Sign Up
For the best experience, choose your profession & state.
You are not currently logged in. Please log in to CEUfast to enable the course progress and auto resume features.

Course Library

Breastfeeding

3 Contact Hours including 3 Pharmacology Hours
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Other, Registered Nurse (RN)
This course will be updated or discontinued on or before Friday, May 5, 2023

CEUFast, Inc. is an AOTA Provider of professional development, Course approval ID#02464.
This distant learning-independent format is offered at 0.3 CEUs Intermediate,
Categories: OT Service Delivery and Foundational Knowledge.
AOTA does not endorse specific course content, products, or clinical procedures. AOTA provider number 9575.

Outcomes

This course is designed to provide quality and current information about the benefits and challenges of breastfeeding so that healthcare professionals can assist lactating women in making and reaching breastfeeding goals.

Objectives

Upon completion of this course, the learner will be able to:

  1. Explain the benefits of breastfeeding regarding infant health and development, maternal health, and broader global benefits.
  2. Identify laws and initiatives that aim to preserve and promote breastfeeding.
  3. Recognize hospital or birth center practices and policies that promote breastfeeding.
  4. Describe four steps facilities can take to reach Baby-Friendly status.
  5. Characterize potential barriers to breastfeeding.
  6. Categorize clients who are most at risk of experiencing barriers to breastfeeding.
  7. Summarize the physiology behind lactation at various stages of infant feeding.
  8. Outline how to assess infant positioning, latch, and signs of effective milk transfer.
  9. Assess for and design individualized solutions for common problems encountered by breastfeeding mother-infant dyads.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

Last Updated:
CEUfast OwlGet one year unlimited nursing CEUs $39Sign up now
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Sarah Schulze (MSN, APRN, CPNP)

Introduction

Among the many approaches and beliefs regarding how to raise healthy and happy children, there is one constant that rings true in nearly all paradigms; feeding infants breast milk is one of the most beneficial choices a parent can make. The reasons to breastfeed are many, and the benefits can stretch well beyond a child's early years, with increased breastfeeding rates having the potential to impact global health on a profound scale.

The most current data regarding breastfeeding rates in the United States, from 2017, indicates that 84.1% of infants are breastfed at some point after birth, but only 58.3% of those infants are still breastfeeding at six months and 35.3% at one year (CDC, 2020). The Healthy People 2030 objectives for breastfeeding are to increase those rates and the public health benefits that come with them. To increase the breastfeeding initiation and continuation rate, women must have adequate information and resources available, including knowledgeable and readily accessible healthcare professionals through every stage of pregnancy and lactation. With a mid-century decline in breastfeeding rates in the 1900s, when the popularity and availability of infant formula increased, there are now several generations of women who have little to no breastfeeding experience. The proverbial " village" of motherhood is often lacking quality breastfeeding advice for modern mothers. Because of this, much of the responsibility to help educate and support lactating women falls on healthcare professionals. The need for practical, accurate, and consistent breastfeeding advice is a necessity for anyone working with pregnant women, new mothers, or infants and children.

This course aims to present current and applicable information about breastfeeding and its challenges. The necessary professionals have the tools they need to make a positive and lasting impact on promoting and protecting breastfeeding in a modern world.

The Gold Standard: Why Breastfeeding Is So Beneficial

It is common knowledge that breastmilk is good for babies, but what exactly is beneficial about this liquid gold? Breastfeeding is a biological norm; breast milk is custom-made for exactly what each mother-baby dyad needs. While synthetic products may be used for adequate caloric intake, no substitutes can provide the biological and psychological advantage of breastfeeding.

Perhaps one of the most beneficial aspects of breastmilk is its immunological properties. During pregnancy, antibodies are passed from mother to baby through the placenta, and these antibodies continue to circulate in the infant's body for several weeks after birth. For breastfed infants, the protection from viruses and bacteria does not stop there, and new antibodies are received each time the infant consumes breastmilk. The antibodies found in breastmilk can change daily based on microorganisms a lactating mother encounters throughout her day, including those that the baby has been exposed to and passes to the mother during feeding. Small amounts of the baby's saliva received through the skin of the nipple are scanned by the mother's immune system and, if any pathogens are found, appropriate antibodies may be included in the breastmilk by the next feeding (La Leche League, n.d.c). As a result of these immune properties, breastfed infants experience fewer illnesses and visits to the doctor's office, urgent care centers, and hospitals. Breastfeeding reduces the rate of common childhood conditions such as (La Leche League, n.d.c):

  • Ear infections
  • Upper respiratory infections (colds)
  • Lower respiratory infections (pneumonia, croup, bronchiolitis, etc.)
  • Allergies
  • Gastroenteritis
  • Obesity
  • Diabetes
  • Childhood cancers
  • And even SIDS

Children are usually several years old before their immune systems are fully developed. Still, with breastmilk support, any illnesses they do experience are generally less severe and have a shorter duration (La Leche League, n.d.c).

Breastmilk also has many nutritional benefits and is customized for each baby's particular needs. All breastmilk comprises some combination of proteins (whey and casein), fat, vitamins, and carbohydrates. The exact composition changes as the baby grows and even changes throughout the day or within the same feeding, depending on the baby's needs. During the first few days of life, babies receive colostrum which is dense in calories and antibodies. Only small amounts of colostrum are needed to fill a newborn's small stomach and meet their nutritional needs with each feeding. It is easily digested and acts as a laxative to help clear meconium from the baby's intestines (La Leche League, 2018b). Over the first few weeks of life, breastmilk transitions to be thinner and primarily carbohydrate-based. Nighttime milk has been found to have higher fat content than milk produced during the day and contains tryptophan and melatonin, which helps the baby develop a more regular sleep/wake pattern (Tilman, 2015).

Babies born prematurely can benefit greatly from breastmilk. Preemie milk has been found to have a different combination of protein, minerals, and fat than term milk and is calorically dense, easier to digest, and promotes brain function, neurological tissue, and eyesight development, all of which are beneficial to premature infants. It is also packed with antibodies that reduce the occurrence of serious conditions common with prematurity, like necrotizing enterocolitis (Stanford Children's Health, n.d.).

The health benefits of breastfeeding extend far beyond infancy as well. Children, teens, and even adults who were breastfed as infants experience lower rates of:

  • obesity
  • dental caries
  • cancer
  • diabetes
  • asthma and allergies
  • cardiovascular disease
  • autoimmune diseases

Higher IQ levels, better speech development, and school performance are also noted in breastfed children. However, this may be heavily influenced by socioeconomic status in addition to just infant feeding methods (La Leche League, n.d.c). Infants and children receiving breastmilk are also found to have better social and emotional development and improved attachment security to their mothers than formula-fed peers (Krol and Grossman, 2018).

Breastfeeding does not just benefit babies. It also has many protective factors for mothers as well. Women who have breastfed experience lower rates of cancers of the reproductive tract and breasts, and decreased risk of diabetes and cardiovascular disease (La Leche League, n.d.c). Studies show higher rates of mother-infant bonding, lower maternal stress, and reduced rates of postpartum depression in mothers who breastfeed (Krol and Grossman, 2018).

Bigger Picture: Impacts of Breastfeeding on a Global Scale

In addition to all of the health benefits breastfeeding affords to individual babies and their mothers, there is also a broader impact to consider. In 2019, a child and maternal health initiative called Alive and Thrive developed a data analysis tool, The Cost of Not Breastfeeding tool, to synthesize data regarding human and economic costs in relation to current breastfeeding rates. The tool can be used by breastfeeding advocates and legislators when considering health initiates and how breastfeeding can affect regional and global health and economics (Walters et al., 2019).

The tool's recent analysis indicates that, globally, nearly 600,000 childhood deaths from diarrheal illnesses or pneumonia could be prevented each year by breastfeeding. Additionally, a staggering 974,956 cases of childhood obesity and 98,238 maternal deaths from breast and ovarian cancers are attributed to a lack of breastfeeding each year.

Globally, this is equivalent to $1.1billion in healthcare treatment costs and $53.7billion in future earnings lost from children and women who died unnecessarily. Using data that suggests non-breastfed children grow up to earn less money than their breastfed peers due to cognitive differences, the tool also calculates a $285.4billion loss in earnings each year. Combined, this all comes out to a whopping $341.3billion economic loss each year, all from unmet breastfeeding goals (Walters et al., 2019).

Breastfeeding is also an excellent way to protect the ecosystem and is a free, sustainable, and essentially waste-free feeding method. The use of infant formulas creates greenhouse gases, pollution, and waste throughout every stage of manufacturing, packaging, marketing, and transporting. It requires energy and creates waste to mix formula, refrigerate or heat it, and sterilize bottles. A significant amount of plastic waste from bottles, nipples, and formula packaging winds up in landfills and oceans. Conversely, breastfeeding requires none of those things and has a nearly undetectable carbon footprint, mostly from increased food and water consumption needed by lactating women (La Leche League, 2020).

The effects of breastfeeding on a woman's reproductive system are also eco-friendly. Breastfeeding can often suppress ovulation and helps with pregnancy spacing and smaller family sizes. Population control is especially important in areas where resources may be scarce. Lactating women often do not resume their periods for an average of 14 months while breastfeeding, which can greatly reduce the amount of waste from sanitary products used during menstruation (La Leche League, 2020).

Breastfed infants also require around 15% fewer visits to a healthcare provider each year, freeing up valuable and limited healthcare resources. The reduction in rates of obesity, cancers, and diabetes has a similar effect, using up fewer resources and producing less strain on the healthcare system (La Leche League, 2020).

Breastfeeding Goals and Initiatives

With all of these potential lives and money-saving benefits, it only makes sense that protecting and promoting the biological norm of breastfeeding would be a huge public health initiative and the focus of national and global health goals.

While the reasons for less-than-ideal breastfeeding rates vary by global region, some of the biggest contributing factors over the years in the United States include:

  • lack of breastfeeding knowledge for women before, during, and after pregnancy
  • lack of appropriate and timely breastfeeding resources and assistance
  • lack of protection for breastfeeding mothers at work or in public
  • decades of unregulated lobbying and marketing practices from the formula industry

Thankfully, in recent years much of this has been identified as problematic, and there are slow but measurable steps being taken in the right direction for breastfeeding advocacy.

On a global scale, the World Health Organization (WHO) and United Nation's Children's Fund (UNICEF) has developed guidelines for the Baby-Friendly Hospital Initiative (BFHI), which aims to increase breastfeeding rates by ensuring healthcare facilities have the knowledge and tools in place to provide the information and help women need to breastfeeding successfully. Since many women begin their breastfeeding journeys at hospitals and birthing centers, it seems these are the best places to reach them and promote breastfeeding.

The BFHI is made up of 10 steps, and the WHO calls upon participating countries to create their organizations, policies, and standards to implement the program. Since its launch in 1991, the program has been adopted by 152 countries and is being implemented at more than 20,000 facilities worldwide (World Health Organization, n.d.). Multiple studies since the program began to support its success in increasing breastfeeding initiation and exclusivity rates. Studies also support that the closer a facility adheres to the program, the better success and longevity their mother's experience on their breastfeeding journeys (Munn et al., 2016). The ten steps of the BFHI are as follows (World Health Organization, 2018):

  1. Have written policies on infant feeding and routinely communicate these standards to staff and patients
    1. Included in this should be full compliance with the International Code of Marketing of Breastmilk Substitutes
    2. This policy should include ongoing monitoring and data management
  2. Ensure that all staff have proper training and skills related to breastfeeding and can provide competent breastfeeding-centered care
  3. Provide pregnant women and their families with information about the importance of breastfeeding
  4. Prioritize skin-to-skin contact immediately after birth (when possible) and encourage mothers to initiate breastfeeding within the first hour of life (known as the Golden Hour)
  5. Show mothers how to breastfeed and navigate common challenges
  6. Do not give newborns any food or drink other than breastmilk unless medically necessary
  7. Practice rooming-in and allow mother and babies to remain together 24 hours a day unless separation is medically necessary
  8. Teach mothers about hunger cues and encourage feeding-on-demand
  9. Discuss the risks of using pacifiers or bottles while trying to establish breastfeeding
  10. Coordinate access to breastfeeding support resources once discharged from the facility

In the United States, this program is adopted and implemented via Baby-Friendly USA. CDC tracking of breastfeeding rates over the last several years indicates that BFHI has, at least in part, contributed to improving breastfeeding initiation, exclusivity, and longevity (Figure 1) (CDC, 2020).

Figure 1: Percentage of U.S. Children Who Were Breastfed, by Birth Year, National Immunization Survey, United States (Percentage ± half 95% Confidence Interval)1,2, 3

Birth Year
 20102011201220132014201520162017
Ever Breastfed76.7±1.279.2±1.280.0±1.281.1±1.182.5±1.183.2±1.083.8±1.284.1±1.0
At 6 months47.5±1.449.4±1.551.4±1.551.8±1.455.3±1.457.6±1.457.3±1.658.3±1.4
At 12 months25.3±1.326.7±1.329.2±1.430.7±1.333.7±1.335.9±1.336.2±1.535.3±1.4
Exclusively through 3 months37.1±1.440.7±1.543.3±1.644.4±1.446.6±1.446.9±1.447.5±1.646.9±1.4
Exclusively through 6 months17.2±1.218.8±1.221.9±1.422.3±1.124.9±1.324.9±1.225.4±1.325.6±1.2
  1. Data from 2010 to 2015 births were based on landline and cellular telephone sampling and data for 2016 births and onwards were based on cellular telephone sampling only. See Survey Methods for details and data prior to 2010 at Data, Trends, and Maps.
  2. Data from U.S. territories are excluded from national breastfeeding estimates to be consistent with the analytical methods for the establishment of Healthy People 2020 targetsexternal icon on breastfeeding.
  3. Exclusive breastfeeding is defined as ONLY breast milk—NO solids, water, or other liquids.

The Healthy People 2030 objectives for breastfeeding include increasing the exclusivity rate at six months to 42.4% and increasing the percentages of infants breastfed in any capacity at 12 months to 54.1% (ODPHP, n.d.). The CDC works to achieve these goals in several ways, including(CDC, 2019c):

  • Tracking breastfeeding data
  • Tracking data for how well states and birthing facilities support breastfeeding mothers
  • Supporting the 10 step Baby-Friendly Hospital Initiative
  • Implementing a call to action from the Surgeon General for nurses and doctors to support breastfeeding
    • Utilize opportunities for learning about breastfeeding and stay up to date on best practices for supporting lactating women
    • Talk with mothers early in pregnancy, throughout pregnancy, and after birth about the benefits of breastfeeding
    • Make breastfeeding support a part of standard care in the hospital setting and clinic setting after birth
    • Create breastfeeding support teams within the hospital or clinic setting and include certified lactation consultants for the highest quality resource
    • Know and utilize community resources for lactation support once mothers leave the hospital
    • Follow the International Code for Marketing of Breastmilk Substitutes and avoid advertising for a formula of giving out free samples
  • Partnering with states to help employers meet standards for pumping breaks and appropriate spaces for pumping and milk storage
  • Recognizing those mothers less likely to have appropriate breastfeeding support (such as Black mothers) and promote the development of and access to community resources for breastfeeding

In recent years, state and federal legislature has also changed to support breastfeeding women in public and the workforce. Under the Affordable Care Act in 2010, the Fair Labor Standards Law of 1938 was amended to require all employers to provide reasonable break time for employees to express milk whenever needed. The new law also requires employers to provide a clean and private space that is not a bathroom for milk expression. Additionally, under the ACA, insurance plans must cover supplies and services related to breastfeeding, such as breast pumps and lactation consultation appointments. In 2019, the Fairness for Breastfeeding Mothers Act was passed, requiring certain public spaces to have clean and private "lactation rooms" for the public to use for breastfeeding or pumping needs. At the state level, all 50 states and the District of Columbia, Puerto Rico, and the Virgin Islands protect the right of women to breastfeed in any public or private space. This legislation aims to promote and protect breastfeeding and helps avoid barriers to women successfully meeting their breastfeeding goals (National Conference of State Legislatures, 2020).

Entrenched in some controversy in the United States is the International Code of Marketing of Breastmilk Substitutes. This list of rules was developed by the WHO in 1981 and is intended to regulate the marketing of breastmilk substitutes, primarily formula, so that marketing ploys for baby-food companies do not undermine breastfeeding. Included in the Code are provisions such as (WHO, 1981):

  • Product advertising, free samples, discounts, and promotions targeted towards pregnant or new mothers are prohibited
  • Product representatives may not contact mothers
  • Warning labels that products are not comparable to breastfeeding must be included on products
  • Healthcare workers should encourage and protect breastfeeding and should only factually discuss substitutes and not promote the use of such products
  • Formula manufacturers may not provide gifts or monetary compensation to healthcare workers who might, in turn, promote their products
  • Product advertisements may not be displayed at healthcare facilities
  • Product labeling cannot contain words such as "humanized," which implies the product is equivalent to breastfeeding
  • Product labels must contain a written warning about the potential risk of contamination with microorganisms

The Code was developed for international use, and 84 countries signed when it was originally written. Still, due to heavy lobbying by formula companies, it was not adopted by the United States until 2010, and even then, no legislation was enacted to enforce it. The present date serves as guidance for facilities that utilize the Baby-Friendly Hospital Initiative but is not enforceable by law - there are widespread violations by the baby-food industry (Walls, n.d.).

Barriers to Breastfeeding

Despite overwhelming evidence to support the benefits of breastfeeding and the somewhat renewed energy being put into supporting it, many women in this country still struggle with a series of barriers to successfully breastfeeding their infants. Health care providers must be aware of these and work to minimize their impact on mothers attempting to breastfeed. The majority of these barriers fall into a few main groups:

  • Lack of knowledge: While "breast is best" is often touted by healthcare professionals and most women are aware that breastfeeding is beneficial to infants, many women do not understand the risks of not breastfeeding and may even feel that modern infant formula is equivalent to human milk. Additionally, many women do not realize that successful breastfeeding is a skill that must be learned by both mother and baby and takes some time to establish. Early feeding struggles may discourage mothers who feel that not immediately "getting it" means something is wrong or that they will never adjust, and so they give up (CDC, 2011).
  • Social norms: The popularity of formula in the mid to late 20th century means several generations of women have never breastfed, making bottle feeding and formula the norm for many households. A woman who decides to breastfeed may be met with a line of relatives who have no advice or support for her, having never breastfed themselves. Poor adherence to The Code also means that formula advertisements and samples are readily available to pregnant women and may influence their opinions early on about what is "popular,” “normal," or what "most" women are doing to feed their babies (CDC, 2011).
  • Among the most frequently encountered barriers is low-income family or social support, which lacks support from the mother's family and social supports. Women who have friends and family in their circle who breastfeed are much more likely to breastfeed their children. The family's lack of support may be because the woman's family members did not breastfeed themselves or attempted to but stopped before meeting their original goals. Family members may not value breastfeeding because they do not understand the health benefits or want a role in feeding and bonding with the baby (CDC, 2011).
  • Embarrassment: While the last few years have seen an increase in acceptance of public breastfeeding and support in legislation for mothers to feed their infants anywhere they choose, the damage of decades of shaming women for “public indecency” and society's view of breasts as sexual objects has created a sense of embarrassment for many women who might need to feed their infants in a public place. The increase of available spaces to breastfeed and normalize breastfeeding through social media and pop culture are steps in the right direction. However, for many women, the stigma is still difficult to overcome (CDC, 2011).
  • Employment issues: Maternity leave in the United States is notoriously short compared to other countries. The lack of quality time at home with a new infant can greatly impact a woman's ability to establish breastfeeding and build an adequate supply. Even for those women who are successful in breastfeeding while on leave, a return to work means now she must find the time to express milk and keep up with her infant's feeding demands while away. Even with a law mandating dedicated lactation breaks and spaces at work, women may feel pressured to skip pumping breaks instead of job performance (CDC, 2011).
  • Issues with healthcare services: Healthcare providers who are not appropriately educated to assist breastfeeding families also represent a barrier to breastfeeding. During pregnancy, mothers may not receive adequate information about feeding choices to make a truly informed decision if their healthcare providers are ill-equipped to answer questions about breastfeeding. Once the baby has arrived, mothers may struggle with breastfeeding if healthcare providers cannot properly address any difficulties or questions or if each different nurse or provider gives varying advice. Additionally, failure to understand the physiology of lactation can lead providers to give a parent the wrong advice and potentially damage the mother's ability to breastfeed, for example: if a nurse offers to keep the baby in the nursery for the night and give the baby a bottle so that the mother can sleep (CDC, 2011).
  • Problems with lactation: The early days of lactation may present many common problems such as engorgement, nipple soreness or cracking, plugged ducts, mastitis, improper latch, and exhaustion in the mother. These issues are easily addressed with minor adjustments and reassurance (worries over inadequate supply are typically unfounded, especially in the early days when colostrum in small quantities is completely normal). Actual problems with supply or oropharyngeal problems that inhibit a proper latch (such as cleft palate) do exist. They must be addressed appropriately, but these issues are rare, and the majority of breastfeeding challenges can be successfully addressed by a skilled lactation consultant (CDC, 2011).
  • Cultural/Racial disparities: It is also important to note the need for racially sensitive practices to help mothers breastfeed successfully. Black women are disproportionately affected by poor breastfeeding initiation and continuation rates due to a myriad of factors, including:
    • generational trauma from enslaved women being used as wet nurses
    • lack of quality healthcare education about the benefits of breastfeeding
    • lack of social/family and healthcare support when Black women do attempt to breastfeed

In 2015, data indicated that 69.4% of Black women initiated breastfeeding in the hospital compared to 85.9% of white women, and 44.7% of Black infants were still breastfed at six months compared to 62% of white infants. Awareness of these disparities is important for all healthcare professionals working with lactating women, particularly those working in areas with large populations of Black women. Efforts for Baby-Friendly policy implementation, community support, and healthcare worker education and sensitivity should be at the forefront of maternal and child health efforts in these communities (CDC, 2019b).

Lactation Support- The Role of the Healthcare Professional

Understanding Lactation

To provide high-quality support and care to breastfeeding women, healthcare professionals must first have a solid grasp of the physiology behind lactation. The anatomy of breasts includes two main parts, lobules and ducts (Figure 2). Lobules are clusters of tiny sacs called alveoli that fill with milk during lactation. The lobules are connected by small tubes called ducts which carry milk from the lobules to the nipple. Lobule development first occurs during puberty when estrogen and progesterone levels begin to fluctuate with menstruation. Young women in their teens will have lobules that are small in size with few alveoli, known as Type 1 Lobules, and increase to slightly larger lobules with more alveoli, known as Type 2 Lobules, by the end of puberty if pregnancy has not occurred. During early pregnancy, the increased exposure to progesterone causes large clusters of alveoli, Type 3 Lobules, to develop, and the epithelial cells lining them mature, preparing to secrete milk (Pillay and Davis, 2020).

Figure 2:

lactating_breast

All women experience lobule development once puberty begins, but only women who experience pregnancy will have lactogenesis. Lactogenesis is the process by which alveolar cells mature and secrete milk (Figure III). Lactogenesis I, or secretory initiation, begins around 16-20 weeks gestation. The high levels of progesterone supplied by the placenta help mature the epithelial cells of the alveoli, and colostrum secretion begins in small amounts. Some women can even leak or express colostrum before delivery, though the ability to do this has nothing to do with breastfeeding success after delivery. Once the placenta is delivered after birth, there is a sharp drop in progesterone levels, accompanied by an increase in prolactin, cortisol, and insulin which stimulate lactogenesis II, or secretory activation, and the body begins to make an increased (and often overabundant) supply of milk around 2-3 days after delivery. Lactogenesis II may be delayed slightly in women who have never lactated before, resulting in a lower initial milk volume or closer to 3-6 days for full milk volume to come in; this is completely normal. This process may be interrupted by anything that disrupts the hormone response following delivery, such as retained placenta fragments, cesarean deliveries, diabetes, or difficult vaginal deliveries. Lactogenesis I and II are hormonally driven and occur whether a woman chooses to breastfeed her baby (Pillay and Davis, 2020).

Suppose a baby is put to breast and nipple stimulation occurs via sucking, around postpartum day 10-14. In that case, milk production regulates and moves into Lactogenesis III, maintained through a supply and demand process involving the hormones prolactin and oxytocin. During lactogenesis III, the number and size of lobules reach their highest capacity, known as Type 4 Lobules. Nipple stimulation and emptying of the lobules stimulate the anterior pituitary to secrete prolactin, the hormone responsible for milk production. Nipple stimulation also triggers the release of oxytocin from the posterior pituitary. This hormone triggers the contraction of the tiny muscles around the alveoli, pushing milk from the lobules into the ducts and out through the nipple via the milk ejection reflex. Oxytocin release also provides mothers with a sense of calm and relaxation and increases bonding with the baby during feedings (Pillay and Davis, 2020).

Continued milk production becomes an autocrine function, dependent on supply (if the breasts are full or being emptied) and demand (if nipple stimulation continues). Prolactin secretion (and therefore milk produced) increases when the nipples are stimulated but decreases when the breasts are unemptied and pressure builds within the lobules. Milk secretion is fastest when the breasts are empty; therefore, frequent or on-demand feeding is the best way to increase milk production. Breasts that are full or not being emptied completely or as often will produce milk at a slower rate (Pillay and Davis, 2020).

As long as milk removal and nipple stimulation continue, a woman will continue to lactate. Once milk removal slows or stops, such as with weaning, milk production drops off and eventually stops as well. Milk making epithelial cells within the alveoli die off, and the breast tissue shrinks back to mostly type 2 and 3 lobules until the next pregnancy; this is called Lactogenesis IV (Pillay and Davis, 2020).

Figure 3
Phases of LactogenesisBreast Changes
Lactogenesis IBegins around week 16 of pregnancy. Epithelial cells mature and begin to secrete colostrum.
Lactogenesis IIHormonal shift triggered by birth increases the volume of milk produced, usually around four days postpartum.
Lactogenesis IIIMilk production shifts to autocrine control and is based on supply and demand from around ten days postpartum until weaning occurs.
Lactogenesis IVMilk production decreases, epithelial cells decrease in number, and breast tissue involution occurs.

Assessment of Mother/Baby Dyads

Besides a proper understanding of the normal lactation process, it is extremely important to gather a thorough history of each mother's history surrounding her general health, pregnancy, and delivery to properly care for her individual breastfeeding needs. Many important factors may affect a woman's breast anatomy, hormone secretion, and progression through the phases of lactogenesis and may affect her plan of care. Historical information that should be assessed includes(Wagner, 2021):

  • Mother's medical history and current medications she may be taking
  • History of any breast problems or procedures: mastitis, augmentation, reduction, cancer, etc
  • Mother's obstetrical history: including all past pregnancies and the most recent one
  • History of labor and delivery with this infant: medications during labor, length of labor, delivery method, any complications
  • Past breastfeeding experiences for mother: how many other infants has she attempted to breastfeed, what were those experiences like/how long did she breastfeed, how does the mother feel about them
  • Infant birth history: gestational age at birth, weight, any complications or NICU stay
  • Feeding of an infant so far: put to the breast within the first hour of birth, support in the hospital, any formula/bottles/pacifiers given at this point, understanding of infant hunger cues, how often feed/feeding on demand
Figure 4
Factors that can reduce supply or breastfeeding success
  • Maternal medication (beta-blockers, antihistamines, epinephrine, corticosteroids, methergine, antipsychotics, hormones)
  • Breast reduction or augmentation
  • Labor induction (increased risk of intervention)
  • Narcotics are given close to delivery (baby may be born sleepier because of this)
  • General anesthesia
  • C-section
  • Retained placenta
  • Maternal exhaustion from long or difficult labor
  • Lack of skin to skin or breastfeeding attempt within an hour of birth
  • Poor confidence from mother, previous failed breastfeeding attempts
  • NICU admission
  • Prematurity or illness in infant or mother
  • Supplementing regularly and skipping feedings at the breast

 

Support with Latch and Establishing Lactation

Special effort should be made for those professionals who work directly in Labor and Delivery to support the Golden Hour when possible. This is where an infant is placed skin to skin with its mother as soon as possible after birth and left uninterrupted to bond and feed; ideally, this occurs within the first hour after birth, if not immediately. Skin-to-skin contact has a calming and regulatory effect on both infant and mother and helps stabilize vital signs for both after delivery. If left alone, infants will go through a period of being highly alert and calm and will even scoot or "crawl" across a mother's chest or abdomen to find the breast and latch. This first feeding is incredibly important to coincide with the hormone shifts experienced by the mother after birth and help move towards Lactogenesis II and give the baby that first feeding of colostrum before they enter a period of deep sleep following birth. It is much easier to help coach new mothers in breastfeeding when the infant is alert and cooperative, and this is the perfect time to get the infant started feeding and stooling for optimum health (La Leche League, n.d.b).

For most other healthcare professionals, you will encounter breastfeeding women and their babies later on in their breastfeeding journey, usually hours, days, or even weeks after birth and those first initial feedings. Lactation may already be affected by perceived problems, ineffective habits/practices, and frustration or discouragement in the mother. It is important to approach the process with patience and optimism and remind mothers that this natural act does not necessarily occur naturally. She and her baby are learning and practicing together to get it right. Assisting mothers during the first two weeks of lactation affords the most opportunity to help establish good practices. Still, the latch and mother-baby relationship can be adjusted and improved at any time in the breastfeeding journey. All interventions should be made in gentle suggestion and guidance rather than abrasive action that may make a mother feel she is not in control or may violate her personal space. Always ask permission before touching a woman's breast or touching her baby to adjust positioning (Wagner, 2021).

Once historical data has been collected, the healthcare professional should observe a feeding. Ideally, the area for lactation support will be private, relaxing, and comfortable seating. Watch how the mother interacts with her baby, is she nervous or uncomfortable handling them? Does she seem stressed or relaxed, frustrated or patient? Assess a mother's understanding of hunger cues; rooting, sucking on hands, alert but quiet, etc. Teach mothers that crying is a late sign of hunger and that a frustrated and very hungry infant will be much more difficult to get to latch effectively (La Leche League, 2021b).

Once you are ready to assess a feeding, allow the mother to get comfortable and position the infant, you may even hand her the baby once she is seated comfortably. There are various possible positions, and mothers should try different ones to see which they find most comfortable. Regardless of position, a baby should be turned towards the mother, with the ear, shoulder, and hip aligned to achieve and proper latch and transfer milk effectively (La Leche League, 2021b). Common positions are outlined below.

Cradle Position: Commonly used in the first weeks. Baby's head rests on the mother's forearm on the same side as the breast he is feeding on, and her arm and palm cradle his back. The mother's opposite hand supports her breast in a C shape and helps guide it into the baby's mouth (La Leche League, 2021b).

cradle_hold

Cross Cradle Position: This is a variation of the cradle position, and many mothers find it useful during the first weeks. The baby should be supported on a pillow across the mother's lap. Using the hand opposite the breast, the baby is feeding on. The mother should support the baby's head and neck by placing her hand in a C shape behind his neck near the ears. The hand on the same side as the breast should be holding the breast (La Leche League, 2021b).

cross_cradle

Clutch or Football Position: This position is good for mothers who have had a C-section, as it keeps the baby off of the mother's abdomen. The baby should be positioned along the mother's side, with legs and feet tucked under the mother's arm, with hips flexed and soles pointing upward to avoid the baby kicked off the chair behind him. The baby's feet are on the mother's side on the same side, and the mother can support his head with the same-sided hand. The mother's opposite hand can support the breast (La Leche League, 2021b).

clutch_football_hold

Side-lying Position: This position may require more practice, and many mothers may not find it useful until they have mastered other positions. This position may be more comfortable and help mothers rest during nighttime feedings. Mother and baby should both lie on their side facing each other. The baby should be cradled in the mother's bottom arm and feed from the bottom of the breast. The baby should have hips flexed, and the mother may be more comfortable with a pillow between her legs or behind her back. She can use her top hand to support the breast if needed (La Leche League, 2021b).

side_lying

Once a comfortable position for mother and baby has been achieved, it is time to assist with the latch. A deep latch is necessary for the proper transfer of milk and to avoid damaging the skin of the nipple. Since the tongue is in the bottom half of the baby's mouth, the deepest latch is achieved by aiming the nipple slightly higher towards the roof of the baby's mouth. Have the mother tickle the baby's mouth with the nipple until he opens his mouth wide. Allow the baby to tip his head back and bring the baby close to the breast. The baby's chin should touch the breast first, and then, once he is latched, his nose should nearly touch the breast as well. The lips should be flanged outward and the mouth opened to a wide-angle (ideally around 140 °). Initially, the baby will suck quickly without swallowing while he positions the nipple and waits for milk to let down. Once the milk is flowing, the baby's sucking should slow, and you will be able to hear him swallowing. The baby's jaw should move in a rocker motion, not up and down, and he should suck in irregular bursts of around two sucks per swallow (La Leche League, 2021b).

Figure 5:

breastfeeding_latch_on

If the latch feels uncomfortable at any point, the mother should be instructed to break the latch and start over. Let the mother know that practicing and correcting an uncomfortable latch is completely normal and how good breastfeeding habits are achieved. There is no shame in it taking time to get it right. Allowing a baby to continue with an improper latch will only lead to nipple trauma and more pain in the long run (La Leche League, 2021b).

Assessing Effectiveness

Even when a proper latch has been achieved, many mothers worry that their infant is not feeding properly or getting enough milk. When an infant takes a bottle of formula or expressed milk, it is easy to visualize just how much milk they have taken. However, the same assessment is not possible when feeding at the breast. There are many other ways to assess that an infant is effectively transferring milk and getting adequate nutrition. Mothers should be cautioned to assess these factors rather than getting caught up in knowing "how much" an infant is eating each feeding. These assessments are also useful for healthcare professionals monitoring the infant's health and ensuring proper growth in the first few weeks and months of life.

  • Urine output: During the first day or two of life, newborns may not produce much urine, but after that, well-hydrated infants should have 8-10 wet diapers per day (La Leche League, 2021a).
  • Stool transitioning: During the first few days of life, an infant's stools transition from tarry meconium to soft, yellow, and seedy. This transition is a good indication that the baby is transferring adequate milk. By four days old, most babies are having several stools per day. Around one month of age, the intestines begin to mature, and breastfed infants may decrease the number of stools per day. This is because breastmilk is so high in nutrient content that there is very little waste. As long as stools are soft, this is not causing concern (La Leche League, 2021a).
  • Satisfied in between feedings: Infants should be relaxed and sleeping often in the first few weeks of life, waking only to feed and for intermittent periods of alertness. Sleeping or being content after feedings are good signs that the infant's hunger has been satisfied for the time being. Often it is observed that an infant will begin feeding with a clenched fist but finish a feeding with a relaxed and open hand. While it is recommended that infants be fed at least every 3 hours (or 8-12 times per day), breastfed infants certainly can be fed more often if they are exhibiting hunger cues, and feeding on demand is an important part of establishing supply. Mothers should be reassured that wanting to eat often, but being satisfied between feedings, is perfectly normal and not a sign of inadequate supply (La Leche League, 2021a).
  • Weight gain: It is normal and expected for all newborns to lose some weight within the first few days of life, typically no more than 10% of their birth weight. After the first week, most infants begin gaining weight at a rate of around an ounce per day and should be back to their birth weight by two weeks of life. Adequate weight gain is a good indication that infants are getting enough to eat at the breast. Tracking infant growth on a standard growth chart may be useful as the baby grows, but pay close attention to the type of growth chart being used. CDC growth charts are made using decades of data from primary formula-fed infants in the United States, who grow at different rates than breastfed infants (typically bigger weights more quickly). WHO growth charts compile data from children worldwide, where breastfeeding is much more prominent, so breastfed infants should be plotted on a WHO growth chart for a more accurate representation of their growth in relation to the "norm" (La Leche League, 2021a).

It should be noted that pumping can be used to relieve discomfort from engorgement, start storing milk for a return to work, or allow others a chance to feed the baby once breastfeeding is well established. Still, pumping is not an accurate depiction of supply. Often pump flanges are ill-fitting, or pump settings are not being used correctly. Mothers are not even aware of this, resulting in an inaccurate representation of how much milk can be removed from each breast. Further, the average pump is not as efficient and does not elicit the same hormonal response from the mother as directly feeding her baby. Mothers should be cautioned to observe their infants for the above signs of adequate feedings rather than using pumped milk amounts as a gauge of their supply (La Leche League, 2021a).

Troubleshooting Common Problems

One of the biggest determinants for a woman's meeting her breastfeeding goals is the amount of support she receives, particularly when encountering problems. Healthcare professionals play an important role in providing that support and helping women navigate common issues that may arise during a breastfeeding journey. Some of the most common issues and their solutions are listed below.

Painful or cracked nipples: Some soreness in the early days is normal, but persistent pain or cracked and bleeding nipples is typically due to improper or shallow latch and will continue to worsen if the latch is not corrected. Observe a feeding and identify the aspects of the latch that need adjusted and coach the mother through how to do this. Encourage her to check to latch every feeding until good habits are established.

Nipple creams, frequently changing breast pads, and breast shells (not the same as nipple shields) may be helpful with healing. Encourage trying different feeding positions throughout the day so that the infant's gums rotate where they are coming in contact with the nipple and not irritating the same spot every feeding (Wagner, 2021).

Flat or inverted nipples: First, remind mothers that the size and shape of the nipple are mostly irrelevant once the baby takes breast tissue into his mouth. With a proper latch, the baby should pull the skin of the nipple and breast into the back of the mouth, forming a teat and sucking milk out that way, regardless of nipple shape. However, learning how to draw the nipple out and properly latch can still be a learning curve for newborns. Some methods to help mothers elongate their nipples before feeding include wearing breast shells inside the bra, pumping before feeding, and nipple stimulation. Breast shields are a potential temporary solution but difficult to break and should not be the first solution offered (La Leche League, n.d.a).

Plugged Ducts/Mastitis/Breast Infection: Sometimes, the flow of milk becomes blocked within the duct, and the breast may become red, tender, or have a hardened area; this is referred to as a plugged duct. Usually, gentle massage, warm compress, drinking water, and frequent feedings (and trying different positions) will clear a plugged duct up quickly.

Sometimes the blockage persists, and an entire section of the breast becomes affected, resulting in increased tenderness, redness, and more systemic flu-like symptoms in the mother. This is known as mastitis. Bacteria may even begin to grow in the area of reduced milk flow, and mothers may notice purulent drainage or blood in their milk. All of the interventions of plugged ducts may be useful, ibuprofen and antibiotics as prescribed by a healthcare provider. Even if there is drainage or blood in the milk, it is safe for the infant to continue feeding, and avoiding feeding on that side may worsen the engorgement and infection or even lead to an abscess. While plugged ducts can be managed easily at home, women with suspected mastitis should be immediately encouraged to contact their healthcare provider (Wagner, 2021).

Poor weight gain or hyperbilirubinemia in the infant: When a breastfed infant does not gain well or becomes extremely jaundice, healthcare providers must strike a balance between giving the baby adequate nourishment and working to increase the mother's supply. Supplemental feeds may be necessary and help the mother commence pumping to support her supply to work toward providing all the breastmilk her infant requires for good growth. Failure to thrive and insufficient milk are complex problems that typically require collaboration between the primary care providers and certified lactation consultants (IBCLCs).

When healthcare providers suggest supplemental feedings for infants, it is important to advise the mother to continue to put the infant to the breast at each feeding before providing the supplement. Pumping is especially important if the infant does not drain the breasts well. The mother must try to simulate the work of the baby with pumping.

Advising a "triple feeding" plan-feed the baby at the breast, offer supplement, and pump the breasts will help support breastfeeding until the family can get in to see an IBCLC and the problems can be sorted out. Also, advise that the supplement offered may be expressed breastmilk in most cases and does not necessarily need to be formula (Wagner, 2021).

Return to work: Keeping the mother and infant together is the best way to support regular breastfeeding. However, this is not always possible, especially if the mother works outside the home. Breastmilk should be expressed when a mother is separated from the infant for an extended time. Expressing milk while separated helps to prevent engorgement and decreased milk supply. Expressed milk should be stored in a clean glass or polypropylene container, labeled with the date, cooled and refrigerated or frozen (DeMaggio, 2016).

Milk at room temperature can be kept for 4 hours optimally and 6-8 hours under very clean conditions. Fresh milk can be stored in the refrigerator for 5-8 days, thawed/fortified milk can be kept for 24 hours, and frozen milk can be stored for 6-9 months (DeMaggio, 2016).

Milk can be expressed by hand or by using a breast pump. Good handwashing is important anytime milk is expressed. Special attention should be paid to the flange's size; correct sizing of the breast flange will help the mother pump comfortably and express the most milk.

Some mothers may find that hand expression is easy and sufficient for their requirements. To express milk, manually put a container under the breast and massage the breast gently toward the nipple. Place a thumb about 1 inch back from the tip of the nipple, and the first finger is placed opposite. Press back toward the chest; gently press the areola between the thumb and finger; then release. Do this in a rhythmic motion until the milk flows or squirts out (La Leche League GB, 2016).

Teething/Nursing strikes
Many nursing mothers dread the appearance of teeth because they assume that the child will soon begin biting and end the nursing relationship. When a child bites at the breast, he is not breastfeeding, likely forgetting where he is and perhaps trying to soothe sore gums. Most children can be taught that biting is not acceptable. If the baby bites, the mother should respond quickly and firmly. A strong "NO!" and stern face, removal of the child from the lap, and the mother walking away for a period of even less than a minute will communicate that biting ends a feeding session (Wagner, 2021).

An infant who is truly ready to wean will usually do so gradually over weeks or months. If an infant has been breastfeeding well and suddenly refuses to nurse, it is probably a nursing strike. Advise mother that most nursing strikes are over within two to four days. They happen for many reasons, and the best plan is to work through the strike with persistence and patience while trying not to take it personally. Seeking out a quiet, dim room and avoiding unnecessary stimulation may be helpful as well (Wagner, 2021).

Birth control
Breastfeeding mothers with their infants full time and nurses on demand typically do not have menses for several months. Nursing tends to postpone fertility, though it is not recommended that breastfeeding women assume that they cannot get pregnant while nursing (La Leche League, 2018a).

Caution should be exercised when taking hormonal contraceptives. Some, not all, women find that using a birth control pill, shot, or IUD can reduce their milk supply. Women should talk with their healthcare providers about choosing the best option for their needs (La Leche League, 2018a).

Maternal illness/medications
Most, but not all, therapeutic drugs are compatible with breastfeeding. In general, the decision to use medications while breastfeeding should reflect the relative risks and benefits to both mother and child. For example, most antidepressants are only present in small amounts in breastmilk, and very little is detectable in infant serum. The mother who finds herself in need of the antidepressant can benefit greatly from it and be reassured that her infant is at very low risk. The nurse should check the available references and provide the family with the most current recommendations and the studies, if any, to support them (Mayo Clinic, 2020).

Typically, there is no need to "pump and dump" after most procedures, even if general anesthesia is required. The same is true for dental procedures, most radiological exams, including those with contrast. The breastfeeding mother can request a list of the drugs that will be used in procedures in advance and ask clinic staff to check the available sources so that she knows how to proceed. The Hale guide, Medications and Mother's Milk, and LactMed website or app are considered highly accurate and trusted resources for checking medication compatibility with breastfeeding (Mayo Clinic, 2020).

Special Cases

In addition to the common struggles and questions many lactating mothers face, there are some special circumstances that not all mothers experience. The potential issues here are numerous and many beyond the scope of this course, but listed below are a few of the more common special circumstances you may encounter.

Prematurity: Many studies show that human milk, either from a baby's mother or donor milk, is extremely beneficial to premature infants and helps reduce the occurrence and severity of complications such as necrotizing enterocolitis, sepsis, retinopathy, and more. Premature breast milk is a dynamic fluid composed of macro and micronutrients especially suited to meet the preterm infant's needs and provide endless benefits to the immature and vulnerable gastrointestinal tract and immune systems of preterm infants (Stanford Children's Health, n.d.).

If the infant can feed at the breast, that is ideal, and skin-to-skin contact may have added benefits to stabilizing the baby's vital signs and minimizing distress. Often, though, preterm infants cannot feed at the breast right away, and mothers will need to hand express or pump to supply their babies with breastmilk. Early and frequent hand expression followed by an efficient, comfortable mechanical pump in the early days post-birth can provide effective nipple stimulation to promote high levels of circulating hormones responsible for adequate milk production and ejection (Stanford Children's Health, n.d.).

Breastfeeding after breast surgery: The choice to breastfeed after breast surgery (augmentation or breast reduction) may require advice from a knowledgeable health care professional to avoid common misunderstandings by mothers and healthcare providers. Breast surgery can interfere with milk production and flow, blood flow, nerve response, and hormonal response because of incisions or scar tissue. The ability to breastfeed in these situations is entirely individualized and depends on what sort of damage occurred to the lobules and ducts due to the surgery (Wagner, 2021).

For women who have undergone a breast reduction, the amount of tissue remaining and the integrity of the ducts will determine if lactation is possible. Even if a mother with a previous reduction can breastfeed, she may need to supplement if her supply is inadequate (Wagner, 2021).

On the other hand, breast augmentation surgery may not interfere with breastfeeding at all. Typically, the implant is placed beneath the chest muscle, and there is little impact on the ducts. Incisions on the underside of the breasts typically result in less damage to the duct than incisions made around the nipple (Wagner, 2021).

Contraindications: Few contraindications to breastfeeding exist. Women who live in developed countries and are infected with the human immunodeficiency virus (HIV) or human T-lymphotropic virus type I (HTLV-I) should not breastfeed. Policy considerations may change over time as research in areas of the world demonstrate that breastfeeding did not increase HIV transmission in infants, but more studies are needed (CDC, 2019a).

Infants born to women who have active untreated tuberculosis should not breastfeed. Also, women undergoing chemotherapy or receiving antimetabolites or radioactive treatments should not breastfeed (CDC, 2019a).

Galactosemia, an inborn error of metabolism, is an absolute contraindication to breastfeeding. Infants with this disorder cannot utilize galactose, a component of the lactose sugar in human milk. Accumulation of galactose leads to adverse consequences, including failure to thrive, liver dysfunction, cataracts, and mental retardation. Breastfeeding is not contraindicated with other inborn errors of metabolism such as phenylketonuria, but infants should be monitored closely for their blood phenylalanine levels (CDC, 2019a).

Women who use street drugs should not be encouraged to breastfeed. Still, women undergoing a Methadone treatment program are encouraged to breastfeed to reduce the effects of drug withdrawal in the infant (CDC, 2019a).

Conclusion

The benefits of breastfeeding are numerous and well documented. Thankfully, the culture of support around breastfeeding seems to be trending in the right direction in the United States in the last few years. This country is still far from reaching its goals for breastfeeding rates, and efforts must continue to educate, support, and encourage women to experience breastfeeding success. Healthcare professionals are at the front lines of this effort and should take the responsibility to impact lactating women positively. While there are many more breastfeeding issues beyond the scope of this course, a basic knowledge of lactation, how it works, why it is important, and how to troubleshoot common issues is a great place to start to improve the health of society through mother's milk.

Case Study

Scenario: A first-time mother presents to the lactation clinic with her five-week-old infant. The mother is concerned about perceived low supply and slow weight gain in the infant. Mother is a healthy 27-year-old woman with a past medical history of mild exercise-induced asthma and a medication list of PRN albuterol. She reports a healthy pregnancy complicated by breech presentation and delivery by scheduled c-section at 39 weeks gestation.

The infant was first put to the breast at 90 minutes old once the mother was out of recovery. The mother reports the baby has latched well from the beginning, with occasional pain if his latch is shallow, but he is easily corrected and relatched. She reports that her supply began increasing around day five postpartum, and she was pumping after feedings to relieve engorgement. The infant gained weight well and had surpassed his birth weight by two weeks of age.

The mother reports that her milk supply seemed to level off around this time, and she stopped feeling engorged and so stopped pumping. She reports that she had quite a bit of stored milk collected, and the baby's father began using it for feedings during the night so that she could sleep uninterrupted. At the infant's four-week appointment at the pediatrician last week, it was observed that he was no longer gaining weight at an acceptable rate, and it was advised that the parents offer a supplement after each feeding.

The mother wanted to supplement with expressed breast milk but reports she could not get even an ounce of expressed milk after each feeding and has had to offer formula. She reports the baby is feeding around every 2 hours, sometimes up to 4 hours at night. One nighttime feeding is via bottle given by Dad where he takes 3 oz. He continues to latch well and feeds for around 10 minutes on each side. He is also taking 1-1.5 oz of formula after most feedings for the last week. He has 2-4 stools per day and 8-12 wet diapers per day.

A feeding is assessed in the clinic, and the mother seems comfortable handling the baby. He latches well, taking an appropriate amount of nipple into the top half of his mouth, lips flanged, and a rocker motion to his jaw. He can be heard sucking and swallowing. A weight check before and after the feeding shows a 1 oz weight gain. He does not seem completely satisfied after the feeding and is still somewhat fussy.

Interventions: The lactation consultant (LC) reassures the mother that the baby's latch is effective but cautions that some of his current feeding habits may be contributing to a decrease in supply. The LC reviews some of the physiology of supply and demand and works with the mother to create a plan to maximize this pattern. Points reviewed include:

  • Breasts that are emptied regularly will produce more milk more quickly. Skipping feedings and allowing milk to build up in the breasts will slow the production of milk. Any time others feed the baby, the mother should express milk to empty the breasts and signal to the body that more milk is needed.
  • Attempt to express milk after each feeding to signal a higher demand and increase supply. Check flange sizes on the pump and swap out for an appropriate size if they do not fit correctly. Consider hand expression as an alternative method of expression as well.
  • A surplus supply during lactogenesis II is fairly normal. It does usually level off during lactogenesis III, so the goal will be for the infant's weight gain to increase and to be able to stop formula supplements, not necessarily to return to a surplus of pumped milk.

Outcome: The mother enacts the above plan and returns in 2 weeks for reassessment. At that time, she reports that the baby's father is still doing one nighttime feeding but waking to pump once as well. She hand expressed milk after most feedings for the first week until she was able to get around 1 oz of extra milk. At that point, she stopped supplementing with formula and attempted a longer feeding at the breast. The infant was more satisfied after feedings, and at his follow-up visit to the pediatrician, his weight gain was back to 1 oz per day.

Discussion of outcomes: By understanding the supply and demand relationship of milk production, the LC identified that increased supplementation and skipping feedings was decreasing the demand, and therefore the supply, of milk. Increasing nipple stimulation and milk expression during the nighttime and after feedings was an effective method to increase supply and return to adequate milk production. Also, providing reassurance to the mother that not being able to pump a large excess of milk is not an indication of a drop in supply is beneficial to the mother's confidence.

Strengths/Weaknesses: Continuing to offer supplementation after each feeding does run the risk of further decreasing demand and therefore supply. There is a fine balance between getting the infant adequate calories during this time and not further damaging the supply. This is why hand expression or pumping after each feeding is important. Assessing pump flange fit and teaching hand expression is also very important and, if not included in the plan of care, could make attempts at increasing supply ineffective. A non-expert may have assessed the infant's latch and, since it was effective, not have known what approach to take. Assessing the whole feeding history is very important to understanding where problems may be occurring and assisting mothers with formulating an effective plan.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

References

  • Centers for Disease Control and Prevention. (2011). Barriers to breastfeeding in the United States. Office of the Surgeon General. Visit Source.
  • Centers for Disease Control and Prevention. (2019a). Contraindications to breastfeeding or feeding expressed breast milk to infants. Visit Source.
  • Centers for Disease Control and Prevention. (2019b). Racial disparities in breastfeeding initiation and duration among U.S. infants born in 2015. Visit Source.
  • Centers for Disease Control and Prevention. (2019c). What CDC is doing. Visit Source.
  • Centers for Disease Control and Prevention. (2020). Breastfeeding among US children born 2010-2017, CDC national immunization survey. Visit Source.
  • DeMaggio, D. (2016). Tips for freezing and refrigerating breast milk. Visit Source.
  • Howland, G. (2020). Breastfeeding positions, have you tried them all? Visit Source.
  • Krol, K. M. and Grossman, T. (2018). Psychological effects of breastfeeding on children and mothers. Visit Source.
  • La Leche League. (n.d.a). Flat and inverted nipples. Visit Source.
  • La Leche League. (n.d.b) Frequency of feeding. Visit Source.
  • La Leche League. (n.d.c). Importance of breastfeeding. Visit Source.
  • La Leche League. (2018a). Birth control. Visit Source.
  • La Leche League. (2018b). Colostrum: general. Visit Source.
  • La Leche League. (2020). Breastfeeding and the Environment. Visit Source.
  • La Leche League. (2021a). Is my baby getting enough milk?Visit Source.
  • La Leche League. (2021b). Positioning. Visit Source.
  • La Leche League GB. (2016). Hand expression of breastmilk. Visit Source.
  • Mayo Clinic. (n.d.). Female Breast Anatomy. Visit Source.
  • Mayo Clinic. (2020). Breastfeeding and medications. What's safe?Visit Source.
  • Munn, A. C., Newman, S. D., Mueller, M., Phillips, S. M., & Taylor, S. N. (2016). The Impact in the United States of the Baby-Friendly Hospital Initiative on Early Infant Health and Breastfeeding Outcomes. Breastfeeding medicine: the official journal of the Academy of Breastfeeding Medicine, 11(5), 222–230. https://doi.org/10.1089/bfm.2015.0135
  • National Conference of State Legislatures. (2020). Breastfeeding state laws. Visit Source.
  • Office of Disease Prevention and Health Promotion. (n.d.). National immunization survey. Healthy People 2030. U.S. Department of Health and Human Services. Visit Source.
  • Pillay, J. and Davis, T. J. (2020). Physiology, Lactation. Stat Pearls. Visit Source.
  • Stanford Children's Health. (n.d.). The benefits of mother's own milk. Retrieved from: https://www.stanfordchildrens.org/en/topic/default?id=the-benefits-of-mothers-own-milk-90-P02339
  • Tilman, B. (2015, October). Breast milk's circadian rhythms. Visit Source.
  • Wagner, C. L. (2021). Counseling the breastfeeding mother. Medscape. Visit Source.
  • Walls, D. (n.d.). ICEA supports the international code of marketing breastmilk substitutes. International Childbirth Education Association. Visit Source.
  • Walters, D. D., Phan, L. T. H., and Mathisen, R. (2019). The cost of not breastfeeding: global results from a new tool. Health Policy and Planning, volume 34, issue 6, pages 407-417. Visit Source.
  • World Health Organization. (n.d.). Promoting baby friendly hospitals. Visit Source.
  • World Health Organization. (1981). International code of marketing of breastmilk substitutes. Visit Source.
  • World Health Organization. (2018). Ten steps to successful breastfeeding. Visit Source.