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.
Upon completion of this course, the learner will be able to:
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.
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):
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:
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).
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).
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:
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):
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).
| Birth Year | ||||||||
|---|---|---|---|---|---|---|---|---|
| 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | |
| Ever Breastfed | 76.7±1.2 | 79.2±1.2 | 80.0±1.2 | 81.1±1.1 | 82.5±1.1 | 83.2±1.0 | 83.8±1.2 | 84.1±1.0 |
| At 6 months | 47.5±1.4 | 49.4±1.5 | 51.4±1.5 | 51.8±1.4 | 55.3±1.4 | 57.6±1.4 | 57.3±1.6 | 58.3±1.4 |
| At 12 months | 25.3±1.3 | 26.7±1.3 | 29.2±1.4 | 30.7±1.3 | 33.7±1.3 | 35.9±1.3 | 36.2±1.5 | 35.3±1.4 |
| Exclusively through 3 months | 37.1±1.4 | 40.7±1.5 | 43.3±1.6 | 44.4±1.4 | 46.6±1.4 | 46.9±1.4 | 47.5±1.6 | 46.9±1.4 |
| Exclusively through 6 months | 17.2±1.2 | 18.8±1.2 | 21.9±1.4 | 22.3±1.1 | 24.9±1.3 | 24.9±1.2 | 25.4±1.3 | 25.6±1.2 |
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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):
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):
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.).
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:
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).
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:
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).
| Phases of Lactogenesis | Breast Changes |
|---|---|
| Lactogenesis I | Begins around week 16 of pregnancy. Epithelial cells mature and begin to secrete colostrum. |
| Lactogenesis II | Hormonal shift triggered by birth increases the volume of milk produced, usually around four days postpartum. |
| Lactogenesis III | Milk production shifts to autocrine control and is based on supply and demand from around ten days postpartum until weaning occurs. |
| Lactogenesis IV | Milk production decreases, epithelial cells decrease in number, and breast tissue involution occurs. |
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):
| Factors that can reduce supply or breastfeeding success |
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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).
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).
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).
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).
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:
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).
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.
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).
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).
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).
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.
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:
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.
