Breast Feeding

Benefits

Decreased incidence of infectious disease and allergy
Complete nutrition for first six months and recommended continuation for first year of life (AAP); WHO and UNICEF recommend continuation for the first two years or more.
Improved child spacing
Psychosocial benefits

Requirements

Supportive OB and pediatric practices (knowledge; expectations)
Avoid promotion of infant formula use
Supportive family; involve fathers and grandparents

Immune system of human milk

Antimicrobial factors

Anti-inflammatory agents

Acetylhydrolase (enzyme which degrades platelet activating factor) may decrease the incidence of NEC
Epithelial growth factor: May help with rapid recovery from diarrheal illnesses
Decreased incidence of atopic disorders (especially important if strong family history)

Immunomodulating factors

Cytokines (activate T cells, enhance IgA production, etc.), alpha-tocopherol, betacasomorphins, etc.
Decreased risk for breast fed infants for Crohn Disease, insulin-dependent diabetes, lymphoma

Nutrients

All of the necessary nutrients and water are provided in human milk for the first six months, with the exception of

Vitamin K: Give 0.5-1 mg vitamin K at birth. When an appropriate oral form becomes available, the AAP recommends 0.2 mg at birth, 0.2 mg at 1-2 weeks and 2 mg at 4 weeks.
Vitamin D:200-300 IU/d if infant is not exposed to sunlight for at least 30 minutes per week wearing only a diaper or 2 hours a week fully clothed with no hat; or if mother has inadequate sources of vitamin D.
Fluoride: 0.25 mg/day after six months of age in areas where the water supply is not fluoridated adequately (i.e., if less than 0.3 ppm fluoride).
Vitamin B12: 0.3-0.5 mcg/day for infants of strict vegetarian mothers who take no B12 supplements.

Solids

Solids do not lengthen night sleep periods
When other foods or liquids are introduced, the bioavailability of iron in human milk is reduced

Human vs Cow

Human milk...

has less protein
has a higher whey:casein ratio
is digested much faster
has greater iron bioavailability (compare: 50% bioavailability in human milk vs 7% in formulas, 4% in cereals)

Tips

If possible, begin breastfeeding soon after birth when infant is alert in the first 1-2 hours after delivery; maximize skin-to-skin contact and minimize interventions
Expect that the first two weeks can be difficult
No bottles before breastfeeding is well established (usually 4-6 weeks); can avoid bottles completely if wean to cup
Night feedings are necessary for adequte nutrition and to promote milk production -- but no need to waken baby fully so feedings do not need to take as long at night
Feed frequently (e.g., q 2 hours) but not for prolonged periods (e.g., 10-15 minutes each breast; or completely on one breast with alternating breasts each feeding (advantage of getting more hindmilk which has higher fat content and lower lactose content than foremilk)
Mother needs to drink plenty of fluids (not necessarily high caloric content)
Mother needs to rest between feedings and to avoid excessive fatigue
Offer help of lactation consultant
Encourage breast feeding even after mother returns to work -- but she needs support

Common Problems

Poor attachment: try different positions; observe a feeding (particularly first feeding). Infant with rooting opens mouth widely; infant gets areola as well as nipple in mouth; mother should feel pain only for the first minute if at all).
Infrequent feedings -- need to try every two hours
Fatigued, anxious mother -- mobilize help
Incorrect expectations (i.e., regarding frequency of feedings, sleep patterns, interpretting crying)
Nonsupportive (though perhaps well intentioned) family members
Sore nipples and engorgement - feed frequently, start on less sore side, try different positions, leave breasts open to air, warm shower, manual expression until less tender, persevere! Treat candida if suspected (nystatin cream applied after feedings for a minimum of 14 days)
Perceived inadequate milk supply -- need reassurance that though colostrum is less abundant, it is very nutritious. Breastfeed frequently. Milk "comes in" about 72 hours after delivery. Growth spurt lasts about 2-7 days and requires increased feedings (more frequent)
Poor let-down or milk ejection reflex (suckling or other stimuli elicit oxytocin release from the pituitary. Oxytoxin causes mammary myoepithelial cells to contract, forcing milk from the alveoli into the ducts). Mother needs to relax.

Avoid

Breast shells ("milk cups") are controversial -- used to help inverted nipple become more protuberant
Nipple shields (artificial nipped placed over mother's nipple) - reduce milk supply and may be difficult to stop using once baby is used to the artificial nipple
Mixed messages (e.g., formula samples)
Maternal medications that preclude breast feeding
Supplementation unless really indicated

Adapted from Global Criteria for the WHO/UNICEF Baby Friendly Hospital Initiative
Birthweight < 1500 g or gestation less than 32 weeks Small for gestational age with potentially severe hypoglycemia Severely ill mother (e.g., psychosis, eclampsia, shock) Inborn error of metabolism (e.g., galatosemia, PKU, MSUD) Acute water loss Maternal medications not compatible with breastfeeding

Other indications to consider supplmentation after evaluating breast feeding
Hypoglycemic (one-touch blood glucose less than 40) after BF Significant dehydration (approaching 10%) Delayed bowel movements, persisting dark stools at day 4-5 Hyperbilirubinemia related to poor po intake Delayed lactogenesis (glandular insufficiency, retained placenta, Sheehan syndrome)

Monitor

Weight (lose less than 10%, then regain birth weight by age two weeks; gaining 15-30 gms daily once milk is in)
Urine output (one to two wet diapers for the first two days of life, then at least 4-6 times per 24 hours after the third day of life)
3-4 bowel movements every 24 hours -- yellow after the third day of life
Pink urate crystals disappear after the third day of life
Intermittent episodes of rhythmic sucking with audible swallows
Infant has alert period when he/she feeds; then content, sleepy periods
Maternal psychosocial conditioning

Contraindications to breastfeeding

Maternal infections

Human Immunodeficiency Virus (HIV)
Human T-lymphotrophic virus I and III (HTLV-I, II)
Active Tuberculosis
Active Herpes Simplex (HSV)

Very low birth weight infants (less than 1500 grams)
Maternal medications if contraindicated in lactation

Consider alternatives to treatment; consider timing of doses; temporarily expresses and discard milk if necessary (pump and dump)

Adapted from a compilation by Philip Anderson, PharmD, Univ California, San Diego.
Contraindicated: Amantidine, amiodarone, antineoplastic agents, bromide, chloramphenicol, cocaine, dipyrone, gold salts, indandione anticoagulants (eg, phenindione), iodide (including topical forms), metamizol, metronidazole, radiopharmaceuticals, salicylates (large doses) Potentially Hazardous (use with caution, avoid if possible): Acebutolol, alcohol, antihistamine/decongestant combinations, atenolol, benzodiazepines (lorazepam, oxazepam preferred), chlothalidone, clindamycin, clonidine, contraceptives with estrogen, doxepin, ergotamine, ethosuximide, fluorescein, fluoxetine, lindane, lithium, methimazole, nadolol, narcotics, nicotine/smoking, nitrofurantoin, phenobarbitol (anticonvulsant dose), piroxicam, quinolone antibacterials (norfloxacin preferred), reserpine, sotalol, sulfonamides (long acting), thiazide diuretics (long acting or high doses) Probably Safe in Usual Doses (but insufficient data to say no adverse effect in BF; effects probably mild or infrequent; potential for allergic or idiosyncratic cannot be ruled out): ACE inhibitors, aminoglycosides, anticholinergics, anticonvulsants (except ethosuximide and phenobarbitol), antihistamines, antitubercular agents, azathioprine, barbituates (except phenobarbitol), butyrophenones (eg, haloperidol), decongestants (oral), ergonovine (short courses), fluconazole, histamine H2-receptor antagonists (famotidine preferred), metoclopramide (10-14 days), nonsteroidal anti-inflammatory agents (ibuprofen preferred), oxazepam, phenothiazines, propylthiouracil, quinidine, salicylates (occasional use), spironolactone, sulfisoxazole, terfenadine, tetracyclines (2 weeks or less), thiazide diuretics (short acting, low doses), tricyclic antidepresseants (nortriptyline, desipramine preferred; avoid doxepin), verapamil Safe in Usual Doses: Potential for rare allergic or idiosyncratic responses, but usual doses pose little first to the infant: acetaminophen, antacids, caffeine, cephalosporins, clotrimazole, contraceptive (progestin only), corticosteroids, decongestant nasal sprays, digoxin, erythromycin, flubiprofen, heparin, inhalers (bronchodilators, corticosteroids), insulin, labetalol, laxatives (bulk forming/stool softening such as psyllium and docusate), lidocaine, magnesium sulfate, methyldopa, methylergonovine (short courses), metoprolol, miconazole, penicillins, propanolol, theophylline, thyroid replacement, vaccines, vancomycin, warfarin

Reviews

Slusser, W. 1997. "Breastfeeding Update 1: Immunology, Nutrition and Advocacy", Pediatrics in Review 18(4).
Powers, N. 1997. "Breastfeeding Update 2:Clinical Lactation Management", Pediatrics in Review 18(5).
Lawrence, R. 1994. Breastfeeding: A guide for the medical profession, 4th edition, St. Louis, MO, Mosby Year Book, Inc.
Knoben, JE, Anderson, PO. 1993. Drug use during breastfeeding. Clinical Pharmacology 10:596-624.

Acknowlegment

This page adapted from a clinic seminar written by Dr. Susan DeMuth, Arlington Hospital, VA.

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Last modification: January 10, 2000