Breast-Feeding – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

  • Breast-feeding is the natural process of feeding an infant human milk directly from the breast.
  • Breast milk feeding is the process of feeding a child human milk that has been expressed either by hand or by pump.
  • The American Academy of Pediatrics (AAP), the American Academy of Family Physicians, and other medical organizations recommend exclusive breast-feeding for approximately the 1st 6 months of life and support for breast-feeding for the 1st year and beyond as long as mutually desired by mother and child (1).

Description

  • Maternal benefits (as compared to mothers who do not breast-feed) include: (2)
    • Decreased postpartum bleeding (due to oxytocin release)
    • Decreased risk of postpartum depression
    • Easier postpartum weight loss
    • Delayed postpartum fertility
    • Decreased risk of breast and ovarian cancer
    • Decreased risk of type 2 diabetes
    • Increased sense of well-being (endorphin response)
    • Increased bonding
    • Convenience
    • Cost
  • Infant benefits (as compared with children who are formula-fed) include: (2)
    • Ideal food: Easily digestible, nutrients well absorbed, less constipation
    • Lower rates of virtually all infections via maternal antibody protection
      • Fewer respiratory and gastrointestinal infections
      • Decreased incidence of otitis media
      • Decreased severe lower respiratory infection
    • Decreased incidence of obesity
    • Decreased incidence of allergies and atopic dermatitis in childhood
    • Decreased incidence of type I and 2 diabetes
    • Decreased risk of childhood leukemia
    • Decreased risk of sudden infant death syndrome
    • Decreased mortality
    • Increased attachment between mother and baby

Epidemiology

Incidence

According to the most recent National Immunization Survey, for births in the US in 2007 (3):

  • Any breast-feeding: 75.0%
  • Breastfeeding at 6 months: 43.0%
  • Breastfeeding at 12 months: 22.4%
  • Exclusive breast-feeding at 3 months: 33.0%
  • Exclusive breast-feeding at 6 months: 13.3%

Risk Factors

Breast surgery, especially reduction surgery, prior to pregnancy may disrupt breast milk production in the future.

General Prevention

Maternal avoidance diets during lactation not recommended to prevent allergic disease (4)[B]

Pathophysiology

The overarching mechanism of milk production is based on supply and demand.

  • 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.
    • Endocrine/Metabolic: Thyroid dysfunction may cause delayed lactation or decreased milk production.

Commonly Associated Conditions

  • Breast milk jaundice should be considered if jaundice persists for greater than 1 week in an otherwise healthy, well-hydrated newborn. It peaks at 10–14 days.
  • Other causes, such as hypothyroidism and infection, should be considered.

Breast feeding, Human breast milk, Infant, Lactation, infant death syndrome, antibody protection, sudden infant death syndrome, digestible nutrients, gastrointestinal infections, childhood leukemia, breast feed,

Diagnosis

Physical Exam

  • Examine breasts, ideally during pregnancy, looking for scars or inverted nipples.
  • Breast cancer incidence low but possible in premenopausal women.
    • A breast lump should be followed to complete resolution or worked up if present and not just attributed to changes from lactation.

Treatment

Additional Treatment

General Measures

  • Flat or inverted nipples:
    • When stimulated, inverted nipples will retract inward, flat nipples remain flat; 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.
  • Contraindications to breast-feeding are few:
    • Maternal HIV infection
    • Active tuberculosis
    • Substances of abuse and some medications that will pass into human milk (5)[B]
    • Infants with galactosemia should not be fed with breast milk.
    • Maternal hepatitis is not a contraindication to breast-feeding.

Issues for Referral

  • Refer to trained physician, nurse, or lactation consultant for inpatient and/or outpatient teaching.
  • Frequent follow-up if having problems with latching, sore nipples, or inadequate milk production.

Complementary and Alternative Medicine

Fenugreek may increase breast milk production. Suggested dose: 3 tablets t.i.d. Safety is not established.

In-Patient Considerations

Initial Stabilization

  • Initiate breast-feeding immediately after birth, ideally placing the infant at the mother’s breast in the delivery room.
  • Get mother in a comfortable position, usually sitting or reclining with the baby’s head in crook of her arm.
    • Side-lying position often useful following cesarean-section delivery.
  • Bring baby to mother to decrease stress on mother’s 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 (6)[C].
  • Feed every 2–4 hours, 20 minutes per side.
  • Rooming-in to encourage on-demand feeding (6)
  • Observation of a nursing session by an experienced physician, nurse, or lactation consultant
  • Avoid supplementation with formula or water.
  • Review expectations, techniques, and feeding cues.
  • Be very encouraging.

Ongoing Care

Follow-Up Recommendations

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  • See mother and baby within a few days of hospital discharge.
  • Primary care-initiated interventions to promote breast-feeding have been shown to be successful with respect to child and maternal health outcomes.

Patient Monitoring

  • Monitor infant’s weight and output closely.
  • Supplementation with infant formula recommended only if infant has lost 7% or more of birth weight, shows signs of dehydration such as decreased urine output, or has less than 3 small stools a day.
  • Given that the mechanism of milk production is supply and demand, supplementation without persistent and regular breast stimulation with frequent feedings or breast pump use will decrease milk production and decrease breast-feeding success.

Diet

  • For mothers:
    • Continue prenatal vitamins.
    • Drink plenty of fluids: 12.5 cups or 3.0 L of fluids per day.
    • Breast-feeding mothers require 1,800–2,300 calories per day; ∼500 more than pre-pregnancy needs.
    • Gassy foods such as cabbage may cause baby to have colic.
    • American Academy of Pediatrics (AAP) suggests limiting maternal caffeine to 300 mg/day.
    • Alcohol should be avoided. 1–2 drinks/week of alcohol may be okay, but mothers should avoid nursing 2–3 hours after a drink. Only <2% of alcohol is passed to baby via breast milk.
  • For infants:
    • In 2008, the AAP increased its recommended daily intake of vitamin D in infants to 400 IU. For exclusively breast-fed babies, this will require taking a vitamin supplement such as Poly-Vi-Sol or Vi-Daylin vitamin drops, 0.5 cc/day, beginning at 2 months of age.
    • In 2010, the AAP recommended adding supplementation for breast-fed infants with oral iron 1 mg/kg per day beginning at age 4 months (7).
      • Preterm infants fed human milk should receive an iron supplement of 2 mg/kg per day by 1 month of age, and this should be continued until the infant is weaned to iron-fortified formula or begins eating complementary foods that supply the 2 mg/kg of iron.
    • Fluoride supplement unnecessary until 6 months of age.

Patient Education

  • The US Preventive Services Task Force (USPSTF) recommends structured breast-feeding education and behavioral counseling programs to promote breast-feeding.
  • Regular promotion of advantages of breast-feeding (8)[C]
  • Emphasize importance of exclusive breast-feeding for 1st 4 weeks of life to allow adequate buildup of sufficient milk supply.
  • Discuss woman’s postpartum plans (i.e., if going to work). Emphasize possibility of nursing part-time after returning to work or nursing until weaning the week before returning to work.
  • Immediate breast-feeding after the birth.
  • Milk will not come in before 3rd day postpartum.
  • Frequent nursing (8–12 feedings per 24 hours) will lead to milk coming in sooner and in greater quantities.
  • Baby should have 5–8 wet diapers per day and 2–5 bowel movements per day.
  • After day 4 of life, should gain 4–7 oz per week
  • See in office within a few days of discharge, especially if 1st time breastfeeding
  • Signs of adequate nursing:
    • Breasts become hard before and soft after feeding.
    • 6 or more wet diapers in 24 hours
    • Baby satisfied; appropriate weight gain (average 1 oz/day in 1st few months)
  • Growth spurts: Anticipate these ∼10 days, 6 weeks, 3 months, and 4–6 months. Baby will nurse more often at these times for several days. This will increase milk production to allow for further adequate growth.
  • The AAP recommends supplementation with vitamin D starting at age 2 months and iron starting at age 4 months (7,9).
  • Weaning:
    • Exclusive breast milk is optimal food for 1st 6 months.
    • Solid food may be introduced at 6 months.
    • For mothers going to work, start switching the baby to breast milk feeding or formula feeding during the hours mother will be gone about a week ahead of time. Do this by dropping a feeding every few days and substituting pumped breast milk or formula, preferably given by another caregiver.
  • Family planning:
    • Lactational amenorrhea method (LAM): Breast-feeding may be used as effective birth control option if (1) infant is less than 6 months old, (2) infant is exclusively breast-feeding, and (3) mother is amenorrheic (10).
    • Other options include barrier methods, implants, Depo-Provera, oral contraception, and intrauterine devices.
    • Most providers use progesterone-only birth control pills in the early postpartum period.
  • The Academy of Breastfeeding Medicine (ABM), a worldwide organization of physicians dedicated to the promotion, protection and support of breastfeeding and human lactation. www.bfmed.org
  • La Leche League at www.llli.org
  • Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services, a joint WHO/UNICEF statement published by the World Health Organization. http://www.unicef.org/newsline/tenstps.htm
  • Thomas Hale’s Medications and Mother’s Milk: A Manual of Lactational Pharmacology.

Complications

  • Plugged duct:
    • 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 (see topic 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 (11)
    • 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 infant weight gain.
    • Review signs of adequate supply; 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 and/or coat with expressed breast milk.
    • Do not wash nipples with soap and water.
    • Check for signs of thrush in baby and on mother’s nipple. If affected, treat both.
  • 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.
      • Breast-feed long enough to empty breasts.
    • Generally resolves within a day or 2.

References

1. http://www.aap.org/advocacy/releases/feb05breastfeeding.htm

2. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries [Structured Abstract]. Rockville, MD: Agency for Healthcare Research and Quality, 2007. Available at: http://www.ahrq.gov/clinic/tp/brfouttp.htm.

3. http://www.cdc.gov/breastfeeding/pdf/BreastfeedingReportCard2010.pdf

4. U.S. Department of Health and Human Services. Healthy People 2010, Conference ed. Vols I and II. Washington, DC: U.S. Department of Health and Human Services, Public Health Service, Office of the Assistant Secretary for Health, January 2000.

5. Berlin CM, Briggs GG. Drugs and chemicals in human milk. Semin Fetal Neonatal Med. 2005;10:149–59.

6. Sinusas K, Gagliardi A. Initial management of breast-feeding. Am Fam Phys. 2001;15;64:981–8.

7. http://www.aap.org/pressroom/Ironfinal.pdf

8. Chung M, Raman G, Trikalinos T, Lau J, Ip S et al. Interventions in primary care to promote breastfeeding: an evidence review for the U.S. Preventive Services Task Force. Ann. Intern. Med. 2008;149:565–82.

9. Casey CF, Slawson DC, Neal LR et al. VItamin D supplementation in infants, children, and adolescents. Am Fam Physician. 2010;81:745–8.

10. http://www.llli.org/ba/Aug93.html

11. Jahanfar S, Ng CJ, Teng CL et al. Antibiotics for mastitis in breastfeeding women. Cochrane Database Syst Rev. 2009;CD005458.

Additional Reading

Cramton R, Zain-Ul-Abideen M, Whalen B et al. Optimizing successful breastfeeding in the newborn. Curr Opin Pediatr. 2009;21:386–96.

13. Grummer-Strawn LM, Shealy KR et al. Progress in protecting, promoting, and supporting breastfeeding: 1984–2009. Breastfeeding medicine: the official journal of the Academy of Breastfeeding Medicine.2009;4 (Suppl 1):S31–9.

Codes

ICD9

V24.1 Postpartum care and examination of lactating mother

Snomed

243094003 Breastfeeding education (procedure)

Clinical Pearls

  • Breast milk is the optimal food for infants with myriad health benefits for mothers and children.
  • USPSTF recommends structured education to promote breast-feeding.
  • Vitamin D and iron supplementation should begin at 2 and 4 months of age, respectively, for exclusively breast-fed infants.

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