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Written by Rebecca Hall Crane, MD MPH April 7, 2010
Research demonstrates the overwhelming health benefits of breastfeeding over formula. The question is no longer whether newborns should breastfeed but how best to support successful long-term breastfeeding. Breastfeeding results in decreased illness for infants and children, including decreased rates of infectious illness, some cancers, allergies and obesity. For women, studies have shown decreased rates coronary artery disease, protection against ovarian and breast cancer, and potentially decreased rates of osteoporosis. In increasing the percentage of exclusively breastfed infants to six months of life, it is estimated that the potential cost savings to the US economy from improved health outcomes, and decreased costs of production, purchasing and disposal of formula supplies, could reach up to $14 billion dollars per year. The American Academy of Pediatrics and American Academy of Family Physicians support exclusive breastfeeding for the first 6 months of life, with continuation of breastfeeding with complementary foods until one year of life and beyond. The American College of Obstetricians and Gynecologists, the World Health Organization, the US Centers for Disease Control, and WIC also recommend and support breastfeeding. The goal set by Healthy People 2010 is to “increase the proportion of mothers who breastfeed their babies” to 75% in immediate postpartum period, to 50% at 6 months postpartum, and to 25% at 12 months postpartum. Data from the CDC (2006 data) show that approximately 74% of women will attempt breastfeeding after delivery; 33% will exclusively feed through 3 months; by six months 43% of women are breastfeeding but only 14% are exclusively breastfeeding. The sharpest decrease in breastfeeding, ~20%, occurs within the first month after discharge. Successful long-term breastfeeding depends on a successful start. Breastfeeding is natural, but it is a learned process, for both mother and infant. The path to successful breastfeeding starts in the prenatal period with education of families to the benefits of breastfeeding and the “risks” of formula feeding. Also required is education of the mother’s support persons, breastfeeding plans for childbirth, preparation of the home environment for breastfeeding as well as return to work breastfeeding plans. It is our imperative as healthcare providers to promote and encourage healthy choices for our patients. Many women do not choose to breastfeed because they are unaware of the benefits of breastfeeding for themselves and their infants. Many women and healthcare providers believe that human milk and formula are equivalent in their nutritional profiles, and that breastfeeding is more of a lifestyle choice than a medical one. Many well-intentioned providers hasten the cessation of breast milk production in new mothers by encouraging supplementation with formula. Many physicians advise mothers to stop breastfeeding prematurely due to assumed incompatibility of common medications, disease states and infant conditions with breastfeeding. This handbook is intended as a point-of-care reference on breastfeeding for healthcare providers. By increasing our knowledge of the medical benefits, physiology, and clinical management of breastfeeding, we will better serve women in supporting their breastfeeding efforts and ensure that all infants get the healthiest start possible.
Rebecca Hall Crane, MD, MPH April 2010
Breastfeeding Medical Conditions and Breastfeeding Maternal Medication Use and Breastfeeding Resources for Information on Medication Use and Breastfeeding Early Prenatal / Pregnancy Early Prenatal Breastfeeding Essentials Indications for Early Prenatal Lactation Consultation Prenatal Breastfeeding-focused History Prenatal Breast Examination Breast Surgery: Augmentation and Breast Reduction Breastfeeding Multiples Potential Obstacles to Breastfeeding Late Prenatal / Delivery Planning Preparing for Delivery / Hospital Stay Cesarean Sections Skin-to-Skin Labor and Delivery / Newborn Period Breastfeeding Essentials Initiation of Breastfeeding after Delivery Skin-to-Skin Cesarean Deliveries Newborn Physiology Pertinent to Breastfeeding Management Elimination Patterns of Normal Newborns in First Week of Life Normal Weight Change in the Newborn Feeding Patterns and Hunger Cues of Breastfeeding Infants Sleepy infant / “won’t wake to feed” Nipple Confusion Milk Expression / Separation of Mother and Infant Hypoglycemia Medical indications for Formula Supplementation Lactogenesis 2 “the milk coming in” Breastfeeding the Late-preterm Infant Decision Not to Breastfeed Hospital Discharge Checklist .5 Table of Contents Breastfeeding Step-by-Step for Clinicians Medical Implications of Breastfeeding Medical Benefits of Breastfeeding Table: Relative Risk of Formula Feeding vs.
Milk Transfer Methods of Human Milk Expression Alternative Methods to Bottle Feeding Infants Reverse Pressure Softening for Breast Engorgement Sample Breastfeeding Intake and Elimination Log Galactogogues Donor Breastmilk / Breastmilk Banking CDC: Breastfeeding and Swine Flu (2009) Travel Recommendations for the Nursing Mother Online Clinician Breastfeeding Education and Training Options PHQ9 Screening Tool for Depression California Breastfeeding Laws and Legislation KP and Community Patient Breastfeeding Resources . Imaging / Radiocontrast Agents Hyperbiilirubinemia Risk and Phototherapy Nomograms Basic Lactation and Breastfeeding Physiology Evaluation of Breastfeeding Technique: Positioning.6 Table of Contents (cont) Post-partum / First week of life Breastfeeding Essentials for the Clinician Assessing Breastfeeding Success for Infant and Mother Vitamin D Supplementation for the Breastfeeding Infant Common Early Post-partum Breastfeeding Issues Pacifier Use Breast Engorgement Hyperbilirubinemia Ankyloglossia “tongue tie” Indications for Post-Partum Lactation Consultation First month of life Growth / Weight Gain of Healthy Full Term Infants Pumping and Storing Breastmilk Contraception and Breastfeeding Lactation Amenorrhea Method of Contraception Insufficient Milk Syndrome Sore Nipples / Nipple Trauma Mastitis / Breast abscess / MRSA / Candidal Infections Co-sleeping / Bedsharing Post-partum Depression Return to Work Weaning Breast Cancer Detection in Breastfeeding Women Environmental Toxins in Breastmilk Breastfeeding Support for Patients / Patient Resources Appendix Breastfeeding Policies: AAP. Vaccines. Latch. ACOG The Baby Friendly Hospital Initiative Healthy People 2010 Breastfeeding Goals Medication Tables. AAFP.
and maternal medication use.. based on their infant’s feeding cues and not on a schedule. if indicated. 11. and support our patients’ long-term breastfeeding efforts! . 7. Know the medical reasons to supplement with formula. 8. and multiple gestation. Educate women that infants feed up to 16 times per day during the first week of life. 12. 3. artificial nipple and bottle use in breastfeeding infants.e. and know that most newborns do not need supplementation of during the first few days of life. returning to work. 14. Ensure that women who are separated from their infants are given a breast pump to simulate nursing. and encourage them to breastfeed. maternal chronic disease.” i. and that this is normal. 4. 13. Refer women to a lactation consultant during pregnancy. Assist women in making a breastfeeding plan for their delivery prior to their due date. Understand normal newborn physiology. 5. 9. and ensure close follow-up and evaluation of both mother and infant post-discharge. such as postpartum return-to-work plans. Educate all women and their families on the medical benefits of breastfeeding for mothers and infants. Educate women about potential breastfeeding difficulties. such as growth spurts. Know the medical implications of breastfeeding on infant and maternal health and the significant medical benefits afforded to both women and children from breastfeeding.7 Breastfeeding Step-by-Step for Clinicians 1. Discourage routine pacifier. Ensure adequate evaluation and instruction of breastfeeding in the hospital post-delivery. 2. and tell them to use it at least every three hours for at least 15 minutes. planned maternal medication use. and use formula only when medically necessary. Reiterate that our goal is to have all infants breastfeed for one year and beyond. Assist mothers in getting a lactation consultation if needed. Address potential barriers to breastfeeding while a woman is pregnant. Assist women in breastfeeding their child within a half-hour of birth. 10. Encourage all pregnant women to attend a breastfeeding class prior to delivery to assist in the family’s preparation for breastfeeding. Instruct women to breastfeed their infants “on demand. encourage women to delay pacifier use until one month of life. 6. This ensures that breast milk production will not drop off during the separation.
Breastfeeding Medical Conditions and Breastfeeding Maternal Medication Use and Breastfeeding Resources for Information on Medication Use and Breastfeeding .9 Medical Implications of Breastfeeding Medical Benefits of Breastfeeding Table: Relative Risk of Formula Feeding vs.
Benefits were seen in women who breastfed for a minimum duration of 6 months. premenopausal breast cancer • Reduced risk of post-menopausal hip fractures. otitis media. but the longer a woman breastfed. gastroenteritis. and adult-onset hypertension • Lower rates of childhood and adult obesity For mothers A 2009 study of nearly 140. meningitis. and urinary tract infections • Lower rates of sudden infant death syndrome (SIDS) • Lower rates of childhood and adult-onset diseases such as insulin dependent diabetes. and cardiovascular disease compared to mothers who never breastfed. . which provides formula to mothers and infants at $950 million per year • decreased parental employee absenteeism due to illness of child and associated work losses • savings from elimination of environmental burden for disposal of formula cans and bottles • savings from elimination of energy demands used for production and transport of formula Please see last page of this booklet for references to the above information. including ovarian cancer. the better.11 Medical benefits of breastfeeding For infants Breastfed infants are protected from many illnesses compared to formula – fed infants. diabetes.S. ulcerative colitis. necrotizing enterocolitis. could potentially save up to $14 billion a year (4) via breastfeeding due to: • improved health outcomes for infants and mothers • decreased public health expenses including expenditures for WIC. (2) Other medical benefits to women from breastfeeding include: • Reduced risk of cancers. and rheumatoid arthritis • Enhanced mother-infant attachment and bonding via skin-to-skin contact. Breastfed infants experience: • Decreased incidence of infectious illnesses such as GI and respiratory infections. asthma.000 per year per infant Decreased healthcare costs due to less MD visits and less prescription medications Decreased missed days from work due to infants with less illness For Kaiser Permanente Estimated cost savings of $400 per infant per year due to decreased infectious GI and respiratory illness in breastfed infants (3). the greater the benefits. lymphoma. likely related to release of oxytocin and prolactin • Enhanced post-partum uterine involution resulting in less blood loss and reduced risk of infection For families • • • Significant cost savings. high cholesterol. formula costs between $1200 to $3. The longer an infant is breastfed.000 women found that women who breastfed for at least one year were 10-15% less likely to have high blood pressure. For the US economy The U. allergies.
Am Fam Physician 2000.2103-4. In: Breastfeeding: a guide for the medical profession.7 times (6) 2. Tragnone A.13 Relative Risk of Formula Feeding vs. Coombs. Graziano L. Scarpellino B. Rogan WJ. 7. Auerbach KG. et al. Papi C.7 to 5 times (1) 3. Pettitt DJ.: Jones and Bartlett. Breastfeeding and incidence of non-insulindependent diabetes mellitus in Pima Indians.27:397-404.26:443-50.8 times (7) 6 to 10 times (2) 1. Andreoli A. Human milk feedings and infection among very low birth weight infants. 3. Hylander MA. 2d ed. 2. St. Silfverdal SA. Lancet 1997. Hanson RL. Lawrence RM. Risk of inflammatory bowel disease attributable to smoking.5 to 1. Hugosson S. Mass. Lawrence RA.4 times (1) 3. Breast-feeding and urinary tract infection. 4. et al. Review of the evidence for an association between infant feeding and childhood cancer. Chen A.113(5):e435-e439 . 5. Caprilli R.61:2093-100. Werner B. Riordan J.9 times (2) 2. 1999. Breastfeeding in modern medicine. Int J Epidemiol 1997.11:29-33. Int J Cancer Suppl 1998.13:203-8. 5th ed.9 times (4) 2. 8. Bennett PH. 6. Corrao G. Cooperative Investigators of the Italian Group for the Study of the Colon and the Rectum (GISC). Bodin L. Sudbury. Esbjorner E. 9. Dhanireddy R.4 times (5) 3 times (1) 1.1 times (8) 2.5 times (3) 1. Mazzarella G. Pediatrics 1998.8 to 6. eczema Urinary tract infections Inflammatory bowel disease Diabetes. References for table: 1. Int J Epidemiol 1998. Forman MR.120:87-9. 2004. 1999. Pisacane A. Moreland.0 times (1) 27% (9) 3 times (1) 50 times (1) 7. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics. Knowler WC.6 to 5. type 1 Gastroenteritis Hodgkin's lymphoma Otitis media Haemophilus influenzae meningitis Necrotizing enterocolitis Pneumonia/lower respiratory tract infection Respiratory syncytial virus infection Sepsis Sudden infant death syndrome Death in first year of life Industrialized-world hospitalization Developing-country morbidity Developing-country mortality 2 to 7 times (1) 2. Garpenholt O. Strobino DM. Davis MK. Trallori G. oral contraception and breastfeeding in Italy: a nationwide case-control study. Zona G. Protective effect of breastfeeding on invasive Haemophilus influenzae infection: a case-control study in Swedish preschool children. In: Breastfeeding and human lactation. Breastfeeding Allergies. Louis: Mosby.9 times (1) Table adapted from Promoting and Supporting Breastfeeding.102:E38. J Pediatr 1992.
lesions should be kept covered. therefore.15 Medical Conditions and Compatibility with Breastfeeding The default answer to “Can a woman breastfeed?” is “yes. Because of this. there is no risk of transmission to the infant via breastmilk. at which time she may resume breastfeeding. however. mother should be isolated from the infant until she is considered non-infectious. breastfeeding is recommended for these infants. • Chronic / acute hepatitis C infected women can breastfeed. Women with active HSV lesions on breast should not breastfeed. Zoster / shingles affected women may breastfeed as long as there are no lesions on the breast. did not develop the disease. untreated tuberculosis in the mother is not compatible with breastfeeding. • Infants born to women who have acute hepatitis A infection may breastfeed after they have received the hepatitis A vaccine and serum immune globulin. the infant may be given expressed breastmilk from the mother (it does not contain the mycobacterium) until treatment is completed and she is considered non-infectious. Common situations that are NOT contraindicated with breastfeeding • • • • • • Maternal fever or infant fever Mastitis Maternal smoking Moderate maternal alcohol use (1-2 drinks per day) Most prescription and over-the-counter medications Chronic hepatitis B and C infection Selected Maternal Conditions and Breastfeeding Hepatitis • Chronic carriers of hepatitis B or women who test positive for hepatitis B surface antigen can safely breastfeed after their infants have received hepatitis B vaccine and hepatitis B immune globulin (HBIG). • • Other Maternal Medical Situations: . otherwise healthy infants born at term with congenital or acquired CMV infections usually are not affected by the virus if they are breastfed. Other infections • • • • HIV or HTLV virus infection in women is not compatible with breastfeeding. and rarely manifested symptoms. Active. Women infected with CMV will have both virus and antibodies in their breastmilk. A study of infants who developed infections during breastfeeding found that the infants also developed an immune response.” There are very few medical conditions or situations that are not compatible with breastfeeding. these infants have the same rate of infection (4%) whether they are breast or bottle-fed. after the infant has received VZIG the mother can provide expressed breastmilk as long as there are no active lesions on the breast. A woman with primary active varicella infection (not zoster) should neither breastfeed nor should her infant be fed her expressed breast milk.
as soon as the mother can respond to her infant she may breastfeed. Dialysis: women undergoing dialysis may breastfeed. Infant conditions contraindicated with breastfeeding These conditions require specialized formulas: • Galactosemia • PKU • Maple syrup urine disease . Illicit drug use.16 • • • • • Imaging: oral and IV iodinated contrast and gadolinium is compatible with breast feeding General anesthesia: these agents pass in negligible amounts into the breast milk. Breast cancer treatment: women undergoing active breast cancer treatment should not breastfeed. or excessive alcohol use is not compatible with breastfeeding.
Commonly used medications NOT contraindicated in breastfeeding: • • • • • • • • • • Morphine Ibuprofen Amoxicillin Methadone SSRIs (paroxetine.) Phenytoin Warfarin Levothyroxine General anesthesia Imaging agents: iodinated contrast. Maternal medication use is a major reason why many women stop breastfeeding. Lexicomp. Almost all prescription and OTC medicines are compatible with breastfeeding.17 Maternal Medication Use and Breastfeeding Tables detailing the compatibility of maternal medication use and breastfeeding are in the appendix of this handbook. the Pocket Pharmacopoeia and Micromedex are poor sources of information regarding medications and breastfeeding! Please see page 19 for the best sources. or are not harmful to the infant. most appear at clinically insignificant levels. Please note: the Physician’s Desk Reference. • Bromocriptine methotrexate. sertraline and nortriptyline are preferred over fluoxetine. usually due to an unfounded fear that the medicine will be harmful to the infant. gadolinium Maternal medications that may pose a risk to breastfeeding infants: When deciding whether a woman should stop breastfeeding. Almost all medications pass in some capacity into breast milk. but may be excreted into breast milk at slightly higher levels than the others listed. epocrates. Many well-intentioned healthcare providers also incorrectly tell breastfeeding mothers that their medications are not compatible with breastfeeding. fluoxetine is not prohibited. cyclosporine. doxorubicin • Doxepin ! Illicit / illegal / recreational drugs • Lithium • Radioactive iodine • Chloramphenicol • Ergot Alkaloids . The following medications are those that pose potential risk to breastfeeding infants: • Amiodarone ! Anticancer Agents: cyclophosphamide. Clinicians must weigh the risks of breastfeeding cessation to the risks of medication exposure via breastfeeding before they advise women to cease or suspend breastfeeding. Surveys in western countries indicate that 90% to 99% of women who breastfeed receive at least one medication during their first week postpartum. however. the clinician must weigh the risks of exposure of medication in breastmilk to the risks of cessation of breastfeeding. very few are not.
healthy infants. . Alcohol may have a negative impact on oxytocin levels and inhibit letdown. • Infants can be breastfed immediately before medication administration when multiple daily doses are needed. single daily-dose medications can be administered just before the longest sleep interval for the infant. Recreational / illicit drugs / drugs of abuse / uncontrolled etoh use These agents are not considered compatible with breastfeeding. Caffeine • • Moderate intake causes no problems for most breastfeeding infants The amount of caffeine excreted into breastmilk is usually less than 1% of the amount ingested by the mother. no adverse effects on breastfeeding infants have been reported from exposure to this substance. this is equal to 0. away from their infants. but if the mother is unwilling to quit she should continue breastfeeding and smoke outside. they should smoke outside. usually after the infant’s bed-time feeding. • Caution is advised when prescribing medications for breastfeeding mothers of premature or otherwise compromised newborns than for breastfeeding mothers of older. • Medications that are safe for administration to an infant are considered compatible with breastfeeding. Medication dosing • If concern exists for exposure to the infant. Recommendation: Ideally.2 drinks per day. A rule of thumb is that if the mother is feeling the effects of alcohol. which usually takes two hours. • Medications that are safe in pregnancy are not always compatible with breastfeeding. it will be excreted in her breastmilk. A breastfeeding mother may want to wait until the alcohol clears her system.5 g of alcohol per kg body weight or 1. which has found to be higher in infants born to mothers who smoke. • Use topical therapy when possible. A negligible amount of nicotine metabolites are found in breastmilk in the form of cotinine. Breastfeeding offers the infant protection against SIDS. the best recommendation is to quit smoking. Alcohol • • • Occasional use of alcohol in limited amounts is compatible with breastfeeding. Research suggests that infants of smoking mothers are healthier if they are breastfed. Maternal Smoking • • • • If women smoke. and this has not been found to be harmful to the infant.18 Minimizing Potential Risk to Nursing Infants from Maternal Medication Use General considerations • Use reliable references for obtaining information on medications in breast milk (see next page).
Among the data included are maternal and infant levels of drugs. University of Rochester: Database of references on drugs. medications.19 Resources for Information on Medication Use and Breastfeeding Note: Physician’s Desk Reference and epocrates are poor sources of information regarding medications and breastfeeding! Online Resources Toxnet.nih. http://www. and contaminants in human breast milk. American Academy of Pediatrics Policy on Drugs and Breastfeeding http://aappolicy. Freeman & Yaffe Breastfeeding: a Human Lactation Study Center.aappublications.org/ Textbook Resources Medications and Mother’s Milk 2008 by Thomas Hale Drugs in Pregnancy and Lactation by Briggs. .nlm.gov/ and click “Lactnet” (or type “LACTMED” into a Google search engine) A peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed. and alternate drugs to consider. possible effects on breastfed infants and on lactation. US National Library of Medicine.
21 Early Prenatal / Pregnancy Early Prenatal Breastfeeding Essentials Indications for Early Prenatal Lactation Consultation Prenatal Breastfeeding-focused History Prenatal Breast Examination Breast Surgery: Augmentation and Breast Reduction Breastfeeding Multiples Potential Obstacles to Breastfeeding .
23 Early Prenatal Breastfeeding Essentials • • • • • • All pregnant women should be educated about the medical benefits of breastfeeding as well as the risks of formula. or other) • Breast or nipple anomalies • Multiple gestation . Breastfeeding should be discussed at first and subsequent prenatal visits. Support from a significant other has been identified as one of the most important factors for those who chose to formula-feed. augmentation. Short hospital stays make teaching difficult. The mother’s support person should be included in breastfeeding education and promotion efforts at every office visit. Prenatal Breastfeeding Assessment Prenatal visits are an essential opportunity for obstetric care providers to discuss and encourage breastfeeding and obtain a medical history relevant to educating the patient about breastfeeding. making the prenatal period the ideal time for the mother to learn about and prepare for breastfeeding. and materials advertising or promoting formula should be removed from waiting rooms and exam rooms. Indications for Early Prenatal Lactation Consultation Consider referring the patient to a lactation consultant at this time if the following conditions are present: • Failed or extreme difficulty with breastfeeding after previous deliveries • Lack of breast changes during pregnancy • History of breast surgeries (reduction. Positive messages about breastfeeding should be displayed in the physician’s office. Prenatal education. Include the mother’s support person in discussions about breastfeeding. encouragement and support of breastfeeding by clinicians significantly increase breastfeeding rates.
e.) supportive of breastfeeding? Address mother’s dietary concerns: o There is no specific breastfeeding diet! o There are no restricted foods for a breastfeeding mother! o Mothers who exclusively breastfeed utilize approximately 500 kcal / day. o If a mother is a strict vegan. infant's father. Women with these conditions can breastfeed but they and their infants may need close post-partum follow-up: o History of hormone-related infertility / PCOS o Depression o Contraception use o Hypothyroidism o Diabetes Discuss current or planned medication use and/or substance abuse Discuss contraceptive planning. o She should drink a glass of water each time she breastfeeds. etc. Most contraception. usually 4 – 6 glasses of water per day when nursing regularly.24 Prenatal Breastfeeding-focused History • Ask open-ended questions: o “Have you noticed your breasts changing in preparation for feeding your baby?” o Avoid asking “are you going to breast or bottle-feed?” which can suggest that the two methods are equivalent. mother's mother. Mother’s plans for return to work following pregnancy Discuss mother’s breastfeeding experience with previous children: o Did patient breastfeed any previous infants? o Were there previous breastfeeding problems? o Is there a negative attitude regarding the success of breastfeeding? o Are others (i. Discuss maternal medical conditions that can affect breastfeeding due to possible decreased milk productions. Please see page *** and medication tables in the appendix for more information. o Moderate caffeine intake and 1 – 2 glasses of alcohol per day are considered compatible with breastfeeding. it is recommended that she take a daily vitamin B12 dietary supplement while she is breastfeeding. • • • • • • . including combined hormonal oral contraception. is compatible with breastfeeding. friends.
• 3% of all breast cancers appear during the post-partum period. • Women with hypoplastic or tubular breasts may have difficulty breastfeeding and should be referred for lactation consultation. Previous breast surgeries: • Breast augmentation: silicone is an inert molecule and silicone breast implants are considered compatible with breastfeeding by the American Academy of Pediatrics. Flat or Inverted Nipples: • Most women with flat or inverted nipples can breastfeed successfully with adequate assistance after delivery. • It can often be difficult to examine a nursing mother’s breasts post-partum. • Research does not warrant breast preparation during pregnancy (i. • Breast reduction surgery: may interfere with adequate milk production post-partum due to potential severing of ducts. • Significant asymmetry should raise red flags for such issues as inadequately developed breasts or hormone deficiencies. etc. • True inverted nipples are rare. rolling nipples. • Nipple rolling after delivery or use of a breast pump for 1 – 2 minutes prior to breastfeeding can facilitate latch-on. stretching nipples. • A thorough prenatal breast exam can help reassure clinicians that a lump found postpartum is not cancer. breast shells.25 Prenatal Breast Examination The physical exam is an excellent opportunity for the clinician to reassure a woman that her breasts are developing and that she is physically capable of feeding her child. Breast Symmetry: • Slight asymmetry of breasts is considered normal.) to aid in changing nipple shape. Breast Size and Shape: • Clinicians must ensure that a woman’s breasts are appropriately increasing in size during pregnancy. these women need close post-partum follow-up to ensure adequate milk production and growth of the infant. . • Women with small or large breasts can breastfeed. Breast Lumps / Masses: • Any lump appreciated in a woman’s breast at this exam should be considered for a full evaluation via ultrasound or biopsy or both. consider specialty evaluation.e.
Breastfeeding Multiples Mothers of twins should be encouraged to breastfeed and reassured that they can expect to fully support their infants’ nutritional needs via exclusive breastfeeding. Women who have had a reduction mammoplasty can also breastfeed.26 Breast Implants / Breast Augmentation Women with silicone breast implants can safely breastfeed. Mothers of higher order multiples will likely need to supplement their breast milk.llli. nursing more than one infant can be very challenging. the concentrations are not elevated over control samples.. There is no evidence at the present time that this polymer is directly toxic to human tissues. their overall success will depend on the degree of interruption to the ductile system. Women who have had breast surgery involving periareolar incisions. Patient information on breastfeeding after breast surgery can be found at: www.the anticolic compound simethicone [which is routinely given to infants] is a silicone and has a structure very similar to the silicone compound in breast implants… The [AAP] Committee on Drugs does not feel that the evidence currently justifies classifying silicone implants as a contraindication to breastfeeding. or women who have had breast reductions should been seen prenatally by a lactation consultant to prepare for breastfeeding. they may have difficulty if their breast surgery involved the complete severing of lactiferous ducts. Breast milk production is infant-driven. as they are at increased risk of producing an insufficient supply of milk.” 2001): “There are only a few instances of the polymer being assayed in the milk of women with implants.. In regards to the safety of breastfeeding from breasts that have silicone implants (American Academy of Pediatrics “The Transfer of Drugs and Other Chemicals into Human Milk. however. and mothers of regularly breastfed twins will produce twice the quantity of milk than mothers of singletons. however. Support groups can be especially helpful for mothers of multiples. . these women will likely benefit from a prenatal lactation consultation.org. and early and frequent follow-up with a pediatrician and lactation consultant following delivery is advised.bfar.” Breast Surgery / Breast Reduction Women who have had breast surgery can expect to successfully breastfeed. However.org (Breastfeeding after Nipple and Breast Surgery) and on the La Leche League website: www. however. They should also be counseled about frequent follow-ups postnatally to evaluate breastfeeding success and infant growth.
” Clinicians can assist women and their partners by eliciting concerns. Some women will decide that the challenges of breastfeeding outweigh the benefits for themselves and their babies. answering questions. Prenatal education: women can be encouraged to attend prenatal classes where they will learn about and increase their confidence about breastfeeding. and that postpartum pain medications are compatible with breastfeeding. reduction or augmentation (see next page) Physical discomfort Concern over need to return to work or school Lack of confidence / fear that infant won’t get enough to eat Jealousy (partner / relative / sibling) Cesarean sections From ACOG 2007: “Women need to know that breastfeeding. and confronting misperceptions about breastfeeding: • • • • • • Informed consent: clinicians can give women information about the medical benefits of breastfeeding. and that they won’t be “abandoned” or made to feel guilty for their decision not to breastfeed. Breastfeeding rights and legislation: women can be reassured that in California there are state laws to protect a woman’s right to breastfeed in public and to express her breastmilk while at work.27 Potential Obstacles to Breastfeeding • • • • • • • • • • Patient and clinician perception that formula is equal to breastmilk or is “good enough” Lack of support of family and friends Feelings of embarrassment Concern over loss of freedom Breast surgery. Cesarean sections: women who have a cesarean section should be reassured that they can breastfeed their infant as well as women who delivery vaginally. Many families find their own solutions to their concerns and fears as they come to understand the substantial medical benefits of breastfeeding to both women and infants. . Separation from infant: information can be given to women about milk expression and storage to assist with their plants to return to work while continuing to breastfeed. like other aspects of having a new baby. Assistance and teaching: patients can be reassured that assistance and follow-up will be provided in the hospital and post-partum to ensure proper breastfeeding technique and infant weight gain. has its demands as well as its rewards. These women should be reassured that they will receive assistance and teaching about infant feeding during their hospital stay and post-partum.
Late Prenatal / Delivery Planning
Preparing for Delivery / Hospital Stay Cesarean Sections Skin-to-Skin
Late-Prenatal Breastfeeding Essentials:
• • • • • • • • • Provide mothers and families with information about her delivery and what to expect in regards to breastfeeding after delivery in the hospital setting. Help mother prepare to breastfeed within the first hour of birth. Reiterate the medical benefits of breastfeeding and risks associated with formula feeding. Continue to address questions and concerns of the mother and family about the initiation and management of breastfeeding. Encourage mothers to read about breastfeeding and to enroll in a breastfeeding education program prior to delivery. Give mother a list of hospital and community breastfeeding resources prior to delivery, including lactation support groups. Educate mothers on their ability to return to work while continuing to breastfeed; mothers should plan on returning to work at the earliest 4 weeks post-partum to ensure proper establishment of breastfeeding. Discuss infant bonding activities for partners and families that don’t involve feeding, such as changing diapers, holding / rocking / burping the infant, etc. Encourage mother to purchase a breast pump prior to delivery to assist in breast softening in the case of engorgement, as well as for breast milk pumping and storage.
. Breastfeeding after Delivery and Skin-to-skin A mother and infant’s first breastfeeding experience should ideally be within the first two hours of life. Labor and Delivery Mother may receive medications during delivery. and a plan to reunite the mother and infant as soon as medically possible following the procedure should be made. Cesarean Deliveries The rate of cesarean sections has climbed to over 50% in the past few years. These medications are. A woman’s intent to breastfeed should be communicated to the operating surgeon and hospital staff. within the first half-hour or hour of birth. with infant skin-to-skin with mother. A woman’s clinician can plan to support a mother’s desire to breastfeed by balancing pain relief during her delivery while avoiding excessive amounts of medication. Research on this initial contact has shown that babies placed skin-to-skin immediately after birth breastfeed for an average of 2. with few exceptions. (CDC. the clinician can reassure the mother that medications routinely used during the procedure. are compatible with breastfeeding (see appendix). with infant skin-to-skin on mother’s chest. such as antibiotics. of the robust bonding experience that occurs at these initial moments. or more. including anesthetics and analgesics.5 times longer than babies who were not. long-term breastfeeding. Research has shown that many hospital practices interfere with the institution and future success of breastfeeding. immediately or shortly after delivery.32 Birth and delivery planning • • • • Informing pregnant women about what to expect when they come into the hospital to deliver greatly increases a women’s confidence to breastfeed and makes the chance of receiving supplementary formula less likely. compatible with breastfeeding immediately after delivery. This may be due to the increased confidence of infant and mother. and regional anesthesia. Demerol is notably not compatible with breastfeeding. Mother and clinician should plan on infant’s first breastfeeding be immediately or shortly after delivery. pain medications. 2008) Women should be reassured that they can breastfeed successfully after cesarean sections like women who delivery vaginally. If a cesarean section is planned. Getting women and babies off to a good start is crucial to the ultimate goal of exclusive. initiation of signals promoting copious milk production.
33 Labor and Delivery / Newborn Period Breastfeeding Essentials Initiation of Breastfeeding after Delivery Skin-to-Skin Cesarean Deliveries Newborn Physiology Pertinent to Breastfeeding Management Elimination Patterns of Normal Newborns in First Week of Life Normal Weight Change in the Newborn Feeding Patterns and Hunger Cues of Breastfeeding Infants Sleepy infant / “won’t wake to feed” Nipple Confusion Milk Expression / Separation of Mother and Infant Hypoglycemia Medical indications for Formula Supplementation Lactogenesis 2 “the milk coming in” Breastfeeding the Late-preterm Infant Decision Not to Breastfeed Hospital Discharge Checklist .
often manual expression is required to get colostrum out of breasts.e. ACOG.35 Labor and Delivery / Newborn Breastfeeding Essentials: • • • • • • • • • Breastfeeding should occur immediately after delivery with infant skin-to-skin with mother. and assessment of infant jaundice. This is normal.” Routine pacifier use in breastfeeding infants should be discouraged. This is because colostrum is high in antibody content and difficult to express via suction only. this log begins in – house and continues for the first few weeks post-partum. . and the US Surgeon General.” Avoid mother / infant separation while in the hospital. Infants can nurse 8 to 12 times. • Consider using a syringe or a cup to feed infants supplemental feedings to prevent nipple confusion. breast stimulation via pumping during the first few days of life ensures that milk production will be adequate at lactogenesis 2. All newborns will have a 48 hour post-discharge well-child check. • Instruct women to use the pump 8 times per day while awake and once during the night for at least 15 minutes on each breast. appropriate infant weight gain. this is called “breastfeeding on demand. Infants do not need formula supplementation for the first few days of life unless medically indicated. Infants should be fed based on their feeding cues and not on a schedule. aka “the milk comes in. Essentially. Mothers should keep a log of their breastfeeding frequency and duration. and may not produce much milk in the first few days. NICU stay for infant) are given a breast pump. this appointment ensures breastfeeding success. optimally within the first 1 – 2 hours of birth. sometimes up to 16 times per day in the first few weeks of life. as well as their infant’s wet diapers stools. • This is primarily for breast stimulation. mothers and infants are “rooming in. AAFP. Inform mothers that breastfeeding to one year and beyond is recommended by the AAP.” • Ensure that mothers who are separated from their infants (i. • Colostrum is the milk present in women’s breasts during the first few days post-partum. For infants who must be separated from their mothers post-partum: In the event of mother – infant separation.
Skin-to-skin Early breastfeeding and skin-to-skin contact has been shown to increase long-term breastfeeding rates in infants. crawl to it. Infants who have a stable cardiovascular and pulmonary status are eligible for this skin-to-skin experience. Optimally. and may even show faster weight gain • Kangaroo care. the infant will have two hours with the mother to complete this first feeding. Infants have a short period of increased alertness immediately following delivery. a blanket then covers the infant. Infants born via c-section can be reunited with their mothers in the recovery room and placed skin-to-skin with mother. Infants wearing only a diaper and hat are placed skin-to-skin against the parent's bare chest. eye ointment application. usually without assistance. these procedures include weighing and measuring the infant. the more likely it is that the infant will receive formula supplementation. administering injections. Research has shown many physiologic benefits of prolonged skin-to-skin contact for both infants and parents: • Infants cry less and spend more time in deep sleep • Infants show less apnea and periodic breathing • Protection of thermoregulation in the infant • Improved oxygen saturation rates • Premature babies may come out of incubators and move to cribs faster • Babies may feed earlier. including rule-out sepsis infants. breast feed more successfully. and applying erythromycin eye ointment can wait until after this first feed and preferably done in the mother’s room following delivery. and latch on to breastfeed. such as weighing and bathing the infant. the infant will be placed skin-to-skin on mother’s bare chest. and vitamin K injections. mothers are encouraged to remove their bras. • • • • . Routine newborn procedures can be delayed until this crucial first breastfeeding experience as been completed. Of note.36 Initiation of Breastfeeding after Delivery All medically stable children (Apgar scores 7 and above) are capable of having this experience. bathing. which enables them to sense the nipple. a type of skin-to-skin contact used in the NICU. Routine nursery procedures. promotes breastfeeding and increases milk production in mothers • Facilitates infant / parent bonding • Can increase confidence in ability to parent in mothers Skin-to-skin Clinical Basics • • Newborns have a short period of increased alertness immediately following delivery where they often instinctively find the mother’s breast and initiate breastfeeding. Both parents can do skin-to-skin: it is easiest when done with shirts that open in the front. Immediately after delivery. the longer a woman and her infant are separated following delivery.
post-surgical pain. Most mothers will need assistance with positioning while avoiding incision area (side-lying hold. • • • • • Rooming-in Rooming-in refers to infants and mothers sleeping in the same room in the hospital. football hold.) If a woman has undergone general anesthesia. sleep more. she can breastfeed as soon as she can respond to her infant. there is no reason to delay breastfeeding following their administration.” • Research shows that rooming-in allows infants to cry less. infants were kept in newborn nurseries with the intention of letting the mother rest following delivery. including anesthetics and analgesics. • Breastfeeding rates are lower in mothers who delivery via c-section. This is thought to be due to many factors. However.) As soon as a woman can respond to her infant. etc. concern about exposing a newborn to mother’s pain medications via breast milk. are compatible with breastfeeding (see appendix. which can inhibit let-down. • Clinicians may be reassured to know that studies of mothers who room-in with their infants 24 hours a day while in the hospital show that they sleep better and have increased milk production. The agents used for general anesthesia are compatible with breastfeeding. . Traditionally. allowing a mother and infant to room-in together has many benefits: • Rooming-in and skin-to-skin contact between mother and infant allows the mother to recognize her infant’s hunger cues and “feed on demand.37 Cesarean Deliveries Women should be reassured that they can breastfeed successfully after cesarean sections like women who delivery vaginally. including separation of the mother and infant following the procedure. The clinician can reassure the mother that medications routinely used during the cesarean sections. and possibly a feeling of ‘failure’ on the mother’s part for not having delivered vaginally. and become adept at breastfeeding sooner. she should be reunited with her infant and encouraged to breastfeed skin-to-skin.
Parents should expect about 6 wet diapers per day after 1 week of age.5 days after birth the stool should be yellow and “seedy. It is physiologic for newborns to receive 1 – 2 ounces of milk / colostrum PER DAY for the first two days of life or until lactogenesis 2 (“milk comes in”) occurs. Bowel Movements • • • Meconium is the first stool after birth and is black. 4 – 6 voids on day of life 3. thick and tarry.3 days of life the stools will look greenish in color. 8% weight loss from birth weight is considered acceptable during the first week of life. Infants are expected to lose weight after birth.39 Newborn Physiology Pertinent to Breastfeeding Management • • • • • • Full . Expect one void on day of life one. At 4 .term. 1 – 2 voids on day of life two. After 2 . and slowly gets bigger. An infant’s stomach is the size of a small marble on day of life 1. Elimination Patterns of Normal Newborns in First Week of Life Wet Diapers Healthy breastfed infants will usually void 1 to 3 times per day in the first two days.” Expected Elimination Patterns of Healthy Newborns Day 1 1 wet diaper 1 meconium stool Day 2 Day 3 Day 4 Day 5 Day 6+ 2 – 3 wet diapers 4 – 6 wet diapers 4 – 6 wet diapers 6 – 8 wet diapers 6 – 8 wet diapers 1 meconium stool Color changes Transition stools 3 – 4 yellow stools > 4 stools . appropriate weight for gestational age infants are born with a “camel’s hump” of nutrition that provides for their metabolic needs during the first two to three days of life.
and educate the family on appropriate / normal weight loss: • • • Weight loss of up to 7 – 8 % of birthweight is acceptable during the first week of life. the infant will consume approximately 3 – 4 ounces every 3 – 4 hours. Typical weight gain is 5 – 7 oz per week for first four weeks (10g/kg per day) Calculate weight loss: Weight loss / Birthweight = 0.2 oz of colostrum per day for the first few days of life. . and experience physiologic weight loss during the first few days of life as they wait for the onset of copious milk production in the mother’s breasts. After copious milk production begins. do not need supplemental feeding for the first 24 – 48 hours. Lack of confidence that the infant is getting enough to eat. However.0X = X% weight loss (50 g weight loss / 3500 g birth weight = 0. Term. Newborns are expected to lose weight at birth. or the hospital staff. This is expected to happen at ~48 – 60 hours post-partum. whether on the part of the mother. Babies will regain their birthweight around the end of the second week of life. or copious milk production in the mother’s breasts. which usually between 48 and 100 hours of life. It is considered physiologic for the breastfeeding infant to consume no more than 1 . and are generally allowed up to 8% weight loss of birth weight during the first week of life before supplementation is considered. as new mothers will often question the adequacy of their milk supply and whether they are making enough milk to feed their infants. the mother’s support person. in general. It is essential that staff and parents understand normal newborn physiology to avoid unnecessary formula supplementation. is the number one reason for formula supplementation in the newborn period.40 Normal Newborn Weight Changes Healthy newborns. infants usually feed “on demand” rather than on a schedule for their first weeks of life. They are also born relatively edematous at birth. One way to reassure a mother that she is making enough breast milk is to weigh the infant. It is important to inform mothers of this normal newborn physiology and the physiology of normal breast milk production. appropriate for age (AGA) weight infants are born with a “camel’s hump” of nutrition at delivery that provides for their metabolic needs during the first two to three days of life.01 = 1% weight loss Other ways to reassure the family about adequate nutrition and breastmilk production is to review normal feeding and elimination patterns with them. This in contrast with the amount of milk the infant will ingest after the onset of lactogenesis 2.
clothing Opening and closing mouth Squirming Rooting at the chest of whoever is holding the infant Pulling up on the mother’s clothes to nurse or by arching back to position himself for nursing A mother should not wait until an infant is crying to breastfeed. fingers. a mother can remove the infant’s clothing and place infant skin-to-skin on her bare chest.” i. breastfed infants should be fed “on demand. Mothers should be instructed to recognize their infant’s feeding/hunger cues and nurse accordingly. The quiet alert state is the best time to initiate breastfeeding. then sleep for a few hours.41 Feeding Patterns and Hunger Cues of Breastfeeding Infants In the newborn nursery and during the first few weeks of life. To promote alertness in a sleepy infant. Late hunger feeding signs / cues include: • Crying • Moving head back and forth • Falling asleep Infants also “cluster feed” at times. where they feed every hour (or more frequently) for a few feeds. This is normal. thus ensuring continued breast milk production in the mother. Rubbing the infant’s feet can also assist in making the infant more alert. Frequent feedings ensure proper nutritional support of the infant and appropriate stimulation to mother’s breasts. he may need to be soothed prior to breastfeeding. This conserves their nutritional and metabolic reserves and correlates with the physiologic delay of lactogenesis 2. they can be expected to enter a period of “hibernation” for the next 24 – 48 hours. However.” A mother should be encouraged to breastfeed 8 – 12 times per 24 hours based on her infant’s feeding cues. If a baby is crying. he may need to be woken up to feed. A mother may report that her infant is “sleepy. if an infant is sleeping for longer than 4 hours at a time during the first 1 – 2 weeks. and not based on a feeding schedule. lips. Crying is considered a “late” hunger sign. Newborns often feed 8 – 12 times (or more) in the first week of life.. based on the infants’ feeding cues. Excessive sleepiness or lethargy is not normal and should be evaluated immediately by an experienced health professional. . Infant hunger cues include: • • • • • • Smacking or licking lips Sucking on hands.e. toys. Sleepy infant / “won’t wake to feed” While infants have a short period of alertness immediately after delivery.
no tongue action is needed. and using a supplemental nursing system. Maternal pain can inhibit the letdown of milk.42 Nipple Confusion Nipple confusion can occur when an infant has not had adequate opportunities to establish correct mouth movements for breastfeeding. spoon-feeding. • Incomplete emptying of the breast will inhibit the mother’s body in adequate breast milk production. and the infant will become frustrated. which will in turn protect against nipple confusion in an infant. This is thought to be caused by early and frequent exposure to artificial nipples and pacifiers. These methods include cup feeding. syringe feeding. The mouth position is much narrower and accommodates a small artificial nipple in the mouth. It is also believed to contribute to breastfeeding problems and early weaning In order to breastfeed successfully. These situations can then ultimately lead to the decreased future production of breast milk. Please see the appendix for diagrams and instructions. . When an infant applies a bottle-feeding technique to the breast it can have many negative consequences: • Breast milk may not be expressed efficiently from the breast. infants must learn to attach and suckle properly at the breast. • an infant must open his mouth widely to accommodate breast tissue • an infant then protrudes his tongue over his bottom lip and use a peristaltic motion to “milk” the breast and extract milk A bottle-feeding infant utilizes a mouth position and technique that is much different than that used for breastfeeding. This is due to a substance in the breast milk that tells the mother’s body to produce less milk for the next feeding. The technique utilizes passive suction / negative pressure for milk extraction by creating a partial vacuum with his mouth. • Improper breastfeeding mouth position and technique in the infant can cause a lot of pain to the mother. which then leads to formula supplementation and thus early weaning: ineffective suckle ! less milk to infant and pain in mother ! diminished let-down ! inadequate emptying of breast ! decreased milk production ! earlier weaning There are other ways to feed an infant besides bottle-feeding.
The reason for breast-pumping during the immediate newborn period is not to provide breast milk to the infant. . prior to lactogenesis 2 (milk coming in). Manual expression can be more effective in expressing colostrum during the first few days of life. Separation of the mother and infant should be avoided or minimized to no more than one hour at a time for hospital procedures. However. including physical exams. Although infants can draw out colostrum due to their mouth latch and peristaltic motion of their tongue.e. the more likely it is that an infant will be given supplemental formula. or the mother may produce inadequate quantities of breast milk. and is due to the inhibitory effect of pregnancy hormones on breast milk production at this time. any expressed milk that is obtained via breast pumping may be fed to the infant.43 Milk Expression / Separation of Mother and Infant • • • • Every effort should be made to keep mothers and their infants together while in the hospital. when lactogenesis 2 occurs. Adequate breast stimulation via breast pumping ensures adequate breast milk production for when lactogenesis 2 does finally occur. breast pumps often cannot express the thick fluid by mere vacuum / suction. blood draws. Mothers who are separated from their infants (i. but to provide stimulation to the mother’s breasts. If this stimulation is not applied. Please see the appendices for more information regarding milk expression and storage and lactation physiology. Mothers may find that they express little or no milk in the immediate post-partum period. This is normal. Mothers can expect more copious milk production to occur at around 60 hours of life. Mothers should be reassured that this does not mean they are not producing enough milk! During the first day or two of life. 8 times during the day and once during the night. The longer a mother and infant are separated while in the hospital. infants transferred to the NICU) should be provided with a breast pump and instructed to use the pump for at least 15 minutes. there is only drops of colostrum and breast milk present in the breasts. medication administration and phototherapy can be performed in the mother’s room. Many hospital procedures. lactogenesis 2 may be delayed.
• Avoid supplementation unless medically indicated. or return the infant to the breast as soon as possible. term newborn infants. Skin-to-skin care is easily done with an IV and may lessen the trauma of an intervention. It is believed that in the event of transient or prolonged hypoglycemia. In an asymptomatic. • Facilitate skin-to-skin contact of mother and infant. it is important to keep the infant at the breast. there is little reason to routinely monitor glucose levels during the newborn period. hypoglycemic infant: • Encourage oral feeding: o breastfeed every 1 – 2 hours or o feed 3 to 5 mL/kg (up to 10 mL/kg) of expressed breast milk or formula • If glucose remains low despite feedings. Ensure that the mother is given a breast pump to provide breast stimulation if she is separated . while also providing physiologic thermoregulation. appropriate for gestation age (AGA) babies. In full-term. • Feedings should be frequent. healthy. • Breastfeeding may continue during IV glucose therapy if the infant is able. To ensure breastfeeding success: • Initiate breastfeeding within 30 to 60 minutes of life and continue on demand. Early and exclusive breastfeeding meets the nutritional and metabolic needs of healthy. During these interventions. and these interventions are temporary. mothers can be reassured that there is nothing wrong with their milk. If supplementation or IV is required to manage hypoglycemia. most infants are capable of a robust ketogenic response to prevent neurologic sequelae. 10 to 12 times per 24 hours in the first few days after birth. asymptomatic. either supplementing or using IV. begin IV glucose therapy and adjust intravenous rate by blood glucose concentration.44 Hypoglycemia Management Transient hypoglycemia is common and physiologic in newborn mammals during the first few hours of birth. or the infant becomes symptomatic. and assist in returning the infant to metabolic homeostasis. Infants who are at highest risk of hypoglycemia are: • Small for gestational age (SGA) and Low birth weight (2500 g) infants • Large for gestational age (LGA) • Infants of diabetic mother. especially if diabetes has been poorly controlled • Infants who suffer perinatal stress including severe acidosis or hypoxia-ischemia • Infants with cold stress • Polycythemia (Hct 70%) • Infants with signs and symptoms of suspected infection • Infants who present in respiratory distress • Infants displaying symptoms associated with hypoglycemia Early breastfeeding is not precluded just because an infant meets the criteria for glucose monitoring.
General guidelines for supplemental feeding: • • • • • • Breast milk is the first choice for supplementation if needed. Mothers should optimally express milk every time her infant receives a supplemental feeding. Banked / donor milk should be considered when supplementation is necessary. However. in order to maintain milk supply. maternal engorgement. Lactation consultants are very helpful in these cases.45 from her infant during the newborn period. In other cases. mastitis). in general. Formula supplementation is not without risk. latch and milk transfer prior to the provision of supplemental feedings.g. sensitize the infant to allergens. Despite the pasteurization of donor milk. very few biologically active compounds are destroyed. An example of supplemental feeds in the first week of life is breastfeeding on demand. do not need ANY supplemental feeding for the first 24 – 48 hours. cup or supplemental nursing system to avoid nipple confusion (see appendix for images and information. or at least every 3 hours beginning on the first day. The physician must always decide if the benefits of supplementation outweigh the potential risks of these feedings. the goal is to feed the infant and optimize maternal milk supply while determining the cause of poor feeding and/or inadequate milk transfer. and interfere with maternal-infant bonding. babies who are too sick to breastfeed or whose mothers are too sick to allow breastfeeding are likely to require supplemental feedings. If supplementation is necessary. Medical Indications for Supplementation Healthy newborns. the infant should be at the breast for milk stimulation. delayed lactogenesis 2. and can prevent the establishment of maternal milk supply. alter infant bowel flora. Small frequent feeds are more physiologically appropriate and less likely to interfere with breastfeeding and lactogenesis. Infants who should not receive breast milk or any other milk except specialized formula: • • • Infants with classic galactosemia Infants with maple syrup urine disease Infants with PKU . have adverse effects on breastfeeding (e. such as excessive infant weight loss. then providing one ounce of supplemental formula or donor breast milk every three hours. All infants should be evaluated for position. leaving banked milk with many protective immunologic and anti-infective components of non-banked human milk. Alternatives to bottle-feeding: Infant can be fed via syringe.
breast pathology or prior breast surgery resulting in poor milk production Delayed lactogenesis o Retained placental fragments (lactogenesis usually resumes after fragments are removed) o Sheehan syndrome . eclampsia.8% in first 48 hours with poor latching and suck skills. babies with poor tone. symptomatic hypoglycemia) Rapid weight loss over 7 . floppy babies. Weight loss of 8 – 10% accompanied by delayed lactogenesis 2 (day 5 or later) Delayed bowel movements or continued meconium stools on day 5 Hyperbilirubinemia o Jaundice where intake is poor despite adequate intervention o Breastmilk jaundice when levels reach >20 – 25 mg/dL in an otherwise thriving infant and where diagnostic interruption of breastfeeding might be helpful Low birth weight o When sufficient milk is not available o When nutrient supplementation is indicated Infant is unable to feed at the breast: premature <37 weeks. cleft palate Infants born weighing <1500g (very low birthweight) Infants born at less than 32 weeks of gestation (very preterm) • • • • Maternal conditions that may require supplemental feedings for infants: • • • • • • • • Intolerable pain during feedings unrelieved by interventions Cracked and bleeding nipples Infant does not latch by 24 hours despite repeated attempts by nurse and mother Infant cannot maintain latch due to malformed nipples (everted. phototherapy. Down’s Syndrome. shock) Infants of mothers who are taking medications that are contraindicated in breastfeeding Primary glandular insufficiency (primary lactation failure) as evidenced by poor breast growth during pregnancy and minimal indications of lactogenesis.46 Infants for whom breast milk remains the best feeding option but who may need other food in addition to breast milk for a limited period: • • • • • Infants with increased metabolic or fluid needs (surgery. flat) Infants of mothers with severe maternal illness (psychosis.
Inadequate. specifically breast reduction • Retained placenta • Hormonal birth control (i. but usually occurs around 60 hours post-partum. or Failure of Lactogenesis 2 Lactogenesis 2 is the start of copious milk production in the mother.” Lactogenesis 2 can occur between 24 – 100 hours of life. The onset of lactogenesis 2 is often accompanied by significant breast engorgement. Conditions that can delay or lessen milk production during lactogenesis 2 include: • Separation of mother and infant • Preterm birth • Endocrine problems including PCOS and hypothyroidism • Breast surgery. See also appendix for more information about the physiology of lactation.e. “Failed” lactogenesis 2 is the inability of a woman to achieve full lactation due to either primary inability to produce or issues with breastfeeding or infant health. depo provera after delivery) • Maternal obesity • Maternal diabetes or hypertension-etiology unknown • Sheehan’s syndrome “Delayed” lactogenesis 2 is defined as extended time between colostrum and full milk production. .47 Delay. which can make it difficult for an infant to latch. Lactogenesis 1 is the production of milk and colostrum during pregnancy and during the first few days post-partum. The engorgement will resolve over the following days and weeks. even he was breastfeeding without difficulty previously. Using a breast pump for 1 – 5 minutes prior to feeding can soften the breasts during this time and allow the infant to latch easily. aka “the milk comes in.
These infants can appear robust like full-term infants. which can result in the poor intake of breast milk during the newborn period. late-preterm infants often have less stamina to breastfeed than full-term infants. However. these infants are at a higher risk for breastfeeding problems of all types. but they need evaluation of their breastfeeding technique and close follow-up postdischarge. or for any concern. 2. All late preterm infants should be observed by a skilled practitioner in lactation while still in the hospital to assure an adequate latch-on while breastfeeding. This is likely due to the reasons listed above. 5. for excessive sleepiness/not waking to feed. including temperature instability. and readmission to the hospital. and these infants should not go for more than 3 hours without a feed in the newborn period. This then leads to decreased stool production therefore inadequate bilirubin excretion. and less alert/awake periods. if his intake or elimination patterns are not adequate. Frequent breastfeeding on demand should be encouraged. and their mother should be encouraged to breastfeed if infant is stable. Late-preterm infants should stay in the hospital for a minimum of 48 hours to ensure physiologic stability. 3. mild hypotonia. These infants can successfully breastfeed. leading to potentially dangerous levels of bilirubin in the infant. and are less likely to achieve “full” breastfeeding status. Poor breastfeeding technique can result in decreased maternal breast stimulation. Mothers should be instructed to keep a detailed breastfeeding. However. They also have increased metabolic requirements due to less glycogen and fat stores. having not benefited from the final deposit of nutrition at the end of pregnancy that full-term infants experience. . The reasons for the higher morbidity in late-preterm infants are many. in the setting of higher metabolic needs. Late-preterm infants who are exclusively breastfed are at risk for hyperbilirubinemia. and should be educated about adequate intake and elimination. they are more prone to medical problems in the newborn period. voiding and stooling log. Serum bilirubin should also be assessed prior to discharge. then decreased milk intake by the infant due to decreased milk production by the mother. breastfeeding ability and adequate milk transfer. hyperbilirubinemia. thus decreased breast emptying. and early and frequent follow-up post-discharge should be planned. 4. preterm and late-preterm infants benefit greatly from the immune protection of breastmilk.49 Breastfeeding the Late-preterm Infant Late-preterm infants are infants born between 34 and 37 weeks gestation. dehydration. She should be instructed to bring her infant in for evaluation if he should become jaundiced. All mothers should be informed that their late preterm infant may not breastfeed as robustly as a term infant. hypoglycemia. including neurodevelopmental immaturity which can cause these infants to have an uncoordinated suckswallow mechanism. In addition. Less acutely. General guidelines for managing breastfed late-preterm infants: 1.
milk production will abate during the first few days after delivery. she may still be able to initiate breastfeeding within the first few days post-partum. however. Lactogenesis 2 will still occur at around 60 hours of life and she may experience engorgement. Options for symptom relief during this period include a well-fitting support bra. analgesics and ice packs. Hormone treatment to stop milk production is not recommended. She also can be assured that if she changes her mind. .50 Decision Not to Breastfeed Women may decide that breastfeeding is not appropriate for her or her family.
as well as number of bowel movements and wet diapers of her infant at home (see Breastfeeding Log in appendix for an example) Mother is given explicit information on how to determine that her infant is breastfeeding well: o Mother understands infant feeding cues.g. breastfeeding length is determined by satiety of infant. Mother should be comfortable with breastfeeding and all questions and concerns regarding breastfeeding have been addressed. and assure continued breastfeeding success. Expressing a small amount of milk prior to feeding can assist in latching of infant onto the breast. . o Infants feed on demand.) A 48 hour post-discharge follow-up visit has been made for the infant and mother to assess infant weight loss. passage of at least one meconium stool during the first two days of life. Most infants feed 8 – 12 times per day with 10 – 15 minutes on each breast (although time can vary) during the first few weeks of breastfeeding. either via manual expression or via electric breast pump. bright yellow bowel movements by day of life 5.51 Hospital Discharge Checklist Prior to discharge. o Mother should be knowledgeable about expressing her breast milk. e. this important information is very helpful when an infant attempts to breastfeed and the mother’s breasts are engorged. the following conditions should be met for all breastfeeding mother / infant pairs: • • • • • • • Trained personnel have observed the mother and infant `during breastfeeding and adequate latch and breastfeeding technique have been ensured. based on feeding cues and not on a schedule. One way a mother can determine adequate milk ingestion is by the presence of loose. Infant has been weighed prior to discharge and adequate weight loss has been documented. jaundice. Adequate elimination patterns have been documented (at least one void per day for the first 2 days. o Mother understands adequate elimination patterns of infants. Mother is instructed to keep a record of breastfeeding frequency and duration of feedings.
Post-partum / First week of life
Breastfeeding Essentials for the Clinician Assessing Breastfeeding Success for Infant and Mother Vitamin D Supplementation for the Breastfeeding Infant Common Early Post-partum Breastfeeding Issues Pacifier Use Breast Engorgement Hyperbilirubinemia Ankyloglossia “tongue tie” Indications for Post-Partum Lactation Consultation
Post-discharge Follow-up Breastfeeding Essentials:
• • • • • • • • Encourage exclusive breastfeeding for all infants up to six months age, with continuation of breastfeeding with complementary foods to one year of age and beyond. Routine formula supplementation will decrease the milk producing requirements of the mother, and thus result in less milk production, making the use of formula more and more necessary. Lack of maternal confidence is a common cause of early discontinuation of breastfeeding, even if an infant is gaining weight appropriately. Discourage use of artificial nipples (bottles) or pacifiers until 4 – 6 weeks of life or until breastfeeding is well established. Review normal weight gain and elimination patterns of neonates. Review typical pattern of growth spurts in infants. Review medical indications for supplementation. All exclusively breastfed babies should receive daily supplementation of 400 IU vitamin D beginning shortly after delivery.
Assess Breastfeeding Success:
• Weight loss of infant o Weight loss of 7 – 8 % of birthweight is considered acceptable in the first week of life. A weight loss of up to 10% can be considered acceptable if physical exam is normal, the infant is term, and overall breastfeeding appears to be going well (infant is latching well, elimination patterns are adequate.) o A follow-up visit in 1 – 2 days for a weight check is warranted if weight loss is a concern. Review elimination patterns of infant Assess breastfeeding technique o Evaluate mother’s comfort, infant positioning, and infant latch (see appendix for information about positioning and latch) o Breast engorgement can prevent effective latch by the infant: lactogenesis 2 occurs around 60 hours post-delivery, and can be accompanied by significant engorgement of the breast and nipples. This can make it difficult for an infant to latch onto the breast to feed, even if he was breastfeeding well prior to lactogenesis 2. o To assist in softening the breast and nipple, a mother can express some milk from her breasts via an electric pump for 1 – 2 minutes, or use manual expression (see appendix for more information.) o Engorgement can occur prior to feeding during the first and second weeks of breastfeeding and then gradually resolves. Assess any pain in mother while breastfeeding o Mild pain during the first few seconds of breastfeeding is normal during the first and second weeks of breastfeeding. o Severe and persistent pain during breastfeeding is not normal. The most common cause of nipple pain while breastfeeding is incorrect latch by the infant. A lactation consultant can be of invaluable assistance in this situation. o Other causes of nipple pain include mastitis and plugged ducts. Evaluate jaundice in infant / bilirubin measurement
dietary intake and nutritional supplement use: • Breastfeeding women need approximately 500 kcal more per day than non-lactating women. • Reassure women that eating a well-balanced diet will provide adequate nutrition in her breastmilk. Mother’s support system and partner involvement: o Other caregivers of the infant can support women in their breastfeeding efforts by bringing the infant to her at feeding times. • DHA (omega fatty acid) supplements are not necessary. a mother can remove the infant’s clothing and place infant skin-to-skin with her.” A woman can breastfeed her newborn and nap when the infant naps. Rubbing the infant’s feet can also assist in making the infant more alert. o Excessive sleepiness or lethargy is not normal and should be evaluated immediately by an experienced health professional.56 • Infant’s eagerness to feed / sleepy infant o A mother may report that her infant is “sleepy. and offering encouragement. o To promote alertness in a sleepy infant. At this time. Essential Breastfeeding Discussion Topics: Maternal fluid. duties of cleaning the house. • A common piece of advice given to mothers is “sleep when your baby sleeps. however. there is no data that shows that breastmilk is deficient in these essential fatty acids and supplementation with DHA is not recommended. o Healthcare providers can assist couples with emotional adjustments by discussing contraceptive planning and sleeping arrangements Maternal medication / drug / etoh / tobacco use Sleeping arrangements • Decreased amount of sleep is common for parents when taking care of newborns. he may need to be woken up to feed. and 1 – 2 glasses of alcohol are compatible with breastfeeding. holding the infant. fluid intake does not typically affect milk volume. . which often begins around 8 weeks of age. if an infant is sleeping for longer than 4 hours at a time during the first 1 – 2 weeks. changing diapers. and lack of sleep contributes to this feeling. • If a woman is a strict vegan. • She should plan on sleeping in periods throughout the day and night until her infant begins sleeping in longer stretches during the night.” A mother should be encouraged to breastfeed 8 – 12 times per 24 hours based on her infant’s feeding cues. • Moderate caffeine intake. she should be instructed to take a vitamin B12 supplement to ensure her infant receives adequate levels of this nutrient. • New mothers may feel overwhelmed with the demands of breastfeeding. however. • Discuss the demands of breastfeeding and that many tasks and duties may need to be deferred for her to conserve her energy. • Encourage women to drink plenty of fluids.
) Reiterate the medical benefits for infants of mothers of breastfeeding for one year and beyond. . and provide reassurance that help is available to her if she needs it. most children in the world sleep with their mothers in early periods of life. has its demands and rewards. like parenting.• • • • 57 shopping. as well as promoting frequent nursing which then promotes adequate milk production and longer duration of breastfeeding. It is important that women and families understand the risks of co-sleeping and bedsharing. Many breastfeeding advocates promote co-sleeping as a way of fostering closeness between mother and infant. discuss safe-sleeping arrangements with her (see “CoSleeping” in this section. Although the AAP does not recommend co—sleeping or bed sharing due to concern over SIDS. and caring for other children may need to be transferred to other caregivers in order for her to get adequate rest. Congratulate the woman for her decision to breastfeed! Acknowledge that breastfeeding. If a woman wishes to co-sleep.
This is achieved with administration of 1ml Trivisol daily. Supplementation should continue until an infant consumes 500ml of vitamin D fortified milk or formula daily.58 Vitamin D Supplementation for Exclusively Breastfed Infant: • • • • Breastmilk has low levels of vitamin D. The American Academy of Pediatrics recommends that all exclusively breastfed infants be supplemented with vitamin D 400 IU beginning shortly after birth. and sun exposure is not considered a safe or adequate method of vitamin D production in the infant. A woman cannot increase the vitamin D content of her breastmilk by eating more vitamin D or taking vitamin D supplementation. .
Studies show a 4-fold increase in weaning by 6 months in pacifier users over non-users: ineffective suckle ! less milk to infant ! pain in mother ! less let down ! less milk ! earlier weaning • Pacifiers should not be given routinely to breastfeeding infants until 4 . which can make breastfeeding difficult for infant and painful to mother. which occurs when an infant has not had the opportunity to establish the correct mouth movements for proper breastfeeding. where the breasts become large and firm and the nipple is often effaced making it difficult for the infant to latch. Common situations that lead to engorgement: • infant sleeping through the night • separation of mother and infant • formula supplementation • infrequent feedings.6 weeks of life.) . Reverse pressure softening can also be used (see appendix. Instruct the mother to feed or pump frequently (8 – 12 times per day). Breast Engorgement A very common breastfeeding scenario is a woman who breastfed without difficulty in the hospital and then is unable to latch her infant to breastfeed after lactogenesis 2. but also due to edema in the breast tissues. To soften the breasts and nipples and enable easier latch is to have the woman pump her breasts for 1-5 minutes. This is most commonly due to engorgement. Frequent use of artificial nipples early in life has been shown to promote a less effective mouth-movement. The mother may need a pain reliever to relieve discomfort and symptoms of engorgement. Engorgement is common in the first week post-partum. Tylenol. aspirin and ibuprofen are all compatible with breastfeeding. Pacifiers have been shown to give infants protection against SIDS.59 Common Early Post-partum Breastfeeding Issues Pacifier Use in Breastfeeding Infants • • • • Pacifiers can cause nipple confusion. A mother can also experience engorgement during lactation when milk is not removed regularly. Instruct the mother to use warm compresses prior to feeding to stimulate let down and cold compresses upon completion of feeding to decrease inflammation. this is due to presence of milk in the breast. at which point breastfeeding is usually well established. or time-limited feedings Management and Treatment • • • • • Instruct the mother to manually hand express or pump her breast milk prior to feedings in order to release enough milk to better enable the infant to grasp the nipple. this often results in successful latch and breastfeeding. breastfeeding is also protective against SIDS. however.
adequate postpartum follow-up of the infant and proper management of breastfeeding can minimize the occurrence of dangerous hyperbilirubinemia. • Evaluate breastfeeding success: evaluate position. • Use supplemental formula if medically indicated. • Encourage frequent feedings of infant to ensure adequate nutrition and continued milk production in infant. They are not a substitute for intensive / treatment phototherapy. poor latch and/or breastfeeding technique. This can be due to delayed lactogenesis. Otherwise. Poor intake of breastmilk results in low stool output. latch and milk transfer. Bili blankets are an option for home use. Breastfeeding Jaundice Breastfeeding jaundice. When an infant cannot breastfeed adequately and/or there is a delay in lactogenesis 2. and exclusive breastfed status are risk factors for hyperbilirubinemia. Late-preterm birth.72 hours) and the increase in breastfeeding rates. . the physical exam is not an accurate method of determining bilirubin levels. with consideration of risk factors for hyperbilirubinemia. the increasing number of cases of kernicterus in this country over the past few decades is postulated to be due to short hospital stays (24 . it is considered “physiologic jaundice. One risk factor is hemolysis due to ABO incompatibility. Education of the mother. Management of Breastfeeding Jaundice: • Measure serum bilirubin.” There are risk factors for potentially dangerous levels of bilirubin. • Consider a referral to a lactation consultant for assistance in evaluating proper breastfeeding technique: positioning. • Educate mother if necessary about appropriate feeding frequency (8 – 12 times per 24 hours). Bilirubin levels should be plotted using the Bhutani curve (see appendix). breastfeeding jaundice can occur. encourage the mother to continue breastfeeding. If an infant is jaundiced and bilirubin levels are below phototherapy guidelines. they are used as prophylaxis in infants where there is concern for significant hyperbilirubinemia. Infants should be admitted for phototherapy if levels indicate (see also appendix).” is caused by a low intake of breastmilk. primiparity. or infrequent feedings in a newborn infant. Adequate stool output is essential in adequate excretion of bilirubin during the newborn period.61 Hyperbilirubinemia Jaundice is common in the newborn period. the infant is well. However. Low stool production results in less excretion of bilirubin. However. A “trial” of formula is not indicated in this situation. also called “non-feeding jaundice. latch and ensure milk transfer. and the elevated bilirubin level cannot be attributed to any specific factor. a mother should be encouraged to continue breastfeeding but follow-up frequently for infant assessment. and infants should be riskstratified. and review feeding and elimination patterns of infant. • Calculate weight loss of infant. if an infant’s weight loss and elimination patterns are appropriate.
congenital hypothyroidism and galactosemia are serious conditions associated with jaundice at this age. Ankyloglossia or “tongue-tie” • • • • • Perceived or actual short sublingual frenulum that prevents tongue from elevating or extending anteriorly Occurs in 3 – 5% of infants Infants with ankyloglossia comprise 13% of infants with breastfeeding problems Problems with breastfeeding include nipple trauma or failure of infant to breastfeed effectively Previous belief that ankyloglossia can cause speech defects has been proven to be unfounded. or there is substantial pain in the mother despite lactation consultation. It is important to evaluate the jaundice with direct and total bilirubin tests to avoid missing significant pathology. prompting the need for continued formula supplementation. however. In cases of breastmilk jaundice. the clinician can consider the frenotomy procedure: o “snipping” of frenulum o no local anesthesia o well-tolerated by infant. beta-glucuronidases and lipases in breastmilk may encourage reuptake of bilirubin in the intestine. A “trial” of formula is not necessary and may result in decreased breastmilk production.62 Management of Breastmilk Jaundice: About 30% healthy newborns will still be jaundiced after 2 weeks of age. ensure adequate growth o Review feeding and elimination patterns o Observe breastfeeding and evaluate infant latch o Evaluate pain in mother with breastfeeding If breastfeeding is unsuccessful due to improper latch. Bilirubin levels will be below those requiring phototherapy. If the baby’s physical exam is normal and urine and stool output are normal. The exact etiology of breastmilk jaundice is unclear. the infant can be observed and followed without intervention. mother can breastfeed immediately after o usually done by ENT at KP LAMC • . the total bilirubin levels can range from 12 – 20 mg/dL and may be elevated for 1 – 3 months. Pathology such as liver disease. Management: • Determine breastfeeding success: o Weigh infant.
preterm • Absence of lactogenesis 2 by day 3 • Failure to thrive / excessive weight loss • Pain in mother while breastfeeding • Ankyloglossia / tongue tie • Mother of infant with congenital anomalies • Mother attempting to breastfeed multiple infants .63 Indications for Post-Partum Lactation Consultation Consider referring the mother to a lactation consultant when the following conditions are present: • Mother in ICU or other complication • Breasts or nipples that require assistive devices for proper latch • Infant born at gestation <38 weeks / late .
65 First month of life Growth / Weight Gain of Healthy Full Term Infants Pumping and Storing Breastmilk Contraception and Breastfeeding Lactation Amenorrhea Method of Contraception Insufficient Milk Syndrome Sore Nipples / Nipple Trauma Mastitis / Breast abscess / MRSA / Candidal Infections Co-sleeping / Bedsharing Post-partum Depression Return to Work Weaning Breast Cancer Detection in Breastfeeding Women Environmental Toxins in Breastmilk Breastfeeding Support for Patients / Patient Resources .
Reassure mothers that their infants are thriving. Discuss plans for mother’s return to work. Review normal weight gain and elimination patterns of neonates. Lack of maternal confidence in breastfeeding or in her ability to produce milk is a common cause of early discontinuation of breastfeeding. mother should plan on returning to work after at least 4 weeks post-partum to ensure breastfeeding establishment. if desired by mother. Ensure daily vitamin D supplementation for infant in exclusively breastfed infants. Discuss contraceptive planning with mother. . and investigate compatibility of medicine with breastfeeding. or if other caregivers will feed the infant during the first year.67 First Month Breastfeeding Essentials: • • • • • • • • • • • • Encourage exclusive breastfeeding for all infants up to six months age. where she can expect the infant to be hungrier and cry more often. Discourage use of artificial nipples (bottles) or pacifiers until 4 – 6 weeks of life or until breastfeeding is well established. Introduce a bottle of expressed breast milk beginning at 4 – 6 weeks of age If a mother is planning on returning to work. with continuation of breastfeeding with complementary foods to one year of age and beyond. and offer referrals to a mental health provider or social worker if indicated. Assist mother in pumping and storing breastmilk. Discuss maternal current or future medication use. Educate mother about growth spurts. if any. Screen mother for postpartum depression.
6 weeks. Typical weight gain is 5 – 7 oz per week for first four weeks (10g/kg per day). however. . often the mother will believe that she is “running out of milk. Infants will usually regain birthweight by the second week of life. 3 months and 6 months of life. which will decrease breast milk production.” Growth spurts most commonly occur at 2 – 3 weeks. Growth spurts are often accompanied by an increase in crying frequency and duration. • Growth spurts usually resolve in 2-3 days. • Growth spurt behavior is the infant’s way to promote continued breast milk production in the mother.68 Growth / Weight Gain of Healthy Full Term Infants • • • 8% weight loss from birthweight is considered acceptable in the first week of life. Growth spurts Growth spurts usually occur at standard intervals where an infant who was breastfeeding successfully will suddenly become fussy. • Encourage mother to continue to breast feed her infant when based on feeding cues. they can happen at any time. • Reassure mother that she is capable of producing enough milk for her infant. appear hungrier and feed more frequently. • Avoid formula supplementation.
Thumb and fingers are then repositioned at 11 and 5 o'clock and the sequence is done again. Manual expression technique (please see appendix for diagrams): • Mother places hand on breast. can be purchased at KP Women’s Center or local store . about an inch to an inch-and-a-half behind the nipple. Requires practice. roll--until the milk flow ceases. Fingers and thumb and rolled forward to squeeze milk out of the milk sinuses. can be purchased at KP Women’s Center or local store Automatic / Electric Breast Pumps: • Run on batteries or plugs into electrical outlet. with the thumb above and fingers underneath. as no extra materials are involved. Both hands can be used to work one breast. thumb and fingers should be directly across the nipple from each other. • Costs run $150 to over $250. Lactation consultation can be very helpful in instructing women how to manually express breastmilk. press. • Easy to use. The process is then transferred to the other side until the milk sinuses have been emptied. which are located under the areola behind the nipple. electric pumps are more efficient. Price range is $30 to $50. or automatic / electric breast pump. Milk Expression Breast milk can be expressed via hand expression. Milk will appear at the nipple when milk sinuses are compressed. as pumping both breasts simultaneously is more effective and saves time. however. instead. If the breast was a clock. skill and coordination. Useful for occasional pumping if mother is away from infant only occasionally. • Can pump one breast or both breasts at the same time. • • • • Manual Breast Pumps: • • • • Hand and wrist operated hand-held device.69 Pumping and Storing Breast milk Infants of breastfed mothers are often cared for by others. thumb would be at 12 o'clock and fingers would be at 6 o'clock. manual pump. Sequence is repeated--position. towards the wall of the chest. Expressing and storing breast milk is a means of providing breastmilk to infants when they are separated from their mothers. • Need place to clean and store the equipment between uses. Fingers should not slide along the skin as this will make breasts sore. • Hands-free models are available. Breast should not be cupped. Hand expression can be cheap and convenient. and many women in this country will return to work soon after delivery. Press thumb and fingers directly back into the breast tissue.
where temperature is most constant. Thawing and warming milk: • • • • • Microwaves should be avoided as they can scald the milk and can denature valuable proteins in the milk. gently swirl and blend the cream portion into the milk. the cream will rise to the top. • Freezer storage: generally store milk in the back of the freezer. Thaw milk by placing it in refrigerator overnight or gently warm it by placing container under warm running water or by placing it in bowl of warm water. storing 2 oz portions and offering additional amounts if baby is hungry will result in less waste. Expect that breast milk will separate during storage because it is not homogenized. Oldest milk should be used first. before feeding. and milk components may adhere to the soft plastic Use containers that have been washed in hot. such as hard plastic or glass Should have airtight seal Plastic bags specifically designed for human milk storage can be used for short-term milk storage (<72 hours). stovetops should be avoided as well for similar reasons. Swirl the container to mix the cream back in. Do not fill container completely to the top as breast milk will expand as it freezes. Miscellaneous breast milk storage guidelines: • • • • Store milk in small portions to minimize waste. Several expressions a day may be combined to get desired volume in a container. if stored in other areas of the freezers. soapy water and rinsed. Babies will often take between 2 – 4 oz every 3 – 4 hours when starting on an alternative feeding method. long term is not recommended as the bags may spill or leak. . store milk in back of main body of refrigerator where it is coolest. refer to following timetables: o Freezer compartment located inside refrigerator (5 deg F) ! two weeks o Refrigerator/freezer with separate doors (0 deg F) ! 3 – 4 months o Deep freezer that is opened infrequently (-4 deg F) ! up to 12 months Storage containers: • • • • • Should be hard-sided. Milk that is thawed and warmed but not used should be discarded. • Milk may be refrigerated (39 deg F) for up to 8 days. and distribute heat evenly. Cleaning in a dishwasher is acceptable.70 Home Storage of Breastmilk General Guidelines: • Milk may be kept at room temperature (up to 77 deg F) for 6-10 hours (hospital storage: 4 hours) • Milk may be kept in an insulated cooler bag with ice packs for up to 24 hours.
Infants are not exposed to clinically significant levels of hormones in women who use hormonal contraception methods. Non-hormonal and hormonal methods of contraception • • Non-hormonal methods are preferred methods of contraception in breastfeeding women (condoms.71 Contraception and Breastfeeding Non-hormonal and hormonal contraception methods are compatible with breastfeeding. it is prudent to recommend additional methods of family planning. ACOG recommends waiting at least 2 .3 weeks post-partum o ACOG recommends waiting 6 weeks prior to using Depo-Provera o ACOG: Hormonal implants may be inserted 6 weeks post-partum Combined estrogen-progestin contraceptives o Some sources caution against any use of combined contraceptive pills (Hale) o ACOG: typically should not be started prior to 6 weeks post-partum. Progestin-only contraception (Nor QD. However. and only after breastfeeding has been well established. Per ACOG in their 2007 statement: “If there is uncertainty regarding the extent to which a woman is breastfeeding. a woman should consider discontinuing her hormonal contraception method if she notices a decrease in breast milk production. • • • Per ACOG in their 2007 statement: “Due to absence of well-designed clinical trials proving an association of hormonal contraception and decreased breast milk production.” . IUDs. Supplemental feedings should be < 5 – 10% of total (less than one every 10 feeds). or if solid foods have been introduced. due to the concern that hormonal methods may decrease total breastmilk production. Nonhormonal methods are preferred.)” Lactation Amenorrhea Method of Contraception. ovulation can be delayed via the lactation amenorrhea method. and initiate estrogencontaining hormonal contraception after the period of hypercoagulability associated with pregnancy has resolved (2 – 4 weeks. Depo-Provera) o Some sources recommend a delay of at least 6 weeks post-partum before starting progestin only pills. diaphragms. there is a chance of ovulation occurring. a clinician may decide to initiate progestin-only methods before hospital discharge. Only for mothers of exclusively breastfed infants! If babies are supplemented with formula. cervical caps). The average time to first ovulation is 45 days post partum. Feeding intervals should be < 4 hours. When exclusive breastfeeding occurs. • • • • • • Provides more than 98% protection against pregnancy. with a range of 25 – 72 days in nonbreastfeeding women.
• What are baby’s ins and outs? Are they appropriate for the infant’s age? Infants should put out 6 – 8 weight diapers per day after day of life 6. galactogogues may be used. separation of mother and infant. and weight gain is 5 – 7 oz per week for the first four weeks (10g/kg per day). specifically breast reduction Retained placenta Unrelieved engorgement Return of menstruation OTC medications Hormonal birth control Obesity (thought to be due to increased circulating estrogen / androgens) Infant causes • • • • Infrequent feeding or frequent supplementation with formula Pacifier use Ineffective suck. elimination patterns are adequate. regular breastfeeding generally ensures adequate milk supply. • How often does mother breastfeed and for how long? It is important for women to breastfeed “on demand” in the first few weeks of life. 20 minutes on each breast every 2 – 3 hours is adequate for a 0 – 14 day old baby. neuromotor problems Oral anatomic problems such as cleft lip or palate Evaluating a possible case of insufficient milk syndrome: • Does mother have any risk factors for delayed lactogenesis? • What was the infant’s birth weight? What is the infant’s weight now. and the infant appears well. See “Galactogogues” section in the appendix for more information. breastfeeding every 3 – 4 hours. prematurity. Other causes include: Maternal causes • • • • • • • • Endocrine problems including PCOS and hypothyroidism Breast surgery. Usually. The most common cause of true decreased production of breast milk is supplementation with formula. and is the infant gaining weight appropriately? Infants should regain their weight by 2 weeks of life. and this extends to breastfeeding multiples and older siblings with newborn infants. or improper latch. Encourage her to continue breastfeeding on demand or at least every 3 hours. Many times when breastfeeding women feel there is “not enough milk” there is in fact plenty of milk and baby is growing well. For older infants. or taking 3 – 4 oz of expressed breast milk every 3 – 4 hours is considered adequate. • If the infant is gaining weight appropriately.73 Insufficient Milk Syndrome Frequent. stools should be yellow and seedy. After day of life 5. infrequent feeds. . and arrange for a follow-up in 1 – 2 days to reassess her progress. In cases of true insufficient milk supply. it is appropriate to reassure the mother. and should total approximately 4 per day.
This is safe for the breastfeeding infant. short tongue can also cause frictional trauma. • Sore nipples without infection that don’t improve with the above regimen can be treated with a combination of mupirocin and triamcinolone 0.74 Sore Nipples / Nipple Trauma Breast and nipple pain is a common factor cited as a reason for breastfeeding cessation.1% ointment applied BID.g. persistent or severe pain during breastfeeding is not normal and should be evaluated. engorgement. Counsel the mother on basic positioning and latch-on techniques. poor latch or positioning) and can be corrected. Nipple sensitivity for the first 30 seconds to 60 seconds of breastfeeding is considered normal during the first and second weeks of breastfeeding. • Infants that use pacifiers typically have a superficial sucking pattern which can cause frictional trauma • Other causes: Nipple shape. • To facilitate healing begin purified lanolin cream or hydrogel pad and breast shells to keep clothing away from skin. eczema. impetigo. However. • The breast may also be tender from a candida infection/thrush. or herpes. cream can be applied immediately after feeding so possible effects are lessened at next feed. or dried colostrum or milk causing nipple to stick to bra or breast pads • The infant’s oral structure: ankyloglossia. . irritation from laundry detergents. improper use of nipple shields or pumps. food particles in the toddler’s mouth. Treatment and Care Most early nipple discomfort and pain is due to the mechanics of breastfeeding (e. high or bubble palate. Causes • The most common cause is poor latch or position and attachment at the breast • Frictional trauma is caused by inadequate amounts of breast tissue being drawn into the the infant’s mouth.
• Antibiotics for staph aureus: dicloxacillin 500mg QID for 10 days. group B streptocci. effective breastmilk removal. Ultrasound guided aspiration has also been successfully used. • Occurs in 2-3 % of lactating women • Occurs most commonly in the second and third week post-partum • Flu-like symptoms occur with marked redness on the affected breast • Most common cause is non-MRSA staph aureus (40%). E coli. Breast Abscess • • • • Abscess is indicated by presence of palpable mass and fever that persist for 48 – 72 hours after appropriate management is initiated.75 Mastitis Mastitis is an infection of the breast. or cephalexin for 10 days (clindamycin is indicated in pcn-allergic women). and pseudomonas. if a mother and infant are separated. Up to ~3% of mastitis cases will progress to abscess Abscesses are generally treated with incision and drainage. enterobacter. klebsiella. • Warm or cool compresses on the sore breast. mother can pump in between feedings with infant. The major feature that distinguishes mastitis from inflammatory breast cancer is knowledge of previous negative breast exam during pregnancy. serratia. Breast milk should be discarded for the first 24 hours after surgery. Consider: inflammatory breast cancer. . enterococcus. delayed initiation of antibiotics can result in abscess formation (see below). consider treating for MRSA (trimethoprim-sulfa and vancomycin are safe and compatible with breastfeeding). with breastfeeding resuming if there is no drainage of exudate into breastmilk. The most common cause of mastitis is bacterial overgrowth (staph aureus) from milk stasis. the infant can safely breastfeed from affected breast. • Analgesics such as ibuprofen or Tylenol may be used for mother’s comfort and are safe in breastfeeding. • Culture and sensitivity should be obtained if there is no response to antibiotics within two days. H parainfluenzae. Treatment • Continue frequent. not the breast milk. It is safe and appropriate to continue breastfeeding with mastitis. even after starting antibiotics! • Discarding the milk from the affected breast is not necessary or recommended. other causes include haemophilus influenza. Prevention of breast infections: frequent nursing. sometimes mother may need to wake up and pump if infant is sleeping through the night and engorgement is uncomfortable or mastitis is recurrent.
as milk and skin cultures are not helpful.76 Methicillin Resistant Staph Aureus (MRSA) Breast Abscess • • • • • Incidence is up to 50% in some studies 95% are community acquired Most are easily treated with oral antibiotics Treatment also ensuring breast emptying via pumping and/or breastfeeding Consider incision and drainage for refractory cases Nipple Candidal Infections • • Not common. but often misdiagnosed Can present with nonspecific signs and symptoms. • Infant often has thrush in this context. including: o nipple pain o itching.000 u/ml) 1 cc po qid inside mouth to breast after each nursing. and pacifiers • Antifungal treatment consists of: o Maternal treatment: nystatin suspension/ cream or clotrimazole applied after each nursing. . o Oral fluconazole — may be prescribed if nipples are not significantly better after several days of topical treatment. bottles. or in cases of reccurrence. and mother and infant should be treated together Objects that contact breast or infants mouth should be sterilized. including pumping supplies. o burning sensation o shooting breast pains that radiate back towards the chest wall Nipple and areola may appear erythematous or shiny or have white patches • Risk factors • Diabetes • Steroid use • Immune deficiency • Antibiotic use • Nipple trauma • Use of plastic-line breast pads that trap moisture Management: • Candida is often difficult to prove as the causative organism in all situations. do not need to wash off before feeds. o Infant: nystatin (100.
• Safe sleeping practices include: o Placing babies to sleep in supine position o Using a firm flat surface for sleeping o Avoiding soft bedding. specifically exclusive breastfeeding in the first four months of life. and argue that there is currently not enough evidence to support routine recommendations against co-sleeping. They put forth that studies show that breastfeeding. recliners and waterbeds) from safer sleeping arrangements. show a lowered risk of SIDS. pillows. However. and some public health authorities have discouraged all parents from bed sharing. The concerns of these authorities focus around the risk of SIDS and asphyxiation with bed sharing. waterbeds. Critics of these recommendations. sofas or recliners o Ensuring that infant’s head will not be covered while sleeping o Never leaving infant alone in an adult bed o Ensuring that there are no spaces between mattress and headboard. General guidelines: • Parents should be educated about risks and benefits of co-sleeping and unsafe cosleeping practices. • Unsafe sleeping practices include: o Environmental smoke exposure and maternal smoking o Sharing sofas or couches with sleeping infant o Placement of infant in side or prone position o Use of alcohol of drugs by adults who are bed sharing o Bed sharing with other children . cite inconsistency of data and state that research showing increased risk of SIDS with bed sharing does not distinguish between unsafe sleep environments (such as sofas. specifically the Academy of Breastfeeding Medicine. bed sharing has become controversial in recent years.77 Co-sleeping / Bed sharing Co-sleeping can help maintain a mother’s milk supply by encouraging regular and frequent feeding. or between mattress and wall where infant can fall and become trapped.
including depressed mood. Screening tools exist to assist clinicians in identifying women who may qualify for the diagnosis of post-partum depression. Cognitive therapy and counseling is helpful and indicated for all cases of PPD. fatigue. This is a common. Mothers may be relieved that their feelings of depression. Women may not volunteer information regarding their depressed mood or negative feelings. anxiety or guilt have a diagnosis and a treatment option. women can be reassured about the safety and compatibility of most antidepressant medication with breastfeeding.” Predictors of PPD include prenatal depression.78 Post-partum Depression Most antidepressants are safe and compatible with breastfeeding. Also. slowed or agitated motor movements. childcare stress. Treatment If an antidepressant is indicated for PPD treatment. Mothers may worry about being judged for having these feelings. many women do not have the time or resources for this treatment. concentration difficulties and guilt. or multiple gestation. or thoughts of death or dying. low social support and socioeconomic status. These numbers are higher in mothers of multiples. low self-esteem. or who could benefit from counseling and/or antidepressants. Many women experience the “baby blues. concentration difficulties.” up to 50% in some studies. poor energy. poor marital relationship. At least 10% to 20% of postpartum mothers suffer from depression. The incidence of psychiatric illness is higher in the postnatal period than at any other period in a woman’s life. temporary condition which resolves in two weeks post-partum or less. however. Children of mothers with post-partum depression can have lasting adverse health outcomes. and 10% to 16% of pregnant women fulfill the American Psychiatric Association Diagnostic and Statistical Manual. attachment difficulties. One screening tool that is commonly used is the PHQ-9 Depression Screening Tool (available in appendix). for 2 weeks or more • Mother has 4 or more symptoms of sleep disruption. and lactation consultants. Therefore. Concern may arise . difficulty with social. • Post-partum depression can occur up to one year after birth. are encouraged to offer non-judgmental. Postpartum depression is not uncommon. including obstetricians. Mothers may also not identify their feelings as depression. excessive guilt. nearly every day. open ended inquiry regarding a mother’s mood and feelings during the post-partum period. edition 4 (DSM-IV) diagnostic criteria for major depression. pediatricians. sleep disruption. post-partum depression is suggested by: • Feeling sad or depressed for most of the day. However. Mothers of infants with “difficult temperaments” are also at risk for PPD. cognitive and behavioral development. all clinicians. including weight loss. are difficult to distinguish from symptoms of true depression. but may describe themselves as being “worried” or “anxious. or having feelings of harming their child. unplanned pregnancy. and are more likely to be victims of abuse and neglect. normal post-partum period changes. Women should be encouraged to accept treatment for symptoms that suggest or qualify for post-partum depression.
Please see the medications tables in appendix for more information on selected antidepressant use and breastfeeding.79 over the demands of breastfeeding in depressed mothers. After initiation of antidepressant medication. should be discussed with the mother. Routine serum monitoring of infants is not indicated. The risks and benefits of the medication. with the mother aware of the benefits of continued breastfeeding and risks of formula. a mother can take her medication immediately after feeding. For breastfeeding women with no prior history of antidepressant use. . the firstline antidepressants are paroxetine and sertraline due to research showing low levels in breast milk of these medications. both mother and infant should be monitored for adverse effects. the decision to discontinue breastfeeding a part of a PPD treatment regimen should be made on an individual basis. as well as the risks of untreated depression. however. If there is concern over infant exposure to maternal medication. • • • • • • Selection of antidepressant medication must be individualized to the patient. there is little evidence to support this practice.
org/econ. concerns about support from employers and colleagues and real or perceived low milk supply. Women and clinicians may need to educate employers about the necessity of time and resources (i. suitable location) required to express milk during the workday. working outside the home is related to a shorter duration of breastfeeding. Benefits to the Employer: • Reduced staff turnover and loss of skilled workers after the birth of a child. Breastfed infants are healthier and have less illness than formula fed infants. The Business Case for Breastfeeding Both employees and employers benefit from lactation programs in the workplace. However. resulting in less work-time lost for parents to care for ill infants. • Enhanced reputation as a company concerned for the welfare of its employees and their families.breastfeedingworks. Employers can be reminded of the medical benefits of breastfeeding to infants.80 Return to Work A woman who wishes to return to work can continue to breastfeed her infant and provide her with breast milk via milk expression and storage. employee satisfaction and morale. • Added recruitment incentive for women. lack of accommodations to pump or store breast milk. • Higher job productivity. From http://www. return to work should be delayed at least 4 weeks after delivery. To ensure breastfeeding success. For example: an employee absence of one day costs the Los Angeles Department of Water and Power average $360 (for a $15 per hour employee). The influence of a clinician in this situation can be invaluable. A breastfeeding plan can help the working mother anticipate logistic problems and devise a practical pumping schedule. and the relationship between healthier infants and less missed days of work by parents caring for sick infants (see below). breastfed infants. and can be expressed in a letter or a phone call. and intentions to work full time are significantly associated with lower rates of breastfeeding initiation and shorter duration. Barriers to expressing milk at work include a lack of flexibility for milk expression in the work schedule.htm . longer if possible. • Lower health care costs associated with healthier.e. to ensure establishment of breastfeeding. • Reduced sick time/personal leave for breastfeeding women and their partners because their infants are more resistant to illness.
Like other developmental milestones. during lactation. If needed. . maternal soap. have an earache. stress in mother. Clinical breast exam and breast selfexamination are recommended for all women. There are several weaning techniques that can be recommended when a mother wishes to encourage the process. mammograms are less reliable because of increased breast tissue density. including breastfeeding women. usually this is temporary. or nasal obstruction. often time infant can be coaxed to begin breastfeeding again with a nursing strike. Studies show that there is a delay in breast cancer detection during pregnancy and lactation. wear comfortable bra. ACOG suggests that providers consider performing a screening mammogram before age 40 years for women planning pregnancies in their late 30s. children can wean themselves when they are ready. ideally should be a gradual process accomplished over a long period. or complete cessation of breastfeeding. possible causes include onset of menses in mother. Mother should express to relieve breast fullness. There is no evidence that a specific age of weaning is necessary or mandated. gradual weaning is preferred. • • • Mother-initiated Weaning: gradually replacing one feeding at a time with solids or a bottle or cup is preferred. To date. If a mass is detected during lactation. Breast Cancer Detection in Breastfeeding Women 3% of all breast cancers occur in the post-partum period. it should be fully evaluated. infant may be teething. and be alert to signs of plugged duct or mastitis • Hormonal therapy to assist in weaning or decreasing milk production is not recommended. a mammogram will not affect milk production. Complete weaning.. deodorant or perfumes. physically and psychologically. However. even though many of these agents are detectable in breast milk. there is little to no evidence suggesting harm to nursing infants from these agents. Sudden Weaning: This is not the ideal way to wean. In general. Infant-initiated Weaning: infants may attempt to wean due to inadequate milk supply or infant illness “Nursing Strike:” infant may suddenly refuse to nurse. Environmental Toxins in Breast milk Concern exists about excretion of environmental toxins into breast milk.81 Weaning Weaning is the time of gradually transitioning infants from mother’s milk to complementary foods or an older child’s diet. Some women may wish to continue breastfeeding during and after a subsequent pregnancy. which may interfere with adequate interpretation.
AAFP. Imaging / Radiocontrast Agents Hyperbiilirubinemia Risk and Phototherapy Nomograms Basic Lactation and Breastfeeding Physiology Evaluation of Breastfeeding Technique: Positioning.83 Appendix Breastfeeding Policies: AAP. Vaccines. ACOG The Baby Friendly Hospital Initiative Healthy People 2010 Breastfeeding Goals Medication Tables. Latch. Milk Transfer Methods of Human Milk Expression Alternative Methods to Bottle Feeding Infants Reverse Pressure Softening for Breast Engorgement Sample Breastfeeding Intake and Elimination Log Galactogogues Donor Breastmilk / Breastmilk Banking CDC: Breastfeeding and Swine Flu (2009) Travel Recommendations for the Nursing Mother Online Clinician Breastfeeding Education and Training Options PHQ9 Screening Tool for Depression California Breastfeeding Laws and Legislation KP and Community Patient Breastfeeding Resources .
and support breastfeeding. 2005: • • • • • • • Exclusive breastfeeding for approximately the first six months and support for breastfeeding for the first year and beyond as long as mutually desired by mother and child. Clinicians should support efforts of parents and the courts to ensure continuation of breastfeeding in cases of separation. AAP.) . not just after weaning. Breastfeeding is the preferred method of feeding for newborns and infants. be breastfed and/or receive expressed human milk exclusively for the first six months of life. and should continue as long as mutually desired. Breast milk offers medical and psychological benefits not available from human milk substitutes. Self-examination of mother's breasts for lumps is recommended throughout lactation. All should work to facilitate the continuation of breastfeeding in the work place and public facilities. with rare exceptions. revised in 2003.85 Breastfeeding Policies of Medical Organizations American Academy of Pediatrics From Breastfeeding and the Use of Human Milk. Breastfeeding beyond the first year offers considerable benefits to both mother and child. Breastfeeding should continue with the addition of complementary foods throughout the second half of the first year. Family physicians should have the knowledge to promote.) American College of Obstetricians and Gynecologists The American College of Obstetricians and Gynecologists strongly supports breastfeeding and calls upon its Fellows. custody and visitation. protect. Recognize and work with cultural diversity in breastfeeding practices. other health professionals caring for women and their infants. skills and support needed for successful breastfeeding. (From their policy statement 1989. (From their statement in 1994. Pediatricians should counsel adoptive mothers on the benefits of induced lactation through hormonal therapy or mechanical stimulation. Health professionals have a wide range of opportunities to serve as a primary resource to the public and their patients regarding the benefits of breastfeeding and the knowledge. The AAFP recommends that all babies. revised in 2007. A pediatrician or other knowledgeable and experienced health care professional should evaluate a newborn breastfed infant at 3 to 5 days of age and again at 2 to 3 weeks of age to be sure the infant is feeding and growing well. hospitals and employers to support women in choosing to breastfeed their infants. Mother and infant should sleep in proximity to each other to facilitate breastfeeding. American Academy of Family Physicians Breastfeeding is the physiological norm for both mothers and their children.
Practice rooming-in: Allow mothers and infants to remain together 24 hours a day. Show mothers how to breastfeed. Give newborn infants no food or drink other than breast milk. Kaiser Permanente Honolulu. 9. 8. 10. San Francisco General Hospital. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. 3. Give no artificial nipples to breastfeeding infants. 2. Inform all pregnant women about the benefits and management of breastfeeding. The goal of the initiative is to recognize hospitals and birth centers that take special steps to provide an optimal environment for breastfeeding.) 10 Steps to Successful Breastfeeding 1. 7.000 hospitals worldwide have received this prestigious award.87 The Baby Friendly Hospital Initiative The Baby-Friendly Hospital Initiative is a worldwide project of UNICEF and the World Health Organization (WHO). and Glendale Memorial Hospital (the first Baby Friendly Hospital in Los Angeles County. and how to maintain lactation even if they should be separated from their infants. Help mothers initiate breastfeeding within half an hour of birth. Develop a written breastfeeding policy and routinely communicate it to all health care staff. Train all health care staff in skills necessary to implement the policy. UCSD Medical Center. 5. 4. Approximately 18. unless medically indicated. Notable hospitals in the US which have achieved Baby Friendly Status include Kaiser Permanente Riverside. Encourage breastfeeding on demand. . 6.
communities. “Healthy People 2010 is a set of health objectives for the Nation to achieve over the first decade of the new century.healthypeople. built on the best scientific knowledge and designed to measure programs over time. Department of Health and Human Services: • • • To increase to 75% the proportion of mothers who breastfeed their babies in the early postpartum period.S.89 Healthy People 2010 Breastfeeding Goals www. Added in 2007: • • To increase to 60% the proportion of mothers who exclusively breastfeed their babies for the first three months of life. To increase to 50% the proportion of mothers who breastfeed their babies through five to six months of age. It can be used by many different people.” Healthy People 2020 goals were in development at the creation of this document. and others to help them develop programs to improve health. Healthy People 2010 builds on initiatives pursued over the past two decades.gov U. and Healthy People 2000: National Health Promotion and Disease Prevention Objectives both established national health objectives and served as the basis for the development of State and community plans. Healthy People. Like its predecessors. professional organizations. The 1979 Surgeon General's Report. . To increase to 25% the proportion of mothers who breastfeed their babies through the end of the first year. states. Healthy People 2010 was developed through a broad consultation process. To increase to 25% the proportion of mothers who exclusively breastfeed their babies for six months.
max dose of 30mg of hydrocodone is recommended and monitor infant for drowsiness and appropriate weight gain. and Dr. Considered safe by AAP. very low transfer into milk following oral and IV dosing. Less preferred. and lower oxygen saturations in newborns after perinatal administration. Maternal Medication Acetominophen NSAIDS Ibuprofen. and low to moderate dosages can be used.91 Medication Tables Information from these tables was obtained by TOXNET of the NIH. ketorolac Naprosyn. metabolite has very long half-life. piroxicam. if used. after lactogenesis 2 nonnarcotic pain relievers are preferred. transfer into milk is very low.” Analgesics General Guideline for maternal analgesic use: If infant exposure is a concern. transfer into milk is negligible. Thomas Hale’s text “Medications and Mother’s Milk. increasing reports in literature of sedation. Not recommended. Total exposure of infant to drug levels via colostrum in first 1 – 2 days is negligible. sulindac. indomethacin Aspirin Opiates Methadone Safe / compatible with breastfeeding? Yes Yes. probably safe for short-term use. Morphine Fentanyl Codeine Hydrocodone Meperidine . Yes. Vicodin is the most commonly used opiate analgesic immediately post-partum. Yes. mothers can breast-feed their infants before taking the analgesics. preferred NSAIDs. decreased Apgar scores. Not recommended due to association with Reye Syndrome. however. Yes Considered safe when used in moderate – low doses. however. amount expressed in breastmilk is insufficient to prevent a withdrawal syndrome following chronic prenatal exposure of methadone. longer half-life of these medications raise concerns of accumulation with prolonged use. however.
metronidazole may impart a metallic taste to milk. may produce higher milk concentrations. In general. fentanyl. morphine. and mothers should be advised to interrupt breastfeeding for about 12 to 24 hours after administration. a healthy term infant can safely nurse as soon after surgery as the mother is awake and alert. Antibiotics Maternal Medication Penicillins Cephalosporins Erythromycin. lidocaine. Negligible amounts of these agents found in breast milk. IV metronidazole mothers should be advised to discontinue breastfeeding for 2 to 3 hours until the plasma concentrations have dropped to values similar to those seen with oral dosing. however. other classes are preferred. use of high maternal doses.92 Anesthetics Maternal Medication Epidural medications: bupivicaine. for long-term use. no adverse effects have been reported.” Yes Vancomycin . enflurane Safe / compatible with breastfeeding? Yes Yes. however. Yes. and some infants may discontinue breastfeeding simply because they do not like the taste. With oral or IV use. minocycline Ciprofloxacin Metronidazole Safe / compatible with breastfeeding? Yes Yes Yes Yes. thiopental sodium. Not recommended due to higher absorption by infants. such as 2 g for treatment of trichomoniasis. sufentanil Propofol. however. azithromycin Trimethoprim-sulfamethoxazole Tetracycline Doxycycline. use should be avoided when nursing infants less than two months of age due to potential for causing increased bilirubin levels. Yes Topical and vaginal preparations are safe in breastfeeding.
rosiglitazone . newborn (first week of life) and infants with renal impairment. No. lethargy. sotalol ACE inhibitors Calcium channel blockers Hydralazine Methyldopa Magnesium sulfate Safe / compatible with breastfeeding? Yes Beta blockers vary widely in the amount excreted into breastmilk. Yes Data is limited. glyburide Safe / compatible with breastfeeding? Yes. excretion is very low into breastmilk. metoprolol. Yes. Reports of cyanosis. however. Metformin Thiazolidinediones: pioglitazone. nifedipine and verapamil are preferred.93 Antifungals Maternal Medication Fluconazole (oral and topical) Topical agents: clotrimazole. monitor infant for signs of hypoglycemia (fussiness.) Yes. nystatin Safe / compatible with breastfeeding? Yes Yes Antivirals Maternal Medication Acyclovir Tamiflu Relenza Safe / compatible with breastfeeding? Yes Yes Yes Cardiovascular Medications Maternal Medication Hydrochlorothiazide Beta blockers Propranolol. no data is available on these agents with breastfeeding. these agents are highly protein-bound and passage into breastmilk is low. no adverse effects have been reported. insulin is not excreted into breastmilk. Caution in early post-partum. bradycardia and hypotension exist in conjunction with use of these agents in breastfeeding women. captopril and enalapril have lowest milk concentrations. Yes No. nadolol. miconazole (Monistat). Caution when breastfeeding preterm. If used. labetalol Atenolol. Yes Yes Yes Oral Hypoglycemic Agents Maternal Medication Insulin Sulfonylureas First generation: tolbutamide Second generation: glipizide.
Yes.” (Toxnet) Yes Diphenhydramine (Benadryl) Loratadine Cetirizine Nasal steroids. withholding nursing for four hours after taking the medication can minimize infant exposure. the mother can take these medications immediately after breastfeeding. nasal cromolyn Asthma medications Maternal Medication Albuterol Ipatroprium Inhaled steroids Oral steroids: prednisone. . although may cause decreased milk production. particularly in combination with a sympathomimetic or before lactation is well established. Yes. Larger doses or more prolonged use may cause drowsiness and other effects in the infant or decrease the milk supply. To reduce the small risk of adverse effects to the infant (lethargy). prednisolone Safe / compatible with breastfeeding? Yes No data currently available on this drug. Yes Yes “Small occasional doses of cetirizine are probably acceptable during breastfeeding. if concern exists.94 Anti-allergy meds Maternal Medication Pseudoephedrine (Sudafed) Antihistamines Safe / compatible with breastfeeding? Yes. fluticasone has lowest serum levels of inhaled steroids.
because there is limited published experience with ergotamine during breastfeeding and it might cause adverse effects in the infant. levels in breast milk are low and bioavailability is poor. adequate weight gain. . Sometimes breastfeeding might have to be limited or discontinued because of excessive drowsiness and poor weight gain. Per Toxnet: “there is a great deal of inter. If phenobarbital is required by the mother. Depakene) Phenobarbital Safe / compatible with breastfeeding? Yes Yes Yes Yes Generally yes. especially in younger. and developmental milestones. no reports of ill effects on infants have been reported. Monitor the infant for drowsiness. Measurement of an infant serum level might help rule out toxicity if there is a concern. infant serum concentrations of phenobarbital can be obtained.95 Anticonvulsants Maternal Medication Topiramate (Topamax) Phenytoin (Dilantin) Carbamazepine (Tegretol) Valproic acid (Depakote. most authorities consider ergotamine to be incompatible. however. No.” Lamotrigine Generally yes. amount transferred is moderate. Phenobarbital in breastmilk apparently can decrease withdrawal symptoms in infants who were exposed in utero. it is not necessarily a reason to discontinue breastfeeding. Medications for Migraine Headaches Sumatriptan Ergotamine Yes. If there is concern. especially when used with other sedating drugs. exclusively breastfed infants and when using combinations of psychotropic drugs.and intrapatient variability in excretion of phenobarbital into breastmilk. but it can also cause drowsiness in some infants.
Citalopram (Celexa). paroxetine Fluoxetine Safe / compatible with breastfeeding? Generally the first choice for treatment of depression in breastfeeding mothers. Yes. infants who have metabolic or renal disorders. the relative risk of problems is low. Newborn and preterm breastfed infants should be monitored for sedation and adequate weight gain. General guidelines: Exercise caution with the use of these medications in breastfeeding mothers of newborns and premature infants. Yes. and amoxapine Buproprion Yes Yes.97 Psychotherapeutic Medications There is extensive research that shows the compatibility of breastfeeding with maternal use of most psychotherapeutic medications. nortriptyline. although some unconfirmed cases of reduced milk production have been reported. 3 case reports of fussiness and tremulousness exist for breastfed infants of mothers taking fluoxetine. Less preferred SSRI. although it has been well studied in pregnant women and is considered safe. caution recommended in breastfeeding infants less than 6 months old. small amount of metabolite is excreted in breastmilk but no untoward effects have been reported. mothers of infants with seizure disorders should not take this medication and breastfeed. The relative safety of antidepressants in breastfeeding is approximately: sertraline = paroxetine > venlafaxine > citalopram = escitalopram > fluoxetine >> MAOI The relative safety of antipsychotics in breastfeeding is approximately: risperidone = olanzapine > haloperidol >>> chlorpromazine Antidepressants Maternal Medication SSRIs Sertraline. Women should be reassured that they can continue treatment with most medications and still continue to safely breastfeed their infants. escitalopram (Lexapro) Venlafaxine (Effexor) Due to a few reports of somnolence in breastfed infants. Trazodone Mirtazapine Yes Yes . Tricyclic antidepressants: amitriptyline. preferred SSRIs. it’s long half-life and potential for accumulation in breast milk makes it’s use controversial during breastfeeding. Consider checking levels of metabolite in infant (desvenlafaxine). desipramine. infants with seizure disorders. and infants who are subject to apnea. however.
Antipsychotics. 776 – 789. No 3. short term or intermittent use is preferred over long-term use due to risk of withdrawal symptoms in breastfed infants. Pharmacology Review: Drug Therapy and Breastfeeding: Antidepressants. Antipsychotics. . The Transfer of Drugs and Other Chemicals into Human Milk. and Sedatives. NeoReviews. Yes. 5: e164 . Antimanics. vol 108. Hale.e456.nih. Spencer et al. Antimanics and Sedatives.5. However. 3. Am Fam Physician 2001.nlm. it is relatively safe. amount excreted in breast milk is very low. Hale. Hale. midazolam. Apr 2004.98 Other Psychotherapeutic Agents Maternal Medication Benzodiazepines: diazepam. pp. Committee on Drugs. the amount expressed in breast milk is insufficient to prevent a withdrawal syndrome following chronic prenatal exposure of these medications. 6. chlorpromazine Phenobarbital Lithium Valproic acid Haldol Risperidone Olanzapine References for Mediation Tables: 1. NIH Toxnet: http://toxnet. Pharmacology Review: Drug Therapy and Breastfeeding: Antidepressants. and Effects on Milk Production.e451 – e456. some sources recommend monitoring liver enzymes and platelet levels in breastfed infants. infant should be observed closely for sedative effects. 4. A one time dose of these medications is probably safe. However. 5: e451 . Risk Factors. Pharmacology Review: Drug Therapy and Breastfeeding: Pharmacokinetics. studies show that if levels in mother and infant are monitored closely. 2. Yes Yes Yes Phenothiazine sedatives: promethazine. Pediatrics 2001.64:119-26. Medications in the Breastfeeding Mother. AAP.gov 5. Yes Not recommended due to high levels of excretion in breast milk.e172. NeoReviews 2004. NeoReviews. lorazepam Safe / compatible with breastfeeding? Yes. Oct 2004. Not recommended for use in women breastfeeding infants under 6 months of age due to possible induction of sleep apnea. Caution is advised. Of note. If used.
this has been studied extensively and virtually none passes into milk. Maternal Vaccine Influenza Yellow fever Safe / compatible with breastfeeding? Inactivated flu vaccine is preferred “Breastfeeding mothers in endemic areas of the world should receive the vaccine. Yes . Both inactivated and live viruses are safe and compatible with breastfeeding.” (Hale) Radiocontrast agents Contrast agents have been studied and found not to enter milk in substantial amounts. Maternal Medication Gadolinium Iodinated contrast Safe / compatible with breastfeeding? Yes.99 Vaccines* In general. Due to minimal transfer to milk and the poor oral bioavailability of these agents. but mothers in other areas of the world should refrain from using this vaccine if possible while breastfeeding. discontinuation of breastfeeding is not necessary following an imaging study using contrast. vaccines are safe for administration in breastfeeding women. Breastfeeding does not affect the immune response of the vaccine.
101 Bilirubin Management Tools Bhutani Curve: Nomogram for designation of risk in well newborns at 36 or more weeks’ gestational age with birth weight of 2000 g or more or 35 or more weeks gestational age and birth weight of 2500 g: Phototherapy guidelines for infants more than 35 weeks gestation: From Clinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. . pp. 297-316. Subcommittee on Hyperbilirubinemia. PEDIATRICS Vol. 1 July 2004. 114 No.
hypothyroidism. The milk ducts and lobules contained in the breast grow and proliferate throughout pregnancy. obesity. which differs from mature milk in its lower energy value (67 kcal/100 mL compared with the 75 kcal/100 mL of mature milk). the faster it will replenish fully. leading to increased milk synthesis and the start of lactogenesis 2. and minerals. Certain medical conditions can inhibit lactogenesis 2. There is a large amount of antibodies in colostrum that provides protection to the newborn against infection. fat-soluble vitamins. and its higher percentage of protein. The rate of breast milk production can vary after each feed and is related to the degree of milk emptying of the breast. and alveoli. the size of the areola increases. placental retention. After 16 weeks of pregnancy.103 Basic Lactation and Breastfeeding Physiology The final stage of breast development and preparation for lactation begins during pregnancy. If milk is left in the breasts after feeding.” which is accomplished through the effect of oxytocin on the myoepithelial cells surrounding the alveoli. particularly bacteria and viruses present in the birth canal. and the breast veins become more prominent. The negative feedback by these hormones on pituitary prolactin release is then lost. . and stress. The more empty a breast is of milk.e. such as type 1 diabetes mellitus. Colostrum The first milk secreted into the breasts is colostrum. this process begins with the delivery of the placenta. when the breast grows larger. polycystic ovary syndrome. which allows prolactin concentrations rise. can delay or inhibit lactogenesis 2. Many hormones are involved in lactation. the presence of residual milk will negatively feedback on further breastmilk production. The secretion of milk remains small until serum progesterone and estrogen concentrations fall. oxytocin is released from the posterior pituitary which causes the milk-ejection reflex or “letdown. When the infant suckles at the breast. Prolactin and placental lactogen stimulate nipple and areolar growth and estrogen facilitates the proliferation and differentiation of the ductal system. Progesterone increases the size of lobes. Colostrum also facilitates the passage of meconium and helps establish beneficial bacteria (i. lactogenesis 1 begins. lobules. Their contraction allows for the breastmilk to be expressed from the breasts. Very small amounts of milk and colostrum are present in the breasts at delivery. when lactogenesis 2 begins. This continues until approximately 60 hours postpartum. lactobacillus bifidus) in the infant’s gut. The volume of colostrum will vary with parity of the mother and the number of feedings of the infant in the early post-partum period. this involves production of small amounts of milk and colostrum in the breast.
these agents include interferon. Fully breastfed babies receive about 0. and the process is not fully established until 12 months of life. white blood cells. growth hormone. Human milk contains many immunomodulating agents which assist in developing an infant’s immune system in the gut and to protect him against infection. and many types of immunoprotective agents. but it is thought that decreased cycles of ovulation and possibly increased utilization of fat stores both play a role. . enzymes. • • • • Many substances in the breast milk play a dual role of nutrition and immune protection / activation Infants do not begin making secretory IgA until 4 months of life. breastfeeding has been shown to be protective against ovarian cancer. including hormones. This is thought to be due to the antiinfective and immunologically active components in breast milk. breast cancer. and cardiovascular disease. Physiologic Basis of Health Protection from Breastmilk Breast milk has been shown to protect the infant against many infectious.104 Mature Milk Triglycerides are the primary constituents of the fat in breast milk. which have been associated with higher visual acuity and cognitive ability in the infant.5 to 1g of secretory IgA daily. etc. Human milk is rich in long-chain polyunsaturated fatty acids. allergic and autoimmune diseases in childhood and later in life. post-menopausal hip fractures. including docosahexanoic acid and arachidonic acid. In women. which provide essential fatty acids and about 50% of its calories. lactoferrin. The exact mechanisms for these protections are unknown. growth factors.
1. and hips should be aligned and the infant should face / be parallel to the mother’s body. or a nursing stool for feet. Cradle Hold .comfort of mother H . if she appears uncomfortable.latching of infant onto the breast A . • Infant should be brought to the breast (not the breast to the infant). pillows. Breastfeeding Positioning In particular. A numerical score of 0.help needed by mother to hold baby to breast. or 2 is assigned to the five letters of the acronym: L . Latch. pillows can provide support.amount of audible swallowing T .type of nipple C . • Infant Position — head. and Milk Transfer LATCH Score Tool The LATCH tool is by nurses and clinicians to evaluate the effectiveness of early breastfeeding.105 Evaluate Breastfeeding Technique Ensure Proper Positioning. look for: • Maternal Comfort — Mother sits in comfortable chair or sits up in bed. shoulders. Lower scores (<5) can indicate the need for assistance for better success at breastfeeding. you can suggest different positions. The head should not be turned to the side.
org/conditions/pregnancy/feeding/positioning.106 Football Hold Side-lying position Breastfeeding position photos from Community Hospital of the Monterey Peninsula Hospital website: http://www.aspx .chomp.
• The infant’s tongue will be cupped around the nipple. o Infant opens his mouth wide. evaluate how the infant is brought to the breast. • Watch how she encourages the infant’s rooting reflex. the mother can release the suction by inserting a clean finger into the corner of the infant’s mouth. • The infant is drawn to the breast. • The infant’s nose and chin will touch the breast and the lips will be flanged outward (infant will be able to breathe through nose when it is touching breast due to nose structure). • Suckling should be fast at first as the let-down reflex is initiated. • The infant will grab the nipple and as much areola as possible and continue to draw it into his/her mouth. but once the milk is ejected the suckling will slow into a rhythmic pattern with noted audible swallowing (if the room is quiet). o Middle of infant’s lip stroked with nipple. from La Leche League International . • Upon completion of nursing.107 Evaluate and Ensure a Correct Latch Latch-On To begin. • Watch mother’s use of the C-hold to make a “breast sandwich” for the infant to latch on to: o 4 fingers underneath and thumb on top of the breast. the mother will feel a gentle tugging with the wave-like movements of the infants tongue and jaw. aiming the nipple toward the hard palate. but should feel no pain. o Mother’s fingers are parallel to the infant’s jaw and well behind the areola. • When the infant is latched correctly.
Mother should be comfortable: • Gentle undulating motion of infant mouth. remove infant and reposition and re-latch. • Lips will be flanged out. Poor infant weight gain. Later signs of incorrect latch • • • Trauma to mother’s nipples and pain. not flanged out. Low milk supply. Nose and chin not touching breast. • The nose and chin of the infant will touch the breast. if pain continues or is severe. . • No pain with feeding. Frequent movement of the infant’s head. clicking noises. Lips curled inward (indicating suction). Lack of swallowing sounds. not sucking.108 Signs of a Correct Latch Areola grasp • Infant grasps the entire nipple and as much of the areola as possible. • Mild pain for the first 30 seconds to one minute is OK. Audible clicking noises. Maternal pain and discomfort. Signs of an Incorrect Latch Immediate signs • • • • • • • • Small amount of areola grasped by infant’s mouth. Infant’s cheeks indenting during suckling.
or in-and-out motion of the tongue Photo from Children’s Hospital of Wisconsin www. Look and listen for: • Audible swallowing o Sucking that begins with rapid bursts to stimulate milk let-down o A rhythm of sucking. compressing it.chw. swallowing. friction.109 Ensuring Milk Transfer Watch the infant as she sucks and swallows and milk is transferred. and pauses following establishment of milk flow o Approximately 1 suckle/swallow per second • Undulating action of tongue— no stroking. This process causes the milk to travel from the lactiferous sinuses to the infant's mouth. extending back to the junction of the hard and soft palate. The infant then raises the anterior portion of the tongue to complete the process. the nipple should not move in the infant's mouth if it is correctly positioned. .org The Infant Breastfeeding Technique: The nipple is drawn well into the mouth. Throughout the suckling cycle. The infant's jaw then moves his or her tongue toward the areola. Milk is extracted by a peristaltic action from the tip of the tongue to the base (not by negative pressure).
these large negatively charged molecules make the colostrum “sticky. thus. and can be used to relieve engorgement. • Place clean container under breast to collect milk.” Infants can get colostrum out via their mouth position and peristaltic action of their tongue. anytime. This is because colostrum is high in proteins and antibodies. Hand expression can be done anywhere. • Massage breast gently towards nipple in a rotational manner. the manual/hand technique can often express more colostrum than a breast pump. • Place thumb and index finger opposite each other outside the areola. • Press back towards chest and gently squeeze to express milk.111 Methods of Human Milk Expression Hand Expression Hand expression is an important skill for the breastfeeding women to learn. To manually express breast milk: • Wash hands with soap and water. Step 1: Step 2: . In the first few days of life. • Repeat last step at different positions around areola.
Requires practice.112 Expression with manual pump • • • • • Hand and wrist operated hand-held device. Useful for pumping if mother is away from infant only occasionally. Price range is $30 to $50. plastic attachments seen in this photo can be purchased separately from the unit. Can be purchased at KP Women’s Center or local store. Suction unit (housed in back pack) does not come into contact with breast milk. Automatic / electronic expression • • • • • • • Runs on batteries or plugs into electrical outlet Easy to use Can pump one or both breasts at the same time Hands-free models are available Costs run $150 to over $250 Unit can be used by another user. skill and coordination. Medela Pump ‘n Style .
Some nurseries have used cup feeding in infants with gestational ages as young as thirty weeks. Cup feeding an infant. Nipple confusion can occur when an infant has not had an opportunity to establish the correct mouth movements for breastfeeding. Specialized cup for infant feeding. where he can lap at it and swallow small amounts at his own pace.113 Alternative methods to bottle feeding Feeding infants with a bottle in the first few days and weeks of life can result in nipple confusion. Cups made especially for infant feeding are available from lactation consultants and from La Leche League International (www. . Nipple confusion negatively impacts breastfeeding success by producing an ineffective latch. The infant is held in an upright position with his head supported and the milk is presented to his lower lip and tipped slightly. Cup and Spoon Feeding A small glass or plastic cup is used to feed an infant a small amount of milk or formula. Eventually. nipple confusion can be avoided by using “alternative” methods for feeding infants.llli. milk production drops off in the mother and supplementation with formula is required. Infants can be fed by a spoon using a similar technique: a spoon is used to offer small amounts of milk to the infant by placing the tip of the spoon on the lower lip. This then results in inadequate milk delivery to infant and pain in mother.org). The child will take the milk at his own pace. Early and frequent use of pacifiers can also result in nipple confusion. If supplementation is needed. The physiologic stability of an infant while cup-feeding has been confirmed in a number of studies.
silicone tubing runs from the container to the tip of mother's nipple and is secured with tape. both for evaluation of appropriate method as well as proper teaching of system. A container for the milk hangs from a cord around mother's neck. Lactation consultation is advised when nursing this method. Nursing supplementers can be used for premature infants and those infants who have trouble latching adequately to the breast i. The technique involves angling the tip towards the infant’s cheeks and depositing a small amount of milk for the infant to swallow. he also takes the tubing into his mouth and receives supplement along with breastmilk. Supplementing this way helps stimulate milk production in the mother’s breasts. This technique of feeding can also be accomplished with an eyedropper.e. The supplemental nursing system is also used by mothers who are nursing adopted babies.) A regular plastic syringe or one with a periodontal tip can be used. Periodontal syringe Supplemental nursing system This device allows infant to receive supplements of milk and formula while suckling at the breast. as well as by mothers who are relactating (reestablishing a milk supply after weaning). .114 Syringe feeding This method uses a syringe to drop milk into the infant’s mouth while being held and supported in an upright position (see cup-feeding picture on previous page. infants with developmental or neurologic or neurologic problems. When the infant latches onto the breast.
. Sequence can be repeated as often as is needed. It is important to soften the areola in the entire one-inch area. It also helps elicit the milk-ejection reflex. Reverse pressure softening briefly moves some swelling backward and upward into the breast to soften the areola so it can change shape and the nipple can extend easily. Delayed or skipped feedings may also increase edema in the breasts. as well as breast milk. firm pressure is applied on areola towards ribcage. Reverse pressure softening can help in the first days after birth if women notice firmness of the areola. • Gentle. Reverse pressure softening should cause no discomfort. Reverse pressure softening can be used prior to each feed. latch pain or breast fullness. which can take 7-14 days to resolve. To utilize the reverse pressure softening technique: • Woman places the fingers or thumbs on areola. Fullness in the early days after birth is due to tissue edema in the breast. • The infant is offered the breast when the areola is soft. • Steady pressure is held for one to 3 minutes. Reverse pressure softening is useful when a woman feels that her breast and areola are swollen and difficult to compress. It can also assist in manual milk expression. Pressure may also be applied by pressing with a ring made by cutting off the nipple part of an artificial nipple. Intravenous (IV) fluid or drugs such as pitocin may also increase edema.115 Reverse Pressure Softening Reverse pressure softening is a way to soften the circle areola to make latching and expressing milk easier while an infant is learning to breastfeed.
117 Sample Breastfeeding Intake and Elimination Log Date / Time DOL 1 1:30pm 3:00pm 5:15pm 6:30pm 7:15pm 10:00pm DOL 2 1:15am 5:00am 7:20am 9:00am 10:15am 12:00pm ETC. Right breast (min) 10 min 10 min 12 min 5 min 10 min 10 min 12 min 5 min 10 min 10 min 12 min 5 min Left breast (min) 12 min 5 min 7 min 15 min 5 min 12 min 5 min 7 min 15 min 5 min 7 min 15 min Formula (oz) None None None None None None None None None None None None 0 1 0 1 0 0 0 0 0 1 0 0 Wet diapers Stool 0 0 1 0 0 0 0 1 0 0 0 0 Crying Notes baby sleepy Mild breast pain .
and earned the medication a black-box warning in 2009. Long-term (>6 months) usage of metoclopramide is associated with irreversible tardive dyskinesia. in these cases the lowest effective dose has been continued for longer periods successfully. These substances are secreted in negligible amounts into breastmilk and are considered safe for use in breastfeeding. Galactogogues are frequently used to augment breast milk production in mothers with infants in the neonatal intensive care unit. Likewise. Occasionally the breastmilk supply will drop off as the dose is reduced. or increasing milk production in women who have had a breast reduction. The most important determinant of initiation and maintenance of an adequate breastmilk supply is early and frequent breastfeeding with complete emptying of the breasts at each feed. but don’t necessarily maintain. is 30 to 45 mg/day in three or four divided doses. milk production declines. Also. more frequent and thorough emptying of the breasts typically results in increased milk production. reestablishing milk supply after weaning). thereby promoting breastmilk production. maintain or augment breast milk production. with a dose-response effect up to 45 mg daily.g. when used as a galactogogue. but these substances are likely safe. maternal milk supply. There is no research to suggest that starting galactogogues prenatally or within the first postpartum week is helpful in establishing or maintaining an adequate milk supply. adoptive nursing. Galactogogues generally increase the secretion of prolactin from the hypothalamus and therefore increase. The typical dose of metoclopramide. and increases prolactin levels by antagonizing dopamine release. The assistance of a lactation consultant in these situations is very helpful.119 Galactogogues Galactogogues are medications used to intitiate. increasing a mother’s milk supply due to maternal or infant illness or separation. Other uses include relactation (e. Short-term use of galactogogues is advised (1-3 weeks). The effects of long-term use of domperidone and fenugreek are not known. Use of galactogogues should only be used after a thorough evaluation for treatable causes of decreased milk production has been completed. a trial of increasing the frequency of breastfeeding or breastmilk expression should also be attempted prior to galactogogue use. . If the breasts are not emptied regularly and thoroughly. Metoclopramide Metoclopramide (Reglan) is the most well studied and most commonly used galactagogue in the United States. It is usually given for 7 to 14 days at full dose with a taper off over 5 to 7 days.
The quality of such products cannot be assured. it can be taken as one cup of strained tea three times per day (1/4 tsp seeds steeped in 8 oz water for 10 minutes). milk. mechanical obstruction. the usual dosage of domperidone is 10 to 20 mg three to four times per day taken for 3 to 8 weeks. Domperidone is available from overseas pharmacies and from compounding pharmacies in the US. domperidone is a dopamine antagonist that is routinely used outside the United States for the treatment of gastroesophageal reflux and emesis.120 Domperidone (Motilium) Like metoclopramide. Reported side effects are rare but include maple like odor to sweat. Most women respond within 3 to 4 days.S. or perforation). Food and Drug Administration (FDA) issued a warning against its use based on safety concerns with IV use and risks associated with drug importation. and the FDA has warned against their use. Side effects in mothers taking domperidone are uncommon. Alternatively. the U.S. Usual dose is one to four capsules (580–610 mg) three to four times per day. although as with most herbal remedies there is no standard dosing.. headache and abdominal cramping. diarrhea. . The excretion of domperidone into breastmilk is negligible and no adverse effects have been reported in breastfed infants whose mothers were taking domperidone. When used as a galactogogue. they include dry mouth. and increased asthmatic symptoms. but some require 2 to 3 weeks to get maximum effect. Domperidone is contraindicated in patients with known sensitivity to the drug and in situations in which gastrointestinal stimulation might be dangerous (e. and urine. Use during pregnancy is not recommended due to its uterine stimulant effects.g. There is no evidence that oral administration is associated with toxicity in either mother or infant. It is a member of the pea family listed as GRAS (generally regarded as safe) by the U. Despite the fact that domperidone is approved for use in most of the developed world and has been used for many years with an excellent safety record. Food and Drug Administration. Fenugreek is the most commonly used herbal galactogogue. as well as a galactogogue. gastrointestinal hemorrhage.
particularly E and A. • Smoking or use of tobacco products. • Regular consumption of more than two alcoholic drinks per day. or syphilis. • Residing in the United Kingdom for more than 3 months or in Europe for more than 5 years between 1980 and 1996. Donor exclusion criteria include: • A positive blood test result for HIV. • Being born in or traveled to Gabon. However. levothyroxine. • The donor or her sexual partner is at risk for HIV infection. sepsis and possible support of long-term positive neurodevelopmental outcomes in very low. • Use of medication or herbal supplements (with the exception of progestin-only oral contraceptives or injections. at milk bank expense. or Equatorial Guinea. hepatitis B or C. much of the biologically active content of breastmilk is preserved. for: • HIV • HTLV I and II • Hepatitis B and C • Syphilis Donors are taught carefully how to pump and collect their milk safely and cleanly and how to keep their pumps and collection systems sterile. human T-cell lymphoma virus (HTLV). • Potential donors undergo a screening history similar to the one used to screen potential blood donors. insulin. The benefits to infants consuming donor milk are similar to breastfed infants. Cameroon. . in large part due to the research showing the many benefits of human milk feeding to infants.and extremely-low birthweight infants. Human milk banks in the United States follow the Human Milk Banking Association of North America (HMBANA) screening standards: • Potential donors are cleared initially by their own physicians to assure that their health and welfare are protected. prenatal vitamins). • Use of illegal drugs. Congo. Niger. Chad. including most of the immunoglobulins present in breastmilk. • An organ or tissue transplant or a blood transfusion in the last 6 months. Donor milk is frozen in sterile containers immediately after collection and maintained in the frozen state until processed by the receiving bank. The pasteurization process does alter the structure of some beneficial proteins. Effective screening and pasteurization techniques make donor breastmilk a safe option for infants whose mothers are unable to provide them with their own breastmilk. All donors undergo serologic screening.121 Donor Breastmilk / Breastmilk Banking The demand for banked human milk has been increasing over the past decade. including decreased rates of necrotizing enterocolitis.
122 Donor milk is cultured for bacterial contamination when received by the bank, and milk that has abnormal findings is not processed for distribution. Such findings include: • Milk that has a high degree of bacterial contamination (ie, > 100 colony-forming units). • Milk contaminated with specific problematic flora (eg, Staphylococcus aureus, Bacillus sp). Donor milk that has passed all of the previous screening steps is then Holder pasteurized at 62.5°C for 30 minutes, a process demonstrated to eliminate known bacterial and viral pathogens. Aliquots of milk are recultured after pasteurization to assure sterility; the presence of any bacterial growth at this point in the process requires discarding of the contaminated batch. Of note, milk banks do not screen potential donors for cytomegalovirus (CMV). The prevalence of CMV seropositivity for pregnant women in North America ranges from about 40% to 60%, therefore, a large proportion of potential donors would be expected to be CMV-positive. Rather than screening and eliminating a very high percentage of potential donors, milk banks have relied on pasteurization to protect against transmission of CMV and other viruses. Pasteurization has been found to be effective in eliminating the virus from the milk. In the past, freezing had been used in an attempt to eliminate the virus but was found to be less effective. Case reports of infants being infected from their own mother’s milk have resulted in relatively mild infection, probably due to passive transfer of antibodies both in utero and through the mother's milk. In terms of CMV, pasteurized donor milk actually may be safer for babies than fresh maternal milk. The current price (as of 2010) of donor breast milk is approximately $3.50 per fluid ounce.
Donor Milk Banks in California:
Mothers' Milk Bank 751 South Bascom Ave San Jose, CA 95128 Phone (408) 998-4550 FAX (408) 297-9208 firstname.lastname@example.org www.milkbanksj.org From Human Milk Banking Association of North America http://www.hmbana.org/
CDC: Breastfeeding and Swine Flu (2009)
From http://www.cdc.gov/h1n1flu/infantfeeding.htm “Infants who are not breastfeeding are particularly vulnerable to infection and hospitalization for severe respiratory illness. Women who deliver should be encouraged to initiate breastfeeding early and feed frequently. Ideally, babies should receive most of their nutrition from breast milk. Eliminate unnecessary formula supplementation, so the infant can receive as much maternal antibodies as possible. If a woman is ill, she should continue breastfeeding and increase feeding frequency. If maternal illness prevents safe feeding at the breast, but she can still pump, encourage her to do so. The risk for swine influenza transmission through breast milk is unknown. However, reports of viremia with seasonal influenza infection are rare. Expressed milk should be used for infants too ill to feed at the breast. In certain situations, infants may be able to use donor human milk from a certified milk bank. Antiviral medication treatment or prophylaxis is not a contraindication for breastfeeding.”
Excerpts from CDC “Novel H1N1 Flu (Swine Flu) and Feeding your Baby: What Parents Should Know”
Does breastfeeding protect babies from this new flu virus?
There are many ways that breastfeeding and breast milk protect babies’ health. Flu can be very serious in young babies. Babies who are not breastfed get sick from infections like the flu more often and more severely than babies who are breastfed. Since this is a new virus, we don’t know yet about specific protection against it. Mothers pass on protective antibodies to their baby during breastfeeding. Antibodies are a type of protein made by the immune system in the body. Antibodies help fight off infection. If you are sick with flu and are breastfeeding, someone who is not sick can give your baby your expressed milk.
Should I stop breastfeeding my baby if I think I have come in contact with the flu?
No. Because mothers make antibodies to fight diseases they come in contact with, their milk is custom-made to fight the diseases their babies are exposed to as well. This is really important in young babies when their immune system is still developing. It is OK to take medicines to prevent the flu while you are breastfeeding. You should make sure you wash your hands often and take everyday precautions (http://www.cdc.gov/flu/protect/habits.htm). However, if you develop symptoms of the flu such as fever, cough, or sore throat, you should ask someone who is not sick to care for your baby. If you become sick, someone who is not sick can give your baby your expressed milk.
Is it okay to take medicine to treat or prevent novel H1N1 flu while breastfeeding?
Yes. Mothers who are breastfeeding and taking medicine to treat flu because they are sick should express their breast milk for bottle feedings, which can be given to your baby by someone who is not sick. Mothers who are breastfeeding and are taking medicines to prevent the flu because they have been exposed to the virus should continue to feed their baby at the breast as long as they do not have symptoms of the flu such as fever, cough, or sore throat.
If my baby is sick, is it okay to breastfeed?
Yes. One of the best things you can do for your sick baby is keep breastfeeding. Do not stop breastfeeding if your baby is sick. Give your baby many chances to breastfeed throughout the illness. Babies who are sick need more fluids than when they are well. The fluid babies get from breast milk is better than anything else, even better than water, juice, or Pedialyte® because it also helps protect your baby’s immune system. If your baby is too sick to breastfeed, he or she can drink your milk from a cup, bottle, syringe, or eye-dropper.
The woman who is unable to nurse for an extended period of time may notice her milk supply diminishing. effective in maintaining an abundant milk supply • Maintain skin-to-skin contact with the child. The traveling mother may find it helpful to take along a sling or other soft infant carrier.cdc. This is also the best way to meet the physical and emotional needs of the infant or child. nursing infants and children may feed on demand. support may be only a phone call away at any time throughout the trip. she may take steps to preserve her milk supply while separated depending upon .125 Travel Recommendations for the Nursing Mother From: http://www.org) to find support groups and breastfeeding experts in other countries. which may be used to: • Ease the burden of carrying a child for extended periods of time • Increase opportunities for unrestricted nursing. Mothers may wish to identify breastfeeding support local to her destination. a mother can overcome many potential obstacles. visit The International Board of Lactation Consultant Examiners. which helps in maintaining a milk supply • Protect the child from some environmental hazards” When a Mother Travels Apart From Her Nursing Infant or Child Prior to departure “A breastfeeding mother planning to be apart from her nursing infant or child may wish to express and store a supply of breast milk for use while she is away.htm Travel need not be a reason to stop breastfeeding. Breastfed infants do not require water supplementation. Infants who have never consumed milk from a bottle or cup will also need opportunities to practice this skill with another caregiver prior to the mother's departure. And. A mother planning a long separation from her nursing infant or child might wish to work with an International Lactation Consultant (IBCLC) or her pediatrician to obtain assistance and suggestions specific to her situation. Mothers can find an IBCLC in the United States online by visiting the websites for the International Lactation Consultants Association or The International Board of Lactation Consultant Examiners. and is most successful when begun gradually over many weeks in advance of the planned separation. To locate lactation consultants worldwide. And. even when traveling internationally. “A mother traveling with her breastfeeding infant or child may find that nursing makes travel easier than it would have been with a bottle-fed infant or child. even in extreme heat environments.gov/breastfeeding/recommendations/travel_recommendations.” Traveling With A Nursing Infant Less Than 6 Months of Age “A mother traveling with her nursing infant less than six months of age need not make provisions to supplement breastfeeding. However. Visit La Leche League International (www. by planning well before the travel date. The most effective way to maintain a mother’s milk supply while traveling is to engage in frequent and unrestricted nursing opportunities. when accompanying their mothers.llli. Building one’s supply of breast milk takes time and patience. In this way.
” Air Travel “No special precautions are necessary for airport security screenings while breastfeeding. A breastfeeding mother expressing her own milk while traveling does not need to declare her milk at U. This duration becomes more flexible and can be maintained for a longer period of time as the child grows older and complementary foods play a greater role in the child’s diet. Milk may be stored and transported in refrigeration. Certainly. Fresh milk may be safely stored in an insulated cooler bag with frozen ice packs for up to 24 hours.” Milk Storage and Handling While Traveling “Expressed milk should be stored in clean. However. regardless if milk is stored. In such a situation it is important to recognize the value of regular expression while separated to help her maintain her milk supply until she and her nursing infant or child can be reunited. however once frozen milk is fully thawed it should be used within one hour. Once milk is cooled. Refrigerated milk can be stored for 5 days. to maintain an abundant milk supply over an extended period of time. it should remain cool until the milk is consumed. Occasionally during prolonged separations. Separation from the infant or child need not be a reason to stop breastfeeding. she may resume breastfeeding upon her return. In many cases. a woman may have greater success using a hospital-grade double breast electric pump. Depending upon the destination. if no reliable milk storage is available. a mother traveling without her nursing infant or child may need to discard her expressed milk. a nursing infant or child will help bring her milk supply to its prior level. Milk expression approximating the frequency with which the infant or child typically nurses (generally every 2-3 hours for infants less than 6 months old) helps a mother maintain her milk supply. the more difficult it is to maintain a full milk supply. tightly sealed containers. infants or children who have grown accustomed to using a bottle or cup may have difficulty transitioning back to the breast. a mother may need to plan for alternative methods of milk expression. soapy water and if it seals tightly. or to discard it before returning home. or frozen in dry ice. a breastfeeding mother needs to consider access to safe storage options in making her decision whether to keep her expressed milk to bring back to her infant or child. Any container may be used if it can be thoroughly cleaned with hot.” How to Maintain Milk Supply While Traveling “A mother who has a flexible schedule while traveling may take regular breaks to express her milk. Many mothers choose to use infant feeding bottles with solid caps to store milk. after returning from travel. Electric breast pumps are . In general. the suckling child will help return a mother’s milk supply to its prior level.S. Because of these requirements. after reuniting mother and baby. the longer the separation between the nursing mother and child. Intermittent milk expression can be done manually or with the help of a small battery or manual breast pump.126 • The amount of time a mother has to prepare for her trip • The duration and destination of her travel • Her flexibility in the use of her time while traveling Even if a woman’s milk begins to diminish. Depending on her destination. Customs when returning to the United States. In many cases. Refrigerated milk can subsequently be frozen. Freshly expressed milk is safe for infant consumption even when stored at room temperature for up to 6–8 hours. separation of a week or less usually poses no major problem for a mother wishing to maintain breastfeeding during separation from her child.
Breastfeeding does not adversely affect immunizations considered routine for the United States. breastfeeding mothers may wish to include an antifungal cream helpful in treating breast infections also known as thrush.cdc. Breastfeeding mothers traveling to malarious areas should ensure the antimalarial included is compatible with breastfeeding before beginning travel.htm . based on recommendations for the specific travel itinerary. or diaper bag.” The Traveler’s Health Kit During Breastfeeding “Most items included in traveler’s health kits are fully compatible with breastfeeding. similar to a laptop computer. Breastfeeding mothers should consult the food-borne and waterborne illness recommendations (www. purse.” Immunizations during Breastfeeding “Most nursing mothers may be immunized routinely.” Source: NCID Yellowbook (www.gov/breastfeeding/disease/index.127 considered personal items during air travel and may be carried on and stowed underneath the passenger seat.htm) when choosing an anti-diarrheal.aspx) From: http://www.cdc. In addition.gov/travel/contentYellowBook. nor is the administration of most vaccines. including live virus vaccines. An oral antifungal could be included as well to treat oral yeast in the infant.gov/breastfeeding/recommendations/travel_recommendations. harmful to breast milk.cdc.
org American Academy of Pediatrics Breastfeeding Residency Curriculum – website with role-play situations. and powerpoint presentations. Senior editor: Richard J.breastfeedingtraining. They offer a free breastfeeding basics curriculum self-study course that can be downloaded from their website: www.129 Online Breastfeeding Education and Training for clinicians Breastfeeding Training – a healthcare provider training project between the Virginia Department of Health and University of Virginia Health System. Breastfeeding for the Medical Profession.wellstart. 2005 Ruth A. preventive medicine and ob/gyn residency programs.and post-tests. www. Lawrence and Robert Lawrence Medications and Mother’s Milk.org/breastfeeding/curriculum Textbooks on Breastfeeding for Clinicians Breastfeeding Handbook for Physicians. 2006 American Academy of Pediatrics and American College of Obstetricians and Gynecologists. MD. www.org Wellstart International is a nonprofit organization that is active and influential in many global events related to the protection. pre.aap. 2008 Dr. family medicine. 7 CME credits are offered after completion of the course. suitable for pediatric. Schanler. FAAP Provides physicians with a concise reference on breastfeeding and human lactation. promotion and support of optimal infant and young child feeding. Thomas Hale ! . internal medicine.
or get along with other people? ____ ____ ____ ____ Not difficult at all Somewhat difficult Very difficult Extremely difficult . take care of things at home. or sleeping too much 4. how difficult have these problems made it for you to do your work. If you checked off any problems. Trouble concentrating on things such as reading the newspaper or watching television 8. or feeling that you have let yourself or your family down 7. Moving or speaking so slowly that other people could have noticed. or hopeless 0 1 2 3 3. Trouble falling asleep. Thinking that you would be better off dead or that you want to hurt yourself in some way 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 Add columns: ________ + ________ + ______ _ Total: ___________________________________ 10.being so fidgety or restless that you have been moving around a lot more than usual 9. feeling that you are a failure. Or the opposite . Feeling tired or having little energy 0 1 2 3 0 1 2 3 5. Feeling bad about yourself. Feeling down. how often have you been bothered by any of the following problems? 1. staying asleep. depressed. Poor appetite or overeating 0 1 2 3 6.131 PHQ-9 screening tool for post-partum depression Over the last 2 weeks. Little interest or pleasure in doing things Not at all Several days More than half the days Nearly every day 0 1 2 3 2.
Break time for an employee that does not run concurrently with the rest time authorized for the employee by the applicable wage order of the Industrial Welfare Commission shall be unpaid. 1033. including the state and any political subdivision.Legal Requirement) Chapter 3. except the private home or residence of another.5 (2000) Allows mother of breastfed child to postpone jury duty for one year and specifically eliminates the need for the mother to appear in court to request the postponement.8.usbreastfeeding. An employer is not required to provide break time under this chapter if to do so would seriously disrupt the operations of the employer. The employer shall make reasonable efforts to provide the employee with the use of a room or other location. public or private. The law also provides that the one-year period may be extended upon written request of the mother (Chap. other than a toilet stall. (a) An employer who violates any provision of this chapter shall be subject to civil penalty in the amount of one hundred dollars ($100) for each violation Jury duty California Civil Code 210.html Lactation Accommodation Law (Assembly Bill 1025 . if possible. 266 [AB 1814] Breastfeeding in Public California Civil Code 43. Section 1030.org/Laws. The room or location may include the place where the employee normally works if it otherwise meets the requirements of this section. shall provide a reasonable amount of break time to accommodate an employee desiring to express breast milk for the employee’s infant child. run concurrently with any break time already provided to the employee.californiabreastfeeding. Every employer.133 California Breastfeeding Laws and Legislation Available at the California Breastfeeding Coalition’s website at: http://www. 1032.org. where the mother and the child are otherwise authorized to be present [AB 157] Other Breastfeeding Legislation The United States Breastfeeding Committee has made available an inventory and analysis of state legislation on breastfeeding and maternity leave that includes legislation related to employment. 1031. for the employee to express milk in private. in close proximity to the employee’s work area. Part 3 of Division 2 of the Labor Code: 1030. . This inventory can be viewed online or downloaded free of charge from http://www.3 (1997) Allows a mother to breastfeed her child in any location. The break time shall.
gov/breastfeeding/ United States Breastfeeding Committee www. RN Monday to Friday 8:30 AM to 3:30 PM Perform 2-4 day weight checks.bfmed.usbreastfeeding.org/california/scpmg/NeoPeri/index.org . 5th floor Sandy Garcia.org U. 783-4345 Kaiser Breastfeeding / Return to Work Class 323/783-4472 Online Neonatal and Perinatal Home Page: Southern California Region http://kpnet. room 3016 in main hospital Outpatient: Women’s Center 4900 Sunset Boulevard.html Breastfeeding Taskforce of Los Angeles www. assist in breastfeeding technique.cdc. Post-partum East 323/783-1634 Allison Tyson.135 Breastfeeding Support for Patients / Patient Resources Kaiser Permanente Los Angeles Medical Center Inpatient Office located 4th floor. breastpump sales 323/783-7808. RN Employee pumping room located on 3rd floor east.kp. Department of Health and Human Services www.gov/breastfeeding U. Centers for Disease Control www.org/ Academy of Breastfeeding Medicine www.womenshealth.S.llli.org La Leche League International www.S.breastfeedingtaskforla. assess for jaundice.
support groups. breast pump sales.137 Los Angeles Community Breastfeeding Resources More local resources can be found at www. The Pump Station Breastfeeding classes. breastfeeding classes. La Leche League 24-hour hotline: 877/452-5324 US Department of Health and Human Services National Breastfeeding “Warm line”: 800/994-9662 . Hollywood 1248 Vine St 323/469-5300 Santa Monica 2415 Wilshire Blvd 310/998-1981 Bellies. breast pumps and accessories for rent and purchase. Babies and Bosoms Prenatal and post-partum classes.org. support groups. Glendale 3461 N.breastfeedingtaskforla. services by appointment only. 818/541-1200 A Mother’s Haven Prenatal breastfeeding classes. post-natal breastfeeding support. sales and rentals of breastpumps. nursing and infantcare products. After hours lactation support: 818/ 601-5381 Encino 15928 Ventura Blvd # 116 818/380-3111 Glendale Memorial Hospital 818/507-4191 Prenatal breastfeeding classes. pre. Huntington Hospital Pasadena 626/397-3172 Prenatal and breastfeeding classes. breastfeeding support group. nursing and babycare products. Thursday support group.and post-natal yoga. nursing accessories. breast pumps and accessories for rent and purchase. Verdugo Rd.
Wright AL. U. 17.113(5):974-982. Pediatr Clin North Am . Healthy People 2010. Pediatrics. DeVine D.e288. April 2007 2. Bobo JK.bfmed. 15. 2008. 13. Chung M. Chew P. Obstet Gynecol. Pediatrics in Review. Trikalinos T. if one repeats Weimer’s calculations using the most current data on breastfeeding rates. 1999.103(4 pt 2):870-876. 6. Am J Epidemiol. 18. Gillespie B. 2009. updating the figures for inflation. Feb 2000. Health care costs of formula-feeding in the first year of life. AAP.417. Breastfeeding Update 1: Immunology.S. May 1997. Stuebe AM. Raman G. 8: e282 .: Food and Rural Economics Division. www. 2001. Powers. Diet. Latha Chandran and Polina Gelfer Breastfeeding: The Essential Principles.2103-4. Issue 1 (February 2001) 9. Promoting and Supporting Breastfeeding. Food Assistance and Nutrition Research Report No. PEDIATRICS Vol. Pediatrics in Review. Vol 4. Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate. Gourley. Department of Health and Human Services. Powers and Wendelin Slusser. Community-acquired methicillin-resistant Staphylococcus aureus among patients with puerperal mastitis requiring hospitalization.119. the true figure would be over $14 billion today. and Advocacy Pediatr. Pediatrics. Section on Breastfeeding.2009. Jul 2007. Sheffield J. Volume 48. 12. Weimer cited a savings of $3. No 3. Breastfeeding and the Use of Human Milk.139 References 1. Duration of lactation and risk factors for maternal cardiovascular disease. Clinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 27: 409 . 51(3): 761-83 8. Pediatric Clinics of North America. Ball TM. Foxman B. Breastfeeding Update 2: Clinical Lactation Management. Philipp BL . de Almeida and Cecilia Maria Draque. Neonatal Jaundice and Breastfeeding. Wendel G. Baby Friendly Way. 4. pp. Schwartz K. Nov 2006. Freiberg MS. 7. Cauley JA. Hernandez J. D'Arcy H. the Best Breastfeeding Start.. Lau J. Allison MA. Roberts S. 19. The rise of breastfeeding in the United States. Glenn R.161. Apr 1997.155(2):103-114. Washington. The Economic Benefits of Breastfeeding: A Review and Analysis. 1 July 2004. Nutrition.31. Obstet Gynecol. 2002. NeoReviews. Magula N. 2004. Ray RM. http://www. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Rev. Breastfeeding and the risk of postneonatal death in the United States. Jr. Coombs. 153 (Prepared by Tufts New England Medical Center Evidence based Practice Center. and Neonatal Hyperbilirubinemia NeoReviews. Stafford I. However. Including chronic diseases in children and mothers would likely result in cost savings of many times that figure (from usbreastfeeding. Rockville. Academy of Breastfeeding Medicine. Rogan WJ. . 18: 111 . 18: 147 .org/Resources/Protocols.org) 5.healthypeople.C. Wendelin Slusser and Nancy G. Pediatrics 2005 115: 496-506.112(3):533-537. Moreland.01JUN-2004. Am Fam Physician 2000. D. 14.gov.aspx 11. 13.) AHRQ Publication No 07 E007. 1: 25 . MD: Agency for Healthcare Research and Quality. Evidence Report/Technology Assessment No.6 billion annually if breastfeeding rates were increased from their current rates to those recommended by Healthy People 2010 goals. Department of Agriculture. Maria Fernanda B. Laibl V. Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States.) 3. Ness RB. Economic Research Service. Ip S.61:2093-100. Nancy G. Subcommittee on Hyperbilirubinemia.113(5):e435-e439 10. 114 No. 297-316 16. Schwarz EB. Breastfeeding. Wright AL. Chen A. This figure is an underestimation of the total savings because it represents cost savings from the treatment of only three childhood illnesses. Weimer J.
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