Breastfeeding and the Use of Human Milk
This policy statement on breastfeeding replaces the previous policy statement of the American Academy of Pediatrics, reflecting the considerable advances that have occurred in recent years in the scientific knowledge of the benefits of breastfeeding, in the mechanisms underlying these benefits, and in the practice of breastfeeding. This document summarizes the benefits of breastfeeding to the infant, the mother, and the nation, and sets forth principles to guide the pediatrician and other health care providers in the initiation and maintenance of breastfeeding. The policy statement also delineates the various ways in which pediatricians can promote, protect, and support breastfeeding, not only in their individual practices but also in the hospital, medical school, community, and nation.
HISTORY AND INTRODUCTION
From its inception, the American Academy of Pediatrics (AAP) has been a staunch advocate of breastfeeding as the optimal form of nutrition for infants. One of the earliest AAP publications was a 1948 manual, Standards and Recommendations for the Hospital Care of Newborn Infants. This manual included a recommendation to make every effort to have every mother nurse her full-term infant. A major concern of the AAP has been the development of guidelines for proper nutrition for infants and children. The activities, statements, and recommendations of the AAP have continuously promoted breastfeeding of infants as the foundation of good feeding practices.
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THE NEED
Extensive research, especially in recent years, documents diverse and compelling advantages to infants, mothers, families, and society from breastfeeding and the use of human milk for infant feeding. These include health, nutritional, immunologic, developmental, psychological, social, economic, and environmental benefits.
Human milk is uniquely superior for infant feeding and is species-specific; all substitute feeding options differ markedly from it. The breastfed infant is the reference or normative model against which all alternative feeding methods must be measured with regard to growth, health, development, and all other short- and long-term outcomes.
Epidemiologic research shows that human milk and breastfeeding of infants provide advantages with regard to general health, growth, and development, while significantly decreasing risk for a large number of acute and chronic diseases. Research in the United States, Canada, Europe, and other developed countries, among predominantly middle-class populations, provides strong evidence that human milk feeding decreases the incidence and/or severity of diarrhea,1-5 lower respiratory infection,6-9 otitis media,3,10-14bacteremia,15,16 bacterial meningitis,15,17botulism,18 urinary tract infection,19 and necrotizing enterocolitis.20,21 There are a number of studies that show a possible protective effect of human milk feeding against sudden infant death syndrome,22-24insulin-dependent diabetes mellitus,25-27 Crohn’s disease,28,29 ulcerative colitis,29lymphoma,30,31 allergic diseases,32-34 and other chronic digestive diseases.35-37 Breastfeeding has also been related to possible enhancement of cognitive development.38,39
There are also a number of studies that indicate possible health benefits for mothers. It has long been acknowledged that breastfeeding increases levels of oxytocin, resulting in less postpartum bleeding and more rapid uterine involution.40 Lactational amenorrhea causes less menstrual blood loss over the months after delivery. Recent research demonstrates that lactating women have an earlier return to prepregnant weight,41 delayed resumption of ovulation with increased child spacing,42-44 improved bone remineralization postpartum45 with reduction in hip fractures in the postmenopausal period,46 and reduced risk of ovarian cancer47 and premenopausal breast cancer.48
In addition to individual health benefits, breastfeeding provides significant social and economic benefits to the nation, including reduced health care costs and reduced employee absenteeism for care attributable to child illness. The significantly lower incidence of illness in the breastfed infant allows the parents more time for attention to siblings and other family duties and reduces parental absence from work and lost income. The direct economic benefits to the family are also significant. It has been estimated that the 1993 cost of purchasing infant formula for the first year after birth was $855. During the first 6 weeks of lactation, maternal caloric intake is no greater for the breastfeeding mother than for the nonlactating mother.49,50 After that period, food and fluid intakes are greater, but the cost of this increased caloric intake is about half the cost of purchasing formula. Thus, a saving of >$400 per child for food purchases can be expected during the first year.51,52
Despite the demonstrated benefits of breastfeeding, there are some situations in which breastfeeding is not in the best interest of the infant. These include the infant with galactosemia,53,54the infant whose mother uses illegal drugs,55 the infant whose mother has untreated active tuberculosis, and the infant in the United States whose mother has been infected with the human immunodeficiency virus.56,57 In countries with populations at increased risk for other infectious diseases and nutritional deficiencies resulting in infant death, the mortality risks associated with not breastfeeding may outweigh the possible risks of acquiring human immunodeficiency virus infection.58 Although most prescribed and over-the-counter medications are safe for the breastfed infant, there are a few medications that mothers may need to take that may make it necessary to interrupt breastfeeding temporarily. These include radioactive isotopes, antimetabolites, cancer chemotherapy agents, and a small number of other medications. Excellent books and tables of drugs that are safe or contraindicated in breastfeeding are available to the physician for reference, including a publication from the AAP.55
THE PROBLEM
Increasing the rates of breastfeeding initiation and duration is a national health objective and one of the goals of Healthy People 2000. The target is to “increase to at least 75% the proportion of mothers who breastfeed their babies in the early postpartum period and to at least 50% the proportion who continue breastfeeding until their babies are 5 to 6 months old.”59 Although breastfeeding rates have increased slightly since 1990, the percentage of women currently electing to breastfeed their babies is still lower than levels reported in the mid-1980s and is far below the Healthy People 2000 goal. In 1995, 59.4% of women in the United States were breastfeeding either exclusively or in combination with formula feeding at the time of hospital discharge; only 21.6% of mothers were nursing at 6 months, and many of these were supplementing with formula.60
The highest rates of breastfeeding are observed among higher-income, college-educated women >30 years of age living in the Mountain and Pacific regions of the United States.60 Obstacles to the initiation and continuation of breastfeeding include physician apathy and misinformation,61-63 insufficient prenatal breastfeeding education,64 disruptive hospital policies,65 inappropriate interruption of breastfeeding,62 early hospital discharge in some populations,66 lack of timely routine follow-up care and postpartum home health visits,67 maternal employment68,69 (especially in the absence of workplace facilities and support for breastfeeding),70 lack of broad societal support,71 media portrayal of bottle-feeding as normative,72 and commercial promotion of infant formula through distribution of hospital discharge packs, coupons for free or discounted formula, and television and general magazine advertising.73,74
The AAP identifies breastfeeding as the ideal method of feeding and nurturing infants and recognizes breastfeeding as primary in achieving optimal infant and child health, growth, and development. The AAP emphasizes the essential role of the pediatrician in promoting, protecting, and supporting breastfeeding and recommends the following breastfeeding policies.
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RECOMMENDED BREASTFEEDING PRACTICES
Human milk is the preferred feeding for all infants, including premature and sick newborns, with rare exceptions.75-77 The ultimate decision on feeding of the infant is the mother’s. Pediatricians should provide parents with complete, current information on the benefits and methods of breastfeeding to ensure that the feeding decision is a fully informed one. When direct breastfeeding is not possible, expressed human milk, fortified wheecessary for the premature infant, should be provided.78,79 Before advising against breastfeeding or recommending premature weaning, the practitioner should weigh thoughtfully the benefits of breastfeeding against the risks of not receiving human milk.
Breastfeeding should begin as soon as possible after birth, usually within the first hour.80-82 Except under special circumstances, the newborn infant should remain with the mother throughout the recovery period.80,83,84 Procedures that may interfere with breastfeeding or traumatize the infant should be avoided or minimized.
Newborns should be nursed whenever they show signs of hunger, such as increased alertness or activity, mouthing, or rooting.85 Crying is a late indicator of hunger.86 Newborns should be nursed approximately 8 to 12 times every 24 hours until satiety, usually 10 to 15 minutes on each breast.87,88 In the early weeks after birth, nondemanding babies should be aroused to feed if 4 hours have elapsed since the last nursing.89,90 Appropriate initiation of breastfeeding is facilitated by continuous rooming-in.91 Formal evaluation of breastfeeding performance should be undertaken by trained observers and fully documented in the record during the first 24 to 48 hours after delivery and again at the early follow-up visit, which should occur 48 to 72 hours after discharge. Maternal recording of the time of each breastfeeding and its duration, as well as voidings and stoolings during the early days of breastfeeding in the hospital and at home, greatly facilitates the evaluation process.
No supplements (water, glucose water, formula, and so forth) should be given to breastfeeding newborns unless a medical indication exists.92-95 With sound breastfeeding knowledge and practices, supplements rarely are needed. Supplements and pacifiers should be avoided whenever possible and, if used at all, only after breastfeeding is well established.93-98
When discharged <48 hours after delivery, all breastfeeding mothers and their newborns should be seen by a pediatrician or other knowledgeable health care practitioner when the newborn is 2 to 4 days of age. In addition to determination of infant weight and general health assessment, breastfeeding should be observed and evaluated for evidence of successful breastfeeding behavior. The infant should be assessed for jaundice, adequate hydration, and age-appropriate elimination patterns (at least six urinations per day and three to four stools per day) by 5 to 7 days of age. All newborns should be seen by 1 month of age.99
Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth.100 Infants weaned before 12 months of age should not receive cow’s milk feedings but should receive iron-fortified infant formula.101 Gradual introduction of iron-enriched solid foods in the second half of the first year should complement the breast milk diet.102,103 It is recommended that breastfeeding continue for at least 12 months, and thereafter for as long as mutually desired.104
In the first 6 months, water, juice, and other foods are generally unnecessary for breastfed infants.105,106 Vitamin D and iron may need to be given before 6 months of age in selected groups of infants (vitamin D for infants whose mothers are vitamin D-deficient or those infants not exposed to adequate sunlight; iron for those who have low iron stores or anemia).107-109 Fluoride should not be administered to infants during the first 6 months after birth, whether they are breast- or formula-fed. During the period from 6 months to 3 years of age, breastfed infants (and formula-fed infants) require fluoride supplementation only if the water supply is severely deficient in fluoride (<0.3 ppm).110
Should hospitalization of the breastfeeding mother or infant be necessary, every effort should be made to maintain breastfeeding, preferably directly, or by pumping the breasts and feeding expressed breast milk, if necessary.
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ROLE OF PEDIATRICIANS IN PROMOTING AND PROTECTING BREASTFEEDING
To provide an optimal environment for breastfeeding, pediatricians should follow these recommendations:
Promote and support breastfeeding enthusiastically. In consideration of the extensive published evidence for improved outcomes in breastfed infants and their mothers, a strong position on behalf of breastfeeding is justified.
Become knowledgeable and skilled in both the physiology and the clinical management of breastfeeding.
Work collaboratively with the obstetric community to ensure that women receive adequate information throughout the perinatal period to make a fully informed decision about infant feeding. Pediatricians should also use opportunities to provide age-appropriate breastfeeding education to children and adults.
Promote hospital policies and procedures that facilitate breastfeeding. Electric breast pumps and private lactation areas should be available to all breastfeeding mothers in the hospital, both on ambulatory and inpatient services. Pediatricians are encouraged to work actively toward eliminating hospital practices that discourage breastfeeding (eg, infant formula discharge packs and separation of mother and infant).
Become familiar with local breastfeeding resources (eg, Special Supplemental Nutrition Program for Women, Infants, and Children clinics, lactation educators and consultants, lay support groups, and breast pump rental stations) so that patients can be referred appropriately.111 When specialized breastfeeding services are used, pediatricians need to clarify for patients their essential role as the infant’s primary medical care taker. Effective communication among the various counselors who advise breastfeeding women is essential.
Encourage routine insurance coverage for necessary breastfeeding services and supplies, including breast pump rental and the time required by pediatricians and other licensed health care professionals to assess and manage breastfeeding.
Promote breastfeeding as a normal part of daily life, and encourage family and societal support for breastfeeding.
Develop and maintain effective communications and collaboration with other health care providers to ensure optimal breastfeeding education, support, and counsel for mother and infant.
Advise mothers to return to their physician for a thorough breast examination when breastfeeding is terminated.
Promote breastfeeding education as a routine component of medical school and residency education.
Encourage the media to portray breastfeeding as positive and the norm.
Encourage employers to provide appropriate facilities and adequate time in the workplace for breast-pumping.
BREASTFEEDING
Before the 20th century, breastfeeding was the main way of feeding babies. If for any reason the natural mother was unable to breastfeed, a wet nurse was used. Attempts were made in 15th century Europe to use cow or goat milk, but these attempts were not successful. In the 18th century, flour or cereal mixed with broth were introduced as substitutes for breastfeeding, but this did not have a favorable outcome either. True commercial infant formulas appeared on the market in the mid 19th century but their use did not become widespread until after World War II.
International Breastfeeding Symbol
WHO actively promotes breastfeeding as the best source of nourishment for infants and young children. Infants should be exclusively breastfed – i.e. receive only breast milk – for the first six months of life to achieve optimal growth, development and health. “Exclusive breastfeeding” is defined as giving no other food or drink – not even water – except breast milk. It does, however, allow the infant to receive oral rehydration salts (ORS), drops and syrups (vitamins, minerals and medicines). Breast milk is the ideal food for the healthy growth and development of infants; breastfeeding is also an integral part of the reproductive process with important implications for the health of mothers.
WHO strongly recommends
– exclusive breastfeeding for the first six months of life;
– breastfeeding should begin within an hour of birth;
– breastfeeding should be “on demand”, as often as the child wants day and night;
– bottles or pacifiers should be avoided.
– at six months, other foods should complement breastfeeding for up to two years or more.
Breastfeeding provides benefits for the infant.
1. Early breast milk is liquid gold – known as liquid gold, colostrum is the thick yellow first breast milk that is made during pregnancy and just after birth. This milk is very rich iutrients and antibodies to protect baby. Although baby only gets a small amount of colostrum at each feeding, it matches the amount his or her tiny stomach can hold.
2. Breast milk changes as baby grows – colostrum changes into what is called mature milk. By the third to fifth day after birth, this mature breast milk has just the right amount of fat, sugar, water, and protein to help your baby continue to grow. It is a thinner type of milk than colostrum, but it provides all of the nutrients and antibodies baby needs.
3. Breast milk is easier to digest – for most babies, especially premature babies, breast milk is easier to digest than formula. The proteins in formula are made from cow’s milk and it takes time for babies’ stomachs to adjust to digesting them.
4. Physical contact is important to newborns. It can help them feel more secure, warm, and comforted.
5. Breast milk fights disease – the cells, hormones, and antibodies in breast milk protect babies from illness. This protection is unique. Breast milk:
– greater immune health – during breastfeeding, approximately 0.25-0.5 grams per day of secretory IgA antibodies pass to the baby via the milk. The main target for these antibodies are probably microorganisms in the baby’s intestine. There is some uptake of IgA to the rest of the body, but this amount is relatively small.Also, breast milk contains several anti-infective factors such as bile salt stimulated lipase (protecting against amoebic infections) and lactoferrin (which binds to iron and inhibits the growth of intestinal bacteria).
– reduces sudden infant death syndrome;
– decreases risk of fewer infections (diarrhea, lower respiratory infection, otitis media, bacteremia, bacterial meningitis, botulism, urinary tract infection);
– prevents diabetes – infants exclusively breastfed have less chance of developing diabetes mellitus type 1 than babies with a shorter duration of breastfeeding and an earlier exposure to cow milk and solid foods.Breastfeeding also appears to protect against diabetes mellitus type 2, at least in part due to its effects on the child’s weight.
– prevents childhood obesity – breastfeeding reduces the risk of extreme obesity in children. The protective effect of breastfeeding against obesity increases with the duration of breastfeeding. Infants who are bottle-fed in early infancy are more likely to empty the bottle or cup in late infancy than those who are breastfed. “Bottle-feeding, regardless of the type of milk, is distinct from feeding at the breast in its effect on infants’ self-regulation of milk intake.” This may be due to factor, that when bottle feeding, parents may encourage an infant to finish the contents of the bottle whereas when breastfeeding, an infant naturally develops self-regulation of milk intake;
– prevents necrotizing enterocolitis (NEC) – necrotizing enterocolitis is an acute inflammatory disease in the intestines of infants. It is mainly found in premature births/ NEC was found to be six to ten times more common in infants fed formula exclusively, and three times more common in infants fed a mixture of breast milk and formula, compared with exclusive breastfeeding. In infants born at more than 30 weeks, NEC was twenty times more common in infants fed exclusively on formula.
– prevents Crohn’s disease, ulcerative colitis, lymphoma, allergic diseases and other chronic diseases;
– enhancement of cognitive development – there is evidence that people who were breastfed perform better in intelligence tests.
Breastfeeding during an emergency
When an emergency occurs, breastfeeding can save lives:
– Breastfeeding protects babies from the risks of a contaminated water supply.
– Breastfeeding can help protect against respiratory illnesses and diarrhea. These diseases can be fatal in populations displaced by disaster.
– Breast milk is the right temperature for babies and helps to prevent hypothermia when the body temperature drops too low.
– Breast milk is readily available without needing other supplies.
Breastfeeding provides benefits for mother.
1. Bonding.
Hormones released during breastfeeding help to strengthen the maternal bond. Teaching partners how to manage common difficulties is associated with higher breastfeeding rates. Support for a mother while breastfeeding can assist in familial bonds and help build a paternal bond between father and child.
The skin-to-skin contact between mother and baby can calm the mother and child.
2. Hormone release.
Breastfeeding contact releases oxytocin and prolactin, hormones that relax the mother and make her feel more nurturing toward her baby.Breastfeeding soon after giving birth increases the mother’s oxytocin levels, making her uterus contract more quickly and reducing bleeding.
3. Weight loss.
As the fat accumulated during pregnancy is used to produce milk, extended breastfeeding—at least 6 months—can help mothers lose weight. It has been observed that prolonged exclusivity of breastfeeding is associated with increased weight loss when controlling for gestational weight gain and postpartum caloric intake
4. Long-term health effects
– less risk of breast cancer, ovarian cancer, and endometrial cancer;
– less risk of coronary heart disease, rheumatoid arthritis;
– mothers who breastfeed longer than eight months benefit from bone re-mineralisation;
– breastfeeding diabetic mothers require less insulin;
– reduced risk of metabolic syndrome;
– reduced risk of post-partum bleeding.Prevent postpartum depression.
5. Life can be easier for mother, who breastfeed –there are no bottles and nipples to sterilize. Mother does not have to buy, measure, and mix formula. And there are no bottles to warm in the middle of the night! Woman can satisfy baby’s hunger right away when breastfeeding.
6. Breastfeeding can save money – formula and feeding supplies can cost well over $1,500 each year, depending on how much your baby eats. Breastfed babies are also sick less often, which can lower health care costs.
7. Mothers miss less work – Breastfeeding mothers miss fewer days from work because their infants are sick less often.
Breastfeeding provides benefits for society.
1. The nation benefits overall when mothers breastfeed. Recent research shows that if 90 percent of families breastfed exclusively for 6 months, nearly 1,000 deaths among infants could be prevented. The United States would also save $13 billion per year — medical care costs are lower for fully breastfed infants thaever-breastfed infants. Breastfed infants typically need fewer sick care visits, prescriptions, and hospitalizations.
2. Breastfeeding also contributes to a more productive workforce since mothers miss less work to care for sick infants. Employer medical costs are also lower.
3. Breastfeeding is also better for the environment. There is less trash and plastic waste compared to that produced by formula cans and bottle supplies.
Breast milk has just the right amount of fat, sugar, water, and protein that is needed for a baby’s growth and development. The composition of breast milk changes depending on how long the baby nurses at each session, as well as on the age of the child.
Why not infant formula?
Infant formula does not contain the antibodies found in breast milk. When infant formula is not properly prepared, there are some risks arising from the use of unsafe water and unsterilized equipment or the potential presence of bacteria in powdered formula. Malnutrition can result from over-diluting formula to “stretch” supplies. Further, frequent feedings maintain the breast milk supply. If formula is used but becomes unavailable, a return to breastfeeding may not be an option due to diminished breast milk production.
How breast milk is made
Knowing how the breast works to produce milk can help you understand the breastfeeding process. The breast itself is a gland that is made up of several parts, including:
Glandular tissue – body tissue that makes and releases one or more substances for use in the body. Some glands make fluids that affect tissues or organs. Others make hormones or assist with blood production. In the breast, this tissue is involved in milk production.
Connective tissue – a type of body tissue that supports other tissues and binds them together. This tissue provides support in the breast.
Blood – fluid in the body made up of plasma, red and white blood cells, and platelets. Blood carries oxygen and nutrients to and waste materials away from all body tissues. In the breast, blood nourishes the breast tissue and provides nutrients needed for milk production.
Lymph – the almost colorless fluid that travels through the lymphatic system and carries cells that help fight infection and disease. Lymph tissue in the breast helps remove waste.
Nerves – cells that are the building blocks of the nervous system (the system that records and transmits information chemically and electrically within a person). Nerve tissue in the breast makes breasts sensitive to touch, allowing the baby’s sucking to stimulate the let-down or milk-ejection reflex and milk production. Learn more about let-down reflex.
Fatty tissue – connective tissue that contains stored fat. It is also known as adipose tissue. Fatty tissue in the breast protects the breast from injury. Fatty tissue is what mostly affects the size of a woman’s breast. Breast size does not have an effect on the amount of milk or the quality of milk a woman makes.
Special cells inside breasts make milk. These cells are called alveoli. When breasts become fuller and tender during pregnancy, this is a sign that the alveoli are getting ready to work. Some women do not feel these changes in their breasts. Others may sense these changes after their baby is born.
The alveoli make milk in response to the hormone prolactin. Prolactin rises when the baby suckles. Another hormone, oxytocin, causes small muscles around the cells to contract and move the milk through a series of small tubes called milk ducts. This moving of the milk is called let-down reflex.
A let-down reflex or milk ejection reflex is a conditioned reflex ejecting milk from the alveoli through the ducts to the sinuses of the breast and the nipple. This reflex makes it easier to breastfeed your baby. Let-down happens a few seconds to several minutes after mother starts breastfeeding baby. It can happen a few times during a feeding, too. Woman may feel a tingle in your breast or you may feel a little uncomfortable. Some women don’t feel anything. Let-down can happen at other times, too, such as when mother hear baby cry or when may just be thinking about baby.
Oxytocin also causes the muscles of the uterus to contract during and after birth. This helps the uterus to get back to its original size. It also lessens any bleeding a woman may have after giving birth. The release of both prolactin and oxytocin may be responsible in part for a mother’s intense feeling of needing to be with her baby.
Time and place for breastfeeding
Feeding a baby “on demand” (sometimes referred to as “on cue”), means feeding when the baby shows signs of hunger. Newborn babies usually express demand for feeding every 1 to 3 hours per 24 hours (resulting in 8-12 times in 24 hours) for the first two to four weeks.
Experienced breastfeeding mothers learn that the sucking patterns and needs of babies vary. While some infants’ sucking needs are met primarily during feedings, other babies may need additional sucking at the breast soon after a feeding even though they are not really hungry. Babies may also nurse when they are lonely, frightened or in pain.
Most US states now have laws that allow a mother to breastfeed her baby anywhere she is allowed to be. In hospitals, rooming-in care permits the baby to stay with the mother and improves the ease of breastfeeding. Some commercial establishments provide breastfeeding rooms, although laws generally specify that mothers may breastfeed anywhere, without requiring them to go to a special area.
Duration of each session
During the newborn period, most breastfeeding sessions will take from 20 to 45 minutes. After the finishing of a breast, the mother may offer the other breast.
Exclusively breastfed infants feed anywhere from 6 to 14 times a day. Newborns consume from 30 to 90 ml (1 to 3 US fluid ounces) per feed. After the age of four weeks, babies consume about 120ml (4 US fluid ounces) per feed. Each baby is different, but as it grows the amount will increase.
It is important to recognize the baby’s hunger signs. It is assumed that the baby knows how much milk it needs and it is therefore advised that the baby should dictate the number, frequency, and length of each feed. The supply of milk from the breast is determined by the number and length of these feeds or the amount of milk expressed. The birth weight of the baby may affect its feeding habits, and mothers may be influenced by what they perceive its requirements to be. For example, a baby born small for gestational age may lead a mother to believe that her child needs to feed more than if it is larger; they should, however, go by the demands of the baby rather than what they feel is necessary.
Number of daily feedings:
First 2 months of life: 7 feedings per day every 3 hours with night break in 6 hrs.
3-5 months of life: 6 feedings per day every 3,5 hours with night break in 6,5 hrs.
After 6 months: 5 feedings per day every 4 hours with night break in 8 hrs.
Correct position and technique for latching
Every mother must know the correct positioning and technique for latching to prevent nipple soreness and allow the baby to obtain enough milk. The “rooting reflex” is the baby’s natural tendency to turn towards the breast with the mouth open wide; mothers sometimes make use of this by gently stroking the baby’s cheek or lips with their nipple to induce the baby to move into position for a breastfeeding session, then quickly moving the baby onto the breast while its mouth is wide open. To prevent nipple soreness and allow the baby to get enough milk, a large part of the breast and areola need to enter the baby’s mouth. Failure to latch on is one of the main reasons for ineffective feeding and can lead to infant health concerns. A study found that inadequate parental education, incorrect breastfeeding techniques, or both were associated with higher rates of preventable hospital re-admissions of newborns.
Technique for latching:
1. Hold baby, wearing only a diaper, against bare chest. Hold the baby upright with his or her head under mother’s chin. Baby will be comfortable in that cozy valley between breasts. Mother’s skin temperature will rise to warm baby.
2. Support his or her neck and shoulders with one hand and hips with the other. He or she may move in an effort to find mother’s breast.
3. Baby’s head should be tilted back slightly to make it easy to suck and swallow. With his or her head back and mouth open, the tongue is naturally down and ready for the breast to go on top of it.
4. Allow breast to hang naturally. When baby feels it with his or her cheek, he or she may open his or her mouth wide and reach it up and over the nipple. Mother can also guide the baby to latch on as in the illustrations below.
5. At first, baby’s nose will be lined up opposite nipple. As his or her chin presses into breast, his or her wide, open mouth will get a large mouthful of breast for a deep latch. Keep in mind that baby can breathe at the breast. The nostrils flare to allow air in.
1. Tickle the baby’s lips to encourage him or her to open wide.
2. Pull your baby close so that the chin and lower jaw moves into your breast first.
3. Watch the lower lip and aim it as far from base of nipple as possible, so the baby takes a large mouthful of breast.
Proper latching onto nipple. Wrong latching onto nipple.
Some moms find that the following positions are helpful ways to get comfortable and support their babies in finding a good latch. Mother also can use pillows under your arms, elbows, neck, or back to give you added comfort and support. Keep in mind that what works well for one feeding may not work well for the next.
Breast feeding technique (video).
Breastfeeding positions:
1. Cradle — Hold your baby in one arm, with its head resting in the bend of your elbow. The baby’s lower arm is tucked out of the way. Its mouth is close to your breast and the two of you are tummy to tummy. This is the most frequently used position. This position can be used when you are sitting up in bed with pillows supporting your back or sitting in a chair.
2. Cross cradle or transitional hold – Useful for premature babies or babies with a weak suck because it gives extra head support and may help babies stay latched. Hold baby along the opposite arm from the breast you are using. Support baby’s head with the palm of your hand at the base of his or her neck.
3. Clutch or “football” hold – Useful for mothers who had a c-section and mothers with large breasts, flat or inverted nipples, or a strong letdown reflex. It is also helpful for babies who prefer to be more upright. This hold allows you to better see and control your baby’s head, and keep the baby away from a c-section incision. Hold your baby at your side, lying on his or her back, with his or her head at the level of your nipple. Support baby’s head with the palm of your hand at the base of the head. (The baby is placed almost under the arm.)
4. Side-lying position – Useful for mothers who had a c-section or to help any mother get extra rest while the baby breastfeeds. Lie on your side with your baby facing you. Pull your baby close so your baby faces your body.
How to know that baby is getting enough milk
Many babies, but not all, lose a small amount of weight in the first days after birth. Baby is getting plenty of milk if he or she is mostly content and gaining weight steadily after the first week of age. From birth to three months, typical weight gain is two-thirds to one ounce each day.
Other signs that your baby is getting plenty of milk:
– He or she is passing enough clear or pale yellow urine, and it’s not deep yellow or orange (see the chart below).
– He or she has enough bowel movements (see the chart below).
– He or she switches between short sleeping periods and wakeful, alert periods.
– He or she is satisfied and content after feedings.
– Mother’s breasts feel softer after feeding baby.
If necessary, it is possible to estimate feeding from wet and soiled nappies (diapers): 8 wet cloth or 5–6 wet disposable, and 2–5 soiled per 24 hours suggests an acceptable amount of input for newborns older than 5–6 days old. After 2–3 months, stool frequency is a less accurate measure of adequate input as some normal infants may go up to 10 days between stools.
Babies can also be weighed before and after feeds.
Common Problems During Breast Feeding.
Although breastfeeding is the recommended method of feeding infants, it is not without complications or occasional discomforts for the mother. By being aware of these common problems, the health care professional can offer advice to mothers to help alleviate potential difficulties. As a general rule, breastfeeding should be continued through most illnesses, including periods of diarrhea. Some of the most common problems are listed below.
Sore nipples
Most women experience sore nipples at some period during their breastfeeding course, especially during the first 2 weeks postpartum. Breastfeeding should be comfortable once mother has found some positions that work and a good latch is established. Woman may also have pain if your baby is sucking on only the nipple.
Prescription for Sore nipples:
– Check for proper positioning. Baby should be latching onto at least 3/4″ of the areola, not just the nipple
– If baby is sucking only on the nipple, gently break your baby’s suction to your breast by placing a clean finger in the corner of baby’s mouth and try again.
– Offer least sore side first
– Break suction at end of feeding by inserting a finger or pulling gently down on baby’s chin.
– After breastfeeding, express a few drops of milk and gently rub it on your nipples with clean hands. Human milk has natural healing properties and emollients that soothe. Also try letting your nipples air-dry after feeding, or wear a soft cotton shirt.
– Avoid wearing bras or clothes that are too tight and put pressure on your nipples.
– Change nursing pads often to avoid trapping in moisture.
– Avoid using soap or ointments that contain astringents or other chemicals on your nipples. Make sure to avoid products that must be removed before breastfeeding. Washing with clean water is all that is needed to keep your nipples and breasts clean.
Engorgement
It is normal for breasts to become larger, heavier, and a little tender when they begin making more milk. Sometimes this fullness may turn into engorgement, when mother’s breasts feel very hard and painful. Woman also may have breast swelling, tenderness, warmth, redness, throbbing, and flattening of the nipple. Engorgement sometimes also causes a low-grade fever and can be confused with a breast infection. Engorgement is the result of the milk building up. It usually happens during the third to fifth day after birth, but it can happen at any time.
Engorgement can lead to plugged ducts or a breast infection, so it is important to try to prevent it before this happens. If treated properly, engorgement should resolve.
Prescription for engorgement:
– Breastfeed often after birth, allowing the baby to feed as long as he or she likes, as long as he or she is latched on well and sucking effectively. In the early weeks after birth, mother should wake baby to feed if four hours have passed since the beginning of the last feeding.
– Work with a lactation consultant to improve the baby’s latch.
– Breastfeed often on the affected side to remove the milk, keep it moving freely, and prevent the breast from becoming overly full.
– Avoid overusing pacifiers and using bottles to supplement feedings.
– Hand express or pump a little milk to first soften the breast, areola, and nipple before breastfeeding.
– Massage the breast.
– Use cold compresses in between feedings to help ease pain.
– If mother is returning to work, she must try to pump milk on the same schedule that the baby breastfed at home. Or, can pump at least every four hours.
– Get enough rest, proper nutrition, and fluids.
– Wear a well-fitting, supportive bra that is not too tight.
Plugged ducts.
It is common for many women to have a plugged duct at some point breastfeeding. A plugged milk duct feels like a tender and sore lump in the breast. It is not accompanied by a fever or other symptoms. It happens when a milk duct does not properly drain and becomes inflamed. Then, pressure builds up behind the plug, and surrounding tissue becomes inflamed. A plugged duct usually only occurs in one breast at a time.
Prescription for plugged duct:
– Breastfeed often on the affected side, as often as every two hours. This helps loosen the plug, and keeps the milk moving freely.
– Massage the area, starting behind the sore spot. Use your fingers in a circular motion and massage toward the nipple.
– Use a warm compress on the sore area.
– Get extra sleep or relax with your feet up to help speed healing. Often a plugged duct is the first sign that a mother is doing too much.
– Wear a well-fitting supportive bra that is not too tight, since this can constrict milk ducts. Consider trying a bra without underwire.
Breast infection (mastitis)
Mastitis is soreness or a lump in the breast that can be accompanied by a fever and/or flu-like symptoms, such as feeling run down or very achy. Some women with a breast infection also have nausea and vomiting. Woman also may have yellowish discharge from the nipple that looks like colostrum. Or, the breasts may feel warm or hot to the touch and appear pink or red. A breast infection can occur when other family members have a cold or the flu. It usually only occurs in one breast. It is not always easy to tell the difference between a breast infection and a plugged duct because both have similar symptoms and can improve within 24 to 48 hours. Most breast infections that do not improve on their own within this time period need to be treated with medicine given by a doctor.
Prescription for mastitis:
– Breastfeed often on the affected side, as often as every two hours. This keeps the milk moving freely, and keeps the breast from becoming overly full.
– Massage the area, starting behind the sore spot. Use your fingers in a circular motion and massage toward the nipple.
– Apply heat to the sore area with a warm compress (not cold).
– Drink plenty of fluids
– Get extra sleep or relax with your feet up to help speed healing. Often a breast infection is the first sign that a mother is doing too much and becoming overly tired.
– Wear a well-fitting supportive bra that is not too tight, since this can constrict milk ducts.
Breastfeeding a baby with health problems
There are some health problems in babies that can make it harder to breastfeed. Yet breast milk and early breastfeeding are still best for the health of both you and your baby — even more so if your baby is premature or sick. Even if your baby cannot breastfeed directly from mother, it’s best to express or pump your milk and give it to baby with a cup or dropper.
Some common health problems in babies are listed below.
Jaundice
Jaundice is caused by an excess of bilirubin, a substance that is in the blood usually in very small amounts. In the newborn period, bilirubin can build up faster than it can be removed from the intestinal track. Jaundice can appear as a yellowing of the skin and eyes. It affects most newborns to some degree, appearing between the second and third day of life. The jaundice usually clears up by two weeks of age and is not harmful.
Two types of jaundice can affect breastfed infants — breastfeeding jaundice and breast milk jaundice.
Breastfeeding jaundice can occur when a breastfeeding baby is not getting enough breast milk. This can happen either because of breastfeeding challenges or because the mother’s milk hasn’t yet come in. This is not caused by a problem with the breast milk itself.
Breast milk jaundice may be caused by substances in the mother’s milk that prevents bilirubin from being excreted from the body. Such jaundice appears in some healthy, breastfed babies after about one week of age. It may last for a month or more and it is usually not harmful.
Jaundice is best treated by breastfeeding more frequently or for longer periods of time. It is crucial to have a health care provider help you make sure the baby is latching on and removing milk well. This is usually all that is needed for the infant’s body to rid itself of excess bilirubin.
Premature and/or low birth weight
Most babies who are low birth weight but born after 37 weeks (full term) can begin breastfeeding right away. They will need more skin-to-skin contact with mom and dad to help keep them warm. These smaller babies may also need more frequent feedings, and they may get sleepier during those feedings.
Many babies born prematurely are ofteot able to breastfeed at first, but they do benefit from expressed milk. Mother can express colostrum by hand or pump as soon as can in the hospital. Once baby is ready to breastfeed directly, skin-to-skin contact can be very calming and a great start to first feeding.
Expressing breast milk and storage
When direct breastfeeding is not possible, a mother can express (artificially remove and store) her milk. With manual massage or using a breast pump, a woman can express her milk and keep it in freezer storage bags, a supplemental nursing system, or a bottle ready for use. Breast milk may be kept at room temperature for up to six hours, refrigerated for up to eight days or frozen for up to four to six months. Antioxidant activity in expressed breast milk decreases over time but it still remains at higher levels than in infant formula. Expressing breast milk can maintain a mother’s milk supply when she and her child are apart. If a sick baby is unable to feed, expressed milk can be fed through a nasogastric tube.
Before express breast milk, mother must wash her hands with soap and water, or a waterless hand cleanser if hands don’t appear dirty. The breast and nipples do not need to be washed before pumping. Also, the area where woman is expressing must be clean.
Ways to express milk
|
Type |
How it works |
What’s involved |
|
Hand expression |
You use your hand to massage and compress your breast to remove milk. |
· Requires practice, skill, and coordination. · Gets easier with practice; can be as fast as pumping. · Good if you are seldom away from baby or need an option that is always with you. But all moms should learn how to hand express. |
|
Manual pump |
You use your hand and wrist to operate a hand-held device to pump the milk. |
· Requires practice, skill, and coordination. · Useful for occasional pumping if you are away from baby once in a while. · May put you at higher risk of breast infection. |
|
Automatic, electric breast pump |
Runs on battery or plugs into an electrical outlet. |
· Can be easier for some moms. · Can pump one breast at a time or both breasts at the same time. · Double pumping may collect more milk in less time, so they are helpful if you are going back to work or school full-time. · Need places to clean and store the equipment between uses. |
Manual pump Electric pumps Milk storage bags and bottles
Storage of breast milk
Breast milk can be stored in clean glass or hard BPA-free plastic bottles with tight fitting lids. You can also use milk storage bags, which are made for freezing human milk. Do not use disposable bottle liners or other plastic bags to store breast milk.
After each pumping
· Label the date on the storage container. Include your child’s name if you are giving the milk to a childcare provider.
· Gently swirl the container to mix the cream part of the breast milk that may rise to the top back into the rest of the milk. Shaking the milk is not recommended — this can cause a breakdown of some of the milk’s valuable components.
· Refrigerate or chill milk right after it is expressed. You can put it in the refrigerator, place it in a cooler or insulated cooler pack, or freeze it in small (2 to 4 ounce) batches for later feedings.
Tips for freezing milk
· Wait to tighten bottle caps or lids until the milk is completely frozen.
· Try to leave an inch or so from the milk to the top of the container because it will expand when freezing.
· Store milk in the back of the freezer — not in the freezer door.
Tips for thawing and warming up milk
· Clearly label milk containers with the date it was expressed. Use the oldest stored milk first.
· Breast milk does not necessarily need to be warmed. Some moms prefer to take the chill off and serve at room temperature. Some moms serve it cold.
· Thaw frozen milk in the refrigerator overnight, by holding the bottle or frozen bag of milk under warm running water, or setting it in a container of warm water.
· Never put a bottle or bag of breast milk in the microwave. Microwaving creates hot spots that could burn your baby and damage the components of the milk.
· Swirl the milk and test the temperature by dropping some on your wrist. It should be comfortably warm.
· Use thawed breast milk within 24 hours. Do not refreeze thawed breast milk.
Recommendations for mother’s diet.
Women who are breastfeeding need to be careful about what they eat and drink, since things can be passed to the baby through the breast milk
· To drink approximately 64 oz of fluids per day.
· The nursing mother requires an additional 500 calories and 20-30 g of protein a day.
· She has to take her prenatal vitamins with iron.
· Breastfeeding women should avoid fish that are high in mercury, and limit lower mercury fish intake
· The mother need not to avoid certain foods unless she observes consistent increased fussiness in the baby in association with the mother ingestion such foods.
Foods commonly incriminated:
• Garlic
• Onions
• Cabbage
• Chocolate
• Great quantities of caffeine.
HIV and breastfeeding
An HIV-infected mother can pass the infection to her infant during pregnancy, delivery and through breastfeeding. Antiretroviral (ARV) drug interventions to either the mother or HIV-exposed infant reduces the risk of transmission of HIV through breastfeeding. Together, breastfeeding and ARV interventions have the potential to significantly improve infants’ chances of surviving while remaining HIV uninfected. WHO recommends that when HIV-infected mothers breastfeed, they should receive ARVs and follow WHO guidance for breastfeeding and complementary feeding.
Regulating breast-milk substitutes
An international code to regulate the marketing of breast-milk substitutes was adopted in 1981. It calls for:
– all formula labels and information to state the benefits of breastfeeding and the health risks of substitutes;
– no promotion of breast-milk substitutes;
– no free samples of substitutes to be given to pregnant women, mothers or their families;
– no distribution of free or subsidized substitutes to health workers or facilities.
Support for mothers is essential
Breastfeeding has to be learned and many women encounter difficulties at the beginning. Nipple pain, and fear that there is not enough milk to sustain the baby are common. Health facilities that support breastfeeding – by making trained breastfeeding counsellors available to new mothers – encourage higher rates of the practice. To provide this support and improve care for mothers and newborns, there are now more than 20 000 “baby-friendly” facilities in 152 countries thanks to a WHO-UNICEF initiative. video
Plan of weaning in breast feeding
To meet the growing needs of babies at six months of age, complementary foods should be introduced as they continue to breastfeed. Foods for the baby can be specially prepared or modified from family meals. WHO notes that:
· breastfeeding should not be decreased when starting complementary feeding (weaning) complementary foods should be given with a spoon or cup, not in a bottle;
· foods should be clean, safe and locally available; and
· ample time is needed for young children to learn to eat solid foods.
In the first 6 months, water, juice, and other foods are generally unnecessary for breastfed infants.
Vitamin D and iron may need to be given before 6 months of age in selected groups of infants (vitamin D for infants whose mothers are vitamin D-deficient or those infants not exposed to adequate sunlight; iron for those who have low iron stores or anemia).
Fluoride should not be administered to infants during the first 6 months after birth, whether they are breast- or formula-fed. During the period from 6 months to 3 years of age, breastfed infants (and formula-fed infants) require fluoride supplementation only if the water supply is severely deficient in fluoride (<0.3 ppm).
WHO recommended plan of weaning in breast feeding
|
Food stuffs |
Time of giving |
Age (in months) depending volume of food |
||||
|
6 |
7 |
8 |
9 |
10 |
||
|
Juice (fruit, vegetable), ml |
6 |
30-50 |
50-70 |
50-70 |
80 |
100 |
|
Fruit puree, ml
|
6 |
40-50 |
50-70 |
50-70 |
80 |
90-100 |
|
Vegetable puree, g
|
6 |
50-150 |
150 |
170 |
180 |
200 |
|
Groats (porridge, rice, buckwheat), g |
6-7 |
5-50 |
50-100 |
150 |
180 |
200 |
|
Cereals (semolina, barley, corn), g |
7-8 |
5-50 |
50-100 |
150 |
180 |
200 |
|
Yoghurt, kefir, ml
|
8-9 |
– |
– |
10-50 |
50-150 |
150-200 |
|
Soft cheese, g
|
6,5-7,5 |
5-25 |
10-30 |
30 |
30 |
50 |
|
Yolk
|
7,0-7,5 |
– |
1/8-1/4 |
¼-½ |
¼-½ |
½-3/4 |
|
Meat puree, g
|
6,5-7,0 |
5-30 |
30 |
50 |
50 |
50-60 |
|
Fish puree, g
|
9-10 |
– |
– |
10-20 |
30-50 |
50-60 |
|
Vegetable oil
|
6 |
½ tsp |
½ tsp. |
1 tsp |
1 tsp |
1 tsp |
|
Butter
|
6-7 |
½ tsp |
½ tsp |
1 tsp |
1 tsp |
1 tsp |
|
Bread, g
|
8-9 |
– |
– |
5 |
5 |
10 |
CONCLUSION
Although economic, cultural, and political pressures often confound decisions about infant feeding, the AAP firmly adheres to the position that breastfeeding ensures the best possible health as well as the best developmental and psychosocial outcomes for the infant. Enthusiastic support and involvement of pediatricians in the promotion and practice of breastfeeding is essential to the achievement of optimal infant and child health, growth, and development.
References
а) Basic
1. Manual of Propaedeutic Pediatrics / S.O. Nykytyuk, N.I. Balatska, N.B. Galyash, N.O. Lishchenko, O.Y. Nykytyuk – Ternopil: TSMU, 2005. – 468 pp.
2. Kapitan T. Propaedeutics of children’s diseases and nursing of the child : [Textbook for students of higher medical educational institutions] ; Fourth edition, updated and translated in English / T. Kapitan – Vinnitsa: The State Cartographical Factory, 2010. – 808 pp.
3. Nelson Textbook of Pediatrics /edited by Richard E. Behrman, Robert M. Kliegman; senior editor, Waldo E. Nelson – 19th ed. – W.B.Saunders Company, 2011. – 2680 p.
b) Additional
1. Denial Bernstein. Pediatrics for medical Students. – Second edition, 2012. – 650 p.
2. Jam W. Ball, Ruth G. Bindler Pediatric Nursing. Caring for Children. – Third edition, 2011. – 984p.
3. Guidelines on HIV and infant feeding 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. World Health Organization, 2010.
5. www.bookfinder.com/author/american-academy-of-pediatrics
7. http://www.nlm.nih.gov/medlineplus/medlineplus.html
8.Work Group on Breastfeeding, 1996 to 1997
Lawrence M. Gartner, MD, Chairperson
