#33353: Breastfeeding

Taken alone, the term "breastfeeding" can describe numerous types of breastfeeding behaviors [1]. Therefore, when reviewing research on breastfeeding, it is important to note the author's definition of the term. For example, some researchers may apply study results to the breastfeeding group if any breastfeeding has occurred at any time. The conclusions drawn, therefore, can be incorrect. By identifying the type of feeding as a research variable (Table 1), the occasionally blurred differences between breastfed and artificially fed infants, especially in developed nations, will become abundantly clear.

Throughout this course, the term "mother" will be used to refer to an individual who has given birth. However, persons of any gender identity and relationship to the infant may give birth and breastfeed. It is important to ask about preferred pronouns and titles and to respect the patient's identity. This is central to patient-centered care; it will help build rapport and improve education efforts.

Before the advent of commercial formula, wet nurses flourished in times and places of sharp class distinctions [4]. The practice of wet nursing was deeply ingrained in ancient cultures. For example, contracts were made between parents and wet nurses in ancient Mesopotamia. In 1800 B.C.E., the Babylonian King, Hammurabi, wrote a set of laws concerning the wet nurse's care of the infant [5]. The practice of wet nursing continued among the aristocracy through the Greek and Roman empires and was probably introduced to Europe during the Roman occupation [5].

Among the wealthy upper class in European countries from 1500 to 1700, the hiring of wet nurses was the norm. When a member of royalty was expecting a child, several wet nurses were kept "on standby." The new heir may have had several wet nurses until weaning. For example, Louis XVI had four wet nurses before he was weaned at the age of 24 months [6].

The expectant mother was responsible for choosing a wet nurse of good temperament and morals. The wet nurse was under the strict supervision of the mother in her home. In return, wet nurses were well cared for and often lived in the same home for years. It was a tremendous employment opportunity for poor women who sought these jobs, and they often neglected, abandoned, or even deliberately suffocated their own infants so they could take a job as wet nurse [6]. While the upper class could pay for wet nurses, the general population resorted to group nursing (i.e., passing the baby around) if the mother was unable to nurse, if she was working in the fields, or if she died [7]. Wet nurses also had a vital function in foundling homes (orphanages), where it has been estimated that they breastfed as often as thirty times a day, producing up to five quarts of milk [6].

Live-in wet nurses went out of fashion for a time, and newborns were sent to live in the wet nurse's home until they were weaned. This "farming out" of newborns removed the child from his or her family and lacked the day-to-day supervisory aspect of the live-in wet nurse. This was probably the beginning of what is called "detached parenting." French laws prohibited a wet nurse from breastfeeding more than two infants (besides her own). Separate beds had to be provided for each baby, and the wet nurse was prohibited from sleeping with the infants [1]. In the mid-18th century it became fashionable again for wealthy Europeans to nurse their own infants. Babies were dying under the care of wet nurses, and there were legitimate concerns that untreatable diseases were being transmitted through breast milk.

Wet nursing was eventually exported to the New World. As early as 1711, colonial newspapers served as a means to locate a wet nurse [6]. In America's pre-Civil War South, privileged children were nursed and cared for by Black wet nurses [4]. The practice of "cross nursing," or wet nursing, the children of close friends or sisters continues in many developing countries when the mother is ill or has died. However, the practice has been discouraged due to the possibility of human immunodeficiency virus (HIV) and hepatitis transmission.

The decline in breastfeeding has been traced to the social changes brought about by the industrial revolution [7]. In 1880, 95% of all infants were breastfed for two to four years, but as mothers began reporting breastfeeding difficulties, physicians blamed the stress of urban life and the "bad" human milk produced by urban women. These mothers, who were just learning about the germ theory of disease and anxious to protect their babies, began to gratefully rely on "scientific" food rather than that produced by their own bodies [5,8].

Cultural phenomena have also contributed to a decline in breastfeeding. These include: the loss of community/family knowledge, role models, and support of breastfeeding; the tendency to hand over responsibility for personal health to the medical profession; an increasingly more patronizing attitude toward patients by the medical professions; a greater reliance on institutions, along with their structured environments; and premature application of poorly conceived and poorly tested medical theory [5].

How a society views infants is also thought to affect whether women decide to breastfeed or bottle feed [6]. For example, at the beginning of the 20th century, psychologists and physicians were convinced that babies developed best if they were raised according to hard and fast rules [9]. This led medical and psychologic communities to advise the mother that she must gain control over the infant and show the child that she is the master. By imposing arbitrary rules with little physiologic basis, these scientific communities sought to regulate the process of breastfeeding [5]. By 1930, however, pediatricians were warning against rigid scheduling that might not correspond with the infant's natural hunger rhythm and could result in prolonged crying and feeding difficulties [5].

Historically, infant feeding has encompassed a wide range of recommendations from the psychology community as well [4,10]:

During World War II, women entered the work force in great numbers. They wanted, and often needed, to work, but they worked in industrial settings that did not provide provisions for breastfeeding mothers and babies. The need for human milk substitutes became greater than ever, and companies that mass-produced artificial baby milk (ABM) were started.

As scientific methods improved, everything was reduced to "scientific" fact. Improvements in sterilization techniques made ABM safer. It was calculated to the last calorie, it was measurable, and its production was very much a scientific process. Breastfeeding, on the other hand, was neither scientific nor sterile. It also was not measurable. ABM was considered "safe," nursing was rejected as unhealthy, and the push was on for "better" babies through "superior" ABMs.

During the 1960s, the ABM industry was in full swing, and ABM was proclaimed the "modern way" to feed a baby. The 1970s "flower children" spawned a back-to-nature movement and a return to breastfeeding, but by the 1980s, it still had not been accepted as the norm. By 1990, only 50% of infants were breastfed at birth, and three-fourths of these infants were weaned by 6 months of age [5].

More than half of the women giving birth today either were not breastfed themselves or were breastfed for only a few weeks or months, often with supplementation beginning at birth. For the last 80 to 90 years, women have been ABM feeding in such great numbers that much of the valuable information once possessed has been (temporarily) lost. During the lifetimes of our mothers and grandmothers—due mostly to profound social changes, but also to smart marketing—bottle feeding became the norm. It is important to work to re-establish the breastfed baby as the norm [11].

Every cultural group holds beliefs about the primary function of a woman's breasts [5]. It is important, therefore, to understand how culture influences the initiation and duration of breastfeeding.

Following World War II, when artificial feeding became a viable option, the cultural context of a woman's breasts began to shift from functional to purely sexual. Photographs in popular magazines began to depict women with large breasts as the ideal in beauty. "Sweater Girls" became popular, and by 1940, the ideal shape of the breast had changed to consist of two pointed cones attached at right angles to the female chest [9]. "Blond Bombshells" were noticeably heavy on top with pencil thin waistlines; movie actresses began to resemble an exaggerated caricature of femininity. The first issue of Playboy appeared in 1953, and its narrow definition of beauty quickly became a part of American culture, which has defined a small range of acceptable breast shapes and sizes [12].

Other western cultural assumptions about female breasts and breastfeeding include: breasts are for sex; breastfeeding serves only a nutritional function; breastfeeding should be limited to very young infants; and breastfeeding (like sexual activity) is appropriate only when done in private [13]. Many of the difficulties women experience in breastfeeding may be traced to these four assumptions. For many women, however, the biggest block to breastfeeding may be related to feelings of shame associated with breastfeeding as a result of the concept of the female breast solely as an object of sexual excitement. This shame, coupled with ignorance about women's breasts, has led to emotional pain, confusion, and, in some instances, serious health problems [1,14].

Women also have felt that there is a social stigma attached to nursing an infant beyond 6 months. This stigma has driven many well-educated, caring, dedicated mothers to closet (i.e., concealed) breastfeed, which may adversely affect other children in the family. Children learn about the breast and breastfeeding from their mothers. When a mother nurses away from her older children or when she forbids them to watch the new baby nurse, the children may associate shame or guilt with the act of breastfeeding and may develop shameful feelings about breasts [1].

To protect breastfeeding women from harassment, states have passed laws that specifically address breastfeeding [15]. As of 2022, all 50 states have passed legislation specifically allowing women to breastfeed in any public or private location, and 31 states exempt breastfeeding from public indecency laws. Thirty states have passed laws related to breastfeeding in the workplace; 22 states exempt breastfeeding mothers from jury duty or allow jury service to be postponed; and 4 states (California, Illinois, Minnesota, Missouri) have implemented or encouraged the development of a breastfeeding awareness education campaign [15,16].

In addition to legislation at the state level, federal legislation related to breastfeeding also has been introduced and/or passed [15,17]:

Breastfeeding is perhaps the most misunderstood aspect of motherhood. A persistent lack of basic breastfeeding knowledge, the depth and strength of "old wives' tales," and an abundance of misinformation has contributed to this misunderstanding. Cultural, social, and medical interventions have modified child care practices and made it difficult to see what nature intended [18]. Belief in the miracle of our innate physiology has been lost in western societies. By becoming so technical, we have lost a respect and reverence for nature and natural processes [19].

Infant mortality has been associated with a variety of factors, including maternal health, quality of and access to medical care, socioeconomic conditions, and public health practices. It is clearly an important indicator of the health of a nation. The infant mortality rate in the United States generally declined throughout the 20th century, from approximately 100 infant deaths per 1,000 live births in 1900, to 5.6 infant deaths per 1,000 live births in 2019 [23]. However, the U.S. infant mortality rate did not decline significantly between 2000 and 2018, which represented the first period of sustained lack of decline since the 1950s. The Healthy People 2030 initiative has set a target goal of 5.0 infant deaths per 1,000 live births [23]. In 2013, the United States ranked 51st internationally in infant mortality, ranking much higher than other countries of similar gross domestic product [24,25,26]. An international comparison compiled by the Organization for Economic Cooperation and Development (OECD) found that in 2020, the United States ranked 33rd out of 37 member countries with 5.7 deaths per 1,000 live births [27].

These statistics have generated concern among researchers and policy makers. All major medical societies in the United States, including the AAP, have recommended breastfeeding for as long as possible in infancy in order to improve childhood survival rates. The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) guidelines have recommended extending breastfeeding for a minimum of two years. This recommendation is supported by research, which has shown a 21% decrease in U.S. infant mortality in breastfed infants [21]. Exclusive breastfeeding, or human milk feeding for a minimum of six months, provides the greatest level of protection against infantile illnesses.

An objective of Healthy People 2030 is to increase the proportion of U.S. mothers who breastfeed their babies through 6 months of age and who continue to breastfeed their babies through 12 months of age. A review of Healthy People 2030 reported the following progress toward achieving this objective [28]:

The Healthy People 2030 breastfeeding objective also includes an increase in exclusive breastfeeding. To monitor progress toward achieving the objectives, the Centers for Disease Control and Prevention (CDC) analyzed data from the National Immunization Survey (NIS) for infants born from 2011 to 2018. According to the analysis, among infants born in 2018, the rates for exclusive breastfeeding through three months and six months were 46.3% and 25.8%, respectively [29]. Rates of exclusive breastfeeding are reported to be significantly lower among Black infants (compared with White infants), infants born to young (20 to 29 years of age) unmarried mothers (compared with married mothers), and infants born in rural areas, particularly infants living in the Southeast [29].

Since the Surgeon General's Workshop on Breastfeeding and Human Lactation in 1984, all maternity settings have been mandated to provide a supportive milieu for breastfeeding. At the nucleus of this mandated support is a strategy of breastfeeding education beginning in the antepartum setting and continuing through the pediatric care of the infant. Hospitals are to have a specially trained person available to help the breastfeeding dyad. By improving the perinatal setting, it was hoped that, by the year 2000, at least 75% of all women would be nursing their newborns at hospital discharge and 35% would continue to breastfeed for a minimum of six months [30,31]. The key elements of the Surgeon General's Workshop (Table 2) were incorporated into the Healthy People 2000, 2010, and 2020 and restated in Healthy People 2030.

The workshop represented a milestone in the effort to highlight breastfeeding as a public health priority. Since its occurrence, many professional health agencies and organizations (e.g., the Agency for Healthcare Research and Quality, the American Academy of Pediatrics, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American College of Nurse-Midwives, American Dietetic Association, and American Public Health Association) have reached a consensus on breastfeeding recommendations. For example, these agencies and organizations have recommended that most infants be breastfed for at least 12 months. They also have recommended that for the first 6 months, infants be exclusively breastfed (i.e., they do not receive any foods or liquids other than breast milk). More than 50 health professional and educational organizations, as well as federal agencies, now participate in the U.S. Breastfeeding Committee, whose mission is "to improve the nation's health by working collaboratively to protect, promote, and support breastfeeding" [32].

The Academy of Breastfeeding Medicine recommends that healthcare facilities should establish a written breastfeeding-friendly office policy. Culturally and ethnically competent care should be offered, with an understanding that families may follow cultural practices regarding discarding of colostrum, maternal diet during lactation, and early introduction of solid foods.

(https://www.bfmed.org/assets/DOCUMENTS/PROTOCOLS/Protocol%20%2314%20-%20English%20Translation.pdf Last Accessed: April 12, 2022)

Level of Evidence: III (Opinions of respected authorities, based on clinical experience, descriptive studies and case reports; or reports of expert committees)

Breastfeeding education for clinicians also has received national attention. In 2000, the Office of the Surgeon General published the Blueprint for Action on Breastfeeding, which represented the first comprehensive framework on breastfeeding for the nation. Among other things, the blueprint recommended action steps for healthcare systems, families, communities, researchers, and employers to promote breastfeeding [33,34]. From 2004 to 2006, the U.S. Department of Health and Human Services (HHS) sponsored a national campaign to increase awareness about the health advantages of breastfeeding. A 2007 national survey (the first of its kind) identified key opportunities for birth facilities and states to more effectively support new mothers in the initiation of breastfeeding. Evidence-based staff training on breastfeeding was one area of need identified that hospitals and birth centers could implement to improve their support of breastfeeding. Workplace support was another area of need identified; women who are employed full-time are less likely to initiate and continue breastfeeding after returning to work [32,35,36,37]. In 2011, the Office of the Surgeon General published The Surgeon General's Call to Action to Support Breastfeeding, with the goals of increasing public health impact, reducing inequities in health care quality for mothers and infants, and improving support for families in job and community settings. The Call to Action discusses the importance of breastfeeding, rates of breastfeeding in the United States, barriers to breastfeeding, and public health approaches to increase breastfeeding [38,39].

In 1991, the WHO and UNICEF launched the Baby-Friendly Hospital Initiative (BFHI), which was designed to create change in healthcare facilities. The aim of the BFHI was to foster an environment that supports, protects, and promotes breastfeeding, as indicated by the WHO's International Code of Marketing of Breast-milk Substitutes[40,41]. The process for obtaining certification as a baby-friendly hospital has been established by UNICEF in collaboration with national governments worldwide. UNICEF's Ten Steps to Successful Breastfeeding has been the basis for evaluating hospitals and healthcare facilities for participation as a designated baby-friendly facility (Table 3). A 2000 statement by the United Nations (UN) regarding the "rights of the child" has been linked to the BFHI. The UN has stated that in order for hospitals with maternity units to be designated "child friendly" they must first fully implement the Ten Steps to Successful Breastfeeding and be accredited by WHO/UNICEF as baby friendly [42]. The Ten Steps to Successful Breastfeeding and the BFHI have been shown to be effective measures to increase breastfeeding initiation, duration, and exclusivity [43,44].

More than 21,000 facilities, or 27.5% of maternity wards worldwide, have achieved baby-friendly status; in the United States, 551 hospitals and birthing centers in all 50 states have achieved this status [46,47]. Hospitals in the United States and elsewhere that have used the BFHI framework, in whole or in part, have demonstrated an extended positive impact on breastfeeding rates and duration [48,49,50,51,52].

The BFHI and the WHO's International Code of Marketing of Breast-milk Substitutes can and should be carried out in the United States, but it will take more time than initially anticipated. Although the baby-friendly evaluation clearly exposes the wide scope of hospital routines that have detrimental effects on successful breastfeeding, achieving change can be difficult. Some routines are so deeply ingrained that staff members may be unable to identify and correct problems. Ambiguous objectives, poorly defined strategies, and the use of a limited number of change agents and techniques additionally make implementing change difficult. What is needed is a structured approach that incorporates training, motivation, and specific practices for implementation [2]. A two- or three-day course that includes practical sessions and counseling skills has been shown to be effective in changing hospital practices, knowledge of healthcare workers, and breastfeeding rates [53]. Ongoing support and education should be provided by individuals with advanced knowledge and training, such as lactation consultants.

Studies have found that healthcare providers represent one of the major barriers to successful breastfeeding [54]. This finding is supported by mothers who have said that they would breastfeed for as long as their physicians said if the physicians stressed to them the importance of breastfeeding [1]. Many women have reported not receiving positive breastfeeding messages from health caregivers and hospital staff. This perceived "neutral attitude" has been associated with mothers not breastfeeding beyond 6 weeks [55]. The language healthcare professionals use to educate women about breastfeeding often is riddled with semantics that place artificial feeding and breastfeeding on the same plane, with only a slight difference in the method of delivery. To support the idea that breastfeeding is the norm, and that artificial feeding can result in adverse effects on infant health, healthcare providers should select and use language that supports breastfeeding [2].

Healthcare professionals should also recognize the negative impact on successful breastfeeding when they agree to display materials produced by ABM manufacturers. The conflict of interest presented when ABM companies "advise" women about breastfeeding should be obvious [56]. U.S. military hospitals do not accept free ABM or other perks because they consider such practices unethical [48]. Giving a new mother ABM samples at hospital discharge may undermine her confidence in her ability to breastfeed. Items such as discharge packs, diaper bags with ABM samples, videos, and discount coupons have been repeatedly shown to decrease the length of exclusive breastfeeding and are in direct violation of the WHO's International Code of Marketing of Breast-milk Substitutes, which was adopted by the World Health Assembly to reverse the decline in breastfeeding related to the production of manufactured breast milk substitutes [40,41]. In recognition of these effects on new mothers, Rhode Island (2011), Massachusetts (2012), Delaware (2015), Maryland (2015), New Hampshire (2016), and West Virginia (2018) banned the inclusion of infant formula in facility-provided gift bags [57,58,59]. Other cities and states are beginning to address this issue as well.

While national initiatives and recommendations from professional organizations may encourage more women to breastfeed, improvement in breastfeeding duration cannot be achieved if healthcare providers lack knowledge about breastfeeding [1]. Clinical lactation skills may be taught by an experienced clinician to perinatal providers in the clinical setting and subsequently to new mothers [56]. Nurses who work with families with children often are responsible for a majority of patient education. In this role, they may significantly affect a woman's decision to initiate and continue breastfeeding. Improving evidence-based practices in nursing programs has been shown to positively impact breastfeeding outcomes both in the hospital and in the community [60].

In addition to a lack of knowledge about breastfeeding among healthcare professionals, breastfeeding research has traditionally been a low priority for federal funding. For example, between 1994 and 1996, federal research funds totaled approximately $40.4 million, and of this amount, only $5.6 million (13.7%) was awarded to projects determined to have an impact on achieving federal goals for increasing the incidence and duration of breastfeeding. A total of 27 (7.5%) funded projects in this category, reflecting $4.1 million, had no relationship to breastfeeding per se; they involved the use of human milk composition and technologies to improve artificial milks and develop new pharmaceuticals and therapies [61]. However, the CDC has begun working with researchers to evaluate the impact of existing breastfeeding interventions across the United States. As of 2005, ten universities had received funding to evaluate [62]:

In 2014, the U.S. Department of Agriculture released nearly $60 million in fiscal funds to its Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The WIC program supports 53% of infants born in the United States and promotes breastfeeding as the best form of nutrition for infants [63]. The National Institute of Child Health and Human Development supports and conducts research on breastfeeding and breast milk through several of its organizational units. The Institute also supports efforts to meet the public health goals outlined in the Healthy People 2030 initiative [64].

It is important to note that FDA approval does not constitute affirmation of the safety of new ingredients added to infant formulas. In the United States, a manufacturer may declare that an ingredient is generally recognized as safe (GRAS) if scientific consensus exists among qualified experts as to the ingredient's safety under the conditions of its intended use. The manufacturer then notifies the FDA, which issues a "letter of no objection" if it has no questions [76]. The FDA has expectations that formula manufacturers will independently pursue post-marketing scientific studies and surveillance of these additives [75].

Application of the GRAS process, however, does not address all concerns about the chemical characteristics, nutritional contributions, and pharmacologic and physiologic activities for the multitude of potential new ingredients in infant formulas. Consequently, the Institute of Medicine (IOM) Food and Nutrition Board has proposed additional safeguards, not required for other foods, for infant formulas to which new ingredients are added. The proposed rule would mandate that manufacturers demonstrate that the formula can sustain infant growth and development over 120 days (the period during which formula is likely to be the sole source of infant nutrition). The IOM also has recommended that data from growth/development studies be submitted as part of material demonstrating safety [76].

Research has indicated that women who were educated regarding the risks of not breastfeeding were more likely to commit to breastfeeding compared to women who were only given information regarding the benefits of breastfeeding [77]. Therefore, it is vital that healthcare professionals include information regarding the risks and disadvantages of ABM in addition to the benefits of breastfeeding when counseling mothers.

ABM carries inherent dangers (e.g., product contamination) that have not been associated with breast milk [78,79,80]. Many of these dangers, such as product recalls, may not be known to the women giving ABM to their infants [81]. Between 1982 and 1994, more than twenty ABM recalls occurred in the United States [82,83]. In February 2022, the FDA issued a recall for three brands of powdered infant formula manufactured at a facility in Michigan [84]. Five infants who received the formulas developed Cronobacter sakazakii and Salmonella Newport infections; two of the five infants died. Based on inspections conducted at the facility, the FDA found that the manufacturer did not have a system of controls for all stages of processing to ensure that the formulas would not become adulterated, and did not ensure that surfaces in contact with the formula were protected from contamination [84]. Worldwide, more than 10 million children die each year before their fifth birthday; approximately 50% of these deaths have been associated with nutrition problems. The use of infant formula tends to increase the illnesses and deaths that have been associated with a wide range of diseases. The risk of mortality has been shown to be about 27% higher among infants who have never been breastfed compared to breastfed infants [20].

Known risks associated with ABM include [1,5,20,82,85,86,87,88]:

Cost is a unique disadvantage of ABM. For example, the average family will spend approximately $150 every month for the first year if using ABM. If a specialized ABM is required, the cost may be as high as $300 per month, or as much as $3,900 for the first year [89,90]. Additional out-of-pocket expenses may include medical care due to the higher incidence of ear infections, gastrointestinal illness, and asthma in ABM-fed babies. One study found that if 90% of mothers complied with recommendations to breastfeed exclusively for six months, the U.S. economy could save $3.7 billion in direct and indirect pediatric health costs and $10.1 billion in premature death from pediatric disease [91,92]. Parents may lose wages if they miss work to care for a sick child. Other costs may not be as easily measured. For example, bottles must be bought and washed. ABM has to be prepared and warmed before use. All these activities take time. Also, because the mother's fertility typically returns sooner if she bottle feeds, additional monies will be needed for birth control methods. A subsequent pregnancy that occurs sooner than planned may put additional financial burdens on the family.

ABM also is not a renewable resource. The cows that produce the milk for ABM must be fed. Growing food for cattle or soybeans for ABM uses large amounts of water and pollutes the environment with fertilizer and pesticide residues. Production uses fuel to power manufacturing. ABM also leaves solid waste products. For example, it has been estimated that 450 million tin cans are discarded each year for every 3 million bottle-fed babies [5].

When compared to the risks associated with ABM, the advantages to its use may seem insignificant. However, many mothers opt to bottle feed their infants. The underlying motives for the decision to bottle feed may include [9]:

Proper education may help to alleviate many of these concerns.

The ABM companies are powerful, and their marketing tactics can be subtle. A history of collusion between physicians and the ABM industry has been documented, and the media has reported that federal health officials yielded to pressure from ABM industry officials by weakening an advertising campaign that was designed to promote breastfeeding [93]. ABM companies openly give hundreds of thousands of dollars to medical professionals, sponsor medical seminars and research, and provide massive amounts of free ABM to hospitals every year [83].

From 2012 to 2013, the global market for functional and fortified foods grew significantly, with infant formula topping the list. In 2013, nearly $5 billion in global sales of infant formula was reported, with sales expected to grow at an annual rate of 11% through 2018 [94]. The revenue from this market is projected to increase to more than $319 billion in 2022 [95]. ABM marketers are specifically and aggressively targeting Asian, African, and Middle Eastern markets in order to compensate for the slower European and American infant-formula markets [94].

The U.S. Government Accountability Office (GAO) has reported that breastfeeding rates are particularly low among infants whose mothers participate in WIC, which provides free food and infant formula to low-income women, infants, and children. Approximately half of all infants born in the United States each year participate in the WIC program [96,97]. While ABM manufacturers generally agree that breastfeeding is best, they continue to market ABM as an "alternative" for mothers who do not exclusively breastfeed. Some ABM manufacturers have used the trademarked WIC acronym in their promotional materials, despite federal restrictions on this practice [96,98].

There are no disadvantages to breastfeeding, except those that may be perceived as inconvenience.

Some of the advantages and benefits of breastfeeding include [2,77,92,99,100,101,102,103,104,105,106,107,108,109]:

Breastfeeding has also been associated with a lower prevalence of hypertension, diabetes, hyperlipidemia, and cardiovascular disease among postmenopausal women.

As stated, infant formula is the single most expensive food item for WIC. To reduce costs, federal law requires that WIC state agencies enter into cost-containment contracts for the purchase of the infant formula used in the WIC program [109]. Cost containment is achieved in the form of rebates from formula manufacturers for each container of formula purchased by WIC. In exchange for the rebates, the WIC state agency agrees to issue the selected manufacturer's infant formula(s) as the "formula of first choice" to its infant participants [109].

Many medical professionals have been hesitant to take anything but a neutral position when discussing infant feeding options. However, parents should hear all the data, including the risk/benefit ratios of the various infant feeding methods, so they may make an informed decision. Healthcare professionals have an ethical responsibility to ensure that parents are aware of the health consequences of their infant feeding decisions [32]. Healthcare professionals should provide the information necessary for parents to make informed decisions and should support and respect their decisions.

Breast milk contains many non-nutritive, bioactive substances that directly affect infant physiology. Breast milk is not a uniform body fluid but a mammary gland secretion of changing composition [1]. No two samples of breast milk are the same, even when taken from the same mother. Because breastfeeding is an interactive process, the infant helps to determine the milk's composition. The major components of human milk include protein, fat (lipids), and lactose. Additional components include vitamins, certain minerals, hormones, enzymes, growth factors, and many types of protective agents (Table 5) [2].

Pregnancy brings increased growth within the breast. The size of the breast varies greatly depending on the amount of fatty tissue present within the breast. By the time the baby is born, glandular tissue will have replaced most of the fatty tissue. Breast size bears no relationship to the amount of milk produced. The rare exception is a condition called insufficient glandular development of the breast. The darkening of the areola during pregnancy may serve to act as a visual target for the newborn. Secondary darkening or patchy pigmentation behind the areolar rim also may occur in pregnancy. The Montgomery glands may become enlarged and elevated, and the nipples may become more pronounced [2,9,135].

Important changes that occur during the first trimester include the expansion of the ductal system and its branches in response to estrogen; the expansion of the glandular tissues of the alveoli in response to hormones such as prolactin; and an increase in the size of the lobes and lobules in response to progesterone. Second trimester changes include continued development and enlargement of the duct system and additional lobule growth (continuing into the third trimester). Under the influence of a ten- to twentyfold increase in placental lactogen, colostrum appears near the end of the second trimester. The breast will produce colostrum if the fetus is born at 16 weeks. However, secretory milk-releasing alveolar cells do not develop until the third trimester [1].

Following lactation, the breasts involute (i.e., the mammary gland returns to its nonproductive state of milk secretion). If milk is not removed from the breasts, as during weaning, the glands become distended. This interferes with the blood supply to the breasts, and milk production ceases. There is also evidence that an enzyme produced by the unremoved milk decreases production. Milk remaining in the alveoli is gradually reabsorbed, and the alveoli collapse or rupture. Initially, after weaning, the breasts may appear smaller than their pre-pregnancy size. This is due to the lack of adipose tissue within the breast. The adipose tissue gradually increases, and the breast returns to its resting state. Some residual growth of the glandular tissue remains after lactation. Women often may express a drop or two of milk for up to 12 months following weaning [2,136].

Women may develop breast lumps at any time. Approximately 29% of cases of breast cancer occurs in women younger than 45 years of age [140]. The average patient is between 32 and 38 years of age [141]. Breast cancer is the most common cancer in pregnant and postpartum women, occurring in about 1 in 3,000 pregnant women; however, this percentage may increase as more women delay childbearing until their mid- to late-30s [141,142,143,144]. The breast changes that accompany pregnancy and lactation often make the mother aware of a lump that she has not felt before. Pregnant and lactating breasts are dense and lumpy. Women may delay treatment because they believe the lump is a disorder of lactation that will remedy itself. Inflammatory breast cancer, the most lethal of localized advanced cancers, often mimics mastitis; however, there are no systemic symptoms [143].

Monthly breast self-examination should continue throughout pregnancy and lactation. It is best for the lactating mother to examine her breasts after a feeding, when a lump might be more apparent [141,143]. It is important to note any new dimpling of the breast or nipple, or any lump that is painless, discrete, fixed, hard, or irregularly shaped. These cases should immediately be referred to a breast surgeon who is familiar with pregnant and lactating women. The most common cause of a breast lump in the lactating woman is a persistent plugged duct, or galactocele; other possible causes include mastitis and breast abscess. Lumps and/or mastitis that do not respond to treatment should be investigated [1]. Fine-needle biopsy may be done where necessary [141].

It is important to ask the mother if she has had breast surgery or surgery around the area of the breasts. Breast surgery may adversely affect a mother's ability to nurse by interfering with normal anatomy and neurohormonal pathways.

Providers also should note the following during the lactation assessment [2]:

The risk/benefit ratio of breastfeeding should be determined by a clinician who is in a position to weigh all the data. This is typically the infant's pediatrician and the mother's obstetrician or family physician. Relative contraindications to breastfeeding include [1,2,28,156]:

HIV infection: Although the risk of postpartum HIV infection of the infant remains unclear, studies have indicated that vertical transmission of HIV through breast milk is possible. The AAP has recommended that women who test positive for HIV not breastfeed in order to help prevent transmission of the virus to their infants. The CDC also has recommended that any woman with known HIV infection should be informed about the risks of HIV transmission through breast milk and counseled not to breastfeed. The WHO guidelines have indicated that when the mother is HIV infected, the additional risk of the infant dying if not breast-fed should be compared to the infant's risk of becoming HIV infected through breastfeeding. The mother who is HIV positive and wants her infant to receive human milk may choose to either pump her own milk and have it pasteurized at a local milk bank or hospital or obtain milk from a breast milk bank.

Lack of desire: The woman who has been fully informed of the risks associated with ABM use and who does not wish to breastfeed should not be compelled to nurse her infant.

Human T-cell leukemia virus type I (HTLV-I): This virus is endemic in the West Indies, Africa, and southwestern Japan. Women in the United States with HTLV-I disease should not breastfeed.

Suspected or confirmed Ebola virus disease (EVD): EVD is spread through direct contact with blood and other bodily fluids, including breast milk. EVD has been detected in samples of breast milk; however, no data exist about when in the course of the disease the virus appears in breast milk or when it is cleared. Those with confirmed EVD and those recently recovered from EVD should not breastfeed.

Breast cancer: The woman with active breast cancer requires treatment for herself. Women with a history of breast cancer should not be prohibited from breastfeeding. However, the infant should be monitored for appropriate growth, as radiation to the breast causes destruction of the milk-producing glands.

Active hepatitis B infection: Hepatitis B transmission through breastfeeding has not been reported. Infants born to hepatitis B-infected mothers should be immunized with hepatitis B immune globulin immediately after birth, plus given a first dose of human hepatitis B vaccine within 12 hours of birth. With appropriate follow-up immunizations, the baby may nurse.

Hepatitis C: Most patients with hepatitis C are asymptomatic with no traceable transmission route. The greatest risk is chronic active hepatitis C. Infection through breast milk appears to be infrequent.

Any life-threatening illness: The mother will need treatment and all additional energy stores for self-healing. This is a clinical judgment that should be made with all the facts presented.

Severe psychosis: When the mother's mental state poses risks to her life or her infant's, it may not be possible to breastfeed. Postpartum depression may be treated with compatible drugs and is not a contraindication to breastfeeding.

Although breast preparations have long been recommended for mothers who wish to breastfeed, studies have suggested that requiring nipple preparation may deter some women from breastfeeding [2]. Additionally, nipple preparation has not been shown to prevent postpartum nipple soreness.

The purpose of a nursing bra is to support the increased weight of the lactating breast. It is important that the bra is comfortable; however, it need not be worn 24 hours a day, unless it is more comfortable to do so. The bras should be purchased in the last trimester of pregnancy to help ensure proper fit. An ill-fitted bra may compress the breast tissue, resulting in plugged ducts. The mother may need to go up one chest size (e.g., from size 36 to size 38) to get cups that are wide enough to prevent compression of the breasts. The mother will need at least two bras initially; additional bras may be purchased after the birth.

The word doula comes from ancient Greek, meaning "woman's servant" [119,161]. Throughout history, doulas have supported women through labor and birth and they continue to do so in much of the world today. Doulas provide continuous psychologic encouragement and physical assistance to the mother [7,161]. Doulas provide specific labor support skills, offer guidance and encouragement, assist mothers to cover gaps in their care, build team relationships, and encourage communication between the mother, nursing staff, and medical caregivers [162].

The Academy of Breastfeeding Medicine asserts that women benefit from the continuous presence of a close companion (e.g., doula, spouse/partner, or family member) throughout labor and delivery. The presence of a doula is known to enhance breastfeeding initiation and duration.

(https://www.bfmed.org/assets/DOCUMENTS/PROTOCOLS/5-peripartum-bf-management-protocol-english.pdf Last Accessed: April 12, 2022)

Level of Evidence: II-1 (Well-designed controlled trials without randomization) and II-2 (well-designed cohort or case-control analytic studies, preferably from more than one center or research group)

Birth doulas provide continuous physical, emotional, and informational support to the mother before, during, and just after childbirth. They provide a level of support that differs from that of a person who is intimately related to the woman in labor; however, they also play an important role in helping the mother's partner become involved in the birth to the extent that the partner is comfortable, without intruding on intimate moments between the couple [161,163]. Postpartum doulas do whatever the mother needs to best enjoy and care for her new baby. These needs often change from day to day. A large part of the role of postpartum doulas is education (e.g., sharing information about baby care, teaching siblings and partners to "mother the mother," assisting with breastfeeding education). They also ensure that the mother is comfortable, well fed, and properly hydrated. Postpartum doula support may last from one or two visits to more than three months. Doulas do not replace nurses or other medical staff. They do not perform clinical or medical tasks (e.g., taking blood pressure, monitoring fetal heart rate). Their role is to provide comfort and support to the mother and enhance communication between the mother and her medical caregivers [161].

Studies have shown that a doula's presence at birth tends to result in [161,163,164]:

The level of support provided by doulas has been shown to have the greatest influence on successful outcomes (Table 7).

Medications, certain procedures, and/or pain management techniques may mediate a woman's pain experience in labor and delivery. Despite the widespread availability of these interventions, however, most women, in all societies and cultures, associate childbirth with pain that exceeds expectations [165]. The amount of pain felt differs from woman to woman and may depend on factors such as the size and position of the baby and the strength of the woman's contractions [166].

Research literature has supported the notion that maternal comfort should be considered a priority and mothers should receive adequate information regarding any medication prior to receiving it [167]. The Academy of Breastfeeding Medicine has recommended that maternity care providers initiate informed consent discussions about pain management in labor during the mother's prenatal period before the onset of labor. The discussion should include what is known about the various modalities, including their risks and effects (on the newborn and on breastfeeding) [160].

Use of pharmacologic agents for pain relief in labor and the postpartum period may relieve suffering during labor and allow mothers to recover from birth, especially cesarean birth, with minimal interference. However, these agents also may affect the course of labor, the neurobehavioral state of the neonate, and the initiation of breastfeeding. Unmedicated birth followed by immediate skin-to-skin contact between mother and infant leads to the highest likelihood of baby-led breastfeeding initiation. Difficult, medicated labors may lower the rate of breastfeeding success due to the effects on the infant, including depressed or delayed suckling (Table 8) [167,168,169].

According to the Academy of Breastfeeding Medicine, intrapartum analgesia may have an impact on breastfeeding, and consideration should be given to the type and dose of analgesia. Epidural analgesia, intramuscular opioids, exogenous oxytocin, and ergometrine have all been associated with lower rates of breastfeeding initiation.

(https://www.bfmed.org/assets/DOCUMENTS/PROTOCOLS/5-peripartum-bf-management-protocol-english.pdf Last Accessed: April 12, 2022)

Level of Evidence: II-2 (Well-designed cohort or case-control analytic studies, preferably from more than one center or research group)

Nonpharmacologic methods for pain management during labor (e.g., hypnosis, Lamaze exercises, intradermal or subcutaneous water injections for back pain) have no known adverse effects on the neonate; however, their effects on breastfeeding outcomes have not been adequately studied.

Table 9 contains a summary of recommendations for analgesia and anesthesia for breastfeeding mothers [160].

Many hospitals have established a period after delivery during which mother and child should not be disturbed. This is sometimes referred to as the "babymooning" period. The first two hours following birth are the optimal time for infants to initiate breastfeeding behaviors, such as rooting and sucking. During this sensitive period, infants are most responsive to tactile, thermal, and odor cues from their mothers. Sensitive periods in biologic phenomena are times when events can alter later behaviors [1,194]. A sensitive period occurs in infancy when success in establishing a skill (e.g., breastfeeding) may enhance survival and the ability to adapt [194]. For women, the first few hours after delivery are a sensitive period for bonding. If immediate contact is delayed (e.g., for general anesthesia, premature birth, illness), the bonding process will also be delayed until the mother's first contact with the infant. Delayed initial contact may result in bonding difficulties [1].

Immediately following birth, infants experience a surge of high levels of circulating catecholamines, which causes extreme sensitivity to odor cues. These cues guide the infant toward the mother's nipples. When skin-to-skin contact is initiated immediately after birth, an alert, active, unmedicated newborn will crawl unaided toward the mother's nipple and latch correctly within about 60 minutes [194,195,196,197]. The baby is most willing to nurse in the first two hours following birth because the suckling reflex is strongest during this period. When gratification of the suckling reflex is delayed, it may make it more difficult for the infant to learn to suckle later. After those first two hours have passed, the baby may be quite sleepy and not willing to nurse for as long as 24 hours. Some infants may not nurse as vigorously as the mother expects following birth or may instead merely "nuzzle" or lick the breast. It is important to reassure the mother that this is normal positive behavior and not a "rejection" of her or her breast [2].

Although a tradition of separating the mother and baby after birth still persists in many parts of the world, including the United States, early mother-infant skin-to-skin contact has been recommended by the AAP and is associated with many benefits, including [49,194,198,199]:

Correct skin-to-skin contact involves placing the infant prone and skin-to-skin on the mother's chest or abdomen immediately following birth. The infant should be gently dried and covered loosely with a warmed blanket; a cap will prevent heat loss. Routine procedures (e.g., assigning Apgar scores, suctioning) may be done if indicated, and the initial physical assessment may be done at this time as well. Ideally, all other interventions (e.g., weighing, measuring, bathing, needle-sticks, eye prophylaxis) should be delayed until the first breastfeeding has been accomplished [21,194].

When a sick or premature infant is separated from its mother in a neonatal intensive care unit (NICU), the "mothering" duties will be assumed by other caregivers. Early discharge practices may further separate the mother from her infant, and she may feel that she is a stranger to her own baby. The ability to counsel the breastfeeding woman in this situation may significantly impact her success [200]. Skin-to-skin contact, peer support, simultaneous breast milk pumping, multidisciplinary staff training, and the baby-friendly accreditation of the hospital have been shown to be effective breastfeeding promotion activities for mothers whose infants are assigned to the NICU [201].

Breastfeeding can be unconsciously sabotaged by hospital routines. Newborn policies can have serious effects on lactation and may contribute to maternal engorgement and routine assignment of any cesarean section baby to the nursery for several hours after birth. In addition to ensuring skin-to-skin contact between mother and infant immediately following birth, nursery and postpartum routines that support lactation include [1,2,21,200,202,203,204,205,206,207,208]:

Assess breastfeeding progress and success. Regularly observe the mother's breasts and nipples for any signs of lactation problems (e.g., pain, cracks, blisters, bruises). Also, regularly observe a feeding, paying attention to:

Continuity of information is vital in the postpartum period. Physician instructions to the patient should not conflict with the nurse's teaching plan (Table 10). The hospital should have a written breastfeeding policy that is known to all staff members. Teaching plans and handouts for new mothers should be written at a reading level that is appropriate to the local population. Verbal discharge instructions should be avoided. Discharge instructions should be written into the hospital policy and not left to chance.

At hospital discharge, the mother should be given simple, specific instructions about when to feed the baby, normal infant behaviors, and how to tell if the baby is getting enough milk (i.e., number of wet diapers, stools). Telling the mother to feed on demand in the first few weeks of breastfeeding is not recommended as some babies may demand feeding only once every six to eight hours. Instruct the mother instead to nurse the baby as often as demanded, but not to allow more than three or four hours between feedings. Also instruct the mother to wake the baby every two hours during the day and every four hours at night for at least the first week. This is important because, immediately following birth, the baby may not wake for hunger pains. Assure the mother that weight loss is normal and that the infant will regain his birth weight between 2 and 3 weeks of age. Mothers should be told the infant's hospital discharge weight. If the weight loss is of concern, the baby should have a weight check between 3 and 5 days of age. If all is well, the baby will have gained weight from the hospital discharge weight.

When the baby is well-aligned, the mother should be able to draw a straight line that connects the baby's ear, shoulder, and hip on either side of the baby's body. Once the mother and the baby are in proper position, the next step is for the mother to guide the infant to the breast so he or she can latch on properly and nurse. Unless the mother is reclining, it will be necessary for her to support her breast, at least in the early days of breastfeeding, so the baby can attach properly. This is especially true as milk production increases the size and weight of the mother's breast [209].

Mother should be taught to support her breast by cupping it in her hand, placing her thumb on top of the breast, and her fingers below the breast, well behind the areola. This is called the "C-hold" because the mother's hand makes the shape of the letter C. Practicing the breast hold in front of a mirror is often helpful. The weight of the breast should rest in her hand in a neutral position. Many women lift, pull, or twist the breast to reach the baby. The mother should be reminded to bring the baby to the breast, not take the breast to the baby [209].

In the past, the rooting reflex was stimulated by the mother offering the breast and stroking the infant's lips with her nipple. The mother would simply use her hand, in the C-hold, to move her entire breast up and down, brushing the infant's lips with her nipple. Many mothers are tempted to use their index finger to stroke the lips or try to pry open the baby's mouth. However, this interferes with the baby's attempt to latch on, and some infants may react to prying efforts with a tight clamp. The mother should continue tickling the lips until the infant opens his or her mouth very wide, as if giving a big yawn [209].

Today, however, there is an emphasis on allowing infants to initiate breastfeeding. Assist the mother into a comfortable position, and allow the infant to make his or her way to the breast. The infant's reflexes will take over, and he or she will self-attach with little or no assistance.

When the baby opens wide, the mother should center the nipple and pull the infant in close (Figure 2). This motion should be done quickly, but gently, while the baby's mouth is wide open. The baby's head should never be held, pushed, or shoved into the breast. This may disturb the rooting reflex and startle the infant, and he or she may refuse to nurse [1,2,209]. The tip of the baby's nose should touch mother's breast. Mother should be able to look down and see the baby's nose. If she cannot see the baby's nose, she should either lift up the breast slightly or raise the infant's buttocks so the infant is level.

LATCH-ON

Figure 2

Source: Southern California Kaiser Permanente Member Health Education. Used with permission

Mothers often worry about the baby's nose. It seems natural to use the thumb to pull the breast tissue away from the baby's nose. This action, however natural, will shift the nipple in the baby's mouth. In many cases, pressing the breast away from the baby's nose has the effect of tipping the nipple upward against the roof of the baby's mouth. The face of the nipple then rubs, with each suckle, against the baby's hard palate, becomes tender, blistered, scabbed, and bleeding, making nursing a painfully difficult process. Or, she may partially pull the nipple out so that the baby is latched-on only to the nipple tip. Painful nipple cracking may result.

All human babies are born with turned up noses. The tip of the nose will touch the breast with plenty of room for air in the open spaces formed around the nostrils. Point out this air space to mother and reassure her. Breathing comes before eating. If a baby cannot breathe, he or she will not stay at the breast.

If the infant is correctly latched-on to the breast, the mother will feel a tugging sensation. The first few suckles will be a bit tender as the infant stretches the nipple into the back of the mouth but should not last more than one or two suckles. The nipple remains sensitive for a few days after delivery. Most mothers report mild latch-on pain in the first week that disappears after the first 30 seconds of a feeding. Pain beyond the first minute or so of nursing is a sign of improper latching and should be immediately corrected. Instruct the mother to take a deep breath and release it slowly. If pain persists, she should detach the baby by inserting her finger in the corner of his or her mouth to break the latch and try again. Baby may need to go on and off the breast several times before the latch is correct [209].

If the baby is actively suckling and swallowing, there is no reason to switch breasts. In the early days, if the baby falls asleep easily, mother should switch breasts when suckling and swallowing slows. If the baby does not nurse at both breasts during a feeding, the mother should start the next feeding on the breast from which baby did not feed. Mother should watch the baby and not the clock. If the baby has 10 minutes of good suckling and falls asleep, the baby is finished with the feeding. Squirming movements are a signal that the baby may need to be taken off and burped.

To take the baby off the breast, mother should press down on her breast, near the baby's mouth, press down on baby's chin, and insert a finger in the corner of the baby's mouth [131,210].

Following the first "get acquainted feeding," when baby may merely nuzzle the breast, the mother should be instructed to watch for feeding cues, such as [2]:

As discussed, for the first week, the baby will need to nurse approximately 10 to 12 times in 24 hours. Instruct the mother that she should attempt to wake the baby after three hours (measured from the start of a feeding to start of the next feeding). The mother should be told not to worry if the baby is sleepy the first 24 hours. The baby should become more alert and eager to nurse after the first 24 hours. It is common for an infant to nurse infrequently in the first 24 to 48 hours [2].

Following the initial quiet alert stage after birth, baby goes into a deep sleep, recovering from the rigors of labor. Deep sleep is followed by increased wakefulness and increased nursing demands called "cluster feeding." Mothers often interpret cluster feeding as an indication that their baby is not getting enough milk [2]. This is the prime time during which mothers request supplemental bottles. Anticipatory guidance about these episodes can prevent the mother from assuming her milk is inadequate and giving supplemental bottles. Assure the mother that cluster feeding is normal and that it is actually a series of mini-feedings that are often followed by another period of deep sleep. Mother should be encouraged to catch up on her own sleep between cluster feedings [2].

Mothers should be encouraged to experiment with different breastfeeding positions prior to discharge from the hospital. There is nothing magical about a particular position, and she should be encouraged to use whatever position works best for her and her infant. The most frequently taught techniques are discussed below [2].

Since the late 1980s, more preterm infants of low gestational age and birth weight have been surviving. The percentage of preterm births in the United States rose 36% from 1984 to 2009 [238]. However, since 2010 the rate has been relatively stable, at 10.1% in 2021 [239,240]. Advances in technology have helped increase survival rates, and infant mortality rates for preterm infants are lower in the United States than in most European countries [238]. The milk from mothers of preterm infants is significantly different from that of mothers who deliver at term, and the composition of human milk changes in relation to how prematurely the infant was born. Discovery of the specialized nutritional and immunologic components in human milk have spawned enthusiasm for its use in the preterm infant.

Human milk is uniquely superior for all infant feeding. Preterm infants fed human milk derive significant benefits, including host protection and improved developmental outcomes, when compared to formula-fed preterm infants. Studies have documented the following health benefits for preterm infants fed human milk [21,241,242]:

Breastfeeding the preterm infant has also been associated with slightly enhanced performance on cognitive development and analgesic effect for infants undergoing painful procedures (e.g., screening heel-stick) [21]. For the mother whose infant is critically ill, human milk feeding becomes an important contribution to the infant's care. Additionally, it may encourage mother-infant attachment and provide maternal empowerment [241,243].

The Academy of Breastfeeding Medicine recommends encouraging breastfeeding ad libitum and on demand. It may be necessary to wake the infant if he or she does not indicate hunger cues within four hours of the previous feed, which is not unusual in the late preterm infant.

(https://www.bfmed.org/assets/DOCUMENTS/PROTOCOLS/9-galactogogues-protocol-english.pdf Last Accessed: April 12, 2022)

Level of Evidence: IV (Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both)

With a preterm birth, the growth and development of the infant's gastrointestinal tract is interrupted and forced to continue under conditions that are less ideal than the environment in utero [244]. The fetus starts swallowing amniotic fluid at around 8 weeks' gestation in volumes of approximately 200–250 mL/kg/day [244]. At term, the baby may be swallowing as much as 500 mL/kg/day, through which it receives carbohydrates, proteins, peptides, electrolytes, lipids, enzymes, and hormones [1,244].

Human milk contains amino acids and fat blends that offer distinct advantages to preterm infants. The protein content of human milk, which is 30% casein and 70% whey, also is more suitable for preterm infants than ABM [243]. Human whey proteins contain lactoferrin, lysozyme, and secretory immunoglobulin A (sIgA), which help prevent nosocomial infections, sepsis, necrotizing enterocolitis, and bacterial and viral infections in the preterm infant [243]. The lipids in human milk also provide nutritional benefits. The fat globules in preterm milk are smaller, aiding in their absorption directly from the immature gut. Premature infants lack the enzymes and bile salts needed for digestion of fats. However, they absorb more than 90% of the fats in human milk [243]. The long chain fatty acids present in human milk have been associated with adequate neurologic growth. This unique protein structure, ability to promote fat absorption, and growth-promoting pattern of fatty acids makes human milk beneficial to preterm infants [243].

Despite the benefits derived from human milk, the incidence and duration of breastfeeding preterm infants remains less than that of term infants. This is primarily due to the challenges of breastfeeding that parents of preterm infants must face, including [19,241,243]:

Establishing and Maintaining a Milk Supply

While a good milk supply is critical to the success of breastfeeding, establishing and maintaining one can be challenging for a variety of reasons. For example, because of their immaturity and inability to suck effectively, preterm infants generally are unable to breastfeed directly immediately after birth. This means that the mother must begin expressing milk immediately and commit to pumping, often for weeks to months, until her infant is physiologically stable and able to attempt nutritive sucking. Early expression is essential as delayed initiation may impair milk production and lead to lack of breastfeeding initiation or breastfeeding failure. Separation from her infant, due to the level of care the infant needs and/or prolonged hospitalization, can make maintaining milk supply uniquely challenging. If the infant's condition is precarious, the mother may be especially stressed and fatigued, which can further depress milk production [243,245].

For women with babies who are ineffective at milk removal or unable to feed at the breast (e.g., premature, hospitalized, hypotonic, anatomic problems), the Academy of Breastfeeding Medicine recommends regularly expressing by hand and/or breast pump. Ensure that the expressing technique and any breast pumps used are effective.

(https://www.bfmed.org/assets/DOCUMENTS/PROTOCOLS/9-galactogogues-protocol-english.pdf Last Accessed: April 12, 2022)

Level of Evidence: Expert Opinion/Consensus Statement

If the baby is ill and feeding will be delayed for longer than 24 hours, mother should begin pumping her milk. It is crucial to have the mother begin pumping within the first 24 to 48 hours after delivery to take advantage of the normal physiologic changes after parturition [2]. If the breasts are not stimulated, prolactin levels will fall by 50% within the first five days after giving birth and will drop to nonpregnant levels in seven days [2]. Very early pumping is for stimulation purposes only. It is important to tell the mother that no one expects her to obtain large volumes of milk initially. Babies can get colostrum easily because they strip the milk from the sinuses, but colostrum does not pump out well. Manual expression is recommended in the colostrum phase. What is important is the regular stimulation of the breasts to enhance the process of lactogenesis and to bring in a full milk supply. An abundant milk supply will assist later in the infant's transition to the breast. Counseling mothers of preterm infants has been shown to increase the incidence of breast milk feeding [246]. Praise the mother's expressing efforts. Assure her that all her milk will be used for her baby. Always use positive reinforcement. Be aware of subtle inferences that could be misconstrued by the mother that the amount of milk pumped is not enough for the baby.

The frequency and duration of milk expression directly correlates to the amount of milk produced [245]. The mother should pump every two or three hours to mimic a baby's natural feeding pattern. A tentative goal of 750–1,000 mL per day by 10 days postpartum will help her maintain her milk supply throughout lactation. This is a special concern in the mothers of preterm infants who often have milk supply difficulties [247]. Pumping should take full advantage of the increased vascularity in the breasts and the high prolactin level following birth. Pumping at least once during the nighttime is vital in the first few weeks to maintain milk supply. Good results may be obtained with a double electric pump system that allows for simultaneous pumping of both breasts. Continued use of either a commercial electric pump or a foot-powered pump appears to increase compliance with pumping and produces greater total volumes of milk [248]. Combining manual expression with electric pumping may increase milk production in the mothers of preterm infants [249].

Protocols for pumping and saving milk vary by hospital. Some hospitals require that all equipment is sterile at every pumping. Most authorities agree that human milk should be stored in sterile glass or polypropylene containers. Some breast pump manufacturers also sell 60-mL bottles specifically designed to avoid loss of components or leaching of plasticizers. Alternatively, 50-mL plastic centrifuge tubes have also been suggested for storage [1]. Plastic nurser bags are not appropriate because there is loss of immune components and a higher risk for contamination and breakage. Milk from several pumpings should not be mixed. If the milk is to be used within 24 hours, then the mother can refrigerate the milk and bring it to the hospital in a cooler. If it is to be used later than 24 hours after pumping, the milk should be frozen and kept frozen during transport [250]. When using pumped milk for infant feedings, a system of confirming proper identification should be used to prevent errors [251]. Even the smallest amounts of colostrum should be saved for the baby. Nurses should try to feed breast milk to the baby in the order that it was pumped to assist in the development of the infant gut.

A great deal of fuss has been made about bottles and pacifiers and ways to avoid them in term, healthy newborns. However, avoiding artificial nipples for the preterm infant often is inescapable and may not be as damaging as once believed. Because a major difficulty for mothers of preterms is the transition to feeding at the breast, nursery staff should try to help with this transition when the infant is stable and ready to begin oral feedings [241,261]. The transition from tube feeding to oral feeding can be accomplished in several ways [2,261,262]:

Imprinting with a bottle in this fashion mimics the multiple let-downs that naturally occur during breastfeeding. It also may help prevent flow preference, give the infant needed rest breaks, and reduce gastric distention from rapid feeding.

Remember that the baby's mouth is very sensitive. Multiple or forceful intrusions into the baby's mouth, often a part of survival for the preterm, may cause the infant to become "orally defensive." Gentleness and the utmost care are the rule.

Premature infants may be difficult to place at the breast in the Madonna (cradle) hold. A modified football (clutch) hold may help the mother latch the baby on, especially if the infant is attached to an IV line and monitor cables. The latch-on process remains the same, with the exception that the mother may wish to place her hand in the C-hold position with her fingers on the sides of the breast (i.e., the "dancer hold"). The premature infant may need jaw support. In the full-term infant, fat pads in the cheeks provide support for the lower jaw. The preterm infant normally has very little subcutaneous fat so the "suck pads" may not be fully developed. With the dancer hold, the baby's chin is supported by the fleshy portion of the mother's hand between the thumb and index finger. The baby's chin rests in the natural curve between thumb and index finger while the heel of the hand supports the mother's breast.

For the first feeding, start the mother out using the cradle hold; it generally feels more natural to her. If the latch-on is difficult, try the football hold. The baby may need help opening his or her mouth. Bring the baby up to the breast, not the breast down to the baby. Keep the baby's mouth in line with the mother's nipple. The mother may need to change the position of her hand in supporting the breast to provide support for the infant's jaw using the dancer hold. Try to stimulate the mother's let-down before latch-on. The mother who has been pumping long term must relearn to let-down to the baby instead of the pump when breastfeeding is initiated. Stimulation of the breast by the baby is different from that of the pump.

The baby may take longer to feed; up to 45 minutes per feeding is not uncommon. Studies have shown that breastfeeding produces less stress on the premature infant than bottle feeding. There is a decline in mean partial pressure of carbon dioxide and body temperature with bottle feeding. Body temperature and oxygen levels rise when the infant is breastfeeding [263].

Much controversy exists over test weighing before and after feedings as a measurement of breast milk intake (1 mL of breast milk weighs 1 gram). Electronic scales may give an accurate estimate of the infant's intake at the breast. The baby can then be complemented with additional expressed milk as needed [2]. The weight of the infant before and after feedings should not be conveyed to the mother as a measure of breastfeeding success.

The first feedings are get-acquainted periods rather than true feedings for nourishment. Non-nutritive breastfeedings will decrease as the infant matures. During these initial breastfeedings, the infant may not take a measurable amount of milk. Reassure the mother that this will improve as the baby matures. Recommend that the mother pump her breasts after each feeding for a few days after beginning breastfeedings until the infant suckle is stronger. The use of a feeding tube device may be needed to help strengthen the suckle.

The infant should not be discharged "breastfeeding" unless he or she is feeding very well and there is adequate follow-up [21]. If possible, contact a lactation consultant and arrange an appointment in the lactation clinic immediately after hospital discharge.

Breast shells are hard shells worn over the nipple between feedings and should not be confused with nipple shields. They can assist with inverted nipples, provide air circulation for healing sore nipples, and alleviate engorgement. Some manufactures make the entire shell of rigid plastic; other shells have a soft silicone face that rests against the breast. Hobbit-type shells have large air holes for ventilation. Shells that provide ventilation are highly recommended. Breast pads that do not occlude air flow should be worn outside the shell, if needed.

Breast shells are associated with problems. For example, they can cause pressure areas on the areola that result in plugged ducts. In clinical practice, cases have been seen in which mastitis either does not resolve after antibiotic treatment or recurs in a mother who is wearing breast shells. Solid shells may retain moisture against the breast, which can result in nipple soreness and/or thrush. The milk collected between feedings in the shells should not be kept to feed to the baby due to high bacterial contamination [2].

Breast pumps are medical devices regulated by the FDA. They are used to extract (express) breast milk. They also may be used to maintain or increase a mother's milk supply, feed multiple babies, relieve engorged breasts and plugged milk ducts, and pull out flat or inverted nipples so that a nursing baby may latch on to its mother's breast more easily [264].

All breast pumps consist of a few basic parts [264]:

The three main types of breast pumps include manual, battery-powered, and electric. They extract milk from the breasts by creating a vacuum around the nipple that pulls air into the breast shield and applies and releases suction. Each suction and release combination is called a "cycle" [264].

Many manual breast pumps use a system of two cylinders to create suction. After the breast shield is placed over the nipple and areola, a small cylinder-shaped tube is pumped in and out of a larger cylinder to create a vacuum that expresses milk and collects it in an attached container. Some manual pumps have a handle or lever that is squeezed to create suction and express milk from the breast. The breast milk is then collected in an attached container. Another type of manual pump is referred to as a bicycle horn pump and consists of a hollow rubber ball attached to a breast shield. One of the earliest breast pump designs, the bicycle horn pump got its nickname from the old-fashioned bicycle horns it resembles. To operate a bicycle horn pump, the breast shield is placed over the nipple and the rubber ball is squeezed and released to create a vacuum that expresses milk. Some experts discourage use of the bicycle horn pump because they may be difficult to clean and dry [264].

A powered breast pump uses an electricity source (batteries or an electrical outlet) to power a small motor that creates suction to extract milk from the breasts. One or more long plastic tubes connect the breast shield to the motor. The motor has a control panel with a dial or switch to control suction. Certain types of powered breast pumps may be adjusted to create different patterns of suction. Some manufacturers claim the adjustable suction allows the user to find a setting that closely mimics her nursing baby. It is important that women who use a powered breast pump are prepared for emergency situations when electricity or extra batteries may not be available. Having extra supplies for pumping and a back-up method, such as a manual breast pump, may help a woman maintain her breast pumping schedule during an emergency [264].

Success with pumps is highly individual; some brands or models work better for some mothers than others. The suction produced by the pump should be intermittent, not constant. It is the rhythm of the suction and compression of the areola inside the flange that empties the milk in combination with the suction. Suction alone will not empty the milk [2].

Numerous studies have shown that breast/nipple creams do not assist in the prevention or healing of sore nipples. Additionally, many ingredients in breast/nipple cream preparations may be hazardous to the newborn [265]. Breast and nipple creams generally are not recommended for the nursing mother by lactation consultants [2]. Table 12 is a brief list of some commonly used agents and comments on each.

There are very few appropriate uses for nipple shields. A nipple shield is an artificial nipple that is worn over the nipple and areola during feeding; the baby nurses through the shield. Nipple shields should not be confused with breast shells. Most nipple shields in use are made of silicone, although in the past rubber and latex versions were available. Studies of the rubber and latex designs have revealed reduced milk transfers of 58% and 22%, respectively [266,267]. Nipple shields have been associated with infant malnutrition and with cases of failure to thrive [2,268,269]. If necessary, only the thin silicone shields should be used, and the need for the device should be revisited frequently.

The available evidence does not demonstrate that nipple shields are safe in the long term for milk supply, infant weight gain, or duration of breastfeeding [267]. Therefore, nipple shields should be viewed as a "prescription" device requiring written documentation of need by clinical impression, a written treatment plan, and close follow-up. Lactation consultants maintain that the nipple shield is a device with a strong potential for misuse. An informed consent should be signed by the mother, father, and the provider recommending the nipple shield. Inappropriate prescribing of nipple shields can have serious legal consequences.

Both the Supplemental Nutrition System (SNS) and the Lact-Aid Nursing Trainer System are feeding tube devices whereby the infant can nurse directly at the breast and receive supplemental breast milk and/or ABM (Figure 3). The presence of an increased flow organizes the infant suckle, making nursing more efficient. Feeding tube devices may be recommended and used in many situations (e.g., failure to thrive, twins, low milk supply, induced lactation, breast surgery) in which other measures have failed in order to prevent complications. The goal of feeding tube devices is to stabilize the infant and maternal milk supply as quickly as possible and wean the baby from the tubes. Because these devices are used only in special situations, close follow-up is imperative to ensure adequate milk intake by the infant and validate correct use by the mother [2]. Use of the tube system in a normal, healthy breastfeeding infant solely for ABM and/or water supplementation is considered inappropriate.

FEEDING TUBE DEVICES

Figure 3

Source: Marie Davis, RN, IBCLC

Repeated calls to the hospital or physician's office for help with seemingly small problems may be indicative of postpartum depression (PPD). The rapid changes in hormone levels after delivery can be expected to cause some minor problems for new mothers. For example, some mothers may lack enough essential fatty acids for hormone production in the postpartum period [270]. In addition, sleep deprivation can cause behavioral changes. An estimated one in seven pregnant women will experience depressive symptoms during pregnancy and the postpartum period [271]. Untreated maternal depression may negatively impact the mother and the mother's other children and, when it occurs during pregnancy, may lead to pre-eclampsia, preterm delivery, and low birth weight [271].

Unfortunately, many women fail to recognize the signs and symptoms of PPD, and when they do, they fail to seek treatment [272]. Women with a history of prior depression, panic disorder, obsessive compulsive disorder, marital problems, premature delivery, premenstrual syndrome, or prior PPD are at highest risk for developing PPD. Additional risk factors include lack of social support, lower income and education, single status, life stress, and unintended pregnancy [271]. The American Academy of Family Physicians has listed the following as warning signs of PPD [273]:

The American College of Obstetricians and Gynecologists recommends that women be screened for depression during and after pregnancy and that the screening be coupled with appropriate follow-up and treatment when indicated [271].

As previously mentioned, the AAP has recommended exclusive breastfeeding for the first 6 months with a gradual introduction of iron-enriched solid foods around 6 months of age as a complement to breastfeeding [20,21]. The unique needs or feeding behaviors of some infants may indicate an earlier (i.e., around 4 months of age) introduction of complementary foods, whereas other infants may not be ready until around 8 months of age. Infants weaned before 12 months of age should not receive cows' milk [21]. Despite recommendations, some mothers introduce solid foods earlier or later than recommended. Education and information that target these mothers may help increase the number of infants being fed as recommended [274].

Mothers may agonize about when to start offering solid foods because they receive conflicting advice. Intense pressure to start solids often comes from well-meaning family members. Mothers also may believe that the introduction of solid foods is baby led and initiated by some physical characteristic or behavioral action of the infant. For example, studies have found that the main reason some mothers initiate solid feeding is a perception that weaning is "necessary" to satisfy the infant [275].

Reassure the mother that she is doing the right thing. Certain developmental milestones can help her determine if her baby is ready for solids [2]:

Total weaning is the complete cessation of all breastfeedings. Prior to 1979, the average age of the baby at weaning worldwide was 4.2 years [1]. The average breastfeeding duration in the United States is well below one year; consequently, many physicians consider six months to be "extended breastfeeding" [13]. However, there is no deadline for a baby to be "off the breast." The benefits of breastfeeding continue for both mother and baby for as long as they nurse. Weaning should be done gradually over a period of weeks or months so it is not stressful for mother or baby. Successful breastfeeding means attaining the mother's personal breastfeeding goal. Whether she chooses to breastfeed for six weeks, six months, one year, two years, or more, the decision is entirely hers to make.

Domperidone and metoclopramide are the most commonly used pharmaceutical galactogogues at present. Both are dopamine antagonists that increase prolactin secretion. The Academy of Breastfeeding Medicine cites a number of older, mainly observational or controlled studies documented increased baseline prolactin levels in lactating women who took metoclopramide or domperidone that provide some evidence for their effectiveness. However, the population that would most benefit from this treatment is still uncertain as it is unknown if all women with low milk supply have low levels of prolactin and whether increasing prolactin increases milk supply in women with both low and normal prolactin levels.

(https://www.bfmed.org/assets/DOCUMENTS/PROTOCOLS/9-galactogogues-protocol-english.pdf Last Accessed: April 12, 2022)

Level of Evidence: IIA (Evidence from at least one controlled study without randomization)

There are few drugs that require that mother stop breastfeeding. Questions that should be considered prior to prescribing drugs to a breastfeeding mother include [276]:

The National Library of Medicine, a division of the National Institutes of Health, provides a searchable database of drugs (LactMed) to which a breastfeeding mother may be exposed. The database provides such information as maternal and infant levels of drugs, possible effects on breastfed infants and on lactation, and alternate drugs to consider (Resources). An AAP policy clinical report on the transfer of drugs and therapeutics into human milk focuses on the use of psychotropic medications, narcotics, galactagogues, and herbal products [276]. The AAP also recommends referring to LactMed for more detailed, up-to-date information.

Physicians who encounter adverse effects in infants who have received drug-contaminated human milk have been urged to document the effects and contact the FDA. Additionally, herbal remedies have become increasingly popular. Table 13 contains a list of commonly used herbs and their effect on the infant through mother's milk.

La Leche League is a support group for breastfeeding women and their families that was founded in 1956 in response to the need for supportive breastfeeding information. It began as a small group and has since grown into an international organization with local chapters in many U.S. cities. Contact information for the League is available in the Resources section of this course.

A lactation consultant is a formally trained breastfeeding expert. The International Lactation Consultant Association (ILCA) is the professional association for International Board Certified Lactation Consultants (IBCLCs) and other healthcare professionals who care for breastfeeding families. An IBCLC is a healthcare professional who specializes in the clinical management of breastfeeding. They are certified by the International Board of Lactation Consultant Examiners, under the direction of the U.S. National Commission for Certifying Agencies. IBCLCs work worldwide in a variety of healthcare settings [283].

Consultants come from a variety of backgrounds, and include nurses, educators, and individuals who have counseled breastfeeding women for many years. Hospitals often have a lactation consultant associated with their maternity unit. Training and approach to difficulties may vary slightly among consultants. The one thing that all lactation consultants have in common is the sincere desire to help women toward a successful breastfeeding experience.

What can I expect in the first few days? Some infants nurse avidly right from the start. Others may take time to recover from labor and should pick up within 24 hours. The first feedings are a "get acquainted" time for both mother and baby.

Typically, the newborn will take one or two tries to latch-on, take four or five suckles, swallow, and then pause and begin suckling again. This is normal. Encourage the mother to keep the baby awake by talking, rubbing, and gently bouncing him or her at the breast when pauses seem too long.

Is there anything in my breasts for my baby? My breasts feel empty. Many think of the breast as a container that is either full or empty. The breast does not work like a bottle. The majority of breast milk is made during feeding. The breasts have very little storage space. Breastfeeding requires a mother to confidently trust that her breasts will do what they are meant to do, even though she cannot see the milk being consumed. She can, however, easily see how many wet diapers and stools the baby is having every day.

Colostrum, the first milk, is produced even before the birth. It is very thick and yellow and is like sucking maple syrup through a straw; so, feedings will seem a little long at first (up to 60 minutes). Colostrum is a super booster of antibodies and contains everything that baby needs. The baby will usually take small amounts of colostrum in the hours after birth, gradually increasing intake so the digestive system starts up slowly.

Are sore nipples normal? Mild tenderness is normal in the early days of nursing. The mother may feel some discomfort in the first minute of a feeding as baby stretches the nipple into his or her mouth. This nipple stretching pain should stop in a few days. When the baby is nursing correctly, the mother should feel a gentle tug, not a pinching sensation. If the latch is incorrect, break the latch and try latching on again until it is not painful. Limiting the time at breast will not prevent sore nipples. Long frequent feedings prevent engorgement, which is a contributor to sore nipples. If the mother develops blisters, scabs, marks, bleeding, or pain between feedings, she should contact a lactation consultant for assistance.

When will my milk come in? Mature milk comes in within three to five days after the baby is born. Because mature milk is thinner, feedings should not take any longer than 40 minutes. If the baby is taking longer than 45 minutes to complete most feedings after the mother's milk is in, there may be a problem. If the baby is having a good number of wet diapers, several stools per 24-hour period, and is gaining weight, then the baby may be a "gourmet-type" eater (i.e., a slow and easy feeder). If there are symptoms of low breast milk intake, the mother should contact a lactation consultant for assistance.

How will I know if I am engorged? A mother's breasts will start to feel heavier and firmer as her milk comes in. This is due to increased circulation in the breast. Mild engorgement is a sign that the mature milk is in. Moderate-to-severe engorgement, during which the breasts become tender, firm, or lumpy, is not normal. Painful engorgement occurs from tissue swelling, trapped milk, or a combination of both. The breasts may not be "full of milk" as many believe. The tissue around the milk-producing glands may be swollen and painful. Sore nipples usually follow engorgement because the areola becomes too firm for the baby to latch on properly.

Why can't I feel my let-down? In the early days of breastfeeding, many mothers do not feel the let-down. It may take a week or two before she can recognize the milk ejection reflex. Occasionally, some mothers never feel the let-down, but they are aware of it because milk drips from the opposite breast during a feeding, she feels warm or thirsty, and/or the baby has bursts of rapid swallowing.

How much rest will I need? Immediately following the birth of the baby, it is important for the mother to get enough rest, whatever the feeding method. Many new mothers neglect their need for rest. The mother's sleep is interrupted by night feedings, so she should be encouraged to nap or, at the very least, rest with her feet up when the baby naps. For a week or two, the mother should not use the baby's slumber time as a time for getting household chores done. In the early weeks after giving birth, the mother's body needs to heal from labor. If she has had a cesarean, at least two full weeks of good rest will be needed. The mother should be encouraged to resist the temptation to be "super mom." By becoming run down, depression can set in and her body will not have enough stores for self-healing, much less the production of breast milk.

What is most important in my diet? The mother should drink enough liquids to quench her thirst. For good health, a minimum of eight, 8-ounce glasses of fluid per day are recommended. A good habit for the mother to develop is to have a glass of something to drink every time she feeds her baby.

Many women worry needlessly about their diets while breastfeeding. Often, women feel deprived because someone told them that they cannot eat certain foods while nursing. Some common myths are that eating chocolate makes chocolate breast milk or that cabbage, beans, and other gas-producing foods will make the baby have gas. Onions, garlic, and other aromatic spices will flavor the milk, but babies rarely object to the difference in taste.

On occasion, some foods may affect the baby. The mother should make note of what the particular food was, eliminate it for about a month, and then reintroduce a little of the food. Usually, the reaction was merely a sensitivity and not a true allergy. The mother should avoid overdoing any one type of food or beverage. Everything in moderation is excellent advice.

The mother should eat a well-balanced diet consisting of all food groups. She will need three meals and at least two small snacks every day. As long as she is nursing, the mother should continue to take her prenatal vitamins to replenish her own body stores. If a mother does not drink milk or use dairy products, a non-lactose calcium supplement should be added to her diet.

The recommended caloric intake for the breastfeeding mother is 2,200–2,500 calories per day or about 500 calories more than her pre-pregnancy diet [284]. (The average U.S. adult woman's diet consists of about 3,000 calories per day.) The majority of the weight she gained in pregnancy should be lost by six to eight weeks postpartum. Most mothers will not gain weight while breastfeeding unless they are severely underweight at the end of pregnancy. Breastfeeding mothers will often retain an extra 5 or 10 pounds until several weeks after weaning. This additional body weight protects the mother's ability to produce milk in case of illness or a severe reduction in caloric intake.

Weight-loss diets are not recommended while breastfeeding. The mother who is gaining weight while breastfeeding should closely examine her diet for "empty calories" and activity level. Fruit juices may be a source of excess caloric intake for the breastfeeding mother. Because she is thirsty, the intake of juice can be quite surprising, sometimes as much as a gallon a day. Another source of calories is whole cows' milk. Many women falsely believe that they need to drink large amounts of cows' milk to make breast milk. Cows' milk is an excellent calcium source, but the calcium is also present in low-fat and skim milk.

If a mother is more than 50 pounds overweight after six weeks, a reduction in calories to not less than 2,200 calories per day is recommended for weight loss while breastfeeding. Weight reduction diets should be started no sooner than six weeks postpartum. Liquid diets, powders, and other very low-calorie diets are not recommended. These diets are basically starvation diets. In the breastfeeding mother, body fat will be retained and lean muscle tissue used for the production of breast milk. When the mother returns to her previous diet, the body will then store more fat as a defense mechanism against future episodes of starvation.

Besides watching calories, an increase in activity is suggested, beginning with a walk outdoors with the baby at least once a day. The mother should gradually work up to an exercise program.

How will various drugs affect me? Just as when she was pregnant, most items the mother ingests can be passed on to the baby through her breast milk. Of primary concern are caffeine, alcohol, nicotine, and over-the-counter remedies. The mother should inform her physician or dentist that she is nursing a baby if a prescription medication is needed to treat an illness.

Alcohol in moderation (an occasional glass of wine or beer) is usually not harmful and can help the mother relax. However, overuse of alcohol reduces the milk supply, is harmful for both the baby and the mother, and is not advised.

Smoking should be avoided. Nicotine appears in quantity in breast milk, and the effects of secondhand smoke negate some of the benefits of breastfeeding. There are a variety of smoking cessation aids available if necessary.

If the mother wants to breastfeed, the fact that she smokes should not be used by healthcare professionals to prevent her from nursing. She should try to limit smoking to only when she "needs" a cigarette, smoke outside, and try not to smoke for at least 20 minutes before nursing the baby. She should never smoke while holding the baby. Other smokers in the home should be encouraged to smoke outside. When given realistic parameters, many women find it easy to comply and may even be able to actually quit after cutting down.

Caffeine can make a baby wakeful, restless, fussy, and/or gassy. However, many babies do not appear to be bothered by caffeine. The mother should be encouraged to limit her intake of caffeine to no more than three servings of caffeine-containing foods or beverages per day (e.g., coffee, tea, cola, chocolate).

The mother should always check with her healthcare provider or a lactation consultant before using any over-the-counter medications, including herbs and holistic remedies.

The maternal use or addiction to illegal drugs should be a cause of major concern to any healthcare professional. Drug use becomes a matter of child endangerment if the mother wishes to breastfeed. Mothers with a history of drug abuse are routinely given a drug screen upon admission in labor by some hospitals. A mother who has a positive drug screen in labor has used drugs recently. If the mother did not stop using during pregnancy, she is not likely to stop using because she wants to breastfeed. ABM is the feeding method of choice in these cases. The mother will need drug counseling, and the appropriate referrals to local agencies must be made.

How can I best care for my breasts? The breasts should be washed daily with water only during the mother's shower. The breast does not need to be washed before or after every feeding. This strips the natural protection from the nipples and may cause nipple soreness. The mother should not use breast creams. Rather than creams, she should apply a few drops of breast milk to the nipple and areola after each feeding. The breasts should then be air dried for a few minutes and clean breast pads placed in her bra. Remind her that she should wash her hands well before each feeding, after changing diapers, and after using the bathroom.

Leaking of milk from the breasts is common in the early weeks of breastfeeding. The mother should use breast pads to absorb any leakage of milk. (Leaking will usually stop in a few weeks.) Nursing pads should be pure paper. The mother should not use pads with plastic liners. (If she is not sure, she should take the pads apart.) Washable pads can also have a moisture-proof barrier in them and can become rough after repeated washing. The mother can make the best reusable pads herself or she can use folded 100% cotton handkerchiefs or super-absorbent diapers.

Inconvenient let-downs may occur any time. If the mother is in a place where she needs to stop a let-down, she should place the heel of her hands against her nipples and press in, toward the chest wall. The pressure will stop the flow. It is important to tell her not to do this too often as repeatedly stopping the flow can lead to painful plugged ducts and mastitis. She should also be told not to stop the leaking that often occurs at the opposite breast when the baby nurses. The milk should be allowed to flow freely. Debate exists about the use of "drip milk" for later feedings. It is believed that the milk dripping from the breast is primarily foremilk. If drip milk alone is used in a subsequent bottle-feeding, there is the possibility that the baby may only receive lower calorie foremilk.

What special clothing will I need? No special clothing is needed to breastfeed. The following is just a suggestion: The new mother should wear a good fitting nursing or supportive bra as much as possible, especially in the early weeks when the breasts are quite heavy. It is not necessary to tell the mother that she must wear a bra at night. Many mothers feel more comfortable if they wear a bra at night, but this may be uncomfortable for other mothers.

How can I nurse without exposing my breasts? Once she is comfortable nursing the baby and that "all-thumbs" feeling goes away, nursing around others will be easy. Nursing fashions with hidden openings are available at maternity shops. Patterns for nursing fashions are available from several companies. Wearing loose-fitting tops that pull up, rather than unbutton, are better for breastfeeding in public. The baby will hide the mother's bare midriff. A blanket or large scarf thrown over her shoulder works well. If a mother is at home and is concerned about visitors, she can just excuse herself and go into another room if needed. People are becoming more accustomed to seeing women breastfeed but will occasionally make comments. Tell the mother to handle comments as diplomatically as possible, but never to make excuses to anyone for breastfeeding her baby. She is nursing because she feels that breastfeeding is best for her baby.

Are there women who do not make enough milk? My experience has been that the majority of women produce an abundant milk supply, enough for twins and triplets. Difficulties arise with milk supply when too many bottles are given or the mother does not keep up her supply by pumping when the baby cannot nurse. Occasionally, women who are critically ill or who have had a mechanical change in the breast, like breast surgery or an injury to the breast, may not produce enough milk. If the mother thinks her supply is low, she should contact a lactation consultant for assistance.

Do I have to wake the baby for feedings? Many babies are sleepy in the first few days of life. This is especially true if the mother had a long labor, received oxytocin or pain medications, or if there is a great deal of molding or bruising of the baby's head. It is important to wake the baby for feedings at least every two to three hours during these early days. The new mother should not skip a feeding so she can rest unless she is severely tired. Repeatedly skipping breastfeedings can interfere with the milk supply and cause engorgement.

Many newborns may not wake for hunger pains at first. Letting the baby sleep may contribute to weight loss and dehydration. To wake a sleepy baby, stimulate by bathing the baby, undress to provide skin-to-skin contact, talk to the baby, or rock and pat the baby. It may also be useful to lower the environmental temperature [136]. (Many infants will fall asleep if it is hotter than 80°F.) The mother should be advised to use pain medication only if needed. She should seek medical assistance if the baby seems too sleepy, does not want to nurse as often as expected, or constantly falls asleep at the breast before at least 10 minutes of active sucking and swallowing.

Once mother's milk is in, she can stop watching the clock. The baby will now need 8 to 10 feedings in a 24-hour period. Nursing styles differ, but it is generally recommended that she go no longer than three to four hours during the day time and a six-hour stretch at night. Of course, if the baby demands to be fed more often, she should feed him or her.

How do I know if my baby is getting enough? Breastfeeding mothers often ask this question. She can be assured that all is well if, at five days postpartum:

Mothers often need to be reminded that babies suck reflexively. Sucking does not always suggest that the baby is still hungry. Reflexive suckling means that the baby will suck on anything that is put in or near his or her mouth. A baby may empty a bottle of water or ABM right after breastfeeding due to this reflex.

Should I give my baby supplemental bottles of water or ABM until my milk comes in? Supplemental bottles of water or ABM are not recommended for the healthy newborn. There is a danger of artificial nipple preference in these early days. There is also some evidence that the hard surface of the bottle nipple is a supernormal stimulus. The baby may not react to the soft nipple and areola with suckling when returned to the breast.

A baby must learn how to nurse. It is best to avoid the use of bottles for at least the first three weeks. By giving bottles, the baby may have difficulty learning to do both or may develop a preference for the fast, easy flow and/or hard surface of the bottle nipple. In addition, mother's body must be convinced that there is a baby to feed while the milk-making hormones are at their highest levels. Bottles of water or ABM can lower the milk supply or lead to painful engorgement. Also, water and ABM do not prevent jaundice.

What if my baby needs bottles after birth because of a medical problem? It would be foolhardy to refuse the use of bottles for a baby who is ill. If the baby gets used to the bottle and is having difficulty latching on, the mother should try:

What if my baby will not latch-on at all? The number one rule is: feed the baby. If mother can express enough milk, she should give it to the baby in a bottle. If she is unable to express enough milk, then ABM is necessary.

Remind the mother that if her baby is not latching on, she needs to pump her breasts at regular intervals (8 to 10 times per 24 hours) to maintain her milk supply until she can get assistance from a lactation consultant with the latch-on problem.

Is it normal for my baby to have liquid stools? Normal breastfed stool is almost all liquid with small milk curds. It is yellow, resembling runny egg yolks, and has very little odor. The baby will most likely have a stool after every feeding. In some cases, the stools are rather explosive sounding. Diarrhea in a breastfed baby is rare. Diarrhea stools are frequent, green in color, full of mucus and/or blood flecks, and are rather foul smelling. If there is any doubt, the mother should contact the baby's physician immediately. True diarrhea in a baby quickly leads to dehydration. The breastfed baby may occasionally have diarrhea-type stools accompanied by colic-like crying if a mother is taking stool softeners after delivery. Stool softeners and laxatives are not recommended for the nursing mother.

Is it normal if my baby sleeps all day? A baby can be overly sleepy in the newborn period. Some infants just stir around a little in their cradle and, if left alone, will fall back to sleep. It is important for the mother to observe the infant for sleep-wake cycles. She should attempt to wake the baby when he or she begins to stir.

To wake the baby, mother should pick him or her up, talk, play, and/or rub his or her feet. Any combination of these may be needed to wake the baby for feedings.

What if my baby is awake all night? For about the first four weeks, most babies have their days and nights mixed up. In utero, the mother's daily activities "rocked" the baby to sleep during the day. Remind her of what happened every time she got into bed at night: the baby would wake up and begin to kick. The baby should settle into a normal day/night routine soon.

Babies begin to sleep through the night (defined as sleeping a six-hour stretch) around 8 to 12 weeks of age. Some babies take longer. Body weight may also play a role. Many babies begin to sleep through the night when they weigh 12 pounds. There are the occasional few who do not sleep through the night until toddlerhood. Mothers frequently believe that if they give the baby ABM or start solid food, the baby will sleep better. Feeding method makes no difference. Giving the baby cereal will not make the baby sleep through the night. It can backfire and make the baby more wakeful or cause gastric distress.

What about parenting advice that recommends scheduling feedings or not allowing the baby to nurse on demand so he or she will learn a routine? Babies have no sense of time. Letting them cry it out, even for a few minutes, can be an eternity of abandonment for infants. Mothers should be told to listen to their instincts, not ill-placed advice. A baby's needs should come first, within reason. If the advice she is following feels wrong for her baby, she should stop. Severely restrictive schedules and unrealistic behavior expectations can lead to failure to thrive or child abuse.

Should my baby be in his or her own room? I firmly believe that as long as the baby is still nursing at night he or she should be close by. Many mothers have told me that if they do not have to get out of bed to feed the baby, they can fall back to sleep much easier. Having the baby close, where mother can pull him or her into bed to nurse is easy.

Some mothers find that they cannot sleep well if the baby is close by because they wake up every time the baby makes a sound. New mothers sleep lighter for a good reason: newborns choke frequently. The mother sleeps lighter to be able to wake easily if any danger is perceived.

The AAP has recommended that, "the infant crib or bassinet be placed in the parents' bedroom, which, when placed close to their bed, will allow for more convenient breastfeeding and contact" [285]. There are special cribs that connect to the parents' bed to allow babies to be moved over to feed, then slid back safely into their own bed. Soft surfaces, bumper pads, waterbeds, blankets, sheets, pillows, heated mattress pads, and stuffed chairs and couches are all dangerous for the baby; both sleeping on the stomach and entrapment are significant causes of infant death. An infant should never share a bed with older children.

Is it safe to have my baby in my bed? Breastfeeding mothers often find it more convenient if the baby sleeps in the same bed for night feedings. Although the possibility of rolling over on the baby exists, most mothers cradle the baby in their arm while they are asleep. Because mothers become amazingly light sleepers, they are aware of the baby's every movement. If a mother were to roll over on her baby, the baby would struggle and mother should wake up. There is evidence both for and against co-sleeping to prevent SIDS.

However, the AAP has stated that bed sharing "can be hazardous under certain conditions" [285]. The AAP's Task Force on SIDS has recommended that "infants not bed share during sleep" [285]. Infants may be brought into bed for nursing or comforting but should be returned to their own crib or bassinet when the parent is ready to return to sleep. This, of course, applies only to normal sleep. The mother (or father) who is taking pain medication, sleeping pills, or drinks any amount of alcohol will sleep very deeply; the baby should not be left in the bed in these cases. Extra pillows can be a hazard if the baby is in the bed. Parents should be warned to never put the baby face down on a traditional waterbed. The waterbed mattress can fold up around the infant's face or trap the infant so that he or she cannot move to breathe. Also, the parent's bed should be in the center of the room, away from any walls on the sides and/or bottom. Headboards should not leave any space where the baby might fall in and become trapped. Parents often place a rolled towel at the head of the bed to help prevent trapping. Infants have died when they have become trapped between the mattress and the wall. A baby should never be left in an adult-sized bed alone. Babies are more mobile than parents realize. It is easy for the baby who is left alone to squirm or crawl into cracks and crevices or under pillows and blankets and possibly suffocate.

What if I get sick? The mother should continue to breastfeed her baby, even if she is ill. Once the signs of a viral infection begin, the baby has already been exposed to the virus for several days before her symptoms started. The antibodies that the mother's body is making against the viral illness will go into the breast milk and help the baby get over the illness faster. If the mother is too ill to nurse, instruct her to pump her breasts. Remind the breastfeeding mother to check with her doctor before using any over-the-counter remedies. Antihistamines will lower the milk supply if she does not keep well hydrated. The mother should drink plenty of fluids and get lots of rest.

What if my baby gets sick? In the event of a fever greater than 101°F, an exceptionally congested nose, vomiting, and/or diarrhea, an infant's medical provider should be contacted. A congested nose will make it difficult for a baby to feed. Babies with ear infections may refuse to nurse because suckling may worsen ear pain. The mother can feed breast milk from an eye dropper, sipper cup, or spoon. The baby may demand to feed more when sick. The medical provider may recommend that the baby receive only liquids for a while; breastfeeding is appropriate. If the baby must be hospitalized, make arrangements with the staff for the mother to stay with the baby while hospitalized. If this is not possible, the mother should pump her breasts on a regular basis to maintain a good milk supply.

What is colic? Colic is a catchall term used by parents for a fussy baby. Infants cry for a variety of reasons. Parents should be told that crying is normal. Lengthy bouts of infant fussiness are often labeled as "colic" by the parents. It is normal for every baby to have a daily, predictable, fussy period, usually between 4:00 p.m. and 11:00 p.m. The baby may be reacting to the increased level of activity in the household. The mother should prepare for the fussy time by getting any possible household duties out of the way, before the baby gets fussy. She should use calming measures such as a warm bath, rocking the baby, soft music, going for a walk outdoors, swaddling, or a baby carrier.

In the medical profession, colic is defined as inconsolable crying accompanied by apparent intestinal discomfort. If the baby cannot be comforted, the mother should seek assistance from the baby's doctor. Do not advise the parents to let the baby "cry it out." This is very dangerous. If the baby is crying, there is a reason. Colic is often defined as crying for more than three hours a day, three times per week, for more than three weeks [286].

Colic may be caused by a variety of things (e.g., an immature digestive or nervous system, excess torsion of the head and neck at birth, sensitivity to the environment). One possibility is that colic is the result of a reaction to foreign proteins, especially to ABM. If there are no identifiable allergens in the mother's diet (e.g., cows' milk, eggs, nuts), colic symptoms are often the result of an overactive let-down reflex or overfeeding syndrome. Infants of mothers with an overabundant milk supply will often gain up to one pound per week. A very small percentage (2% to 3%) of infants diagnosed with colic have true colic. The remaining percentage can be attributed to other causes.

If the infant is exceptionally gassy or is gulping and choking at the breast, the baby may be getting too much milk too fast or swallowing large amounts of air. The mother should be instructed to burp the baby more often. If burping more frequently does not help with the fussiness, the baby should be examined by a pediatrician for any signs of illness. If illness has been ruled out, the mother should be referred to a lactation consultant before the baby is placed on any medication for colic. In most cases, reaction to oversupply syndrome is quite simple to correct by changing the baby's feeding pattern. A baseline infant weight is critical before mother changes the feeding pattern. After a change is made, the baby should have several weight checks, one week apart, to determine if the baby is continuing to gain well.

What if my baby has a slow weight gain? Seek assistance from a lactation consultant at once. The consultant will try to identify if there is a problem with the breastfeeding. Together with the baby's physician, a lactation consultant can suggest a method of treatment to assist with the lack of weight gain. The mother should always continue to see the baby's doctor for follow-up care and any testing that may be needed to determine or eliminate a medical cause while under the care of a lactation consultant.

Is my baby getting all the necessary vitamins? Breast milk contains everything necessary for the baby. Vitamins, including fat-soluble A, D, E, and K, are present in highly usable forms in breast milk. The AAP has recommended that all breastfed infants receive 400 IU of oral vitamin D drops daily beginning during the first 2 months of life and continuing until the daily consumption of vitamin D-fortified formula or milk is 1,000 mL. The AAP also has recommended that supplementary fluoride not be provided during the first 6 months of life. From 6 months to 3 years of age, the decision whether to provide fluoride supplementation should be made on the basis of the fluoride concentration in the water supply and in other food and fluid sources and toothpaste [21,287].

Should I give my baby extra water or juice? Breast milk is approximately 90% water. Baby gets all the water he or she needs from breast milk, even on the hottest days. To ensure an adequate supply of breast milk, the mother should drink to quench thirst.

I will be returning to work. How can I best introduce my baby to a bottle? If the baby will need to take a bottle later because the mother is returning work, the first bottle should be introduced between 3 and 6 weeks of age. An occasional bottle after three or four weeks usually will not interfere with the milk supply or cause "nipple confusion." If the mother waits too long to introduce the first bottle, the infant may not accept it. Bottles should be given by someone other than baby's mother.

The first bottle feedings should be given at a time when the baby is not overly hungry. The caregiver should not hold the baby in the "nursing position." The baby should not be upset by the experience, so the caregiver should not insist that the baby take the bottle. If the baby does become upset, he or she should be soothed first and then the bottle tried again. Bottles of expressed breast milk or ABM should be continued once or twice a week.

There is the occasional baby who absolutely will not take a bottle. Some laypersons may believe that the baby should be left hungry to "starve him into submission." This attitude defies logic and is dangerous. An eye dropper, spoon, or a small cup (shot glass) can be tried when the baby will not accept the bottle. Infants who refuse to take anything other than the breast will often choose to sleep while the mother is away and "stack up" or frequency feed when she is home. This refusal is the ultimate compliment (although it may not seem like it at first) because the baby truly prefers the mother's breast.

What if I lose my milk? This is highly unlikely. For the first few weeks, the mother's body is not aware that she did not have twins. After about six weeks, the breasts become more efficient at making milk and no longer need to overproduce. Supply has finally caught up with demand. The firmness once felt as engorgement is expected to disappear. Production of milk is now entirely dependent on the infant nursing at regular intervals. When the baby suddenly seems hungrier than usual, one thing to consider is that he or she may be having a "growing day." The baby is trying to bring the mother's milk supply up to these new needs. These growth spurts usually occur around 3 weeks, 6 weeks, 3 months, and 6 months of age. The baby should be back to the normal schedule within 24 to 48 hours. The mother should be instructed to count wet diapers for an estimate of infant intake. The baby should have a minimum of six to eight wet diapers per day.

What if I feel like my milk supply is low? The mother should be advised to improve her nutritional status with three meals and two small snacks per day (2,200–2,500 calories) of well-balanced foods. Other helpful hints include:

Will a breastfed baby become constipated? For the entirely breastfed infant, constipation is rare. Because ABM has more waste products, constipation is a common problem with ABM use. Constipation means the passage of dry, hard stools, not the frequency of stools. After 6 weeks of age, it is not uncommon for the baby to go two or three days without a stool. Near 6 weeks of age, the bowel matures, and the stool pattern becomes more regular. It is important to teach the mother that her baby will develop his or her own stooling pattern. If any ABM is used, the infant should have a stool at least once a day.

What if my baby suddenly refuses to nurse? An ear infection can make it painful for the baby to nurse. Nasal congestion can also make nursing difficult. If the baby is ill or has a fever, call the baby's physician.

When babies wean themselves from the breast, it is a gradual process. Provided there are no signs of illness, this may be a "nursing strike." Has nursing become stressful? Is the household overly busy? Has the baby been frightened at the breast? Has he or she had a mouth injury? Is he or she teething? Did the mother change bath soap, deodorant, or perfume? Has the baby been getting a bottle or pacifier frequently? Is the baby learning how to crawl? (Pre-crawling boredom can make a baby too restless to settle down to nurse.) There are several things to try. Nurse the baby when he or she is asleep or almost asleep, in a darkened room. Offer the breast frequently but do not insist. If the problem continues for longer than 24 hours, seek assistance first from the baby's physician to be sure that the baby is not ill, then refer to a lactation consultant.

What if my baby only takes one breast and will not take the other? Babies occasionally develop a preference for one breast over the other. Ask the mother whether there is any difference in the shape of the nipple or the entire breast. Have her offer the breast that the baby will not take between feedings or when the baby is almost asleep. Also, she can try to hold the baby in the same position as when nursing from the other breast. The problem should resolve itself in one or two days. If the baby will not take the other breast at all, the mother should pump the breast that the baby has not nursed on to prevent plugged ducts and mastitis and to help keep the milk supply even. If the problem does not resolve quickly, she should refer to a lactation consultant for assistance.

What can I do when my baby bites? Newborns do not bite; they clamp. Biting occurs more often in the baby who is 4 to 6 months of age and older. If the baby bites, the mother should immediately break the latch and gently tell the baby, "Don't bite." She should then put the baby down and walk away. This signals that the feeding is over. The baby will soon understand that biting means not finishing the feeding. The mother should take care not to frighten the baby or raise her voice, as this can induce a nursing strike. Secondly, tell the mother to begin to pay close attention to the baby's nursing pattern. Mother will be able to feel the tongue pull back just before the bite. She should be instructed to quickly insert a finger into baby's mouth and stop the feeding. She should always end the feeding with the same words: "Don't bite." Babies usually bite when they are teething, so mother should check the baby's mouth for swollen gums or the beginning tips of the teeth poking through the gum. The pressure feels good on the sore gums. Babies are most likely to bite at the beginning of a feeding or as they fall asleep.

What if my baby will not sleep unless he or she nurses? Most children younger than 3 years of age cannot go to sleep without assistance of some kind. Nursing helps them relax and doze peacefully off. In some cases, a baby will become so overly tired that it will take quite a bit of effort to settle down enough to sleep.

If the baby begins to wake again during the night, the mother may need to nurse him or her back to sleep. Night waking usually resumes during teething. The mother should try calming the baby first.

Is it appropriate to nurse in front of my other children? Yes. What better way is there of teaching them the value and normalcy of breastfeeding than to be an example to them? The bottle is considered so normal in this culture that children's stories depict animals using bottles. Baby dolls and stuffed toys come with bottles. Children can grow up believing babies are supposed to be bottle fed. Breastfed toddlers have been known to "nurse" their dolls, imitating the mothering skills they have seen. A child may ask her mother to nurse a doll or teddy bear. Have the mother play along with the game.

What should I do if one of my older children asks to nurse? First, do not panic. This is a normal question. The mother should try to discover the reason for the question. Most children are merely curious about the taste of breast milk, especially if they are told that they were nursed, or they may want to know why the baby likes it so much. The mother can express her breast milk into a cup and let the child taste it.

What if my husband feels like he has nothing to do for the baby? In the early weeks, the father's job is to "mother the mother." He can be in charge of making sure she rests, gets enough to eat, help with the household chores, protect her from too many visitors and people with negative attitudes about breastfeeding, and help her assume her new role as a mother. Taking care of a baby involves more than feeding. Dad can change diapers, take the baby for a walk, play, or cuddle. The options are endless.

Will breastfeeding interfere with my sex drive? A new baby is a full-time job. The mother may simply need to go to bed to sleep and nothing more. This will happen no matter how she chooses to feed the baby. Some women report an increase in sex drive while nursing. Others report that they do not have as much of a drive as they used to. Either extreme or a combination of these is quite normal. It is important for couples to remember to make time for intimacy.

What about birth control? Breastfeeding may help with natural family spacing. As long as a baby is exclusively breastfed, women usually do not ovulate, and menstrual periods may not return for several months. While breastfeeding delays the return of ovulation, the mother should be informed that awaiting the onset of menstruation before beginning contraception is not advised and may put her at risk of unintended pregnancy [170]. There are many contraceptive regimens available for breastfeeding women, including hormone, barrier, and sterilization options. It is important to note that the lactational amenorrhea method (LAM) of birth control is only effective if the mother is exclusively or almost exclusively breastfeeding, feedings are no more than six hours apart, and menstruation has not returned.

What if my breasts leak during sex? If the breasts leak during intercourse, the mother should nurse the baby before intercourse and pad the bed with towels. The same hormone that causes the let-down reflex, oxytocin, is released with orgasm. In the early weeks, the breasts often respond to the mother's orgasm with a let-down. This is not harmful and is quite normal.

Can my partner fondle or kiss my breasts? Yes. Some women find that their breasts are more (or less) sensitive to touch while they are nursing. If they are too sensitive, she should tell her partner. Some men may falsely believe that they will harm the milk if they touch or kiss the breasts, and some men are fascinated by the whole process of lactation. If her partner has an active herpes outbreak, however, he should not kiss the breasts, as the virus could be transmitted to the baby.

Is it normal to have trouble with vaginal dryness? The hormones involved with breastfeeding can cause vaginal dryness, which makes intercourse uncomfortable. Recommend using a water-soluble lubricant especially made for this purpose.

Will I lose my figure if I breastfeed? Quite the contrary, as the body has been storing fat (especially in the stomach, hip, and thigh areas) for nine months in preparation for breastfeeding. Nursing helps metabolize the majority of this stored fat quickly. If the mother is gaining weight while breastfeeding, she is not eating properly.

Do women ever get sexual sensations while they are nursing? Because the hormones involved in lactation are the same as those involved in orgasm, it is believed that a woman could have an orgasm while breastfeeding. Because oxytocin causes the uterus to contract, some women may misinterpret the cramping sensations as orgasmic contractions [288]. The most common description of sensation has been of a "warm afterglow," which many women experience following orgasm. Women appear to have the innate ability to separate the breast's maternal function from sexuality while they are nursing. Prolactin, the mothering hormone, gives the mother a calm, warm, peaceful feeling after nursing. These sensations are quite normal.

Is there a particular type of pump to use? There are several types of breast pumps available on the market. How and why a mother intends to use the pump can assist you in recommending a pump that suits her needs.

Will insurance companies cover the cost of the pump rental? Few insurance companies will reimburse the parents for the cost of the rental for a sick baby. Companies may view the rental of a hospital-grade electric pump as a luxury when there are small hand pumps available at a lesser cost. If the pediatrician writes a prescription for the hospitalized baby for "breast milk," the parents should send a copy of the prescription and the pump rental receipt to the insurance carrier for reimbursement.

How do I keep the equipment clean? Always use clean equipment for pumping. Instructions for cleaning come with most pumps. Only the parts that contact the breast or milk must be cleaned after each use. The mother should rinse the parts immediately after each use in cold water to remove any residual milk. The parts should then be washed in hot, soapy water and rinsed well. Between uses, the pump kit should be stored in a clean area or clean plastic zip-type bag. Daily sterilization of the breast pump parts (not the tubing) is recommended only when the milk is collected for a hospitalized infant. Sterilization can be done by boiling the parts in a large pot at full boil for five minutes. If the mother notices hard water spots on the equipment, adding a little white vinegar to the water each time she sterilizes the parts should help. If the tubing has a filter, be sure that the filter does not get wet, as this will block the suction.

Will I pump as much as the baby takes? The pump is not as efficient as the baby. It also will take a while for the mother's let-down reflex to become trained to the pump. If no let-down reflex occurs, the mother can expect to obtain 0.5 to 1 ounce or less of milk from each breast. The mother who is pumping immediately after delivery for a sick baby may at best express only a drop or two of colostrum. The goal of early pumping is to establish a milk supply by repeated stimulation of the breasts.

When a mother is learning to use the breast pump before returning to work, I recommend that she begin at the first morning feeding. Nurse the baby from one breast, and then pump the other. The baby will help get the breast "primed." If the pump does not seem to work the first time she uses it, the mother should be encouraged to practice pumping frequently. If the pump still does not seem to work after a week of practice, the mother should try a different type of pump or see a lactation consultant.

How can I encourage let-down? While not all techniques work for all mothers, there are many things she can do to encourage the let-down reflex:

How is manual expression of breast milk done? Manual expression of breast milk is easy after a mother has learned the technique. The mother will need a clean, wide-mouthed jar, bowl, or funnel because it is difficult to aim the streams of milk into a small opening. With practice, some mothers feel that manual expression is easier and less time-consuming than a breast pump. The technique for manual expression involves the following steps:

MANUAL EXPRESSION OF BREAST MILK

Figure 4

Source : Marie Davis, RN, IBCLC

How should I store my milk? Store milk in sealed, sterilized containers. Containers should be labeled with the date and time that it was expressed. Place the container in ice water to cool it quickly. If the expressed milk is to be used for the baby within 24 to 48 hours, keep it refrigerated until just before use. When freezing milk, containers of breast milk should be placed in the back of the freezer. Never store breast milk in the freezer door or near freezer walls. Breast milk will keep in the refrigerator for 24 to 48 hours and in the refrigerator-freezer for about three months; in a chest freezer, or deep freeze, breast milk will keep for about one year at 0°F. However, because breast milk is constantly changing to meet the baby's needs at a given age, it is best to use breast milk within one or two weeks of expression. Breast milk should not be stored for long periods.

It is best to freeze milk in small amounts (2 oz.) to avoid waste and decrease defrost time. Baby bottles are not ideal for freezer storage because there can be a large air space at the top and the bottle may not be airtight. Special bags are available that protect the breast milk from freezer burn. Plastic nurser bags or bottle liners should not be used.

How should I defrost breast milk? If the milk will be used within the next 24 hours, defrost it in the refrigerator overnight. Frozen milk can be quickly defrosted by placing it in tepid (warm, not hot) tap water and gradually adding warm water. Never heat breast milk on a stove or in a microwave oven. High heat alters the proteins in the breast milk. Shake or rotate the container gently to mix the contents while it is defrosting. Be sure to discard any milk left in the bottle after a feeding. Reuse can cause serious illness.

Why does my milk have a yellow layer at the top? A yellow or white layer at the top of cooled or frozen breast milk is simply the cream layer of the milk that separates as the milk is cooled.

Can I mix my milk and ABM in the same bottle? ABM may inactivate some of the components of breast milk. It is best not to mix breast milk and ABM in the same bottle. Give the breast milk first and make up the rest of the feeding, if needed, with ABM added to the empty bottle.

What type of nipple should be used for bottle feedings? Actually, there is no single "best" type of bottle nipple, except the one the baby will take. The orthodontic nipple is said to be similar to the shape of the mother's breast in the infant's mouth. It has a small hole on the top side, rather than a large hole in the tip. The small hole keeps the flow from becoming too fast for the breastfed infant to control. A soft silicone nipple works well. The baby's mouth should be open wide around the base of the nipple, not closed around the narrower neck of the nipple. Short, stubby nipples that do not allow the baby to open his or her mouth wide can interfere with proper latch-on by encouraging the baby to feed at the tip. Standard bottle nipples should not have a large hole. (Test by holding the bottle upside down; milk should drip slowly from the top, not run out.)

Can I breastfeed and work? The primary problem in working and nursing is that the woman is the working mother of a young infant. The feeding method does not change some of the difficulties associated with working with an infant at home. However, in reality, thousands of mothers work and continue to breastfeed. Each mother has to decide what is best for her and her baby. There are several ways to manage working and breastfeeding. Here are a few suggestions:

How often will I need to pump? It will depend on the age of the baby when the mother returns to work and how long she will be away from the baby. If she returns to work when the baby is 6 weeks old, she will need to pump at least every four hours, or more often, depending on how frequently her baby has been nursing. If a mother can wait to return to work until the baby is 6 months of age, she may only need to pump once in the middle of her workday, or she may not need to pump at all.

What is the best breast pump for a working mother? I think the best pump for the mother who returns to work early and works full time (away from baby eight hours or more) is an electric breast pump with a double pumping kit. When the mother pumps both breasts simultaneously, pumping will take 10 to 15 minutes. Hand or single electric pumps require 30 minutes or longer to use. Double pumping also will help maintain her milk supply.

Is renting an electric pump expensive? The initial cash needed for renting a pump can be high because most rental stations require that the rental fee and a security deposit be paid in full at the time of rental. In most states, sales tax is added to the rental fee. Call around and get several price quotes. Pump rental averages $30 to $60 per month. Some rental stations offer a reduced rate for long-term rentals. Many women find this less expensive than ABM over the same span of time.

Are the large electric pumps available for purchase? The mother can purchase a large hospital-type electric pump from the manufacturers. Cost varies from $500 to $2,500. Most of these pumps have a life span of 30 years. Non-hospital-grade electric pumps are also available for $50 to $400. Under the Affordable Care Act, marketplace health insurance plans (except grandfathered plans) must cover the cost of a breast pump, whether rented or purchased [289]. Individual plan guidelines will vary.

On Monday I can pump several ounces, then less and less by Friday. Is this normal? The mother's body is adjusting to infrequent nursing at the breast. To increase the amount of breast milk, mother should increase her fluid intake, pump more frequently throughout the workday, rest, and nurse the baby as much as she can when she is home.

How can I store milk safely at work? Many women use a small cooler when a refrigerator is unavailable for storage. Cooler bags, which look like tote bags, are available through pump rental stations and baby shops. The cooler will usually hold several bottles of milk and may have a place for pumping equipment. Reusable cooling units are less messy than blocks or cubes of ice.

How can I tell if breast milk has gone bad (turned sour)? Unlike cows' milk, breast milk may not smell sour if it has spoiled. If the milk is curdled, severely separated, or has a bad or nasty smell, throw it out.

What if the baby will not eat while I am gone? Tell the sitter to keep trying but do not insist. If the baby will not take a bottle, an eye dropper or a spoon may work. Some mothers find that they have to experiment with several types of bottle nipples before they find one that the baby "likes." If the baby is older (i.e., 4 to 6 months), ask your pediatrician if solids may be safely introduced. The sitter may be able to give the baby solid foods instead of giving a bottle while the mother is away. Some babies prefer to "stack-up" on feedings while the mother is at home and not eat when she is gone. Other babies may nurse frequently when she arrives home.

How long is long enough to breastfeed? The choice is entirely the mother's to make. Authorities agree that all babies should be breastfed for as long as possible in infancy. There is never a time when breastfeeding no longer provides benefits for the baby and the mother. It is best to give the mother who asks this question general recommendations and let her decide when to discontinue breastfeeding. Major health agencies recommend exclusive breastfeeding for at least the first four to six months and continued breastfeeding during the introduction of solids. The Surgeon General and the AAP have recommended breastfeeding through the first year. The WHO has recommended at least two years [21].

How is weaning usually done? Weaning begins when the baby starts taking solids at 4 to 6 months or is given ABM feedings to replace breastfeedings. The mother can begin by eliminating the least stressful feeding of the day and substituting solid food or ABM. Gradually, reduce the number of breastfeedings per day over a period of weeks. The last two feedings to be eliminated are first thing in the morning and at bedtime. The mother will need to decide which feeding is the most important for the baby and eliminate that one last.

What if my baby will not wean? Then the baby is not ready to wean. An older child may sense what the mother is doing and resist all efforts by wanting to nurse more. Tell the mother to try distraction. La Leche League International has suggested: "Don't offer. Don't refuse." When the child asks to nurse the mother should use a "not now, but later" routine and be sure that when later arrives, she does nurse as promised. This will help restore the child's trust that mother is not abandoning him or her.

Should I wean my baby from my breast to a cup or a bottle? Depending on the age of the baby, a cup may be the better choice. After four to six months, a baby can handle liquids from a training cup well. If the mother weans to a bottle, remind her that she will later have to wean the baby from the bottle.

When should I start my baby on solids? Solids should be introduced between 4 to 6 months of age. The baby should have doubled his or her birth weight, lost the extrusion reflex (the reflex to push everything out of the mouth), and begun to show an interest in what others are eating. Some babies are not ready for solids until 6 to 8 months of age. Let the infant take the lead. The mother should hold the baby in her lap for the first few feedings and use infant-sized spoons. Cereal or other solids should never be put in a bottle or infant feeder. If a baby cannot take food from a spoon, he or she is not ready for solids. The pediatrician will give the mother a schedule of what foods to introduce and when. Usually a baby starts on cereal, vegetables, fruit, meat, and finally egg whites. The order may vary depending on the pediatrician. The most important thing to remember is to go slowly. Do not overfeed the baby. Breast milk or ABM should remain the major source of nutrition until 1 year of age.

Should I give my baby cows' milk? Children younger than 1 year of age should not receive cows' milk. It is irritating to the baby's intestine and can cause occult intestinal bleeding that results in anemia. If breastfeeding is discontinued before the baby is 1 year of age, the mother should use commercial ABM. Kitchen-prepared formulas are not nutritionally complete. After 1 year, cows' milk may be used. Whole milk, not skim or low-fat milk, is often recommended for young children. Babies need larger amounts of fat in their diets compared to adults to assist with brain and nervous system growth. Do not allow cows' milk to become the child's major source of calories. An infant needs a well-balanced diet to grow properly. Watch out for fruit juices as well. If a baby is constantly drinking fruit juice, the major source of calories will be from the sugar in the fruit juice. Hunger will be satisfied, and baby may not eat other foods or may nurse less often. Too much sugar can contribute to childhood obesity.

Can I put the baby to bed with a bottle? Putting the baby to bed with a bottle of ABM, milk, or juice can cause "nursing bottle" cavities in the baby's teeth. This type of dental decay is rare in infants who are nursed to sleep. Breast milk does not appear to have the same high sugar that leads to dental cavities. If a mother must put the baby to bed with a bottle, it should be plain water, and she should watch for choking. The baby should not suck on a bottle all night, or all day, for that matter. The bottle should be taken away after the baby is asleep.

Includes a list of Baby-Friendly Hospitals in the United States as well as information for: