1. Human milk is recognized by the American Academy of Pediatrics as the optimal feeding for all infants, although supplementation with specially formulated human milk fortifiers is required to meet the nutritional needs of premature infants. Recommendations include exclusive breastfeeding for the first 6 postnatal months and continuation of breastfeeding for at least the first year. In the United States today, only 68% of new mothers even attempt nursing, and at least 50% quickly abandon it with only 30% nursing at 6 months. The goal of Healthy People 2010 is to increase the proportion of women who initiate breastfeeding and continue for six months to 75 and 50 percent, respectively. Exclusive breastfeeding means no supplementation of any type including formula, water, juice or foods.Some examples of the benefits of breastfeeding include:
Research has demonstrated decreases in the incidence of bacterial meningitis, bacteremia, respiratory tract infection (RSV), NEC, otitis media, urinary tract infection, and late onset sepsis in the preterm infant. These benefits are in part due to high concentrations of secretory IgA, other IG, lysozyme, lactoferrin, cytokines and leukocytes in human milk.
Evidence suggests that breastfeeding contributes to the prevention of diabetes, celiac disease, childhood cancer, SIDS and obesity. The longer the duration of breastfeeding the greater is its protective effect.
Neurodevelopmental benefits have been suggested in the areas of cognitive development and improved visual function due to docosahexanoic and arachidonic acid.
Benefits to mother include decreased postpartum bleeding and more rapid uterine involution, decrease risk of ovarian and breast cancer, earlier pregnancy related weight loss and possible decrease risk of osteoporosis. Most importantly, breastfeeding promotes maternal/infant bonding.
Finally economic and societal benefits include the cost savings due to reduced formula consumption, combined with the reduction in office, emergency room and hospital visits. In addition there is a potential for cost savings due to the associated reduction in chronic diseases.
There are few absolute contraindications to breastfeeding and they include:
infants with galactosemia
mothers with untreated tuberculosis, until mother and infant are both on appropriate therapy
mothers with HTLV -1, HTLV-2
mothers with HIV in developed countries, debatable in developing
mothers with herpetic lesions on breasts
some medications including – radioactive isotopes, antimetabolites, chemotherapy as well as certain individual drugs such as lithium, cyclosporine and iodides.
caution is raised with infants with G6PD deficiency
Of note, Hepatitis B, C and CMV are not absolute contraindications.
Both the Canadian and US Preventative Health task forces have suggested that to improve the rates of breastfeeding, there needs to be antepartum programs combining education with practical skills training, and postpartum support. Breastfeeding rates are higher in populations where mothers are older, had close relatives who breastfed or had successfully breastfed a previous infant.
The risks of breastfeeding are related to excessive weight loss (>7%) which lead to the complications of dehydration, hypernatremia, and/or jaundice.
The Baby Friendly Hospital Initiative was launched by the WHO and UN Children’s Fund in 1991 to improve breastfeeding rates. A hospital can be designated Baby Friendly if they comply with the following 10 steps.
Written policy on breastfeeding communicated to staff.
Train all staff in the skills needed to implement policy.
Help mother start breastfeeding within one hour of delivery.
Show mothers how to breastfeed and maintain lactation even if they are separated from their infants.
Give newborns human milk only unless medically indicated. Hospital must pay fair market price for formula and feeding supplies.
Allow mother and infant to remain together at all times.
Encourage breastfeeding on demand.
Provide no pacifier or artifical teats to nursing infants.
Foster the establishment of breastfeeding support groups and refer mothers to them.
Inform all pregnant women of the benefits and management of breastfeeding.
2. Healthy infants should be in direct skin to skin contact with their mothers immediately after birth (within the first hour). Infants are frequently awake for the first 1-2 hours and then drowsy for the next 48 hours. Mother and infants should room in during their postpartum stay in the hospital with no supplementation. Infants should nurse on demand, at least every 3-4 hours in the initial 48 hours as milk comes in. Successful signs of early nursing are based on observation of breastfeeding technique, frequency of feeds, presence of colostrum and then transitional milk, signs of elimination, and lack of excessive weight loss. Trained personnel in the hospital such as nurses and lactation consultants should observe the position, latching on and milk transfer during breastfeeding. Different nursing positions should be reviewed. Successful latching on includes initial rooting reflex, followed by mouth over nipple and as much of areola as feasible, chin and nose in close proximity to breast, full cheeks, lower lip turned outward against the breast with tongue over the lower dental ridge and in contact with the breast. The initial milk secreted is colostrum which has higher protein, fat soluble vitamins, minerals and antibodies than in transitional and mature milk. The more frequent the nursing the greater the milk supply. Stools initially are meconium, 1-2 per day, followed by transitional stools by day 2 - 3. At least 1-2 wet diapers per day are to be expected in the first 48 hours, possibly with pink urate crystals. Infants discharged at 48 hours should be seen by day of life 3-5.
3. Breastfed infants feed on demand with reversed sleep wake cycles often causing the infant to appear fussy at night. Beware the very “good” baby who cries little and has more than one interval of sleep for 4 hours or more in a day. These infants need to be awakened to feed and need their weight monitored.
The 3 – 5 day visit should include observation of breastfeeding, infant swallowing, weight and an exam for hydration and jaundice. Jaundice at this age is either due to breastfeeding (dehydration) or breastmilk. Both are caused by increased enterohepatic circulation. Breastmilk jaundice begins after 3-5 days and peaks by 2 weeks of age. It is felt to be related to an unidentified component of human milk that enhances intestinal absorption of bilirubin. Inquire about the color of infant stools(not meconium) and any maternal history of let down reflex (milk comes in around 72 hours), breast problems including painful feedings and engorgement. Markers of successful breastfeeding include less than a 7% weight loss, lactation established in mother by 2 – 4 days and 8 – 12 breastfeeding events per day. Mothers learn to recognize the behavior changes in their infants accompanying hunger including increased alertness, movement of hands towards mouth, sucking on fist, rooting, fussiness and finally crying. Supplementation is considered if the infant has lost more than 7% of his/her birth weight, exhibits signs of dehydration, stool output less than 3 per day and /or maternal milk supply is limited. Signs of a disorganized suck include early release of the breast, spilling of milk from the mouth during feeding, coughing and gagging.
A mother can be reassured he infant is receiving enough breastmilk at home based on the suck and swallow, lack of constant fussiness after feeds, as well as elimination patterns. Infant elimination patterns include 3-5 urines and 3-4 stools per day by 3-5 days of life. 3-6 stools and 4-6 voids are expected by 5 – 7 days of age. Duration of feeds initially is 15 to 20 minutes per side and by age one month the duration is 8 – 10 minutes. Thorough emptying of the breast is essential for the delivery of the hind milk, which has high fat content and promotes rapid infant growth, as compared to short feedings of mostly foremilk.
The next visit is at age 2 – 3 weeks. Birthweight should be regained by at least 2 weeks of age. Feeding may decline to 8 times per day as the infant matures.
4. This mother may have mastitis and should contact her provider for further medical management. While on antibiotics for mastitis, mothers should continue to nurse. This raises the issue of common maternal complications which impact the success of breastfeeding.
Complications include:
a. Engorgement – breast swelling, due early in nursing to edema and accumulated milk, late in nursing, due to accumulated milk alone (milk stasis). Management includes frequent nursing, massage and cool compresses. Warm showers help late engorgement.
b. Sore nipples – often due to poor latch on. Management includes reviewing latch on, treatment of superficial infection, commonly due either to Staph aureus or Candida.
c. Plugged duct – milk stasis resulting in a palpable lump with tenderness. No systemic symptoms. Treated with massage, warms soaks and directed nursing.
d. Mastitis – hard, red, tender, swollen area of breast associated with fever and flu like symptoms. Management is continued nursing, antibiotics (Diclox or Keflex), antiinflammatories, and warm soaks.
5. The increased feeding is most likely due to a growth spurt, which occurs periodically in nursing infants, lasting 2 – 7 days. The provider needs to assess weight, hydration, ask the mother if her breasts are completely emptying and then reassure the mother. Often, nursing frequency needs to increase for a few days in order to increase supply for the growth spurt.
Plans around returning to work are often stressful for new mothers. Nipple confusion is lessened if bottle introduction is delayed until age 4 – 6 weeks. Discussion should occur about plans for pumping while at work or weaning. Freshly expressed breastmilk can be used safely for up to 8 hours at room temperature without bacterial contamination. Milk can be stored up to 5 days without bacterial contamination in the refrigerator and must be shaken before use. Milk can be kept for 3 months in a self defrosting freezer. Frozen milk should be thawed in the refrigerator, used in 24 hours, not put in a microwave.
From CDC Web Site
TABLE 8-5. Human Milk Storage for Healthy Infants (4)
| LOCATION | TEMPERATURE | DURATION | COMMENTS |
| Countertop, table | Room temperature (up to 77° F or 25° C) | 6-8 hours | Containers should be covered and kept as cool as possible; covering the container with a cool towel may keep milk cooler. |
| Insulated cooler bag | 5-39° F or -15-4° C | 24 hours | Keep ice packs in contact with milk containers at all times, limit opening cooler bag. |
| Refrigerator | 39° F or 4° C | 5 days | Store milk in the back of the main body of the refrigerator. |
| Freezer—Compartment of refrigerator Freezer — Refrigerator/freezer with separate doors Freezer — Chest or upright manual defrost deep freezer | 5° F or -15° C 0° F or -18° C -4° F or -20° C | 2 weeks 3-6 months 6-12 months | Store milk toward the back of the freezer, where temperature is most constant. Milk stored for longer durations in the ranges listed is safe, but some of the lipids in the milk undergo degradation, resulting in lower quality. |
Finally weaning is a personal choice in breastfeeding. When a mother is ready and depending on the infant’s age, it is easiest to eliminate the midday feedings first and wean to a cup.
Supplementation: Minerals and Vitamins
a. Vitamin K – phytonadione, 1mg, is given at birth to prevent hemorrhagic disease of the newborn.
b. Vitamin D – content is low, Vitamin D 200IU po is begun by age 2 months in breastfed infants to prevent rickets, continued until daily consumption of Vitamin D containing formula is 500ml (more than 16 oz per day).
c. Vitamin B12 – mothers on vegan diet may be deficient, mother should receive B12 supplementaion and eat fortified foods ( ie. Cereals).
d. Iron – by age 6 months iron rich foods, such a cereal, should be introduced. Iron content is lower in breastmilk but more bioavailable due lactose and Vitamin C which enhances absorption.
e. Flouride – after age 6 months consider supplementation based on water supply
f. Vitamin A and E – good levels in breastmilk.
g. Calcium and Phosphorous – lower concentration, enhanced absorption, no supplementation
6. The summary of how human milk, cow’s milk and different types of formulas compare are reviewed in Table 1 of the 2006 Pediatrics in Review Reference.
Notable points include:
a. Protein – 70% protein in human milk is whey (18% in cow’s milk), and 30% casein. Whey is more easily digested and the major human whey protein is lactalbumin. Lactoferrin, lysosyme and secretory IgA are specific human whey proteins that improve host defenses.
b. Lipid – 50% of calories, mostly triglycerides, provides essential fatty acids, including docosahexanoic acid and arachidonic acid associated with higher visual acuity and cognitive ability.
c. Carbohydrate – lactose, enhances Ca absorption, metabolized to glucose and galactose.
d. Nucleotides – non protein nitrogen, important for normal development, maturation and repair of the GI tract.
Premature infants – Premature infants can receive breastmilk which may help reduce their rates of NEC and infection. Mother/ infant skin to skin contact is encouraged as soon as possible. Expressed breastmilk may be gavaged. Human milk can be fortified with commercial fortifiers which supplement calcium, phosphorous, protein, iron and vitamins.
