Description

• Maternal benefits (as compared with those who do not breast/chest feed) include the following:
  • Rapid involution/decreased postpartum bleeding
  • Decreased risk of postpartum depression and increased bonding
  • Postpartum weight loss
  • Decreased risk of breast cancer and association of decreased risk of pre- and postmenopausal ovarian cancer (2), decreased risk of type 2 diabetes, hypertension, hyperlipidemia, rheumatoid arthritis, and cardiovascular disease
  • Decreased risk of prematurity
  • Increased bone density
• Infant benefits include the following:
  • Ideal food: easily digestible, nutrients well absorbed, less constipation
  • Lower rates of virtually all infections via maternal antibody protection
    • Fewer respiratory and GI infections
    • Decreased risk of ear infections, bacterial meningitis, pneumonia, and sepsis
    • Decreased incidence of otitis media and necrotizing enterocolitis
  • Decreased incidence of obesity and type 1 and 2 diabetes
  • Decreased incidence of allergies, clinical asthma, and atopic dermatitis in childhood
  • Decreased risk of developing celiac disease and inflammatory bowel disease
  • Decreased risk of childhood leukemia
  • Decreased risk of sudden infant death syndrome (SIDS)
  • Enhanced neurodevelopmental performance including intelligence (3)
  • Increased attachment between birth parent and baby

Epidemiology

Etiology and Pathophysiology

• The mechanism of milk production is based on several hormones: Prolactin triggers milk production and oxytocin releases milk based on supply and demand. Endocrine control system triggers making of colostrum at 5 months’ gestation.
• Alveoli make milk in response to hormone prolactin. Sucking stimulates secretion of prolactin, which triggers milk production.
• Stimulation of areola causes secretion of oxytocin. Oxytocin is responsible for let-down reflex when myoepithelial cells contract and milk is ejected into milk ducts.
• Endocrine/metabolic: Cystic fibrosis, diabetes, galactosemia, phenylketonuria, and thyroid dysfunction may cause delayed lactation or decreased milk.

General Prevention

Most vaccinations can be given to breastfeeding mothers, including COVID-19 immunization. The CDC recommends that the diphtheria-tetanus-acellular pertussis, hepatitis B, inactivated influenza virus (as opposed to live attenuated), measles-mumps-rubella (MMR), and inactivated polio and varicella vaccines can be given. The CDC recommends avoiding the yellow fever or smallpox vaccine in breastfeeding mothers.

Physical Exam

Breast/chest examination during pregnancy; assess for scars, lumps, or flat/inverted nipples. Confirm history of infertility, endocrine disorders, breast and hormonal pathology, overall health and psychosocial concerns, perinatal complications, and previous breastfeeding problems.

General Measures

Breast/chest feeding initiation

• Initiate breast/chest feeding immediately after birth, ideally placing the infant naked on birth parent’s chest uninterrupted skin-to-skin in first hour.
• As baby opens wide, bring baby close, tucking baby in “belly to belly.” Line baby’s nose to nipple, baby tilts its head back with wide open mouth, bring baby close as baby latches to ensure baby’s gum takes in more of the areola.
• Baby’s lips are flanged, rounded cheeks, no clicking or popping sounds, and absence of nipple pain when latched.
• Feed baby 2 to 8 times for the first 24 hours and 8 or more times per 24 hours, feeding 10 or more minutes.
• Observation of a nursing session by an International Board Certified Lactation Consultant (IBCLC), nurse, or experienced physician
• Avoid supplementation with infant formula or water and/or artificial nipples unless medically indicated.
• Contraindications to breastfeeding are few (WHO).
  • Maternal HIV (in industrialized world) or human T-cell leukemia virus (HTLV) infection
  • Active untreated tuberculosis
  • Active herpes simplex virus (HSV) lesions on the breast
  • Substances of abuse without evaluation and discontinuation of use
  • Review medications that will pass into human milk.
  • Infants with galactosemia or maple syrup urine disease should not be fed with breast milk. Infants with phenylketonuria may be fed breast milk under close observation.
  • Mothers who develop varicella 5 days before through 2 days after delivery
  • Suspected or confirmed Ebola virus disease
  • Maternal hepatitis is not a contraindication.

Issues for Referral

• Refer to IBCLC, experienced nurser, or physician for inpatient and/or outpatient teaching.
• Frequent follow-up if having problems with latching, nipple/breast pain, breast infection, overactive let down, oversupply or inadequate milk production
• Appropriate screening/referral for postpartum depression as related to unresolved pain with breastfeeding.

Complementary & Alternative Medicine

Galactagogues

• Metoclopramide, domperidone, fenugreek, goat’s rue, and milk thistle have mixed results in improving milk production, but efficacy and safety data are lacking in literature.

Follow-up Recommendations

See mother and baby within 48 to 72 hours after hospital discharge, especially if first time breastfeeding.

• Risk factors for suboptimal initiation
  • Breast surgery or reduction surgery prior to pregnancy may disrupt breast milk production.
  • Severe postpartum hemorrhage may lead to Sheehan syndrome associated with difficulty breastfeeding due to poor milk production.
  • Other factors: delivery mode, duration of labor, gestational age, maternal infection, parity, culture, birth parent–infant separation, maternal anxiety, maternal depression, use of artificial nipple or use of non–breast milk fluids

Diet

• For chestfeeding/breastfeeding
  • Healthy choices from protein-rich foods, vegetables, fruits, and whole grains. Drink plenty of fluids to satisfy thirst and optimal hydration.
  • Breastfeeding/chestfeeding parent may require ~500 more calories per day.
  • Limit caffeine to <300 mg/day.
  • Alcohol should be avoided. Possible long-term effects of alcohol in maternal milk remain unknown.
• For infants:
  • In 2008, the AAP increased its recommended daily intake of vitamin D for infants from 200 to 400 IU. For exclusively breastfed babies, this will require taking a vitamin supplement, such as Poly-Vi-Sol or Vi-Daylin vitamin drops, 0.5 mL/day, beginning in the first few days of life.
  • In 2010, the AAP recommended adding supplementation for breastfed infants with oral iron 1 mg/kg/day beginning at age 4 months. Preterm infants fed by human milk should receive an iron supplement of 2 mg/kg/day by 1 month of age, and this should be continued until the infant is weaned to iron-fortified formula or begins eating complementary foods that supply the 2 mg/kg of iron.

Patient Education

• Support measures to normalize breast/chest feeding have been shown to be successful with respect to infant/child and maternal health outcomes.
  • Emphasize importance of exclusive breast/chest feeding for the first 6 weeks of life to allow adequate buildup of sufficient milk supply.
  • Regular promotion of the advantages of breast/chest feeding and risks of not breastfeeding
• Breast milk usually transitions to mature milk about 3 to 5 days postpartum.
• Signs of adequate nursing
  • Baby feeding on demand (8 to 12 feedings per 24 hours by day 2)
  • Baby should have 6 to 8 wet diapers per day and 3 to 4 bowel movements per day by day 6 to 8.
  • Proper latching and positioning
  • Baby satisfied; appropriate weight gain (average of 1 oz/day in first few months)
• Weaning
  • Solid food may be introduced at 4 months with continuation of breastfeeding.
  • Breast/chest-feeding parent returning to work/school should begin alternative feeding methods 1 to 2 weeks prior. Initiate breast pumping plan.
• Family planning
  • Options include lactational amenorrhea method (LAM), barrier methods, implants, medroxyprogesterone (Depo-Provera), oral contraception, and intrauterine devices (IUDs). ACOG recommends that progesterone-only pills be used 2 to 3 weeks postpartum and that medroxyprogesterone (Depo-Provera), IUDs, combined OCPs, and etonogestrel implant (Nexplanon) can used between 2 and 28 days postpartum can protect against pregnancy.
  • Monitor for changes in milk supply after starting a contraceptive.

Complications

• Breast milk jaundice should be considered if jaundice persists for >1 week in an otherwise healthy, well-hydrated newborn. It peaks at 10 to 14 days.
• Plugged duct
  • Mother is well except for sore lump in one or both breasts and is without fever. Use moist, cold compress or ice pack on lump prior to, and during, nursing; more frequent nursing on affected side. Avoid excessive pumping on affected breast.
• Mastitis (see “Mastitis”)
  • Sore lump in one or both breasts plus maternal fever and/or redness on skin overlying lump
  • Use cold compress or ice pack on lump prior to nursing to reduce pain and inflammation.
  • Antibiotics covering for Staphylococcus aureus (most common organism)
  • Other possible sources of fever should be ruled out, that is, endometritis and pyelonephritis.
  • Mother should get increased rest; use acetaminophen (Tylenol) PRN.
  • Fever should resolve within 48 hours or consider changing antibiotics. Lump should resolve. If it continues, an abscess may be present, requiring surgical drainage.
• Milk supply inadequate
  • Review health concerns; breast changes; infant weight loss; signs of adequate supply; technique, feeding frequency, and duration of nursing; use of lactation aids during feeding or additional supplementation with non-breast milk fluids.
• Sore nipples
  • Check positioning techniques and improve latch-on.
  • Baby should be taken off the breast by breaking the suction with a finger in the mouth.
  • Check for signs of thrush in baby and on mother’s nipple. If affected, treat both.
  • Check for evidence of ankyloglossia (tongue tie) in the infant. Correction of ankyloglossia may lead to decreased nipple soreness and improved breastfeeding.
  • Nipple bleb (a blister on the nipple that can be filled with serous fluid or another fluid) due to improper positioning; cold compress or ice pack and improve position/latch techniques.
• Flat or inverted nipples
  • When stimulated, inverted nipples will retract inward; flat nipples remain flat; check for this on initial prenatal physical. Assess latch if using nipple shield to aid in latching and review rationale for use with breastfeeding.
• Engorgement
  • Begins 3 to 5 days after birth and subsides within 12 to 48 hours
  • Signs are warm, hard, sore breasts.
    • Frequent nursing; breastfeed long enough to empty breasts.
    • Pump to relieve discomfort.
    • Explore reasons for ongoing problems.

Additional Reading

• American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Breastfeeding Handbook for Physicians. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2023.
• Mitchell KB, Johnson HM, Rodríguez JM, et al; for Academy of Breastfeeding Medicine. Academy of Breastfeeding Medicine clinical protocol #36: the mastitis spectrum, revised 2022. Breastfeed Med. 2022;17(5):360–376.  [PMID:35576513]

ICD-10

Z39.1 Encounter for care and examination of lactating mother

SNOMED

69840006 normal breast feeding (finding)