BREAST-FEEDING

BREAST-FEEDING - Kathy Mariani, MD
BASICS
DESCRIPTION
Breast-feeding is the natural process of feeding an infant human milk. Nursing an infant directly at the breast is usually done, but in many circumstances the milk may be expressed by hand or a pump to be fed to the infant at another time.
• Maternal benefits include
- Easier postpartum weight loss
- Decreased postpartum bleeding due to oxytocin release
- Increased bonding
- Convenience of feeding
- Delayed postpartum fertility
- Increased sense of well being (endorphin response)
- More rapid and complete reversion of mother's pelvis and uterus to prepuerperal state
- Decreased risk of breast cancer
- Possible decreased risk of osteoporosis
- Economical
• Infant benefits include
- Maternal antibody protection
- Decreased incidence of otitis media
- Decreased upper respiratory infection and sepsis
- Fewer respiratory and gastrointestinal infections
- Decreased incidence of obesity
 Ideal foodeasily digestible, nutrients well absorbed, less constipation
- Increased attachment between mother and baby
- Decreased incidence of allergies in childhood
• Contraindications
- HIV infection
- Active tuberculosis
- Hepatitis is not a contraindication.
- Substances of abuse will pass into human milk; see reference on drugs in lactation
• Physiology
- Stimulation of areola causes secretion of oxytocin.
- Oxytocin is responsible for let-down reflex when milk is ejected from cells into milk ducts.
- Sucking stimulates secretion of prolactin, which triggers milk production. Thus milk is made in response to nursing and increases supply.
• Technique
- Initiate immediately after birth
- Get in comfortable position, usually sitting or reclining with baby's head in crook of mother's arm (side-lying position often useful following cesarean-section delivery)
- Bring baby to mother to decrease stress on back.
- Baby's belly and mother's belly should face each other or touch (belly to belly).
- Initiate the rooting reflex by tickling baby's lips with nipple or finger. As baby's mouth opens wide, mother guides her nipple to back of her baby's mouth while pulling the baby closer. This will ensure that the baby's gums are sucking on the areola, not the nipple.
- Feed every 2-4 hours, 20 minutes per side
• System(s) Affected: Endocrine/Metabolic; Skin/Exocrine
EPIDEMIOLOGY
• Predominant age: 16-45 years
• Predominant sex: Female only
Incidence
According to Healthy People 2010, in 2002, 70% of new mothers initiated breast-feeding, and 29% were doing at least some breast-feeding at 6 months of age. The national goal is 75-50%, respectively

TREATMENT
STABILIZATION
Outpatient
GENERAL MEASURES
See "Patient Teaching."
Diet
• Adequate calorie and protein intake while nursing.
• Drinking cow's milk is not necessary.
• Drink plenty of fluids (8-12 oz. glasses/day).
• Continue prenatal vitamins.
• Fluoride supplement unnecessary
• New National Academy of Science guidelines recommend that children get at least 200 IU/d of vitamin D beginning in the newborn period to prevent rickets. For exclusively breast-fed babies, this will require taking a vitamin supplement such as PolyViSol or Vi-Daylin vitamin drops, 1/2 cc/d.
Activity
No restrictions
FOLLOW-UP
PROGNOSIS
Healthy baby
COMPLICATIONS
• Plugged ducts (mother is well except for) sore lump in 1 or both breasts without fever
- Use moist hot packs on lump prior to and during nursing; more frequent nursing on affected side; ensure good technique
• Mastitis
- Sore lump in 1 or both breasts plus fever and/or redness on skin overlying lump
- Use moist hot packs on lump prior to and during nursing; more frequent nursing on affected side; antibiotics covering for Staphylococcus aureus (the most common organism) for at least 7 days
- Patients can be quite ill with mastitis.
- Other possible sources of fever should be ruled outendometritis, pyelonephritis in particular. Mother should get increased rest, use acetaminophen (Tylenol) as necessary. Fever should resolve within 48 hours or consider changing antibiotics. Lump should also resolve. If it continues, an abscess may be present, requiring surgical drainage.
• Milk supply inadequate
- Check weight gain
- Review signs of adequate supply; review technique, frequency, and duration of nursing.
- Check to see if mother has been supplementing, thereby decreasing her own milk production.
• Sore nipples
- Check technique
- Baby should be taken off the breast by breaking the suction with a finger in the mouth.
- Air-dry nipples after each nursing; no breast creams and do not wash nipples with soap and water; check for signs of thrush in baby and mother
• Engorgement
- Usually develops after milk 1st comes in (day 3 or 4)
- Signs are warm, hard, sore breasts.
- To resolve, offer baby more frequent nursing; may have to hand express a little milk to soften areola enough to let baby latch on; nurse long enough to empty breasts; generally resolves within a day or 2.
• Flat or inverted nipples
- When stimulated, inverted nipples will retract inward, flat nipples remain flat; should check for this on initial prenatal physical
- Nipple shells, a doughnut-shaped insert, can be worn inside the bra during the last month of pregnancy to gently force the nipple through the center opening of the shell.
- Babies can nurse successfully even if the shell does not correct the problem before birth. A lactation consultant or La Leche League member may be a good resource in this situation. Another source: J Human Lactation. 1993;9:27-29.
PATIENT MONITORING
See mother and baby within a few days of hospital discharge if she is a 1st-time breast-feeder.
REFERENCES
1. Berlin CM, Briggs GG. Drugs and chemicals in human milk. Semin Fetal Neonatal Med. 2005;10(2):149-159.
2. Meek J, ed. New Mother's Guide to Breastfeeding. American Academy of Pediatrics. 2002
3. Moreland J, Coombs J. Promoting and supporting breast-feeding. Amer Fam Physician. 2000;61:2093-2100, 2103-2104.
4. Sinusas K, Gagliardi A. Initial management of breast-feeding. Amer Fam Physician. 2001;15;64:981-988.