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Breastfeeding Support

and Promotion
Joan Younger Meek, MD, FAAP
AAP Section on Breastfeeding

Management of Breastfeeding
• Breastfeeding initiation
• Recommended breastfeeding
• Weight pattern
• Hypoglycemia
• Jaundice
• Employment

Breastfeeding Promotion in Physicians’
Office Practices Curriculum
3 Key Educational Tools for Physicians to
Teach New Mothers
• Nutritional parameters
• Hand expression
• Latch and positioning

AAP Policy Statement
Recommended Breastfeeding Practices
• Initiate in the first hour.
• Keep newborn and
mother together in
recovery and after.
• Avoid unnecessary oral
• Avoid traumatic
AAP Pediatrics 2012;129:e827-841.

Breastfeeding Initiation
• Skin-to-skin contact
– Promotes physiologic
– Provides warmth
– Enhances feeding
– Infant crawls to breast
and self-attaches

Photo © Joan Younger Meek, MD, FAAP

• Delay weights and measurements, vitamin K
and eye prophylaxis until after first feeding
• Knowledgeable breastfeeding advocate in
labor & delivery

AAP Policy Statement
Recommended Breastfeeding
•Avoid the routine use of supplements
unless there is a true medical indication
and the physician has ordered the
•Avoid the use of pacifiers in healthy, term
infants, until breastfeeding is well
established (approximately 3-4 weeks of

Medical Indications for
• Very low birth weight or some premature infants
• Hypoglycemia that does not respond to
• Severe maternal illness
• Inborn errors of metabolism
• Acute dehydration not responsive to routine
breastfeeding or excessive weight loss
• Maternal medication use incompatible with
Academy of Breastfeeding Medicine Clinical Protocol #3: Hospital
guidelines for the use of supplementary feedings in the healthy
term breastfed neonate.(

AAP Policy Statement
Feeding Pattern
• Encourage at least 8–12 feedings per day.
• Alternate the breast that is offered first.
• Allow infant to nurse on at least one side until
infant falls asleep or comes off the breast to
increase fat and calorie consumption.

Infant Assessment
Infant Weight
• Weight Loss
– Average loss of about 6% over the first 3–4 days.
– Loss greater than 8-10% mandates careful
evaluation of breastfeeding.

• Weight Gain
– Begins with increase in mother’s milk production by
at least day 4–5.
– Expect gain of 15–30 g/day (1/2 to 1 oz per day)
through the first 2–3 months of life.

Infant Assessment
Poor Weight Gain
• Problem
– Inadequate milk supply or milk transfer.
• Solution
– Weigh infant, feed infant, weigh again.
– Evaluate infant at the breast.
– Correct latch and positioning.
– Improve milk production and transfer.
– Increase frequency and duration of

Infant Assessment
Elimination Pattern
• Expect
– 4-6 pale or colorless voids/day by day 4
– 3-4 loose, yellow, curd-like stools after most
feedings by day 4, continuing through the first
• Constipation is unusual in the first month—may
indicate insufficient milk intake.
• Infrequent stools are common after the first
month in the healthy breastfed infant.

Infant Assessment
Breastfeeding evaluation

Proper positioning at the breast
Proper latch and lip closure
Sufficient areola in infant’s mouth
Tongue extends over lower gums
Adequate jaw excursion with suckling
Effective swallowing motion
Coordination of suck-swallow-breathe

AAP Policy Statement
Recommended Breastfeeding
• Formal evaluation of breastfeeding

during the first 24–48 hours and again at
3–5 days of age
• Assess
– Infant weight
– General health
– Breastfeeding
– Jaundice
– Hydration
– Elimination pattern

AAP Policy Statement
Recommended Breastfeeding
• Do not give water, juice, or solids in the

first 6 months.
Initiate iron supplements only if indicated
clinically in the first 6 months.
Include iron-rich foods or supplements after
6 months of age.
Supplement with 400 IU vitamin D daily.
Provide fluoride after 6 months if household
water supply is deficient (< 0.3 ppm).
Avoid cow’s milk before 12 months.

Maternal Trouble Signs

• Nipple pain
• Nipple trauma

Photo © Joan Meek, MD, FAAP

Neonatal Hypoglycemia
• No need to monitor asymptomatic low risk
infants for hypoglycemia
• Routine monitoring of healthy term infants
may harm the mother-infant breastfeeding
• Early, exclusive breastfeeding meets the
nutritional needs of healthy term infants
and will maintain adequate glucose levels
AAP; World Health Organization
Academy of Breastfeeding Medicine

Neonatal Hypoglycemia
• Routine supplementation of healthy, term
infants with water, glucose water or
formula is unnecessary and may interfere
with establishing normal breastfeeding
and normal metabolic compensatory
• Healthy term infants should initiate
breastfeeding with 30-60 minutes of life
and continue feeding on demand.
AAP; World Health Organization;
Academy of Breastfeeding Medicine

Maternal Trouble Signs
• Engorgement

Photo © Joan Younger Meek, MD, FAAP

Jaundice and Breastfeeding
• Infants <38 weeks gestational age and breastfed
are at higher risk
• Systematic assessment of all infants before
discharge for the risk of severe hyperbilirubinemia
is warranted
• Provide parents with written and verbal
information about newborn jaundice
• Provide appropriate follow-up based on the time of
discharge and the risk assessment

AAP Subcommittee on Hyperbilirubinemia Clinical
Practice Guideline: Pediatrics 2004; 114: 297-316.

Management of
• Promote and support successful breastfeeding
• Perform a systematic assessment before
discharge for the risk of severe
• Provide early and focused follow-up based on
the risk assessment

AAP Subcommittee on Hyperbilirubinemia Clinical
Practice Guideline: Pediatrics 2004; 114: 297-316.

Primary Prevention of Jaundice
• Recommendation 1.0
– Clinicians should advise mothers to nurse their
infants at least 8 to 12 times per day for the first
several days.

• Recommendation 1.1
– The AAP recommends against routine
supplementation of nondehydrated breastfed
infants with water or dextrose water.
• “Supplementation with water or glucose
water will not prevent hyperbilirubinemia or
decrease total serum bilirubin levels.”
AAP Subcommittee on Hyperbilirubinemia Clinical
Practice Guideline: Pediatrics 2004; 114: 297-316.

Risk Assessment for Jaundice
before Discharge
• Recommendation 5.1
– Before discharge assess risk for severe
• Every nursery should have formal protocol
• Essential for infants discharged before 72 hrs
• Best method: measure serum or
transcutaneous bilirubin in every infant
before discharge
• Plot on Bhutani curve (perform at same time
as metabolic blood sampling)
AAP Subcommittee on Hyperbilirubinemia Clinical
Practice Guideline: Pediatrics 2004; 114: 297-316.

AAP Clinical Practice Guideline
• Management of Hyperbilirubinemia in the
Newborn Infant 35 or More Weeks of

Nomogram for designation of risk in 2840 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 or more based on the hour-specific serum bilirubin

AAP Subcommittee on Hyperbilirubinemia. Pediatrics.

Management of Breastfeeding
Increase caloric intake
Increase breastfeeding
frequency to 10–12
Increase duration of
Improve latch and
Provide supplements
only when medically

Enhances milk
and transfer
Increased stool
Lower serum

Breast Milk Jaundice
• Definition
– Begins after day of life 5–7
– Increased bilirubin reabsorption from
– Lasts several weeks to months

Breast Milk Jaundice
• Management

– Avoid interruption of breastfeeding in
healthy term babies.
– No routine indication for water or
formula supplementation.
– If bilirubin >20 mg/dL, consider
– Rule out other causes of prolonged

Nursing Supplementation

Illustration by Tony LeTourneau

Milk Expression
• Wash hands before manual or hand
• Use a good-quality electric pump for
regular expression.
• Milk storage
– Chill as soon as possible.
– Refrigerate milk for up to 4 days.
– Freeze for longer storage.

Milk Expression

Photo © Jane Morton, MD, FAAP

Photo © Kay Hoover, MEd, IBCLC

Return to the Workplace or
• Continued breastfeeding is feasible and
desirable for mother and infant.
• Prepare ahead by discussing with the
employer or school personnel.
• Delay introduction of bottles until milk
supply well established at 3–4 weeks.

Employed Mother
Workplace support
• Breaks for
• Private, clean
place to pump
• Refrigerator
or cooler with
ice packs to
store and transport

Illustration by Tony LeTourneau

Adolescents and Breastfeeding
• Highly recommended for adolescent mothers
• Prenatal education and postpartum support
are essential
• Arrange with school personnel to express
milk at school or use on-site child care
program, if available
• Maintain healthy diet with adequate calories,
1,300 mg calcium per day, 15 mg iron, and a
daily multivitamin

• Breastfeeding is the preferred feeding for
almost all infants.
• Skin-to-skin contact should be initiated
immediately after delivery.
• Supplementation is rarely indicated and
interferes with successful lactation.
• Good breastfeeding technique can help to
minimize problems.
• Close follow-up in the early days and
weeks is essential for breastfeeding