Breastfeeding

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Introduction — Human milk is widely recognized as the optimal source of nutrition for all infants. Breast milk promotes development of the infant's immune system and meets the nutritional needs of a full-term infant until approximately six months of age, when complementary foods and fluids are usually added to the diet. The benefits of breast milk for infants include a reduced risk of upper respiratory infections, ear infections, vomiting and diarrhea due to infections, and asthma, among others. Breastfeeding may also reduce the child's risk of obesity.

Most national and international groups recommend exclusive breastfeeding without the use of infant formula or other foods or liquids for the first six months, and partial breastfeeding for at least 12 months. Despite the overwhelming evidence in favor of breastfeeding, in the United States, only about 70 percent of women breastfeed immediately after birth and only about 30 percent of women are still breastfeeding at six months. There are many reasons that women choose not to breastfeed, including embarrassment, lack of knowledge about the benefits of breast milk, belief that formula is equal to breast milk, and myths about the "ease" of formula feeding compared to breastfeeding.

Banked human milk or commercial infant formula may be necessary in some situations, such as for infants of women with human immunodeficiency virus (HIV), who are at risk of transmitting their disease through breast milk. In rare cases, a woman's breasts may be incapable of providing a sufficient amount of breast milk. A list of conditions with which breastfeeding is and is not recommended is available in the following table.

Breastfeeding is not recommended for women or infants with the following conditions:

• Women who have human immunodeficiency virus (HIV)
• Women with human T-cell lymphotropic virus type I or II (HTLV)
• Women being treated with radioactive isotopes (eg, radioiodine)
• Women exposed to radioactive materials
• Women being treated with chemotherapy agents
• Women using drugs of abuse (eg, heroin, cocaine, crystal meth, marijuana)
• Women with herpes simplex lesions on the breasts (ok to breastfeed if one breast has no lesions)
• Women who were recently infected with cytomegalovirus (CMV) whose infant is very low birth weight (<1500 grams); freezing or pasteurizing the breast milk decreases the risk of infecting the infant
• Infants with classic galactosemia (galactose 1-phosphate uridyltransferase deficiency)

Breastfeeding is encouraged for women or infants with the following conditions:

• Women with hepatitis B
• Women with hepatitis C
• Women who are carriers of cytomegalovirus (CMV) (eg, infection occurred in the past)
• Infants who develop jaundice

Breast changes and milk production — Over the course of a woman's pregnancy, the breasts undergo a number of changes that enable them to produce milk after the baby is born. Most women's breasts enlarge during early pregnancy as the milk producing glands mature. Later in pregnancy, the milk forming glands fill with light yellow milk called colostrum. Colostrum contains unique substances that seal and protect the infant's immature digestive tract shortly after birth.

The production of breast milk is triggered by the following:

• Surges in prolactin, stimulated by the infant's suckling at the breast after birth.
• Regular removal of milk from the breast.

Most women begin to produce large volumes of breast milk by two to three days after delivery, although this can occur as late as seven or more days after delivery. Initial milk production is under hormonal control. All women, whether they choose to breastfeed or not, will experience breast filling. Continued production is dependent upon the breasts being routinely emptied, which then stimulates further production. Most women know their milk is increasing in volume when the breasts become full and firm and sometimes, milk begins to leak spontaneously.

Healthy women who exclusively breastfeed produce approximately 750 to 800 mL (about 3 cups) of milk per day after two to four weeks, when lactation is fully established. However, milk volume varies and can range from 450 to 1200 mL or more (about 2 to 5 cups) per day.

Women who are fatigued, ill, stressed, taking certain medications, malnourished, overworked, or who smoke cigarettes may have more difficulty establishing and maintaining a full milk supply. A woman with one or more of these issues is encouraged to seek assistance and support from a lactation consultant, experienced nurse or doctor, or breastfeeding counselor during the first few weeks of breastfeeding.

Benefits of breast feeding — There are a number of benefits of breastfeeding, many of which continue even after breastfeeding is discontinued. The benefits for the infant and mother increase as breastfeeding continues. However, even breastfeeding for a short period of time provides some protection.

For infants — Some of the benefits of breastfeeding for infants include the following:

• Better gastrointestinal function and protection from gastrointestinal infections, such as vomiting and diarrhea.
• A reduced risk of respiratory infections, ear infections, and wheezing.
• Some studies suggest that breastfeeding reduces the risk of obesity, cardiovascular disease, and autoimmune diseases, such as type 1 diabetes mellitus.

For women — Compared to mothers who feed formula, women who breastfeed experience:

• Reduced blood loss after childbirth as a result of a hormone, oxytocin, which is released into the mother's bloodstream while breastfeeding. Oxytocin helps the uterus to contract, which reduces uterine bleeding.
• Reduced levels of stress in the mother as a result of several hormones released during breastfeeding.
• Increased weight loss after pregnancy (if breastfeeding continues for at least six months).
• Decreased risk of breast cancer

For family — Families who breastfeed experience:

• Reduced infant feeding costs. Infant formula and associated supplies are estimated to cost at least $1000 during the first 12 months.
• Reduced costs related to healthcare, including doctor's visits, hospital costs, and lost time from work. Infants who are breastfed are less likely to become ill and less likely to be hospitalized, reducing the potential costs and anxieties of caring for an ill child.

HOW TO BREASTFEED

Preparing to breastfeed — Many women who plan to breastfeed wonder about the best way to prepare. A common myth is that women must "toughen" their nipples, although there is no evidence that this is necessary or helpful.

If the nipples are flat or inverted before delivery, it is occasionally difficult for an infant to latch-on. However, there is no benefit to stretching or treating the nipples before delivery. If needed, a lactation consultant or nurse can provide assistance to women with flat or inverted nipples who have breastfeeding challenges after delivery.

Most women are able to produce an adequate amount of milk for their infant. However, breast reduction, and to a lesser degree, breast enlargement, surgery may interfere with a woman's ability to produce an adequate supply of milk. A decreased ability to produce milk is most likely when an incision is made around the areola or when the nipple has been removed and replaced surgically, which can cut milk ducts, interrupt nerve passages, and interrupt blood flow. However, having breast surgery does not always mean that a woman will be unable to breastfeed. In this situation, a woman can attempt breastfeeding while monitoring the infant's weight gain and the number of wet diapers.

It is not necessary to buy any breastfeeding supplies before delivery. Some women choose to purchase a breast pump, although this is not usually needed until the woman returns to work. If a pump is needed sooner (eg, to pump milk for a premature infant), a hospital lactation consultant or nurse can often help to coordinate this. If a lactation consultant or breastfeeding counselor is not available in the hospital, one can often be located by phone or e-mail.

When to start nursing — Breastfeeding should begin within the first few hours of delivery, if possible, by allowing the baby to rest or nurse, skin-to-skin, on the mother's chest. During this time, most infants are alert and interested in nursing. However, there is no evidence that it will be more difficult or impossible to breastfeed if the infant cannot nurse within this time period.

In some situations, the infant or mother must be separated for several hours or even days after delivery. Pumping the breasts and then storing the milk for use is recommended to stimulate the continued production of breast milk; this can be initiated as soon as it is safe, optimally within the first 12 hours after delivery.

In the first few days after delivery, the woman produces a small amount of a yellowish milk called colostrum. Colostrum is rich in nutrients and provides all the calories a baby needs for the first few days.

Many women worry that their infant is not getting enough milk immediately after delivery, when only small amounts of colostrum are normally produced. Infants are born with an excess of fluid and sugar stores that they are able to utilize as the milk increases in volume. Parents should be reassured that it is normal to produce small amounts in the beginning. With continued frequent breastfeeding, a larger amount of mature milk will be produced within two or three days. Infants normally lose weight during the first few days of life and gradually regain this weight by two weeks after delivery.

Positioning — A woman may use one of several positions to hold her infant while breastfeeding. There is no one "best" position for every infant and woman; the best position is one that is comfortable for the woman and allows the infant to latch-on, suckle, and swallow easily.

 A woman may have several preferred positions depending upon the baby's size, the baby or mother's medical condition(s), and feeding location (eg, in bed versus in a chair).

In all positions, the baby should not have to turn his or her head to nurse; the baby's nose should be aligned with the mother's nipple.

Turning the head in any direction makes it more difficult to coordinate suckling and swallowing, and can potentially make it more difficult for the baby to latch correctly.

Pillows or nursing supports can help to ensure that both the woman and the infant are comfortable. When the mother is sitting in a chair, a foot stool or ottoman is helpful in supporting the infant's weight and preventing fatigue in the mother's arms, shoulders, and neck.

• Cradle hold —The cradle hold can be done while the mother sits in a chair. To feed from the left breast, the infant's head and body are supported by the mother's left forearm.

The mother's left hand usually supports the baby's buttocks or upper thighs. Some women use a pillow to support this arm. The baby's stomach should be flat against the mother's chest and the baby's head should be in line with the body (not turned). The mother's free hand (the right hand in this example) supports and guides the breast to the infant's wide open mouth. The thumb on the free hand may be placed on top of the areola and the breast supported with the cupped fingers. Care should be taken to position the hand away from the nipple so that the thumb and fingers do not interfere with latching.

• Cross-cradle hold — The cross-cradle hold can also be done while the mother sits in a chair. To feed from the left breast, the infant's head and body are supported by the mother's right hand and forearm. Some women use a pillow to support this arm.

The baby's stomach should be flat against the mother's chest and the baby's head should be in line with the body (not turned). The mother's free hand (the left hand in this example) supports and guides the breast to the infant's wide open mouth. The thumb on the free hand may be placed on top of the areola and the breast supported with the cupped fingers. Care should be taken to position the hand away from the nipple so that the thumb and fingers do not interfere with latching.

• Football hold — The football position allows a woman to easily see the baby at her breast. It is often preferred by women who have an abdominal incision, after a Cesarean section, or by women with large breasts or a small or premature baby. The baby is supported by a pillow as the mother sits, which should allow the baby's head to be at the level of the mother's breast.

To feed from the left breast, the baby's body and legs are under the left arm, with the head supported with the mother's left hand.

The mother's free hand (the right hand in this example) supports and guides the breast to the infant's wide-open mouth.

• Side-lying hold — The side-lying hold allows the mother to nurse while lying down. When using this position, there should be no excess bedding around the infant. The side-lying hold should not be used on a waterbed, a couch, or a recliner because this poses a suffocation hazard to the infant.

To nurse from the left breast, the woman lies on her left side. The baby's head and body lie parallel to the woman's body, with the baby's mouth close to and facing the woman's left breast.

 

The woman may prefer to have a pillow under her head, with her left hand between her head and the pillow. The mother's free hand (the right hand in this example) supports and guides the breast to the infant's wide open mouth. The thumb on the free hand may be placed on top of the areola and the breast supported with the cupped fingers. Care should be taken to position the hand away from the nipple so that the thumb and fingers do not interfere with latching.

Latch-on — Latching on refers to the infant's formation of a tight seal around the nipple and most of the areola with his or her mouth. A correct latch-on allows the infant to obtain an adequate amount of milk and helps to prevent nipple soreness and trauma.

Signs of a good latch-on include:

• The top and bottom lips should be open to at least 120º. 
• The lower lip (and, to a lesser extent, the upper lip) should be turned outward against the breast
• The chin should be touching the breast while the nose should be close to the breast
• The cheeks should be full
• The tongue should extend over the lower lip during latch-on remain below the areola during nursing (visible if the lower lip is pulled away)

When an infant is latched correctly, the woman may feel discomfort for the first 30 to 60 seconds, which should then decrease. Continued discomfort may be a sign of a poor latch-on. To prevent further pain or nipple trauma, the woman should insert her clean finger into the infant's mouth to break the seal. She can then reposition the infant and assist him or her to latch-on again. Information about painful or sore nipples is available separately.

Signs of poor latch-on include:

• The upper and lower lip are touching at the corners of the mouth
• The cheeks are sunken
• Clicking sounds are heard, corresponding to breaking suction
• The tongue is not visible below the nipple (if the lower lip is pulled down)
• The nipple is creased after nursing

A video that describes how to latch a baby correctly is available online at www.ameda.com/community/videos.aspx.

Suckling and swallowing — An infant must be able to suckle and swallow correctly to consume an adequate amount of milk. It should be possible to hear the infant swallow. These early swallows may sound like the letter "C" in cat. The infant's jaw should move quickly to start the flow of milk, with a swallow heard after every one to three jaw movements.

Frequency and duration of feeding — Women are encouraged to attempt breastfeeding as soon as the infant begins to show signs of hunger. Early signs of hunger include awakening, searching for the breast (called rooting), or sucking on the hands, lips, or tongue. Most infants do not cry until they are very hungry; waiting to breastfeed until an infant cries is not recommended.

In the first one to two weeks, most infants will breastfeed eight to 12 times per day. Some infants will want to nurse frequently, as often as every 30 to 60 minutes, while others will have to be awakened and encouraged to nurse. A baby may be awakened by changing the diaper or tickling the feet. During the first week of life, most clinicians encourage parents to wake a sleeping infant to nurse if four hours have passed since the beginning of the previous feeding. Some babies will cluster feed, meaning that they feed very frequently for a number of feedings and then sleep for a longer period.

Caring for an infant can be an exhausting experience. However, it may be comforting to know that breastfeeding is no more time consuming than formula feeding, which often requires additional time to purchase and prepare the formula and wash bottles and nipples.

The length of time an infant needs to finish breastfeeding varies, especially in the first few weeks after delivery; some infants require as little as five minutes while others need 20 minutes or more. Most experts recommend that the infant be allowed to actively breastfeed for as long as desired; timing the feeding (ie, watching the clock) is not recommended. "Active" breastfeeding means that the infant is regularly suckling and swallowing.

It is not necessary to switch sides in the middle of a nursing session. Thorough emptying of one breast allows the baby to consume hind milk, which has a higher fat content than milk available at the start of a nursing session.

Most infants signal that they are finished nursing by releasing the nipple and relaxing the facial muscles and hands. Infants younger than two to three months often fall asleep during nursing, even before they are finished. In this case, it is reasonable to try and awaken the child and encourage them to finish nursing. After finishing one breast, offer the other side with the understanding that the infant (especially an older infant) may not be interested.

Pacifiers — Parents often use a pacifier to soothe their infant, although pacifiers should not be used to delay feedings. If an infant appears hungry he or she should be offered the breast. Pacifiers do have a benefit, although they are not usually recommended for breastfeeding infants until after about four weeks of age or when breastfeeding is well established. When an infant sucks on a pacifier, the sucking action may prevent the infant from falling into a very deep sleep. Breastfed infants also follow this pattern because they must eat frequently. Pacifiers should not be forced nor should they be placed back into an infant's mouth if it falls out after the infant falls asleep.

Growth spurts — It is common for an infant to occasionally nurse more frequently or for longer periods during the first year. However, every infant is different, and increases in appetite may occur at different times. Parents are encouraged to allow their infant to nurse more frequently when the infant shows interest.

How much is enough? — Many parents are concerned that their infant is not getting enough milk because it is not possible to see how much milk the baby consumes. There are a few clues that parents can use to estimate whether the baby is getting enough breast milk.

Monitor diapers — Keep a written record of the number of wet and dirty diapers per day. Many parents keep a written record of wet and dirty diapers for the first week or two.

Normally, by the fourth to fifth day after birth, an infant should have at least six wet diapers per day with clear or pale yellow urine. Fewer than six wet diapers, or dark yellow or orange urine in the diaper are signs of inadequate intake and should be reported to the child's clinician.

Meconium is the sticky dark-colored stool that infants normally produce for the first few days after birth. An infant's stool should become mustard yellow to light brown, often with visible milk curds, by the fourth to fifth day. Most infants have four or more stools per day by day four. Stools are a better indicator of how well breastfeeding is going in the initial days.

Monitor weight — It is normal for infants to lose weight after delivery, with the average infant losing four to five ounces within the first few days of life. Normally, infants stop losing weight by five days of age and typically regain their birth weight by one to two weeks of age.

Infants who lose more than this amount may be at risk for becoming dehydrated and/or developing jaundice. If this occurs, the healthcare provider will try to determine the cause of the infant's weight loss and whether supplementation with banked human milk, pumped milk, or infant formula is needed.

The American Academy of Pediatrics recommends that all healthy breastfeeding newborns are weighed and examined by a healthcare provider three to five days after birth and again two to three weeks after birth; this allows the provider to monitor for signs of jaundice, dehydration, weight loss, or other complications, and to answer parents' questions.