A supplement to

MPR Pediatricians’ edition

May 2011

Pediatric Nutrition: Practical Perspectives

Breastfeeding:
Optimal Nutrition for Infants

AUTHOR
Carol Ann Friedman, MSN, RN, IBCLC • Certified Lactation Consultant, Pasadena, California
COURSE DIRECTORS
Marguerite M. Mayers, MD • Attending Physician, Children’s Hospital at Montefiore • Professor of
Clinical Pediatrics • Albert Einstein College of Medicine, Bronx, New York
Kathleen Ronca, MSN, PNP, ANP, APRN-BC, DNPc • Nurse Practitioner, Montefiore, Bronx, New York

CME/CE/CPEU Activity
Release date: May 31, 2011 • Expiration date: May 31, 2012

Sponsored by the Albert Einstein College Sponsored by Supported by an Produced by

of Medicine of Yeshiva University Montefiore educational grant from
Breastfeeding: Optimal Nutrition for Infants
NEEDS ASSESSMENT
Breastfeeding is considered the nutritional gold standard for infants. According to
the American Academy of Pediatrics, healthcare professionals should encourage
feeding with human milk for all term infants unless specifically contraindicated,
and infants should continue to breastfeed for at least 12 months.1 Although 74%
of new mothers in the United States initiate breastfeeding with their newborn,2
breastfeeding rates clearly decrease rapidly during infancy.3,4 This suggests that
new mothers may lack the support in the hospital setting needed to overcome
barriers to breastfeeding.
In 2010, the US Breastfeeding Committee noted that the Baby-Friendly Hospital
Initiative “10 Steps to Successful Breastfeeding”4,5 enhances breastfeeding
outcomes.6 Postpartum lactation support is key to continued success with breast-
feeding, particularly after the nursing couple goes home from the hospital.
To help ensure that breastfeeding is accepted as “a cultural norm,” pediatric
practitioners need to be kept abreast of current breastfeeding practices, practices
to help new mothers overcome obstacles to breastfeeding, recommendations
for initiating breastfeeding in the hospital, and overall benefits of breastfeeding,
including reduced risk for atopic disease and obesity in children.
References
1. A
 merican Academy of Pediatrics Policy Statement. Committee on Nutrition.
Prevention of Pediatric Overweight and Obesity. Pediatrics. 2003;112:424-430.
2. C
 enters for Disease Control and Prevention. Breastfeeding Report Card—United
States, 2010. http://www.cdc.gov/breastfeeding/data/reportcard.htm. Accessed
February 28, 2011.
 epartment of Health and Human Services (2010). Healthy People 2020.
3. D
www.healthypeople.gov. Accessed December 2, 2010.
4. H
 ealthy People 2010. http://healthypeople.gov/2020/topicsobjectives2020/
objectiveslist.aspx?topicid=26. Accessed February 21, 2011.
 orld Health Organization/United Nations Children’s Fund. Protecting,
5. W
Promoting and Supporting Breastfeeding: The Special Role of Maternity
Services. Geneva, Switzerland: World Health Organization; 1989.
 nited States Breastfeeding Committee. Implementing The Joint Commission
6. U
Perinatal Care Core Measure on Exclusive Breast Milk Feeding. Rev ed.
Washington, DC: United States Breastfeeding Committee; 2010.
LEARNING OBJECTIVES
Upon completion of this educational activity, participants should be better able to:
• Compare current US breastfeeding practices to recommended standards for
breastfeeding
• Describe obstacles to breastfeeding and practices to help new mothers
overcome them, including the Baby-Friendly Hospital Initiative
• Outline recommendations to help initiate, assess, and document breastfeeding
for new mothers in the hospital
• Explain how breastfeeding is associated with reduced risks for atopic disease
and obesity in children
INTENDED AUDIENCE
Pediatricians, nurses, pediatric nurse practitioners, registered dietitians, and other
healthcare professionals involved in the care of children
ACCREDITATION STATEMENTS
PHYSICIAN
This activity has been planned and implemented in accordance with the Essential
Areas and policies of the Accreditation Council for Continuing Medical Education
(ACCME) through joint sponsorship of Albert Einstein College of Medicine of
Yeshiva University and Haymarket Medical Education LP. Albert Einstein College of
Medicine of Yeshiva University is accredited by the ACCME to provide continuing
medical education for physicians.
Albert Einstein College of Medicine of Yeshiva University designates this enduring
monograph for a maximum of 1.0 AMA PRA Category 1 credit.™ Physicians
should only claim credit commensurate with the extent of their participation in
the activity. This CME activity was planned and produced in accordance with the
ACCME Essentials.
NURSING
Montefiore, Division of Education & Organizational Development, is an approved
provider of continuing nursing education by the New York State Nurses
Association, an accredited approver by the American Nurses Credentialing Center’s
Commission on Accreditation.
This activity is awarded 1 contact hour and is assigned approval code 7UZLNN-
PRV-09-158.
DIETITIANS
The following activity has been approved by the ACCME, whose approval is recog-
nized by the Commission on Dietetic Registration and, as such, RDs/DTRs will be
able to receive CPEUs equivalent to one (1) contact hour.
CONFLICTS OF INTEREST DISCLOSURE STATEMENTS
The “Conflict of Interest Disclosure Policy” of Albert Einstein College of Medicine
of Yeshiva University requires that faculty participating in any CME activity
disclose to the audience any relationship(s) with a pharmaceutical or equipment
company. Any presenter whose disclosed relationships prove to create a conflict
of interest with regard to their contribution to the activity will not be permitted
to present.
It is the policy of Montefiore to ensure balance, independence, objectivity,
and scientific rigor in all its educational activities. All faculty participating in
our programs are expected to disclose any relationships they may have with
commercial companies whose products or services may be mentioned, so that
participants may evaluate the objectivity of the presentations. In addition, any
discussion of off-label, experimental, or investigational use of drugs or devices
will be disclosed by the faculty.
AUTHOR
Carol Ann Friedman, MSN, RN, IBCLC, Certified Lactation Consultant,
Pasadena, California
COURSE DIRECTORS
Marguerite M. Mayers, MD, Attending Physician, Children’s Hospital at
Montefiore; Professor of Clinical Pediatrics, Albert Einstein College of Medicine,
Bronx, New York
Kathleen Ronca, MSN, PNP, ANP, APRN-BC, DNPc, Nurse Practitioner,
Montefiore, Bronx, New York
DISCLOSURES
Carol Ann Friedman, MSN, RN, IBCLC, has served as a consultant for Nestlé
Nutrition.
Marguerite M. Mayers, MD, has nothing to disclose with regard to commercial
support.
Kathleen Ronca, MSN, PNP, ANP, APRN-BC, DNPc, has nothing to disclose
with regard to commercial support.
Publishing Staff:
Mary Jo Krey, Mary Pinkowish, Sharon Hill-Ingram, Lynne Callea, Anne
Bardsley, and Denise Stern of Haymarket Medical Education have nothing to
disclose with regard to commercial support.
Accreditor Staff:
The staff of the Center for Continuing Medical Education of Albert Einstein College
of Medicine of Yeshiva University and Montefiore has nothing to disclose with
regard to commercial support.
DISCLOSURE OF UNLABELED USE
This educational activity may contain discussion of published and/or investigational
uses of agents that are not indicated by the FDA. Nestlé Nutrition Institute, Albert
Einstein, and Haymarket Medical Education do not recommend the use of any
agent outside the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do
not necessarily represent the views of Nestlé Nutrition Institute, Albert Einstein, and
Haymarket Medical Education. Please refer to the official prescribing information for
each product for discussion of approved indications, contraindications, and warnings.
DISCLAIMER
Participants have an implied responsibility to use the newly acquired information
to enhance patient outcomes and their own professional development. The infor-
mation presented in this activity is not meant to serve as a guideline for patient
management. Any procedures, medications, or other courses of diagnosis or
treatment discussed or suggested in this activity should not be used by clinicians
without evaluation of their patient’s conditions and possible contraindications on
dangers in use, review of any applicable manufacturer’s product information, and
comparison with recommendations of other authorities.
©2011 Haymarket Medical Education LP
25 Philips Parkway, Suite 105, Montvale, NJ 07645
www.myCME.com
Cover image: iStockphoto®
Estimated time to complete this activity: 1.0 hour.
Release Date: May 31, 2011
Expiration Date: May 31, 2012
Breastfeeding: Optimal Nutrition for Infants

Breastfeeding: Optimal Nutrition for Infants

Carol Ann Friedman, MSN, RN,
IBCLC

B
reastfeeding is considered
the nutritional gold standard
for infants. Breast milk in
infants is well tolerated, is
least associated with aller-
gic reactions, and tends to result in
softer stools. According to the Centers
for Disease Control and Prevention
(CDC), 74% of new mothers in the
United States initiate breastfeeding
with their newborns.1 However, a
more in-depth analysis reveals that
other aspects of breastfeeding practice
are less encouraging; among African
American women, for example, only
60% of new mothers ever breastfeed,
and a mere 28% are breastfeeding at
all at 6 months.2 In contrast, 78% of
white women ever breastfeed, and
45% are still doing so at 6 months; to breastfeed for at least 12 months, Table 1 shows a sobering comparison
among Hispanic mothers, the cor- with complementary, iron-rich foods of the breastfeeding goals specified
responding figures are 81% and 46%.2 introduced at age 6 months or when the in Healthy People 2020 and current
For pediatric healthcare professionals, infant shows signs of readiness for solids.4 rates.5,6 After a robust start, breastfeeding
much work lies ahead to ensure that Do current US infant feeding prac- rates clearly decrease rapidly during
breastfeeding is accepted as “a cultural tices reflect current recommendations? infancy.
norm,” as the American Academy of
Pediatrics (AAP) recommends.3 TABLE 1. Breastfeeding Goals: Healthy People 2020

Current Breastfeeding Breastfeeding Goal1 Current Rate2

Practices versus goals
According to AAP recommenda- Ever-breastfed infants 82% 74%
tions, healthcare professionals should Exclusive breastfeeding at 3 mos 44% 33%
encourage feeding with human milk
for all term infants unless specifically Breastfeeding at 6 mos 61% 43%
contraindicated.4 Supplements such as
water, sugar water, or formula should Exclusive breastfeeding at 6 mos 24% 14%
not be given to a nursing newborn Breastfeeding at 12 mos 34% 23%
except when medically indicated. In the
1. D
 epartment of Health and Human Services (2010). Healthy People 2020. www.healthypeople.gov. Accessed
early postpartum weeks, infants should December 2, 2010.
be fed at the breast 8 to 12 times in a 2. H
 ealthy People 2010. http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=26. Accessed
February 21, 2011.
24-hour period. Infants should continue

May 2011 3
Breastfeeding: Optimal Nutrition for Infants
New mothers may lack the support needed
to overcome barriers to breastfeeding.
The percentage of babies who are
exclusively breastfed is maximal at
age 3 months, based on analysis of
breastfeeding practices data from the
Infant Feeding Practices Study II (IFPS
II). Until 4 months of age, exclusive
breastfeeding is more common than
other types, such as breastfeeding
supplemented with infant formula
or cereal. Although the AAP recom-
mends breastfeeding newborns 8 to
12 times a day, almost half of the IFPS
II respondents typically breastfed their
newborns fewer than 8 times daily.
By the time infants were 3 months
old, nearly 75% of infants were being
breastfed less frequently than recom-
mended. At age 1 year, the median
feeding frequency was 3.5 sessions per
day. Duration of individual feeding
sessions also diminished over the first
year. Feedings less than 10 minutes long
were rare among neonates, but by age 1
year, 40% of infants had feeding sessions
lasting less than 10 minutes.The IFPS II
findings also showed that approximately
6% of participants reported that they
only pumped breast milk and that their
infants were never fed at the breast. Not
surprisingly, only one-third of mothers
who reported exclusive breast milk
pumping were still providing breast
milk to their infants 1 month after
delivery.7
Attitudes Toward/obstacles
to Breastfeeding
Clearly, most new mothers intend to
breastfeed. However, the low percent-
ages who continue to do so exclusively
or partially when infants are aged 3,
6, and 12 months suggest that new
mothers may lack the support needed
to overcome barriers to breastfeeding.
In its 2010 Breastfeeding Report Card,
4 may 2011
the CDC stated that the “average level
of support that birth facilities provide to
mothers and babies as they get started
with breastfeeding is inadequate, and
hospital practices and policies that
interfere with breastfeeding remain
common.”1
The following five obstacles to
breastfeeding are cited in the Surgeon
General’s Call to Action to Support
Breastfeeding 2011:8
• Lack of experience or understanding
among family members about how
to best support the nursing couple
• Limited opportunities to communi-
cate about breastfeeding with other
nursing mothers
• Lack of accommodations for breast-
feeding or expressing milk in the
workplace
• Lack of up-to-date instruction
and information from healthcare
professionals
• Hospital practices that impede
successful breastfeeding and hinder
getting professional help from a
knowledgeable nurse or lactation
consultant
Lack of knowledge plays a large role
in a woman’s decision to breastfeed,
according to several different studies.8-12
Only about one-third of new mothers
know that breastfeeding protects against
infant diarrhea, and only one-quarter
of all adults believe that feeding infant
formula increases the chances that an
infant will get sick. Many new mothers
also lack a basic understanding of how
breastfeeding “works” on a practical
level. “Even though breastfeeding is
often described as ‘natural,’ it is also an
art that has to be learned by both the
mother and the newborn,” states the
Surgeon General’s report.8
In a study by Li and colleagues in
2008, more than 1,300 mothers who
participated in IFPS II were asked why
they had stopped breastfeeding at
different points during the first year
after birth. Compared with women
who continued to breastfeed, those
who stopped breastfeeding early were
more likely to have had their first
child and be younger, unmarried,
less educated, poorer, a participant in
the Special Supplemental Nutrition
Program for Women, Infants, and
Children (WIC), and living in the
South or Midwest. Among mothers
who stopped nursing their infants
during the first month, the most
commonly cited reasons were
lactational and nutritional. Mothers
reported that their infants had trouble
latching or sucking, that breast milk
alone did not satisfy the infant’s appetite,
or that the mother was unable to
produce enough milk. As infants got
older, more mothers additionally
reported increasing psychosocial and
milk-pumping concerns. Some said
milk-pumping was not worth the effort
when they wanted to go out for several
hours and leave the baby at home.
Others reported that the baby had lost
interest in nursing or had started biting
the nipple.13
In one study, breast milk was expressed
by 85% of nursing mothers with infants
aged 1.5 to 4.5 months, usually so that
another person could feed the infant in
the mother’s absence.The practice was
more common among women who
were employed, had a higher income,
and who used electric pumps rather
than manual ones.14 Of course, a return
to full- or part-time work is likely to
disrupt breastfeeding.Women who can
feed the infant directly from the breast
during the workday are using “the most
effective strategy for combining breast-
feeding and work,” according to data
from IFPS II.15 The authors highlighted
the need to provide mothers with
on-site childcare or another strategy
for keeping the child at work, such as
increasing options for telecommut-
ing, allowing the mother to leave the
work site to breastfeed, and facilitating
bringing the child to the work site for
feeding.15 No randomized, controlled
trials have studied the efficacy of these
interventions, however.16
How and Why to Initiate
Breastfeeding in the Hospital
In a 2007 Cochrane Review including
34 trials and more than 29,300 mother-
infant pairs in 14 countries, the authors
determined that support from lay and
professional sources had a statistically
significant, beneficial effect on extend-
ing the duration of breastfeeding.17
More detailed information comes
from a study conducted by the CDC
as part of the IFPS II to evaluate the
impact of “Baby-Friendly” hospital
practices. Since 1991, the World Health
Organization (WHO) and United
Nations Children’s Fund (UNICEF)
have promoted the Baby-Friendly
Hospital Initiative, which includes a
breastfeeding-promotion component.
This initiative was incorporated in
the Healthy People 2010 initiative.
The Baby-Friendly Hospital Initiative
has identified “10 Steps to Successful
Breastfeeding”:6,18
• Have a written breastfeeding policy
that is routinely communicated to all
healthcare staff
• Train all healthcare staff in skills nec-
essary to implement this policy
• Inform all pregnant women about
the benefits and management of
breastfeeding
• Help mothers initiate breastfeeding
within 1 hour of birth
• Show mothers how to breastfeed
and how to maintain lactation, even
if they should be separated from
their infants
• Give newborn infants no food or
drink other than breast milk unless
medically indicated
• Practice rooming-in by allowing
The Baby-Friendly Hospital Initiative has
identified “10 Steps to Successful Breastfeeding.”
mothers and infants to remain
together 24 h/d
• Encourage breastfeeding on demand
• Give no artificial teats, pacifiers,
dummies, or soothers to breastfeed-
ing infants
• Foster the establishment of breast-
feeding support groups and refer
mothers to them upon discharge
from the hospital or clinic
In the document “Implementing the
Joint Commission Perinatal Care Core
Measure on Exclusive Breast Milk
Feeding,” revised in 2010, the United
States Breastfeeding Committee advis-
es that the steps listed above enhance
breastfeeding outcomes.19 Each
additional step to which a mother is
exposed increases the chances that she
will be breastfeeding her child at the
time of hospital discharge.20 Further,
the committee notes that women who
give birth in hospitals that implement
these steps are six times more likely
to practice exclusive breastfeeding
than women who deliver at other
facilities.21
The United States Breastfeeding
Committee makes several practical,
evidence-based recommendations that
are likely to improve rates of exclusive
breastfeeding. Initial skin-to-skin con-
tact even before the umbilical cord is
cut is encouraged to “facilitate imprint-
ing of proper breastfeeding technique.”
The Committee notes that a baby who
is placed skin-to-skin will likely find
the breast and initiate breastfeeding
within the first 60 minutes of life.19
The Committee discourages the use
of all unnecessary glucose or water
supplements.When supplementation is
necessary, the Committee recommends
using the mother’s own expressed milk
or banked human donor milk in prefer-
ence to formula because breast milk
will “preserve the bowel flora and pH of
the newborn’s gut and avoids exposure
to potentially sensitizing non-human
antigens.” And, of course, healthcare
providers are encouraged to provide
“continuous physical, emotional, and
informational support” to mothers.19
The Healthy People 2020 update
contains an additional three steps for
further development of the Baby-
Friendly Hospital Initiative:5
• Increasing the number of participat-
ing hospitals to 8% of the total, from
the current 2.9%
• Increasing workplace accommoda-
tions for breastfeeding mothers to 38%
of workplaces, from the current 25%
• Reducing in-hospital formula sup-
plementation to 15.6% of newborns,
from the current 25.6%.
In the IFPS II analysis, the prac-
tices most likely to be associated with
continuation of breastfeeding beyond
6 weeks were initiation during the
first hour after birth, providing the
infant with access only to breast milk,
and not using pacifiers. Other factors
included bringing the baby to the
mother for feeding at night among
those who were not rooming-in
and not giving pain medications to
mothers during delivery. Compared to
mothers who were exposed to these
components of the Baby-Friendly
initiative, those who were not were
13 times more likely to discontinue
breastfeeding before 6 weeks.20 These
data speak directly to the observation
that the most difficult hurdles occur
when the nursing couple goes home
from the hospital.
The Baby-Friendly Hospital Initiative
May 2011 5
Breastfeeding: Optimal Nutrition for Infants

is closely aligned with recommenda- The mother should expect that the The ABM recommends that similar
tions from the AAP and the Academy baby will take only 1-2 tsp or 5-10 mL assessments be conducted every 8 to
of Breastfeeding Medicine (ABM), per feeding during the first 2 days of life 12 hours during hospitalization and
described in the following sections. equivalent to 1-2 oz/d. (Parents often once during the final 8 hours before
overestimate how much a newborn discharge.Things to look for include:
Prenatal and Immediate must ingest.) To confirm that the baby • Infant positioning
Postnatal Care is adequately hydrated and nourished, • Latch
All the major medical organizations the mother should observe bright yel- –– Poor latch can often be improved
involved in the care of pregnant women low bowel movements by days 4-5. by improving positioning
and their newborns encourage educating Most mothers may assume that if –– Sore nipples may signal poor latch
pregnant women about the importance their newborn requires intensive care, • Signs of milk transfer
of breastfeeding. After being dried, breastfeeding will not be feasible. This is –– Can the mother hear the baby
weighed, measured, and given Apgar certainly not always the case, and these swallow?
scores, a healthy newborn should be mothers may need more information –– Do the mother’s breasts feel less
given to the mother for direct, skin- and encouragement from the healthcare full after she has fed the baby?
to-skin contact, which may increase team. The mother needs to learn how –– Does the mother feel tingling in
the duration of breastfeeding.Within to express milk and the necessary her breasts while feeding?
6 hours, the infant should be allowed arrangements must be made to keep –– Does she feel uterine cramps
to attempt to feed or at least to latch. the mother in close proximity to her while nursing?
Rooming-in is also encouraged to maxi- infant at this time. Each situation is best • Infant’s weight and percentage of
mize mother-infant bonding. According handled on a case-by-case basis. Some lost birth weight
to the ABM, mothers get as much sleep guidelines are presented in Table 2. • Stool/urine output
when babies room-in as when they are
returned to the nursery for the night.22 Recommendations At According to the AAP, a member
The mother should understand that Discharge of each nursing shift should formally
newborns lose an average of 7% (but The AAP recommends that a trained evaluate the breastfeeding practice
not more than 10%) of their body observer make a structured assessment (position, latch, suckling) in each
weight in the days after delivery. This of 2 breastfeeding sessions prior to mother-infant pair and document it in
weight is usually regained by day 10. discharge of mother and infant. the medical record.4
It is also essential for the clinician to
TABLE 2. When a newborn and mother must be separated… speak with the mother directly to learn:
• Is she experiencing nipple pain?
Mothers who are separated from their newborns for more than 8 hours will be: • Can she express milk by hand?
• Does she have any doubts about the
• Assisted with and instructed about how to hand-express colostrum
nutritional quality or quantity of
• Assisted with and instructed about how to use the double electric pump every 3 hours
her milk?
(or 6-8 times per day, with no period >5 hours between 2 sessions)
• Is her family supportive?
• Encouraged and taught how to provide small volumes of fresh colostrum
• Given a pumping diary/log to record pumping history
The clinician should be aware of any
• Encouraged to practice skin-to-skin care as soon as the baby is stable
reservations she may have, because a
• Encouraged to initiate nonnutritive suckling as soon as mother’s and baby’s conditions
permit. Initiating oral feedings at the breast is preferred over bottle feeding
new mother may begin supplementing
• Encouraged to initiate breastfeeding on demand as soon as mother’s and baby’s
with formula if she feels her baby is
conditions permit not getting adequate nourishment. Any
• Taught proper collection, storage, and labeling of human milk problems should be documented in the
• Instructed about how to hand-express and, if needed, to use effective techniques with chart. A new mother should know how
pumps once milk “comes in” to express milk by hand or with a pump
• Provided anticipatory guidance, when appropriate, on management of engorgement so that she can relieve engorgement,
• Assisted with obtaining electric pump (hospital grade) for home use prior to discharge stimulate milk production, or store milk.
Adapted from American Academy of Pediatrics Section on Breastfeeding. Sample hospital breastfeeding policy on
During the pre-discharge evaluation,
newborns. Tools for Clinicians. http://www.aap.org/breastfeeding/curriculum/documents/pdf/Hospital%20Breast­ the clinician should remain encouraging
feeding%20Policy_FINAL.pdf. Accessed May 11, 2011.
Continued on page 8

6 may 2011
 Case
A New Mother Who Wants to Breastfeed Following C-Section
Study
A first-time mother who intends to breastfeed has delivered a
healthy, full-term male infant by C-section. Labor was long and
surgery was prompted by sudden, excessive maternal bleeding,
requiring prompt intervention. The mother is doing well post-
operatively, according to the obstetrician and the nurses. She
has a great deal of fatigue and discomfort, but this is consid-
ered normal in the context of an emergency C-section.
Because the mother intends to breastfeed and it is institution
policy to encourage breastfeeding, a nurse helps the mother
put the baby to breast when her bleeding is clearly under
control and she is recovering from delivery. The baby is not very
interested, and the father expresses alarm. He believes that
the infant is stressed and that the strain of the C-section has
been too much for his wife. He wonders if she should abandon
plans for breastfeeding altogether. The wife’s mother, who has
arrived at the hospital to see her grandchild, agrees that her
daughter is “overwhelmed” and believes that the newborn
should start on formula.
Six hours after delivery, the mother tries again to breastfeed
the baby, who remains uninterested. The nurse then helps the
mother express milk, a process that she explains will help bring
in the milk supply. When the mother sees that her milk is actu-
ally watery, pale, and not plentiful, she becomes visibly upset
about “not making anything—that’s not milk.”
Now the father becomes agitated and insists that the baby
“must be starving,” although the infant is not interested in
the breast and appears content. The father asks that they be
provided with formula because he thinks that letting the baby
continue to suck on an “empty” breast will “frustrate” him.
The infant’s grandmother agrees and tells her daughter that
she was unable to make enough milk for her children and that
this apparent inability to breastfeed “must run in the family.”
The new mother begins to cry. One of the nurses sees that
the situation is going downhill fast and asks to have a chat
with mom and dad as the grandmother sits nearby.
Factors Affecting the Mother’s Recovery
Primiparous mothers, who may not have a clear idea of what
to expect during labor and delivery, tend to have a more
challenging emotional and physical recovery than mothers
who have delivered previously. Second-time mothers usually
have an easier time recovering even from a tough labor, pos-
sibly because they are no longer suffering from “first-time-
mother jitters.” An emergency during labor, like this mother’s
excessive bleeding and C-section, add to the difficulty of
recovery—and in this case, labor also was long. First-time
parents often may not have fully understood what was hap-
pening during delivery involving a C-section, and the nurses
and physicians might not have had an opportunity to explain
the situation thoroughly and calmly. These circumstances
may contribute to a rougher physical and emotional recovery
for the mother, which may increase the risk for postpartum
depression and have a negative effect on the initial phase
of lactogenesis. Post-delivery discomfort and fatigue—not
unusual after delivery under the best circumstances—also
influence a woman’s recovery. In addition, some women may
feel guilty about having a C-section.
The family members’ reservations about breastfeeding are
common and understandable and reflect their concerns about
the mother’s recovery as well as the baby’s nourishment.
Although well-meaning, concerned comments that the mother
is “doing too much” and that the baby might be traumatized
and need the comfort of bottle-feeding may engender feelings
of guilt in the mother. This situation can lead to confusion
and communication problems between the mother and her
family as different members try to sway her views. She may
wish to confer with a nurse or, ideally, a lactation consultant.
Most mothers want to “nourish” their babies regardless of the
circumstances.
The Nurse’s Instructions to the New Parents
Despite her intentions, this mother’s early breastfeeding efforts
are discouraging. The nurse explains to her and her husband
that newborns typically are not interested in eating right after
delivery. This mother is also taken aback when, 6 hours after
delivery, the nurse helps her use a pump and she sees the low
volume of liquid she is producing. To make matters worse, it
does not look like the milk that she expected to see.
To help calm both parents, the nurse describes the time line
for breast-milk production. She explains that the mother has
expressed colostrum, also called “first milk,” which contains
high concentrations of nutrients, antibodies, carbohydrates,
and protein, with low fat concentrations. The volume of
colostrum is very low because the newborn’s small digestive
tract cannot handle large volumes of liquid. The nurse assures
the father that the baby will not be frustrated by sucking when
there is not much milk. The infant is not hungry yet and is not
ready for a full supply of mom’s milk. But pumping and letting
the infant suck at the breast will help bring in a good supply
of milk, typically a few days after delivery. It will also provide
the baby with some practice sucking. The nurse additionally
reassures the mother that she is doing a fabulous job with the
pumping. It is essential to support a woman’s confidence at
this important juncture. Continued on page 8
May 2011 7
Breastfeeding: Optimal Nutrition for Infants

Case Study (Continued): A New Mother Who Wants to Breastfeed Following C-Section
Continued from page 7
The mother seems reassured, but the father is still worried
about his son’s nutritional status. After explaining that the
newborn’s stomach is the size of a walnut, the nurse describes
three cardinal signs they should look for to confirm that the
baby is well-hydrated and sufficiently fed: weight gain, wet
diapers, and meconium. As a rule of thumb, in the first 24 hours
after delivery an infant should have a minimum of 1 urination
(or wet diaper) and 1 bowel movement, and a 2-day-old baby
should have 2 wet diapers and at least 1 bowel movement.
Newborns are weighed once daily in the hospital, and the
nurses keep track of the diapers and the baby’s weight.
This is the time to assure the parents that there are no
familial predictors of milk supply. The fact that her mother had
a difficult time nursing should have no bearing on this new
mother’s milk production. What is important is getting ample
breast stimulation by putting the baby to breast and/or pump-
ing from the day of birth and thereafter.
The nurse tells the couple that her goal for them is to have
the mother’s milk coming in by the time they are discharged.
She instructs them to keep in touch with her via phone during
the first week or two at home to ensure that they settle into
a good nursing routine. Although breastfeeding initiation
rates are very high in the hospital, the percentage rate falls
off dramatically during the first week home from the hospital,
especially among mothers with inadequate outpatient support.
Postpartum lactation support is key to continued success with
breastfeeding.
She explains that after discharge, most pediatricians ask to
see the baby during the next day or two for a weight check. If
the pediatrician believes the newborn needs to eat more, the
parents will be told to provide more feedings and to keep track
of urinary output and bowel movements. Supplementation us-
ing a nursing supplementer, syringe, eyedropper, or cup feeding
can encourage feeding without the newborn getting used to
bottle-feeding. A lactation consultant/educator can help with
these alternatives.

Continued from page 6

and remind the mother how important about the quantity of her colostrum or newborns usually lose weight after birth
it is to continue breastfeeding for at least breast milk. New parents should be told but regain it by the time they are 10 to
6 months.The mother should under- to expect the following indicators of 14 days old—which usually coincides
stand that her breast milk does not lack adequate breast milk intake: 6 urinations with a newborn visit.
anything her infant needs. Reminding (wet diapers) a day, 3 to 4 stools a day Ideally, upon discharge, the new family
her of how small a newborn’s stomach is by day 4, and yellow bowel movements should be given contact information for
may help allay any anxiety she may have by day 5. They also should know that healthcare professionals who are available
24 hours a day to answer ques​tions about
breastfeeding. These services may be
Resources for Breastfeeding Mothers available through the hospital, lactation
consultants in the community, or
and Families organizations like the La Leche
League (see Sidebar: Resources for
Academy of Breastfeeding Medicine: http://www.bfmed.org/ Breastfeeding Mothers and Families).
American Academy of Family Physicians: http://www.aafp.org/online/en/
home/policy/policies/b/breastfeedingpositionpaper.html Overall Benefits of
Breastfeeding
American College of Obstetricians and Gynecologists: http://www.acog.org/ Several health risks associated with not
departments/dept_notice.cfm?recno=18&bulletin=3197 breastfeeding are listed in The Surgeon
La Leche League International: http://www.llli.org/ General’s Call to Action to Support
Breastfeeding 2011. The biggest risk
Lamaze Institute for Normal Birth: http://www.lamaze.org/ExpectantParents/ increase among full-term infants is a
PregnancyandBirthResources/tabid/171/Default.aspx 257% excess risk for hospitalization
United States Breastfeeding Committee: http://www.usbreastfeeding.org/ for lower respiratory tract infections
during the first 12 months of life. This
Wellstart International: http://www.wellstart.org/ is followed by a 178% risk increase for
diarrhea and vomiting and a 100% risk

8 may 2011
increase for acute ear infections. Other
risk increases include asthma in children
with (67%) and without (35%) a family
history of asthma, type 2 diabetes (64%),
sudden infant death (56%), and eczema
(47%). The risks for acute lymphocytic
and acute myelogenous leukemia are
increased by 23% and 18%, respectively.
In preterm infants, lack of breastfeeding
is linked to a 138% increase in necrotiz-
ing enterocolitis.8
Mothers also benefit from breastfeed-
ing.The risks for breast cancer and for
ovarian cancer are increased in women
who have never breastfed.8
In addition to numerous health
benefits, economic benefits have been
associated with breastfeeding. These
include a savings of $1,200 to $1,500
per year per family associated with
skipping purchasing infant formula, and
a reduction of $13 billion in healthcare
costs if 90% of American families were
to breastfeed infants exclusively for 6
months.23 Better infant health reduces
healthcare costs and insurance claims. It
also facilitates work productivity when
less parental time is required for the care
of a sick infant.8
Association Between
Breastfeeding and reduced
Risk for Atopic Disease
During the past several decades, the
prevalence of atopic diseases, including
asthma, atopic dermatitis (eczema),
and food allergies, has increased sub-
stantially among American children.24
Asthma incidence is up 160%, and the
incidence of atopic dermatitis has at
least doubled.25 Several studies suggest
that in infants with a family history
of atopy, exclusive breastfeeding for
4 months reduces the risk for atopic
dermatitis compared with breastfeed-
ing supplemented with cow’s milk
formula. Breastfeeding coupled with
supplementation of hydrolyzed infant
formula may confer benefits similar to
those for exclusive breastfeeding.
According to the AAP, the evidence
suggests that this benefit for atopic
dermatitis risk is not increased if
exclusive breastfeeding extends
beyond 4 months of age. Furthermore,
among infants with no family history
of atopic disease, there is no evidence
that breastfeeding decreases the risk
for atopy.24
The relationship between breastfeed-
ing and asthma is murkier, especially
among older children. Some studies
have suggested that breastfeeding
by mothers who have asthma may
increase the risk for asthma in their
infants over the long term or more
than 6 years.24 However, some of these
studies have been dogged by uncer-
tainties about how asthma was defined
or diagnosed. On the other hand, sev-
eral other large investigations suggest
that asthma risk is decreased between
ages 2 years and 5 years among chil-
dren who are breastfed exclusively.24
These studies provide evidence that
breastfeeding protects infants from the
wheezing episodes that sometimes
accompany lower respiratory tract
infections and result in the hospitaliza-
tion of many infants each year.24,26
Food allergies are more common
in infants with atopic dermatitis and
asthma, and it has proved difficult to
tease out any independent association
between food allergies and breastfeed-
ing. Again, the available information
suggests that a benefit of breastfeeding
on the development of food allergies
is likely to be more pronounced in
children with a family history of atopic
disease. Exclusive breastfeeding for the
first 4 months of life has been linked
to a reduced risk for cow’s milk allergy
in toddlers.27 Other studies have come
to different conclusions, however.
According to Greer et al, it is not yet
possible to speak definitively about a
relationship between food allergies and
breastfeeding.24 There is no evidence
that delaying the introduction of solid
food beyond ages 4 to 6 months is
protective against atopy.24
Association Between Breast-
feeding and reduced Risk for
Childhood Obesity
Recent government publications,
including The Surgeon General’s Call
to Action to Support Breastfeeding
2011, First Lady Michelle Obama’s
“Let’s Move” campaign, and the White
House Task Force on Childhood
Obesity, have reiterated a message borne
out by decades of research: Infants
breastfed for at least 6 months are less
likely to become obese than other
children.8,28-30 The AAP recognizes an
inverse relationship between breastfeed-
ing duration and risk for diabetes.4 A
meta-analysis by Owen et al in 2005
of nearly 300,000 subjects suggested a
small beneficial effect of breastfeeding
on obesity risk that persisted even after
controlling for the known confounders
of parental obesity, maternal smoking,
and socioeconomic status.31 In a study
at the Children’s Hospital of Pittsburgh,
more than 73,000 black and white
infants born to low-income families
were followed for 4 years. Breastfeeding
was linked to a lower risk for obesity in
infants born to white mothers who did
not smoke during the pregnancy, and
only when breastfeeding had continued
for 16 weeks without formula or 26
weeks with formula.32
May 2011 9
Breastfeeding: Optimal Nutrition for Infants
Conclusion
As we enter the second decade of the
21st century, clinicians can keep in
mind that the Healthy People 2020
breastfeeding goals are for 82% of
infants to be breastfed at some point in
their lives, for 61% to be breastfeeding
at age 6 months, and for 34% to be
breastfeeding at 1 year.5 These goals
serve as an ongoing challenge for all
professionals who help provide optimal
care for pregnant women and new
mothers and their infants.
References
1. Centers for Disease Control and Prevention. Breastfeed-
ing Report Card—United States, 2010. http://www.
cdc.gov/breastfeeding/data/reportcard.htm. Accessed
February 28, 2011.
In the Diabetes Autoimmunity Study 2. Centers for Disease Control and Prevention. Breastfeed-
in the Young (DAISY), of 1,178 children ing among U.S. Children Born 1999—2007, CDC
National Immunization Survey. http://www.cdc.gov/
with an elevated genetic risk for type 1 breastfeeding/data/NIS_data/index.htm. Accessed
diabetes, predictors of increased child- February 21, 2011.
3. Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding
hood body mass index (BMI) included and the use of human milk. Pediatrics. 2005;115:496-
shorter duration of breastfeeding as well 506.
4. American Academy of Pediatrics Policy Statement. Com-
as female gender, diabetes exposure mittee on Nutrition. Prevention of Pediatric Overweight
before birth, large size for gestational age, and Obesity. Pediatrics. 2003;112:424-430.
5. Department of Health and Human Services (2010).
and rapid weight gain during infancy.33 Healthy People 2020. www.healthypeople.gov. Accessed
A CDC study using data from the December 2, 2010.
6. Healthy People 2010. http://healthypeople.gov/2020/
2005-2007 IFPS II suggested that topicsobjectives2020/objectiveslist. aspx?topicid=26.
delayed bottle-feeding may enhance an Accessed February 21, 2011.
7. Shealy KR, Scanlon KS, Labiner-Wolfe J, et al. Charac-
infant’s ability to self-regulate feeding. teristics of breastfeeding practices among US mothers.
Only 27% of infants in late infancy who Pediatrics. 2008;122:S50-S55.
8. US Department of Health and Human Services. The
had been exclusively breastfed in early Surgeon General’s Call to Action to Support Breast-
infancy finished bottles during regular feeding. Washington, DC: US Department of Health
and Human Services, Office of the Surgeon General;
feedings. In contrast, 54% of infants 2011. http://www.surgeongeneral.gov. Accessed
who were fed by breast and bottle in February 21, 2011.
9. McCann MF, Baydar N, Williams RL. Breastfeeding
early infancy, and 68% of those who attitudes and reported problems in a national sample of
were exclusively bottle-fed, finished WIC participants. J Hum Lact. 2007;23:314-324.
10. Li R, Rock VJ, Grummer-Strawn L. Changes in public
bottles.34 This might possibly explain attitudes toward breastfeeding in the United States,
the association between breastfeeding 1999–2003. J Am Diet Assoc. 2007;107:122-127.
11. Gibson ME. Getting back to basics: the curious history
and lower risk for obesity. of breastfeeding in the United States. Am J Nurs.
Using data from a nationally repre- 2005;105:72c–73c.
12. Moore ER, Anderson GC, Bergman N. Early skin-to-skin
sentative survey of American families contact for mothers and their healthy newborn infants.
(976 subjects), researchers assessed the Cochrane Database Syst Rev. 2007(3):CD003519.
13. Li R, Fein SB, Chen J, et al. Why mothers stop breast-
relationship between breastfeeding feeding: mothers’ self-reported reasons for stopping
and obesity in sibling pairs in which during the first year. Pediatrics. 2008;122:S69-S76.
14. Labiner-Wolfe J, Fein SB, Shealy KR, et al. Prevalence of
one sibling was breastfed and the other breast mild expression and associated factors. Pediat-
was not. Investigators determined that rics. 2008;122:S63-S68.
15. Fein SB, Mandal B, Roe BE. Success of strategies for
breastfeeding predicted a lower BMI combining employment and breastfeeding. Pediatrics.
in adolescence, with a difference of 2008;122:S56-S62.
16. Teferi A, Snow ME. Interventions in the workplace
more than 13 lb in an adolescent of to support breastfeeding for women in employment.
average height.35 Cochrane Database Syst Rev. 2007, Issue 3.
10 may 2011
17. Britton C, McCormick FM, Renfrew MJ, et al. Sup-
port for breastfeeding mothers. Cochrane Database
System Rev. 2007, Issue 1. Art. No.: CD001141. DOI:
10.1002/14651858.CD001141.pub3.
18. World Health Organization/United Nations Children’s
Fund. Protecting, Promoting and Supporting
Breastfeeding: The Special Role of Maternity Services.
Geneva, Switzerland: World Health Organization;
1989.
19. United States Breastfeeding Committee. Implementing
The Joint Commission Perinatal Care Core Measure on
Exclusive Breast Milk Feeding. Rev ed. Washington, DC:
United States Breastfeeding Committee; 2010.
20. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of
maternity-care practices on breastfeeding. Pediatrics.
2008;122:S43-S49.
21. Declercq E, Labbok MH, Sakala C, O’Hara M. Hospital
practices and women’s likelihood of fulfilling their
intention to exclusively breastfeed. Am J Public Health
2009;99:929-935.
22. Academy of Breastfeeding Medicine Protocol
Committee. ABM Clinical Protocol #5: Peripartum
Breastfeeding Management for the Healthy Mother
and Infant at Term Revision, June 2008. Breastfeed
Med. 2008;3:129-130.
23. Bartick M, Reinhold A. The burden of suboptimal breast-
feeding in the United States: a pediatric cost analysis.
Pediatrics. 2010;125:e1048-e1056.
24. Greer FR, Sicherer SH, Burks AW; American Academy of
Pediatrics Committee on Nutrition; American Academy
of Pediatrics Section on Allergy and Immunology. Effects
of early nutritional intervention on the development
of atopic disease in infants and children: the role of
maternal dietary restriction, breastfeeding, timing of
introduction of complementary foods, and hydrolyzed
formulas. Pediatrics. 2008;121(1):183-191.
25. Eichenfield LF, Hanifin JM, Beck LA, et al. Atopic derma-
titis and asthma: parallels in the evolution of treatment.
Pediatrics. 2003;111:608-616.
26. Kull I, Almqvist C, Lilja G, et al. Breastfeeding reduces
the risk of asthma during the first 4 years of life. J Al-
lergy Clin Immunol. 2004;114:755-760.
27. Muraro A, Dreborg S, Halken S, et al. Dietary prevention
of allergic diseases in infants and small children. Part III:
critical review of published peer-reviewed observational
and interventional studies and final recommendations.
Pediatr Allergy Immunol. 2004;15:291-307.
28. Let’s Move. http://www.letsmove.gov/healthymoms.php.
Accessed February 21, 2011.
29. Arenz S, Ruckerl R, Koletzko B, von Kries R. Breast-
feeding and childhood obesity—a systematic review. Int
J Obes Relat Metab Disord. 2004;28:1247-1256.
30. White House Task Force on Childhood Obesity Report to
the President. Solving the Problem of Childhood Obesity
Within a Generation. May 2010. http://www.letsmove.
gov/pdf/TaskForce_on_Childhood_Obesity_May2010_
FullReport.pdf. Accessed February 21, 2011.
31. Owen CG, Martin RM, Whincup PH, et al. Effect of in-
fant feeding on the risk of obesity across the life course:
a quantitative review of published evidence. Pediatrics.
2005 May;115(5):1367-1377.
32. Bogen DL, Hanusa BH, Whitaker RC. The effect of
breast-feeding with and without formula use on the
risk of obesity at 4 years of age. Obes Res. 2004
Sep;12(9):1527-1535.
33. Lamb MM, Dabelea D, Yin X, et al. Early-life predictors
of higher body mass index in healthy children. Ann Nutr
Metab. 2010 February; 56(1):16-22. Published online
2009 November 27. doi: 10.1159/000261899.
34. Li R, Fein SB, Grummer-Strawn LM. Do infants fed from
bottles lack self-regulation of milk intake compared
with directly breastfed infants? Pediatrics. 2010
Jun;125(6):e1386-e1393. Epub 2010 May 10.
35. Metzger MW, McDade TW. Breastfeeding as obesity
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posttest
To participate in this activity and receive your certificate instantly, log on to www.myCME.com/pednutrition and click on the activity to
answer the test questions and complete the evaluation form. This program is approved by Albert Einstein College of Medicine of Yeshiva
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1. According to American Academy of Pediatrics
recommendations, healthcare professionals should:
A. Encourage feeding with human milk for all term infants
unless specifically contraindicated.
B. Give supplements such as water, sugar water, or formula
when appropriate to a nursing newborn.
C. Feed infants at the breast 6 to 10 times in a 24-hour period
in the early postpartum weeks.
D. Recommend continuing to breastfeed for a maximum of
12 months.
2. Among the five obstacles to breastfeeding cited in the
Surgeon General’s Call to Action to Support Breastfeeding
2011 are:
A. Limited number of lactation specialists in the United States.
B. Fears regarding difficulty of breastfeeding and belief in
superior safety of infant formulas.
C. Lack of desire to breastfeed on the part of mothers return-
ing to work.
D. Hospital practices that impede successful breastfeeding
and hinder getting professional help from a knowledgeable
nurse or lactation consultant.
3. The Baby-Friendly Hospital Initiative “10 Steps to
Successful Breastfeeding” includes which of the
following?
A. Practice rooming-in by allowing mothers and infants to
remain together during the daytime hours.
B. Give artificial teats, pacifiers, dummies, or soothers to
breastfeeding infants.
C. Help mothers initiate breastfeeding within 1 hour of birth.
D. Encourage breastfeeding at specified times throughout the day.
4. The United States Breastfeeding Committee discourages:
A. The use of expressed milk or banked human donor milk.
B. The use of all unnecessary glucose or water supplements.
C. Initial skin-to-skin contact until the umbilical cord is cut.
D. Rooming-in until the mother has recovered from delivery.
5. New mothers should be educated regarding:
A. Getting enough sleep when babies are returned to the
nursery for the night.
B. The unfeasibility of breastfeeding if intensive care is
required.
C. The importance of breastfeeding and maximizing mother-
infant bonding.
D. The baby will take about 5 tsp per feeding during the first
2 days of life.
6. Which of the following is correct regarding the
assessment of breastfeeding?
A. Sore nipples may signal poor latch.
B. Engorgement occurs during milk transfer.
C. Infant positioning may affect the quality of breast milk.
D. Proper breastfeeding does not affect infant stool/urine
output.
7. Essential to continued success with breastfeeding is:
A. Large volume of breast milk per feeding.
B. Familial predictors of breast milk supply.
C. Supplementation using a nursing supplementer.
D. Postpartum lactation support.
8. Which of the following is correct regarding the
association between breastfeeding and various risks?
A. Breastfeeding reduces the risk for all food allergies.
B. In infants with a family history of atopy, exclusive breast-
feeding for 4 months reduces the risk for atopic dermatitis.
C. Infants breastfed for at least 6 months are more likely to
become obese than other children.
D. Predictors of increased childhood body mass index included
longer duration of breastfeeding.
May 2011 11
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