Increase frequency and effectiveness of feeding or pumping. Place infant skin to skin. Pump after nursing sessions. If pumping often, use a hospital-grade double pump. Get plenty of sleep and try to reduce stress.
- Q: How long can expressed breast milk be stored safely (applies to term infants only)?
- A: At room temperature (up to 77 �F) for 3-6 hours. In the back of a refrigerator for 3 (ideal)-8 days if very clean container. For 6-12 months if in the freezer. Thawed breast milk should be refrigerated and used within 24 hours of thawing.
- Q: How long should breastfeeding be continued?
- A: The AAP recommends breastfeeding at least until 12 months of age, and as long afterward as is mutually desired. The WHO recommends breastfeeding for at least 2 years. Exclusive breastfeeding is nutritionally adequate for the first 6 months.
- Q: Can adoptive mothers breastfeed?
- A: Induced lactation is possible. Lactation experts should be consulted.