Breast Feeding:

 Benefits: bonding, interaction

o BM has antimicrobial, antinflammatroy properties to help infant’s
immune system develop
 IgA  passive immunity to infant
o To baby: species-specific nutrients, growth factors, immune
factors, hormones, decrease incidence/severity of infectious
disease, enhance neurodevelopment, decrease obesity, chronic
illness, and atopic disease
o To mom: increases metabolism, contraceptive effects, decreased
breast cancer and osteoporosis, reduces costs
 Term Infant Recommendations:
o Exclusive breastfeeding for first 6mo
o EBM if cant directly BF
o 8-12 feeds/24hr, immediate skin-skin after birth
o Do not give supplements (water, formula) unless indicated
o Do not introduce pacifiers or bottles until breast feeding is well
established
o Complimentary foods + at 6mo, continue BF up to 1yr
o Supplemental fluoride after 6mo if indicated
o Vitamin D drops (oral), 400 IU/daily within first few days of life
 BM contains all required nutrients except VitD and K for the first 6mo.
o Colostrum: first milk produced during late pregnancy until 3-4d
pp; rich in proteins and immunoglobulins
o If they are vegan or vegetarian – vitamin B12 supp.  refer to
dietitian
 Physiology oflactation
o Lactogenesis: the process of mammary epithelial cell
differentiation and milk production in the mammary gland that
begins mid pregnancy as a result of
increased estrogen and progesterone levels
o Lactation is initiated by the delivery of
the placenta → abrupt ↓ progesterone levels
→ ↑ prolactin → stimulation of milk secretion
o Suckling stimulates prolactin release from AP  stimulates
lactogenesis (milk production) and disrupts GnRH secretion
(lactational amenorrhea)
o Oxytocin from PP  milk ejection (letdown) and uterine
contractions
 Management/support
o Before discharge: assessment by lactation consultant or nursing
specialist + info about positioning, minimum anticipated feeding
frequency (8/24hrs), expected small colostrum intakes (15-20ml
in first 24hrs), signs of hunger and adequacy of intake, and
common breast conditions encountered
 Signs of a good latch
 Pain free for mom
 Most of the areola and nipple in baby;s mouth
 Infant’s mouth open and evertd, chin and nose
resting on breast
 Rhythmic cuscking and swallowing in baby
 Signs of infant satiety after feed – decreased sucking,
limb extension, relaxing the fingers, pushing or
arching away, turning from breast or bottle
o Within 3-5d of life, baby should see a pediatrician to ensure baby
has stopped losing weight (no more than 8-10%), has yellow
seedy stools (not meconium stained) ~3/d, and has 6 wet
diapers/day.
 Should return to birth weight between 12-14 days and +1/2
oz/day during first mo.
 If not, and no other health conditions, assess
adequacy of BF:
o Infant attachment
o Normal physio signs of lactogenesis: breast
fullness, leaking
o Can weight diapered infant before and after
feel, 1g=1ml
 If problems, can supplement with EBM
 Using mechanical pump after feeding will allow
further breast stimulation to increase milk production
 BF problems
o Sore, tender nipples
 Hormones and friction
 Intense onset at latching and rapid subsiding as milk flow
increases
 Should diminish in first few weeks
 Lanolion or EMB applied to nipples post-feed can help
o Traumatized, painful nipples
 Bleeding, bilsters, cracks
  Ineffective latching or sucking, removing infant before
breaking suction, nipple conditions/infection (yeast,
eczema)
 Assess mother’s techniques and tx any underlying
conditions
 If severe  temporary cessation of BF, but maintain
mechanical/hand expression
o Engorgement
 Increased fullness 3-5 d PP signaling onset of copious milk
production
 Inadequate breast stimulation  swollen, hard breasts,
warm
 Diffuclty latching until engorgement resolves
 Tx: warm and cold alternating compresses to tx edema,
gentle hand expression to soften areola and facilitate infant
atachement, gentle massage of breast during feeding or
milk expression, mild analgesic (acetaminophen) or anti-
inflam (naproxen) for pain relief and reduction of
inflammation
o Plugged ducts
 Palpable lump that does not soften during feeding or
pumping
 Ill fitting bra, tight clothing, or missed feedings
 Tx: frequent feedings, moist heat, massage during
feedings, position infant’s chin toward affected area for
maximum suction to facilitate emptying
o Mastitis
 Affects only one breast
 Rapid onset of fatigue, body aches, headache, fever, and
tender, reddened breast area
 Tx: immediate bes rest, continued feeding on both sides,
frequent and efficient milk removal – pump if needed, ABX
for 10-14d, comfort measures to relieve discomfort and
malaise (analgesics, warm compress, massage)
 Special situations
o *note: if BF is ever delayed, it is important to electronically pump
to ensure maintenance of lactation
o Infant conditions
 Congenital anomalies
 Craniofacial 9cleft lip/palate, Pierre-Robin) – ability to
latch affected  modified positioning and special
devices (obturator or nipple shield)
 Cardiac/resp conditions – may need fluid restriction
and special attention to pacing of feeds to minimize
fatigue during feeding
 Restrictive lungual frenulum (tongue tie) – dec.
ability to extend tongue over lower gum line and lift
tongue to compress underlying breast tissue 
compromises effective milk transfer  frenulotomy
 Premature infants
 Even if they cant BF, EBM has benefits
 PDBM is an option when mom’s milk is not available
o But mom’s milk has the greatest benefits to
preterm and high ris infants
o Always obtain consent
 Late-preterm and near-term (35-37 weeks) who are
discharged before feeding effectively
o Mechanical milk expression concurrent with BF
until infant is BF effectively
o Documentation and ssessment of BF by trained
observer
o Weighing infant before and after feeds to
evaluate adequacy of milk intake and need for
supplementation
o Maternal conditions
 Endocrine diseases
 DM
o Encouraged to BF, may improve glucose
metabolism
o Can have a delay in secretory phase of
lactogenesis (1-2d), so monitor closely for
infant growth and adequacy of lactation
 Thyroid disease
o Without tx they can have poor milk production
(hypo) or maternal weight loss, agitation, and
heart palpitations (hyper) that may negatively
affect lactation
o With tx, BF not affected
  Gestational ovarian techa lutein cysts and retained
placental fragments are conditions that delay the
secretory phase of lactogenesis
 Hx of breast or ches surgery should be able o BF
 Assess procuedure and approach to evaluate level of
follow up indicated in early postpartum period to
monitor progress of breastfeeding and adequacy of
milk production and infant growth
 Contraindications
o Infant with galactosemia (bc lactose = glucose + galactose)
o Mother with active untreated Tb
o +HIV
o Other infections: human T-cell lymphoma virus, Ebola,
brucellosis, Mpox
o Certain medications – radioactive, chemotherapy, meds that
decrease milk supply
o Discourage use of alcooh, marijuana, and tobacco
 But if opioid use disorder + stable tx dose (methadone or
buprenorphine) should be encouraged to breastfeed
 Not contraindications
o Hyperbilirubinema – ensure adequate feeding bc it will enhance
gut motility and facilitate bilirubin excretion
o Most meds enter BM to some degree but concentrations are
usually low and deliver subclinical doses to the infant
o Mothers HepB surface antigen+
 Give infant HepB immune golublin ans Hep B vaccine
 Hep C in BM, but has not been found to be transmitted
 CMV: benefits > risk of transmission
 Frozewn milk or pasteurization can reduce risk
 Febrile mothers
 Mothers exposed to low-level environmental chemical
agents
 Smoking (but advised to avoid)
 Small alcoholic drinks acceptable, avoied BF for 2hrs. after
drink
 Alcohol concentrates in milk and inhibits short term
milk production
*higher energy needs and more protein the more preterm; sometimes more
fluid (enteral)
Formula types:

Term formula – 19-20 kcal/oz

Soy (galactosemia) formula – 20kcal/oz

Preterm (33-36wks) formula – 22kcal/oz (Neosure or Enfacare)

Partially hydrolyzed formula – 20kcal/oz – Pregestimil, Nutramigen

Elemental formula – 20kcal/oz – Elecare, Neocate