breast feeding handbook for physicians

Breastfeeding Step-by-Step

Handbook for Clinicians

Written by Rebecca Hall Crane, MD MPH April 7, 2010

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Introduction Research demonstrates the overwhelming health benefits of breastfeeding over formula. The question is no longer whether newborns should breastfeed but how best to support successful long-term breastfeeding. Breastfeeding results in decreased illness for infants and children, including decreased rates of infectious illness, some cancers, allergies and obesity. For women, studies have shown decreased rates coronary artery disease, protection against ovarian and breast cancer, and potentially decreased rates of osteoporosis. In increasing the percentage of exclusively breastfed infants to six months of life, it is estimated that the potential cost savings to the US economy from improved health outcomes, and decreased costs of production, purchasing and disposal of formula supplies, could reach up to $14 billion dollars per year. The American Academy of Pediatrics and American Academy of Family Physicians support exclusive breastfeeding for the first 6 months of life, with continuation of breastfeeding with complementary foods until one year of life and beyond. The American College of Obstetricians and Gynecologists, the World Health Organization, the US Centers for Disease Control, and WIC also recommend and support breastfeeding. The goal set by Healthy People 2010 is to “increase the proportion of mothers who breastfeed their babies” to 75% in immediate post-partum period, to 50% at 6 months postpartum, and to 25% at 12 months postpartum. Data from the CDC (2006 data) show that approximately 74% of women will attempt breastfeeding after delivery; 33% will exclusively feed through 3 months; by six months 43% of women are breastfeeding but only 14% are exclusively breastfeeding. The sharpest decrease in breastfeeding, ~20%, occurs within the first month after discharge. Successful long-term breastfeeding depends on a successful start. Breastfeeding is natural, but it is a learned process, for both mother and infant. The path to successful breastfeeding starts in the prenatal period with education of families to the benefits of breastfeeding and the “risks” of formula feeding. Also required is education of the mother’s support persons, breastfeeding plans for childbirth, preparation of the home environment for breastfeeding as well as return to work breastfeeding plans. It is our imperative as healthcare providers to promote and encourage healthy choices for our patients. Many women do not choose to breastfeed because they are unaware of the benefits of breastfeeding for themselves and their infants. Many women and healthcare providers believe that human milk and formula are equivalent in their nutritional profiles, and that breastfeeding is more of a lifestyle choice than a medical one. Many well-intentioned providers hasten the cessation of breast milk production in new mothers by encouraging supplementation with formula. Many physicians advise mothers to stop breastfeeding prematurely due to assumed incompatibility of common medications, disease states and infant conditions with breastfeeding. This handbook is intended as a point-of-care reference on breastfeeding for healthcare providers. By increasing our knowledge of the medical benefits, physiology, and clinical management of breastfeeding, we will better serve women in supporting their breastfeeding efforts and ensure that all infants get the healthiest start possible. Rebecca Hall Crane, MD, MPH April 2010

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Table of Contents Breastfeeding Step-by-Step for Clinicians Medical Implications of Breastfeeding

Medical Benefits of Breastfeeding Table: Relative Risk of Formula Feeding vs. Breastfeeding Medical Conditions and Breastfeeding Maternal Medication Use and Breastfeeding Resources for Information on Medication Use and Breastfeeding

Early Prenatal / Pregnancy

Early Prenatal Breastfeeding Essentials Indications for Early Prenatal Lactation Consultation Prenatal Breastfeeding-focused History Prenatal Breast Examination Breast Surgery: Augmentation and Breast Reduction Breastfeeding Multiples Potential Obstacles to Breastfeeding

Late Prenatal / Delivery Planning

Preparing for Delivery / Hospital Stay Cesarean Sections Skin-to-Skin

Labor and Delivery / Newborn Period

Breastfeeding Essentials Initiation of Breastfeeding after Delivery Skin-to-Skin Cesarean Deliveries Newborn Physiology Pertinent to Breastfeeding Management Elimination Patterns of Normal Newborns in First Week of Life Normal Weight Change in the Newborn Feeding Patterns and Hunger Cues of Breastfeeding Infants Sleepy infant / “won’t wake to feed” Nipple Confusion Milk Expression / Separation of Mother and Infant Hypoglycemia Medical indications for Formula Supplementation Lactogenesis 2 “the milk coming in” Breastfeeding the Late-preterm Infant Decision Not to Breastfeed Hospital Discharge Checklist

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Table of Contents (cont) Post-partum / First week of life

Breastfeeding Essentials for the Clinician Assessing Breastfeeding Success for Infant and Mother Vitamin D Supplementation for the Breastfeeding Infant Common Early Post-partum Breastfeeding Issues Pacifier Use Breast Engorgement Hyperbilirubinemia Ankyloglossia “tongue tie” Indications for Post-Partum Lactation Consultation

First month of life

Growth / Weight Gain of Healthy Full Term Infants Pumping and Storing Breastmilk Contraception and Breastfeeding Lactation Amenorrhea Method of Contraception Insufficient Milk Syndrome Sore Nipples / Nipple Trauma Mastitis / Breast abscess / MRSA / Candidal Infections Co-sleeping / Bedsharing Post-partum Depression Return to Work Weaning Breast Cancer Detection in Breastfeeding Women Environmental Toxins in Breastmilk Breastfeeding Support for Patients / Patient Resources

Appendix

Breastfeeding Policies: AAP, AAFP, ACOG The Baby Friendly Hospital Initiative Healthy People 2010 Breastfeeding Goals Medication Tables, Vaccines, Imaging / Radiocontrast Agents Hyperbiilirubinemia Risk and Phototherapy Nomograms Basic Lactation and Breastfeeding Physiology Evaluation of Breastfeeding Technique: Positioning, Latch, Milk Transfer Methods of Human Milk Expression Alternative Methods to Bottle Feeding Infants Reverse Pressure Softening for Breast Engorgement Sample Breastfeeding Intake and Elimination Log Galactogogues Donor Breastmilk / Breastmilk Banking CDC: Breastfeeding and Swine Flu (2009) Travel Recommendations for the Nursing Mother Online Clinician Breastfeeding Education and Training Options PHQ9 Screening Tool for Depression California Breastfeeding Laws and Legislation KP and Community Patient Breastfeeding Resources

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Breastfeeding Step-by-Step for Clinicians 1. Know the medical implications of breastfeeding on infant and maternal health and the

significant medical benefits afforded to both women and children from breastfeeding. 2. Educate all women and their families on the medical benefits of breastfeeding for mothers

and infants, and encourage them to breastfeed. 3. Address potential barriers to breastfeeding while a woman is pregnant, such as post-

partum return-to-work plans, planned maternal medication use, maternal chronic disease, and multiple gestation. Refer women to a lactation consultant during pregnancy, if indicated.

4. Encourage all pregnant women to attend a breastfeeding class prior to delivery to assist in

the family’s preparation for breastfeeding. 5. Assist women in making a breastfeeding plan for their delivery prior to their due date. 6. Assist women in breastfeeding their child within a half-hour of birth. 7. Discourage routine pacifier, artificial nipple and bottle use in breastfeeding infants;

encourage women to delay pacifier use until one month of life. 8. Know the medical reasons to supplement with formula, and use formula only when

medically necessary. 9. Understand normal newborn physiology, and know that most newborns do not need

supplementation of during the first few days of life. 10. Instruct women to breastfeed their infants “on demand,” i.e., based on their infant’s feeding

cues and not on a schedule. Educate women that infants feed up to 16 times per day during the first week of life, and that this is normal.

11. Ensure that women who are separated from their infants are given a breast pump to

simulate nursing, and tell them to use it at least every three hours for at least 15 minutes. This ensures that breast milk production will not drop off during the separation.

12. Ensure adequate evaluation and instruction of breastfeeding in the hospital post-delivery,

and ensure close follow-up and evaluation of both mother and infant post-discharge. 13. Educate women about potential breastfeeding difficulties, such as growth spurts, returning

to work, and maternal medication use. Assist mothers in getting a lactation consultation if needed.

14. Reiterate that our goal is to have all infants breastfeed for one year and beyond, and

support our patients’ long-term breastfeeding efforts!

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Medical Implications of Breastfeeding

Medical Benefits of Breastfeeding

Table: Relative Risk of Formula Feeding vs. Breastfeeding

Medical Conditions and Breastfeeding

Maternal Medication Use and Breastfeeding

Resources for Information on Medication Use and Breastfeeding

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Medical benefits of breastfeeding

For infants Breastfed infants are protected from many illnesses compared to formula – fed infants. The longer an infant is breastfed, the greater the benefits. Breastfed infants experience: • Decreased incidence of infectious illnesses such as GI and respiratory infections, otitis

media, necrotizing enterocolitis, gastroenteritis, meningitis, and urinary tract infections • Lower rates of sudden infant death syndrome (SIDS) • Lower rates of childhood and adult-onset diseases such as insulin dependent diabetes,

allergies, asthma, lymphoma, ulcerative colitis, and adult-onset hypertension • Lower rates of childhood and adult obesity

For mothers A 2009 study of nearly 140,000 women found that women who breastfed for at least one year were 10-15% less likely to have high blood pressure, diabetes, high cholesterol, and cardiovascular disease compared to mothers who never breastfed. Benefits were seen in women who breastfed for a minimum duration of 6 months, but the longer a woman breastfed, the better. (2) Other medical benefits to women from breastfeeding include: • Reduced risk of cancers, including ovarian cancer, premenopausal breast cancer • Reduced risk of post-menopausal hip fractures, and rheumatoid arthritis • Enhanced mother-infant attachment and bonding via skin-to-skin contact, likely related

to release of oxytocin and prolactin • Enhanced post-partum uterine involution resulting in less blood loss and reduced risk of

infection

For families • Significant cost savings; formula costs between $1200 to $3,000 per year per infant • Decreased healthcare costs due to less MD visits and less prescription medications • Decreased missed days from work due to infants with less illness

For Kaiser Permanente Estimated cost savings of $400 per infant per year due to decreased infectious GI and respiratory illness in breastfed infants (3).

For the US economy The U.S. could potentially save up to $14 billion a year (4) via breastfeeding due to: • improved health outcomes for infants and mothers • decreased public health expenses including expenditures for WIC, which provides formula

to mothers and infants at $950 million per year • decreased parental employee absenteeism due to illness of child and associated work

losses • savings from elimination of environmental burden for disposal of formula cans and bottles • savings from elimination of energy demands used for production and transport of formula Please see last page of this booklet for references to the above information.

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Relative Risk of Formula Feeding vs. Breastfeeding Allergies, eczema 2 to 7 times (1) Urinary tract infections 2.6 to 5.5 times (3) Inflammatory bowel disease 1.5 to 1.9 times (4) Diabetes, type 1 2.4 times (5) Gastroenteritis 3 times (1) Hodgkin's lymphoma 1.8 to 6.7 times (6) Otitis media 2.4 times (1) Haemophilus influenzae meningitis 3.8 times (7) Necrotizing enterocolitis 6 to 10 times (2) Pneumonia/lower respiratory tract infection

1.7 to 5 times (1)

Respiratory syncytial virus infection 3.9 times (2) Sepsis 2.1 times (8) Sudden infant death syndrome 2.0 times (1) Death in first year of life 27% (9) Industrialized-world hospitalization 3 times (1) Developing-country morbidity 50 times (1) Developing-country mortality 7.9 times (1) Table adapted from Promoting and Supporting Breastfeeding, Moreland, Coombs. Am Fam Physician 2000;61:2093-100,2103-4. References for table: 1. Lawrence RA, Lawrence RM. Breastfeeding in modern medicine. In: Breastfeeding: a guide for the medical

profession. 5th ed. St. Louis: Mosby, 1999. 2. Riordan J, Auerbach KG. In: Breastfeeding and human lactation. 2d ed. Sudbury, Mass.: Jones and Bartlett,

1999. 3. Pisacane A, Graziano L, Mazzarella G, Scarpellino B, Zona G. Breast-feeding and urinary tract infection. J

Pediatr 1992;120:87-9. 4. Corrao G, Tragnone A, Caprilli R, Trallori G, Papi C, Andreoli A, et al. Risk of inflammatory bowel disease

attributable to smoking, oral contraception and breastfeeding in Italy: a nationwide case-control study. Cooperative Investigators of the Italian Group for the Study of the Colon and the Rectum (GISC). Int J Epidemiol 1998;27:397-404.

5. Pettitt DJ, Forman MR, Hanson RL, Knowler WC, Bennett PH. Breastfeeding and incidence of non-insulin-dependent diabetes mellitus in Pima Indians. Lancet 1997;13:203-8.

6. Davis MK. Review of the evidence for an association between infant feeding and childhood cancer. Int J Cancer Suppl 1998;11:29-33.

7. Silfverdal SA, Bodin L, Hugosson S, Garpenholt O, Werner B, Esbjorner E, et al. Protective effect of breastfeeding on invasive Haemophilus influenzae infection: a case-control study in Swedish preschool children. Int J Epidemiol 1997;26:443-50.

8. Hylander MA, Strobino DM, Dhanireddy R. Human milk feedings and infection among very low birth weight infants. Pediatrics 1998;102:E38.

9. Chen A, Rogan WJ. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics. 2004;113(5):e435-e439

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Medical Conditions and Compatibility with Breastfeeding The default answer to “Can a woman breastfeed?” is “yes.” There are very few medical conditions or situations that are not compatible with breastfeeding.

Common situations that are NOT contraindicated with breastfeeding • Maternal fever or infant fever • Mastitis • Maternal smoking • Moderate maternal alcohol use (1-2 drinks per day) • Most prescription and over-the-counter medications • Chronic hepatitis B and C infection

Selected Maternal Conditions and Breastfeeding Hepatitis • Chronic carriers of hepatitis B or women who test positive for hepatitis B surface

antigen can safely breastfeed after their infants have received hepatitis B vaccine and hepatitis B immune globulin (HBIG); there is no risk of transmission to the infant via breastmilk.

• Chronic / acute hepatitis C infected women can breastfeed; these infants have the same rate of infection (4%) whether they are breast or bottle-fed; therefore, breastfeeding is recommended for these infants.

• Infants born to women who have acute hepatitis A infection may breastfeed after they have received the hepatitis A vaccine and serum immune globulin.

Other infections • HIV or HTLV virus infection in women is not compatible with breastfeeding. • Women with active HSV lesions on breast should not breastfeed. • Active, untreated tuberculosis in the mother is not compatible with breastfeeding;

however, the infant may be given expressed breastmilk from the mother (it does not contain the mycobacterium) until treatment is completed and she is considered non-infectious.

• A woman with primary active varicella infection (not zoster) should neither breastfeed nor should her infant be fed her expressed breast milk; after the infant has received VZIG the mother can provide expressed breastmilk as long as there are no active lesions on the breast; mother should be isolated from the infant until she is considered non-infectious, at which time she may resume breastfeeding.

• Zoster / shingles affected women may breastfeed as long as there are no lesions on the breast; lesions should be kept covered.

• Women infected with CMV will have both virus and antibodies in their breastmilk. Because of this, otherwise healthy infants born at term with congenital or acquired CMV infections usually are not affected by the virus if they are breastfed. A study of infants who developed infections during breastfeeding found that the infants also developed an immune response, did not develop the disease, and rarely manifested symptoms.

Other Maternal Medical Situations:

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• Imaging: oral and IV iodinated contrast and gadolinium is compatible with breast feeding

• General anesthesia: these agents pass in negligible amounts into the breast milk; as soon as the mother can respond to her infant she may breastfeed.

• Dialysis: women undergoing dialysis may breastfeed. • Breast cancer treatment: women undergoing active breast cancer treatment should not

breastfeed. • Illicit drug use, or excessive alcohol use is not compatible with breastfeeding.

Infant conditions contraindicated with breastfeeding These conditions require specialized formulas: • Galactosemia • PKU • Maple syrup urine disease

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Maternal Medication Use and Breastfeeding Tables detailing the compatibility of maternal medication use and breastfeeding are in the appendix of this handbook. Please note: the Physician’s Desk Reference, epocrates, Lexicomp, the Pocket Pharmacopoeia and Micromedex are poor sources of information regarding medications and breastfeeding! Please see page 19 for the best sources. Maternal medication use is a major reason why many women stop breastfeeding, usually due to an unfounded fear that the medicine will be harmful to the infant. Many well-intentioned healthcare providers also incorrectly tell breastfeeding mothers that their medications are not compatible with breastfeeding. Almost all prescription and OTC medicines are compatible with breastfeeding; very few are not. Almost all medications pass in some capacity into breast milk; however, most appear at clinically insignificant levels, or are not harmful to the infant. Surveys in western countries indicate that 90% to 99% of women who breastfeed receive at least one medication during their first week postpartum. Clinicians must weigh the risks of breastfeeding cessation to the risks of medication exposure via breastfeeding before they advise women to cease or suspend breastfeeding.

Commonly used medications NOT contraindicated in breastfeeding: • Morphine • Ibuprofen • Amoxicillin • Methadone • SSRIs (paroxetine, sertraline and nortriptyline are preferred over fluoxetine;

fluoxetine is not prohibited, but may be excreted into breast milk at slightly higher levels than the others listed.)

• Phenytoin • Warfarin • Levothyroxine • General anesthesia • Imaging agents: iodinated contrast, gadolinium

Maternal medications that may pose a risk to breastfeeding infants: When deciding whether a woman should stop breastfeeding, the clinician must weigh the risks of exposure of medication in breastmilk to the risks of cessation of breastfeeding. The following medications are those that pose potential risk to breastfeeding infants:

• Amiodarone ! Anticancer Agents: cyclophosphamide, cyclosporine, • Bromocriptine methotrexate, doxorubicin • Doxepin ! Illicit / illegal / recreational drugs • Lithium • Radioactive iodine • Chloramphenicol • Ergot Alkaloids

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Minimizing Potential Risk to Nursing Infants from Maternal Medication Use General considerations

• Use reliable references for obtaining information on medications in breast milk (see next page).

• Medications that are safe for administration to an infant are considered compatible with breastfeeding.

• Medications that are safe in pregnancy are not always compatible with breastfeeding. • Use topical therapy when possible. • Caution is advised when prescribing medications for breastfeeding mothers of

premature or otherwise compromised newborns than for breastfeeding mothers of older, healthy infants.

Medication dosing

• If concern exists for exposure to the infant, single daily-dose medications can be administered just before the longest sleep interval for the infant, usually after the infant’s bed-time feeding.

• Infants can be breastfed immediately before medication administration when multiple daily doses are needed.

Alcohol • Occasional use of alcohol in limited amounts is compatible with breastfeeding; this is

equal to 0.5 g of alcohol per kg body weight or 1- 2 drinks per day. • A breastfeeding mother may want to wait until the alcohol clears her system, which

usually takes two hours. A rule of thumb is that if the mother is feeling the effects of alcohol, it will be excreted in her breastmilk.

• Alcohol may have a negative impact on oxytocin levels and inhibit letdown.

Maternal Smoking • If women smoke, they should smoke outside, away from their infants. • Research suggests that infants of smoking mothers are healthier if they are breastfed.

Breastfeeding offers the infant protection against SIDS, which has found to be higher in infants born to mothers who smoke.

• A negligible amount of nicotine metabolites are found in breastmilk in the form of cotinine; no adverse effects on breastfeeding infants have been reported from exposure to this substance.

• Recommendation: Ideally, the best recommendation is to quit smoking, but if the mother is unwilling to quit she should continue breastfeeding and smoke outside.

Caffeine • Moderate intake causes no problems for most breastfeeding infants • The amount of caffeine excreted into breastmilk is usually less than 1% of the amount

ingested by the mother, and this has not been found to be harmful to the infant.

Recreational / illicit drugs / drugs of abuse / uncontrolled etoh use These agents are not considered compatible with breastfeeding.

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Resources for Information on Medication Use and Breastfeeding Note: Physician’s Desk Reference and epocrates are poor sources of information regarding medications and breastfeeding!

Online Resources Toxnet, US National Library of Medicine, http://www.nlm.nih.gov/ and click “Lactnet”

(or type “LACTMED” into a Google search engine) A peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed. Among the data included are maternal and infant levels of drugs, possible effects on breastfed infants and on lactation, and alternate drugs to consider.

American Academy of Pediatrics Policy on Drugs and Breastfeeding

http://aappolicy.aappublications.org/

Textbook Resources Medications and Mother’s Milk 2008 by Thomas Hale Drugs in Pregnancy and Lactation by Briggs, Freeman & Yaffe Breastfeeding: a Human Lactation Study Center, University of Rochester: Database of

references on drugs, medications, and contaminants in human breast milk.

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Early Prenatal / Pregnancy

Early Prenatal Breastfeeding Essentials

Indications for Early Prenatal Lactation Consultation

Prenatal Breastfeeding-focused History

Prenatal Breast Examination

Breast Surgery: Augmentation and Breast Reduction

Breastfeeding Multiples

Potential Obstacles to Breastfeeding

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Early Prenatal Breastfeeding Essentials • All pregnant women should be educated about the medical benefits of breastfeeding as

well as the risks of formula. • Breastfeeding should be discussed at first and subsequent prenatal visits. • Prenatal education, encouragement and support of breastfeeding by clinicians significantly

increase breastfeeding rates. • Include the mother’s support person in discussions about breastfeeding. • Short hospital stays make teaching difficult, making the prenatal period the ideal time for

the mother to learn about and prepare for breastfeeding. • Positive messages about breastfeeding should be displayed in the physician’s office, and

materials advertising or promoting formula should be removed from waiting rooms and exam rooms.

Prenatal Breastfeeding Assessment Prenatal visits are an essential opportunity for obstetric care providers to discuss and encourage breastfeeding and obtain a medical history relevant to educating the patient about breastfeeding. The mother’s support person should be included in breastfeeding education and promotion efforts at every office visit. Support from a significant other has been identified as one of the most important factors for those who chose to formula-feed.

Indications for Early Prenatal Lactation Consultation Consider referring the patient to a lactation consultant at this time if the following conditions are present: • Failed or extreme difficulty with breastfeeding after previous deliveries • Lack of breast changes during pregnancy • History of breast surgeries (reduction, augmentation, or other) • Breast or nipple anomalies • Multiple gestation

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Prenatal Breastfeeding-focused History • Ask open-ended questions:

o “Have you noticed your breasts changing in preparation for feeding your baby?” o Avoid asking “are you going to breast or bottle-feed?” which can suggest that

the two methods are equivalent. • Discuss maternal medical conditions that can affect breastfeeding due to possible

decreased milk productions. Women with these conditions can breastfeed but they and their infants may need close post-partum follow-up:

o History of hormone-related infertility / PCOS o Depression o Contraception use o Hypothyroidism o Diabetes

• Discuss current or planned medication use and/or substance abuse • Discuss contraceptive planning. Most contraception, including combined hormonal oral

contraception, is compatible with breastfeeding. Please see page *** and medication tables in the appendix for more information.

• Mother’s plans for return to work following pregnancy • Discuss mother’s breastfeeding experience with previous children:

o Did patient breastfeed any previous infants? o Were there previous breastfeeding problems? o Is there a negative attitude regarding the success of breastfeeding? o Are others (i.e. infant's father, mother's mother, friends, etc.) supportive of

breastfeeding? • Address mother’s dietary concerns:

o There is no specific breastfeeding diet! o There are no restricted foods for a breastfeeding mother! o Mothers who exclusively breastfeed utilize approximately 500 kcal / day. o If a mother is a strict vegan, it is recommended that she take a daily vitamin B12

dietary supplement while she is breastfeeding. o She should drink a glass of water each time she breastfeeds, usually 4 – 6 glasses

of water per day when nursing regularly. o Moderate caffeine intake and 1 – 2 glasses of alcohol per day are considered

compatible with breastfeeding.

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Prenatal Breast Examination The physical exam is an excellent opportunity for the clinician to reassure a woman that her breasts are developing and that she is physically capable of feeding her child. Breast Lumps / Masses: • Any lump appreciated in a woman’s breast at this exam should be considered for a full

evaluation via ultrasound or biopsy or both. • It can often be difficult to examine a nursing mother’s breasts post-partum. • 3% of all breast cancers appear during the post-partum period. • A thorough prenatal breast exam can help reassure clinicians that a lump found post-

partum is not cancer. Breast Size and Shape: • Clinicians must ensure that a woman’s breasts are appropriately increasing in size during

pregnancy. • Women with small or large breasts can breastfeed. • Women with hypoplastic or tubular breasts may have difficulty breastfeeding and should be

referred for lactation consultation. Breast Symmetry: • Slight asymmetry of breasts is considered normal. • Significant asymmetry should raise red flags for such issues as inadequately developed

breasts or hormone deficiencies; consider specialty evaluation. Flat or Inverted Nipples: • Most women with flat or inverted nipples can breastfeed successfully with adequate

assistance after delivery. • True inverted nipples are rare. • Research does not warrant breast preparation during pregnancy (i.e. breast shells, rolling

nipples, stretching nipples, etc.) to aid in changing nipple shape. • Nipple rolling after delivery or use of a breast pump for 1 – 2 minutes prior to breastfeeding

can facilitate latch-on. Previous breast surgeries: • Breast augmentation: silicone is an inert molecule and silicone breast implants are

considered compatible with breastfeeding by the American Academy of Pediatrics. • Breast reduction surgery: may interfere with adequate milk production post-partum due

to potential severing of ducts; these women need close post-partum follow-up to ensure adequate milk production and growth of the infant.

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Breast Implants / Breast Augmentation Women with silicone breast implants can safely breastfeed, however, these women will likely benefit from a prenatal lactation consultation. In regards to the safety of breastfeeding from breasts that have silicone implants (American Academy of Pediatrics “The Transfer of Drugs and Other Chemicals into Human Milk,” 2001): “There are only a few instances of the polymer being assayed in the milk of women with implants; the concentrations are not elevated over control samples. There is no evidence at the present time that this polymer is directly toxic to human tissues...the anticolic compound simethicone [which is routinely given to infants] is a silicone and has a structure very similar to the silicone compound in breast implants… The [AAP] Committee on Drugs does not feel that the evidence currently justifies classifying silicone implants as a contraindication to breastfeeding.”

Breast Surgery / Breast Reduction Women who have had breast surgery can expect to successfully breastfeed, however, they may have difficulty if their breast surgery involved the complete severing of lactiferous ducts. Women who have had a reduction mammoplasty can also breastfeed; however, their overall success will depend on the degree of interruption to the ductile system. Women who have had breast surgery involving periareolar incisions, or women who have had breast reductions should been seen prenatally by a lactation consultant to prepare for breastfeeding. They should also be counseled about frequent follow-ups postnatally to evaluate breastfeeding success and infant growth, as they are at increased risk of producing an insufficient supply of milk. Patient information on breastfeeding after breast surgery can be found at: www.bfar.org (Breastfeeding after Nipple and Breast Surgery) and on the La Leche League website: www.llli.org.

Breastfeeding Multiples Mothers of twins should be encouraged to breastfeed and reassured that they can expect to fully support their infants’ nutritional needs via exclusive breastfeeding. However, nursing more than one infant can be very challenging, and early and frequent follow-up with a pediatrician and lactation consultant following delivery is advised. Breast milk production is infant-driven, and mothers of regularly breastfed twins will produce twice the quantity of milk than mothers of singletons. Mothers of higher order multiples will likely need to supplement their breast milk. Support groups can be especially helpful for mothers of multiples.

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Potential Obstacles to Breastfeeding • Patient and clinician perception that formula is equal to breastmilk or is “good enough” • Lack of support of family and friends • Feelings of embarrassment • Concern over loss of freedom • Breast surgery; reduction or augmentation (see next page) • Physical discomfort • Concern over need to return to work or school • Lack of confidence / fear that infant won’t get enough to eat • Jealousy (partner / relative / sibling) • Cesarean sections

From ACOG 2007: “Women need to know that breastfeeding, like other aspects of having a new baby, has its demands as well as its rewards.” Clinicians can assist women and their partners by eliciting concerns, answering questions, and confronting misperceptions about breastfeeding:

• Informed consent: clinicians can give women information about the medical benefits of breastfeeding.

• Prenatal education: women can be encouraged to attend prenatal classes where they will learn about and increase their confidence about breastfeeding.

• Cesarean sections: women who have a cesarean section should be reassured that they can breastfeed their infant as well as women who delivery vaginally, and that post-partum pain medications are compatible with breastfeeding.

• Separation from infant: information can be given to women about milk expression and storage to assist with their plants to return to work while continuing to breastfeed.

• Assistance and teaching: patients can be reassured that assistance and follow-up will be provided in the hospital and post-partum to ensure proper breastfeeding technique and infant weight gain.

• Breastfeeding rights and legislation: women can be reassured that in California there are state laws to protect a woman’s right to breastfeed in public and to express her breastmilk while at work.

Many families find their own solutions to their concerns and fears as they come to understand the substantial medical benefits of breastfeeding to both women and infants. Some women will decide that the challenges of breastfeeding outweigh the benefits for themselves and their babies. These women should be reassured that they will receive assistance and teaching about infant feeding during their hospital stay and post-partum, and that they won’t be “abandoned” or made to feel guilty for their decision not to breastfeed.

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Late Prenatal / Delivery Planning

Preparing for Delivery / Hospital Stay

Cesarean Sections

Skin-to-Skin

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Late-Prenatal Breastfeeding Essentials: • Provide mothers and families with information about her delivery and what to expect

in regards to breastfeeding after delivery in the hospital setting. • Help mother prepare to breastfeed within the first hour of birth. • Reiterate the medical benefits of breastfeeding and risks associated with formula feeding. • Continue to address questions and concerns of the mother and family about the initiation

and management of breastfeeding. • Encourage mothers to read about breastfeeding and to enroll in a breastfeeding

education program prior to delivery. • Give mother a list of hospital and community breastfeeding resources prior to delivery,

including lactation support groups. • Educate mothers on their ability to return to work while continuing to breastfeed;

mothers should plan on returning to work at the earliest 4 weeks post-partum to ensure proper establishment of breastfeeding.

• Discuss infant bonding activities for partners and families that don’t involve feeding, such as changing diapers, holding / rocking / burping the infant, etc.

• Encourage mother to purchase a breast pump prior to delivery to assist in breast softening in the case of engorgement, as well as for breast milk pumping and storage.

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Birth and delivery planning • Informing pregnant women about what to expect when they come into the hospital to

deliver greatly increases a women’s confidence to breastfeed and makes the chance of receiving supplementary formula less likely.

• Research has shown that many hospital practices interfere with the institution and future success of breastfeeding.

• Getting women and babies off to a good start is crucial to the ultimate goal of exclusive, long-term breastfeeding.

• Mother and clinician should plan on infant’s first breastfeeding be immediately or shortly after delivery, within the first half-hour or hour of birth, with infant skin-to-skin with mother.

Labor and Delivery Mother may receive medications during delivery, such as antibiotics, pain medications, and regional anesthesia. These medications are, with few exceptions, compatible with breastfeeding immediately after delivery. Demerol is notably not compatible with breastfeeding. A woman’s clinician can plan to support a mother’s desire to breastfeed by balancing pain relief during her delivery while avoiding excessive amounts of medication. Cesarean Deliveries The rate of cesarean sections has climbed to over 50% in the past few years. (CDC, 2008) Women should be reassured that they can breastfeed successfully after cesarean sections like women who delivery vaginally. If a cesarean section is planned, the clinician can reassure the mother that medications routinely used during the procedure, including anesthetics and analgesics, are compatible with breastfeeding (see appendix). A woman’s intent to breastfeed should be communicated to the operating surgeon and hospital staff, and a plan to reunite the mother and infant as soon as medically possible following the procedure should be made.

Breastfeeding after Delivery and Skin-to-skin A mother and infant’s first breastfeeding experience should ideally be within the first two hours of life, immediately or shortly after delivery, with infant skin-to-skin on mother’s chest. Research on this initial contact has shown that babies placed skin-to-skin immediately after birth breastfeed for an average of 2.5 times longer than babies who were not. This may be due to the increased confidence of infant and mother, of the robust bonding experience that occurs at these initial moments, initiation of signals promoting copious milk production, or more.

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Labor and Delivery / Newborn Period

Breastfeeding Essentials

Initiation of Breastfeeding after Delivery

Skin-to-Skin

Cesarean Deliveries

Newborn Physiology Pertinent to Breastfeeding Management

Elimination Patterns of Normal Newborns in First Week of Life

Normal Weight Change in the Newborn

Feeding Patterns and Hunger Cues of Breastfeeding Infants

Sleepy infant / “won’t wake to feed”

Nipple Confusion

Milk Expression / Separation of Mother and Infant

Hypoglycemia

Medical indications for Formula Supplementation

Lactogenesis 2 “the milk coming in”

Breastfeeding the Late-preterm Infant

Decision Not to Breastfeed

Hospital Discharge Checklist

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Labor and Delivery / Newborn Breastfeeding Essentials: • Breastfeeding should occur immediately after delivery with infant skin-to-skin with

mother, optimally within the first 1 – 2 hours of birth. • Infants do not need formula supplementation for the first few days of life unless

medically indicated. • Infants can nurse 8 to 12 times, sometimes up to 16 times per day in the first few

weeks of life. This is normal. • Infants should be fed based on their feeding cues and not on a schedule; this is called

“breastfeeding on demand.” • Avoid mother / infant separation while in the hospital. Essentially, mothers and infants

are “rooming in.” • Routine pacifier use in breastfeeding infants should be discouraged. • Mothers should keep a log of their breastfeeding frequency and duration, as well as

their infant’s wet diapers stools; this log begins in – house and continues for the first few weeks post-partum.

• All newborns will have a 48 hour post-discharge well-child check; this appointment ensures breastfeeding success, appropriate infant weight gain, and assessment of infant jaundice.

• Inform mothers that breastfeeding to one year and beyond is recommended by the AAP, AAFP, ACOG, and the US Surgeon General.

For infants who must be separated from their mothers post-partum: In the event of mother – infant separation, breast stimulation via pumping during the first few days of life ensures that milk production will be adequate at lactogenesis 2, aka “the milk comes in.” • Ensure that mothers who are separated from their infants (i.e. NICU stay for infant)

are given a breast pump. • Instruct women to use the pump 8 times per day while awake and once during the night

for at least 15 minutes on each breast. • This is primarily for breast stimulation, and may not produce much milk in the first few

days. • Colostrum is the milk present in women’s breasts during the first few days post-partum;

often manual expression is required to get colostrum out of breasts. This is because colostrum is high in antibody content and difficult to express via suction only.

• Consider using a syringe or a cup to feed infants supplemental feedings to prevent nipple confusion.

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Initiation of Breastfeeding after Delivery All medically stable children (Apgar scores 7 and above) are capable of having this experience, including rule-out sepsis infants. Infants have a short period of increased alertness immediately following delivery, which enables them to sense the nipple, crawl to it, and latch on to breastfeed, usually without assistance. Of note, the longer a woman and her infant are separated following delivery, the more likely it is that the infant will receive formula supplementation. Routine nursery procedures, such as weighing and bathing the infant, administering injections, and applying erythromycin eye ointment can wait until after this first feed and preferably done in the mother’s room following delivery.

Skin-to-skin Early breastfeeding and skin-to-skin contact has been shown to increase long-term breastfeeding rates in infants. Research has shown many physiologic benefits of prolonged skin-to-skin contact for both infants and parents:

• Infants cry less and spend more time in deep sleep • Infants show less apnea and periodic breathing • Protection of thermoregulation in the infant • Improved oxygen saturation rates • Premature babies may come out of incubators and move to cribs faster • Babies may feed earlier, breast feed more successfully, and may even show faster

weight gain • Kangaroo care, a type of skin-to-skin contact used in the NICU, promotes breastfeeding

and increases milk production in mothers • Facilitates infant / parent bonding • Can increase confidence in ability to parent in mothers

Skin-to-skin Clinical Basics • Newborns have a short period of increased alertness immediately following

delivery where they often instinctively find the mother’s breast and initiate breastfeeding.

• Immediately after delivery, the infant will be placed skin-to-skin on mother’s bare chest. Infants who have a stable cardiovascular and pulmonary status are eligible for this skin-to-skin experience. Infants born via c-section can be reunited with their mothers in the recovery room and placed skin-to-skin with mother.

• Routine newborn procedures can be delayed until this crucial first breastfeeding experience as been completed; these procedures include weighing and measuring the infant, bathing, eye ointment application, and vitamin K injections.

• Optimally, the infant will have two hours with the mother to complete this first feeding.

• Both parents can do skin-to-skin: it is easiest when done with shirts that open in the front; mothers are encouraged to remove their bras.

• Infants wearing only a diaper and hat are placed skin-to-skin against the parent's bare chest; a blanket then covers the infant.

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Cesarean Deliveries Women should be reassured that they can breastfeed successfully after cesarean sections like women who delivery vaginally. • Breastfeeding rates are lower in mothers who delivery via c-section. This is thought

to be due to many factors, including separation of the mother and infant following the procedure, post-surgical pain, concern about exposing a newborn to mother’s pain medications via breast milk, and possibly a feeling of ‘failure’ on the mother’s part for not having delivered vaginally, which can inhibit let-down.

• The clinician can reassure the mother that medications routinely used during the cesarean sections, including anesthetics and analgesics, are compatible with breastfeeding (see appendix.)

• As soon as a woman can respond to her infant, she should be reunited with her infant and encouraged to breastfeed skin-to-skin.

• Most mothers will need assistance with positioning while avoiding incision area (side-lying hold, football hold, etc.)

• If a woman has undergone general anesthesia, she can breastfeed as soon as she can respond to her infant.

• The agents used for general anesthesia are compatible with breastfeeding; there is no reason to delay breastfeeding following their administration.

Rooming-in Rooming-in refers to infants and mothers sleeping in the same room in the hospital. Traditionally, infants were kept in newborn nurseries with the intention of letting the mother rest following delivery. However, allowing a mother and infant to room-in together has many benefits:

• Rooming-in and skin-to-skin contact between mother and infant allows the mother to recognize her infant’s hunger cues and “feed on demand.”

• Research shows that rooming-in allows infants to cry less, sleep more, and become adept at breastfeeding sooner.

• Clinicians may be reassured to know that studies of mothers who room-in with their infants 24 hours a day while in the hospital show that they sleep better and have increased milk production.

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Newborn Physiology Pertinent to Breastfeeding Management • Full - term, appropriate weight for gestational age infants are born with a “camel’s

hump” of nutrition that provides for their metabolic needs during the first two to three days of life.

• It is physiologic for newborns to receive 1 – 2 ounces of milk / colostrum PER DAY for the first two days of life or until lactogenesis 2 (“milk comes in”) occurs.

• An infant’s stomach is the size of a small marble on day of life 1, and slowly gets bigger.

• Expect one void on day of life one, 1 – 2 voids on day of life two, 4 – 6 voids on day of life 3.

• Infants are expected to lose weight after birth. • 8% weight loss from birth weight is considered acceptable during the first week of

life.

Elimination Patterns of Normal Newborns in First Week of Life

Wet Diapers Healthy breastfed infants will usually void 1 to 3 times per day in the first two days. Parents should expect about 6 wet diapers per day after 1 week of age.

Bowel Movements • Meconium is the first stool after birth and is black, thick and tarry. • After 2 - 3 days of life the stools will look greenish in color. • At 4 - 5 days after birth the stool should be yellow and “seedy.”

Expected Elimination Patterns of Healthy Newborns

Day 1 1 wet diaper 1 meconium stool

Day 2 2 – 3 wet diapers 1 meconium stool

Day 3 4 – 6 wet diapers Color changes

Day 4 4 – 6 wet diapers Transition stools

Day 5 6 – 8 wet diapers 3 – 4 yellow stools

Day 6+ 6 – 8 wet diapers > 4 stools

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Normal Newborn Weight Changes Healthy newborns, in general, do not need supplemental feeding for the first 24 – 48 hours. Term, appropriate for age (AGA) weight infants are born with a “camel’s hump” of nutrition at delivery that provides for their metabolic needs during the first two to three days of life. They are also born relatively edematous at birth, and experience physiologic weight loss during the first few days of life as they wait for the onset of copious milk production in the mother’s breasts. This is expected to happen at ~48 – 60 hours post-partum. Newborns are expected to lose weight at birth, and are generally allowed up to 8% weight loss of birth weight during the first week of life before supplementation is considered. It is considered physiologic for the breastfeeding infant to consume no more than 1 - 2 oz of colostrum per day for the first few days of life. This in contrast with the amount of milk the infant will ingest after the onset of lactogenesis 2, or copious milk production in the mother’s breasts, which usually between 48 and 100 hours of life. After copious milk production begins, the infant will consume approximately 3 – 4 ounces every 3 – 4 hours. However, infants usually feed “on demand” rather than on a schedule for their first weeks of life. It is important to inform mothers of this normal newborn physiology and the physiology of normal breast milk production, as new mothers will often question the adequacy of their milk supply and whether they are making enough milk to feed their infants. Lack of confidence that the infant is getting enough to eat, whether on the part of the mother, the mother’s support person, or the hospital staff, is the number one reason for formula supplementation in the newborn period. It is essential that staff and parents understand normal newborn physiology to avoid unnecessary formula supplementation. One way to reassure a mother that she is making enough breast milk is to weigh the infant, and educate the family on appropriate / normal weight loss: • Weight loss of up to 7 – 8 % of birthweight is acceptable during the first week of life. • Babies will regain their birthweight around the end of the second week of life. • Typical weight gain is 5 – 7 oz per week for first four weeks (10g/kg per day) Calculate weight loss: Weight loss / Birthweight = 0.0X = X% weight loss (50 g weight loss / 3500 g birth weight = 0.01 = 1% weight loss Other ways to reassure the family about adequate nutrition and breastmilk production is to review normal feeding and elimination patterns with them.

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Feeding Patterns and Hunger Cues of Breastfeeding Infants In the newborn nursery and during the first few weeks of life, breastfed infants should be fed “on demand,” i.e., based on the infants’ feeding cues, and not based on a feeding schedule. Mothers should be instructed to recognize their infant’s feeding/hunger cues and nurse accordingly. Newborns often feed 8 – 12 times (or more) in the first week of life. This is normal. The quiet alert state is the best time to initiate breastfeeding. If a baby is crying, he may need to be soothed prior to breastfeeding.

Infant hunger cues include: • Smacking or licking lips • Sucking on hands, fingers, toys, lips, clothing • Opening and closing mouth • Squirming • Rooting at the chest of whoever is holding the infant • Pulling up on the mother’s clothes to nurse or by arching back to position himself for

nursing A mother should not wait until an infant is crying to breastfeed. Crying is considered a “late” hunger sign. Late hunger feeding signs / cues include:

• Crying • Moving head back and forth • Falling asleep

Infants also “cluster feed” at times, where they feed every hour (or more frequently) for a few feeds, then sleep for a few hours.

Sleepy infant / “won’t wake to feed” While infants have a short period of alertness immediately after delivery, they can be expected to enter a period of “hibernation” for the next 24 – 48 hours. This conserves their nutritional and metabolic reserves and correlates with the physiologic delay of lactogenesis 2. A mother may report that her infant is “sleepy.” A mother should be encouraged to breastfeed 8 – 12 times per 24 hours based on her infant’s feeding cues. However, if an infant is sleeping for longer than 4 hours at a time during the first 1 – 2 weeks, he may need to be woken up to feed. Frequent feedings ensure proper nutritional support of the infant and appropriate stimulation to mother’s breasts, thus ensuring continued breast milk production in the mother. To promote alertness in a sleepy infant, a mother can remove the infant’s clothing and place infant skin-to-skin on her bare chest. Rubbing the infant’s feet can also assist in making the infant more alert. Excessive sleepiness or lethargy is not normal and should be evaluated immediately by an experienced health professional.

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Nipple Confusion Nipple confusion can occur when an infant has not had adequate opportunities to establish correct mouth movements for breastfeeding. This is thought to be caused by early and frequent exposure to artificial nipples and pacifiers. It is also believed to contribute to breastfeeding problems and early weaning In order to breastfeed successfully, infants must learn to attach and suckle properly at the breast.

• an infant must open his mouth widely to accommodate breast tissue • an infant then protrudes his tongue over his bottom lip and use a peristaltic motion to

“milk” the breast and extract milk A bottle-feeding infant utilizes a mouth position and technique that is much different than that used for breastfeeding. The mouth position is much narrower and accommodates a small artificial nipple in the mouth. The technique utilizes passive suction / negative pressure for milk extraction by creating a partial vacuum with his mouth; no tongue action is needed. When an infant applies a bottle-feeding technique to the breast it can have many negative consequences:

• Breast milk may not be expressed efficiently from the breast, and the infant will become frustrated.

• Improper breastfeeding mouth position and technique in the infant can cause a lot of pain to the mother. Maternal pain can inhibit the letdown of milk.

• Incomplete emptying of the breast will inhibit the mother’s body in adequate breast milk production. This is due to a substance in the breast milk that tells the mother’s body to produce less milk for the next feeding.

These situations can then ultimately lead to the decreased future production of breast milk, which then leads to formula supplementation and thus early weaning:

ineffective suckle ! less milk to infant and pain in mother ! diminished let-down ! inadequate emptying of breast ! decreased milk production ! earlier weaning

There are other ways to feed an infant besides bottle-feeding, which will in turn protect against nipple confusion in an infant. These methods include cup feeding, spoon-feeding, syringe feeding, and using a supplemental nursing system. Please see the appendix for diagrams and instructions.

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Milk Expression / Separation of Mother and Infant • Every effort should be made to keep mothers and their infants together while in the

hospital. • Separation of the mother and infant should be avoided or minimized to no more than one

hour at a time for hospital procedures. • Many hospital procedures, including physical exams, blood draws, medication

administration and phototherapy can be performed in the mother’s room. • The longer a mother and infant are separated while in the hospital, the more likely it is that

an infant will be given supplemental formula. Mothers who are separated from their infants (i.e. infants transferred to the NICU) should be provided with a breast pump and instructed to use the pump for at least 15 minutes, 8 times during the day and once during the night. The reason for breast-pumping during the immediate newborn period is not to provide breast milk to the infant, but to provide stimulation to the mother’s breasts. Mothers may find that they express little or no milk in the immediate post-partum period. Mothers should be reassured that this does not mean they are not producing enough milk! During the first day or two of life, prior to lactogenesis 2 (milk coming in), there is only drops of colostrum and breast milk present in the breasts. This is normal, and is due to the inhibitory effect of pregnancy hormones on breast milk production at this time. Adequate breast stimulation via breast pumping ensures adequate breast milk production for when lactogenesis 2 does finally occur. If this stimulation is not applied, lactogenesis 2 may be delayed, or the mother may produce inadequate quantities of breast milk. Mothers can expect more copious milk production to occur at around 60 hours of life, when lactogenesis 2 occurs. However, any expressed milk that is obtained via breast pumping may be fed to the infant. Manual expression can be more effective in expressing colostrum during the first few days of life. Although infants can draw out colostrum due to their mouth latch and peristaltic motion of their tongue, breast pumps often cannot express the thick fluid by mere vacuum / suction. Please see the appendices for more information regarding milk expression and storage and lactation physiology.

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Hypoglycemia Management Transient hypoglycemia is common and physiologic in newborn mammals during the first few hours of birth. In full-term, asymptomatic, healthy, appropriate for gestation age (AGA) babies, there is little reason to routinely monitor glucose levels during the newborn period. It is believed that in the event of transient or prolonged hypoglycemia, most infants are capable of a robust ketogenic response to prevent neurologic sequelae. Infants who are at highest risk of hypoglycemia are:

• Small for gestational age (SGA) and Low birth weight (2500 g) infants • Large for gestational age (LGA) • Infants of diabetic mother, especially if diabetes has been poorly controlled • Infants who suffer perinatal stress including severe acidosis or hypoxia-ischemia • Infants with cold stress • Polycythemia (Hct 70%) • Infants with signs and symptoms of suspected infection • Infants who present in respiratory distress • Infants displaying symptoms associated with hypoglycemia

Early breastfeeding is not precluded just because an infant meets the criteria for glucose monitoring. Early and exclusive breastfeeding meets the nutritional and metabolic needs of healthy, term newborn infants. To ensure breastfeeding success:

• Initiate breastfeeding within 30 to 60 minutes of life and continue on demand. • Feedings should be frequent; 10 to 12 times per 24 hours in the first few days after birth. • Avoid supplementation unless medically indicated. • Facilitate skin-to-skin contact of mother and infant.

In an asymptomatic, hypoglycemic infant:

• Encourage oral feeding: o breastfeed every 1 – 2 hours or o feed 3 to 5 mL/kg (up to 10 mL/kg) of expressed breast milk or formula

• If glucose remains low despite feedings, or the infant becomes symptomatic, begin IV glucose therapy and adjust intravenous rate by blood glucose concentration.

• Breastfeeding may continue during IV glucose therapy if the infant is able. If supplementation or IV is required to manage hypoglycemia, mothers can be reassured that there is nothing wrong with their milk, and these interventions are temporary. During these interventions, either supplementing or using IV, it is important to keep the infant at the breast, or return the infant to the breast as soon as possible. Skin-to-skin care is easily done with an IV and may lessen the trauma of an intervention, while also providing physiologic thermoregulation, and assist in returning the infant to metabolic homeostasis. Ensure that the mother is given a breast pump to provide breast stimulation if she is separated

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from her infant during the newborn period.

Medical Indications for Supplementation Healthy newborns, in general, do not need ANY supplemental feeding for the first 24 – 48 hours. However, babies who are too sick to breastfeed or whose mothers are too sick to allow breastfeeding are likely to require supplemental feedings. In other cases, such as excessive infant weight loss, the goal is to feed the infant and optimize maternal milk supply while determining the cause of poor feeding and/or inadequate milk transfer. All infants should be evaluated for position, latch and milk transfer prior to the provision of supplemental feedings. Lactation consultants are very helpful in these cases. Formula supplementation is not without risk, and can prevent the establishment of maternal milk supply, have adverse effects on breastfeeding (e.g. delayed lactogenesis 2, maternal engorgement, mastitis), alter infant bowel flora, sensitize the infant to allergens, and interfere with maternal-infant bonding. The physician must always decide if the benefits of supplementation outweigh the potential risks of these feedings. Banked / donor milk should be considered when supplementation is necessary. Despite the pasteurization of donor milk, very few biologically active compounds are destroyed, leaving banked milk with many protective immunologic and anti-infective components of non-banked human milk.

General guidelines for supplemental feeding: • Breast milk is the first choice for supplementation if needed. • If supplementation is necessary, the infant should be at the breast for milk stimulation. • Small frequent feeds are more physiologically appropriate and less likely to interfere

with breastfeeding and lactogenesis. • Mothers should optimally express milk every time her infant receives a supplemental

feeding, or at least every 3 hours beginning on the first day, in order to maintain milk supply.

• An example of supplemental feeds in the first week of life is breastfeeding on demand, then providing one ounce of supplemental formula or donor breast milk every three hours.

• Alternatives to bottle-feeding: Infant can be fed via syringe, cup or supplemental nursing system to avoid nipple confusion (see appendix for images and information.

Infants who should not receive breast milk or any other milk except specialized formula:

• Infants with classic galactosemia • Infants with maple syrup urine disease • Infants with PKU

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Infants for whom breast milk remains the best feeding option but who may need other food in addition to breast milk for a limited period:

• Infants with increased metabolic or fluid needs (surgery, phototherapy, symptomatic hypoglycemia)

• Rapid weight loss over 7 - 8% in first 48 hours with poor latching and suck skills. • Weight loss of 8 – 10% accompanied by delayed lactogenesis 2 (day 5 or later) • Delayed bowel movements or continued meconium stools on day 5 • Hyperbilirubinemia

o Jaundice where intake is poor despite adequate intervention o Breastmilk jaundice when levels reach >20 – 25 mg/dL in an otherwise thriving

infant and where diagnostic interruption of breastfeeding might be helpful • Low birth weight

o When sufficient milk is not available o When nutrient supplementation is indicated

• Infant is unable to feed at the breast: premature <37 weeks, floppy babies, babies with poor tone, Down’s Syndrome, cleft palate

• Infants born weighing <1500g (very low birthweight) • Infants born at less than 32 weeks of gestation (very preterm)

Maternal conditions that may require supplemental feedings for infants:

• Intolerable pain during feedings unrelieved by interventions • Cracked and bleeding nipples • Infant does not latch by 24 hours despite repeated attempts by nurse and mother • Infant cannot maintain latch due to malformed nipples (everted, flat) • Infants of mothers with severe maternal illness (psychosis, eclampsia, shock) • Infants of mothers who are taking medications that are contraindicated in breastfeeding • Primary glandular insufficiency (primary lactation failure) as evidenced by poor breast

growth during pregnancy and minimal indications of lactogenesis, breast pathology or prior breast surgery resulting in poor milk production

• Delayed lactogenesis o Retained placental fragments (lactogenesis usually resumes after fragments are

removed) o Sheehan syndrome

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Delay, Inadequate, or Failure of Lactogenesis 2 Lactogenesis 2 is the start of copious milk production in the mother, aka “the milk comes in.” Lactogenesis 2 can occur between 24 – 100 hours of life, but usually occurs around 60 hours post-partum. Conditions that can delay or lessen milk production during lactogenesis 2 include:

• Separation of mother and infant • Preterm birth • Endocrine problems including PCOS and hypothyroidism • Breast surgery, specifically breast reduction • Retained placenta • Hormonal birth control (i.e. depo provera after delivery) • Maternal obesity • Maternal diabetes or hypertension-etiology unknown • Sheehan’s syndrome

“Delayed” lactogenesis 2 is defined as extended time between colostrum and full milk production. “Failed” lactogenesis 2 is the inability of a woman to achieve full lactation due to either primary inability to produce or issues with breastfeeding or infant health. The onset of lactogenesis 2 is often accompanied by significant breast engorgement, which can make it difficult for an infant to latch; even he was breastfeeding without difficulty previously. Using a breast pump for 1 – 5 minutes prior to feeding can soften the breasts during this time and allow the infant to latch easily. The engorgement will resolve over the following days and weeks. Lactogenesis 1 is the production of milk and colostrum during pregnancy and during the first few days post-partum. See also appendix for more information about the physiology of lactation.

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Breastfeeding the Late-preterm Infant Late-preterm infants are infants born between 34 and 37 weeks gestation. These infants can appear robust like full-term infants. However, they are more prone to medical problems in the newborn period, including temperature instability, hypoglycemia, hyperbilirubinemia, dehydration, and readmission to the hospital. These infants can successfully breastfeed, but they need evaluation of their breastfeeding technique and close follow-up post-discharge. The reasons for the higher morbidity in late-preterm infants are many, including neurodevelopmental immaturity which can cause these infants to have an uncoordinated suck-swallow mechanism, mild hypotonia, and less alert/awake periods. They also have increased metabolic requirements due to less glycogen and fat stores, having not benefited from the final deposit of nutrition at the end of pregnancy that full-term infants experience. Late-preterm infants who are exclusively breastfed are at risk for hyperbilirubinemia. This is likely due to the reasons listed above, which can result in the poor intake of breast milk during the newborn period, in the setting of higher metabolic needs. In addition, late-preterm infants often have less stamina to breastfeed than full-term infants. Less acutely, these infants are at a higher risk for breastfeeding problems of all types, and are less likely to achieve “full” breastfeeding status. Poor breastfeeding technique can result in decreased maternal breast stimulation, thus decreased breast emptying, then decreased milk intake by the infant due to decreased milk production by the mother. This then leads to decreased stool production therefore inadequate bilirubin excretion, leading to potentially dangerous levels of bilirubin in the infant. However, preterm and late-preterm infants benefit greatly from the immune protection of breastmilk, and their mother should be encouraged to breastfeed if infant is stable.

General guidelines for managing breastfed late-preterm infants: 1. All late preterm infants should be observed by a skilled practitioner in lactation while still

in the hospital to assure an adequate latch-on while breastfeeding. 2. Frequent breastfeeding on demand should be encouraged, and these infants should not

go for more than 3 hours without a feed in the newborn period. 3. Late-preterm infants should stay in the hospital for a minimum of 48 hours to ensure

physiologic stability, breastfeeding ability and adequate milk transfer. Serum bilirubin should also be assessed prior to discharge.

4. All mothers should be informed that their late preterm infant may not breastfeed as robustly as a term infant, and early and frequent follow-up post-discharge should be planned.

5. Mothers should be instructed to keep a detailed breastfeeding, voiding and stooling log, and should be educated about adequate intake and elimination. She should be instructed to bring her infant in for evaluation if he should become jaundiced, if his intake or elimination patterns are not adequate, for excessive sleepiness/not waking to feed, or for any concern.

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Decision Not to Breastfeed Women may decide that breastfeeding is not appropriate for her or her family. Lactogenesis 2 will still occur at around 60 hours of life and she may experience engorgement, however, milk production will abate during the first few days after delivery. Hormone treatment to stop milk production is not recommended. Options for symptom relief during this period include a well-fitting support bra, analgesics and ice packs. She also can be assured that if she changes her mind, she may still be able to initiate breastfeeding within the first few days post-partum.

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Hospital Discharge Checklist

Prior to discharge, the following conditions should be met for all breastfeeding mother / infant pairs: • Trained personnel have observed the mother and infant `during breastfeeding and

adequate latch and breastfeeding technique have been ensured. • Mother should be comfortable with breastfeeding and all questions and concerns regarding

breastfeeding have been addressed. • Infant has been weighed prior to discharge and adequate weight loss has been

documented. • Adequate elimination patterns have been documented (at least one void per day for the first

2 days, passage of at least one meconium stool during the first two days of life.) • A 48 hour post-discharge follow-up visit has been made for the infant and mother to assess

infant weight loss, jaundice, and assure continued breastfeeding success. • Mother is instructed to keep a record of breastfeeding frequency and duration of feedings,

as well as number of bowel movements and wet diapers of her infant at home (see Breastfeeding Log in appendix for an example)

• Mother is given explicit information on how to determine that her infant is breastfeeding well:

o Mother understands infant feeding cues. o Infants feed on demand, e.g. based on feeding cues and not on a schedule. Most

infants feed 8 – 12 times per day with 10 – 15 minutes on each breast (although time can vary) during the first few weeks of breastfeeding; breastfeeding length is determined by satiety of infant.

o Mother understands adequate elimination patterns of infants. One way a mother can determine adequate milk ingestion is by the presence of loose, bright yellow bowel movements by day of life 5.

o Mother should be knowledgeable about expressing her breast milk, either via manual expression or via electric breast pump; this important information is very helpful when an infant attempts to breastfeed and the mother’s breasts are engorged. Expressing a small amount of milk prior to feeding can assist in latching of infant onto the breast.

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Post-partum / First week of life

Breastfeeding Essentials for the Clinician

Assessing Breastfeeding Success for Infant and Mother

Vitamin D Supplementation for the Breastfeeding Infant

Common Early Post-partum Breastfeeding Issues

Pacifier Use

Breast Engorgement

Hyperbilirubinemia

Ankyloglossia “tongue tie”

Indications for Post-Partum Lactation Consultation

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Post-discharge Follow-up Breastfeeding Essentials: • Encourage exclusive breastfeeding for all infants up to six months age, with

continuation of breastfeeding with complementary foods to one year of age and beyond. • Routine formula supplementation will decrease the milk producing requirements of

the mother, and thus result in less milk production, making the use of formula more and more necessary.

• Lack of maternal confidence is a common cause of early discontinuation of breastfeeding, even if an infant is gaining weight appropriately.

• Discourage use of artificial nipples (bottles) or pacifiers until 4 – 6 weeks of life or until breastfeeding is well established.

• Review normal weight gain and elimination patterns of neonates. • Review typical pattern of growth spurts in infants. • Review medical indications for supplementation. • All exclusively breastfed babies should receive daily supplementation of 400 IU vitamin D

beginning shortly after delivery.

Assess Breastfeeding Success: • Weight loss of infant

o Weight loss of 7 – 8 % of birthweight is considered acceptable in the first week of life. A weight loss of up to 10% can be considered acceptable if physical exam is normal, the infant is term, and overall breastfeeding appears to be going well (infant is latching well, elimination patterns are adequate.)

o A follow-up visit in 1 – 2 days for a weight check is warranted if weight loss is a concern.

• Review elimination patterns of infant • Assess breastfeeding technique

o Evaluate mother’s comfort, infant positioning, and infant latch (see appendix for information about positioning and latch)

o Breast engorgement can prevent effective latch by the infant: lactogenesis 2 occurs around 60 hours post-delivery, and can be accompanied by significant engorgement of the breast and nipples. This can make it difficult for an infant to latch onto the breast to feed, even if he was breastfeeding well prior to lactogenesis 2.

o To assist in softening the breast and nipple, a mother can express some milk from her breasts via an electric pump for 1 – 2 minutes, or use manual expression (see appendix for more information.)

o Engorgement can occur prior to feeding during the first and second weeks of breastfeeding and then gradually resolves.

• Assess any pain in mother while breastfeeding o Mild pain during the first few seconds of breastfeeding is normal during the first

and second weeks of breastfeeding. o Severe and persistent pain during breastfeeding is not normal. The most

common cause of nipple pain while breastfeeding is incorrect latch by the infant. A lactation consultant can be of invaluable assistance in this situation.

o Other causes of nipple pain include mastitis and plugged ducts. • Evaluate jaundice in infant / bilirubin measurement

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• Infant’s eagerness to feed / sleepy infant o A mother may report that her infant is “sleepy.” A mother should be encouraged

to breastfeed 8 – 12 times per 24 hours based on her infant’s feeding cues; however, if an infant is sleeping for longer than 4 hours at a time during the first 1 – 2 weeks, he may need to be woken up to feed.

o To promote alertness in a sleepy infant, a mother can remove the infant’s clothing and place infant skin-to-skin with her. Rubbing the infant’s feet can also assist in making the infant more alert.

o Excessive sleepiness or lethargy is not normal and should be evaluated immediately by an experienced health professional.

Essential Breastfeeding Discussion Topics: Maternal fluid, dietary intake and nutritional supplement use:

• Breastfeeding women need approximately 500 kcal more per day than non-lactating women.

• Reassure women that eating a well-balanced diet will provide adequate nutrition in her breastmilk.

• Moderate caffeine intake, and 1 – 2 glasses of alcohol are compatible with breastfeeding.

• If a woman is a strict vegan, she should be instructed to take a vitamin B12 supplement to ensure her infant receives adequate levels of this nutrient.

• DHA (omega fatty acid) supplements are not necessary. At this time, there is no data that shows that breastmilk is deficient in these essential fatty acids and supplementation with DHA is not recommended.

• Encourage women to drink plenty of fluids; however, fluid intake does not typically affect milk volume.

Mother’s support system and partner involvement:

o Other caregivers of the infant can support women in their breastfeeding efforts by bringing the infant to her at feeding times, changing diapers, holding the infant, and offering encouragement.

o Healthcare providers can assist couples with emotional adjustments by discussing contraceptive planning and sleeping arrangements

Maternal medication / drug / etoh / tobacco use

Sleeping arrangements • Decreased amount of sleep is common for parents when taking care of newborns. • New mothers may feel overwhelmed with the demands of breastfeeding, and lack of

sleep contributes to this feeling. • A common piece of advice given to mothers is “sleep when your baby sleeps.” A

woman can breastfeed her newborn and nap when the infant naps. • She should plan on sleeping in periods throughout the day and night until her infant

begins sleeping in longer stretches during the night, which often begins around 8 weeks of age.

• Discuss the demands of breastfeeding and that many tasks and duties may need to be deferred for her to conserve her energy; duties of cleaning the house,

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shopping, and caring for other children may need to be transferred to other caregivers in order for her to get adequate rest.

• Although the AAP does not recommend co—sleeping or bed sharing due to concern over SIDS, most children in the world sleep with their mothers in early periods of life.

• Many breastfeeding advocates promote co-sleeping as a way of fostering closeness between mother and infant, as well as promoting frequent nursing which then promotes adequate milk production and longer duration of breastfeeding.

• It is important that women and families understand the risks of co-sleeping and bedsharing.

• If a woman wishes to co-sleep, discuss safe-sleeping arrangements with her (see “Co-Sleeping” in this section.)

Reiterate the medical benefits for infants of mothers of breastfeeding for one year and beyond. Congratulate the woman for her decision to breastfeed! Acknowledge that breastfeeding, like parenting, has its demands and rewards, and provide reassurance that help is available to her if she needs it.

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Vitamin D Supplementation for Exclusively Breastfed Infant: • Breastmilk has low levels of vitamin D, and sun exposure is not considered a safe or

adequate method of vitamin D production in the infant. • A woman cannot increase the vitamin D content of her breastmilk by eating more vitamin D

or taking vitamin D supplementation. • The American Academy of Pediatrics recommends that all exclusively breastfed

infants be supplemented with vitamin D 400 IU beginning shortly after birth. This is achieved with administration of 1ml Trivisol daily.

• Supplementation should continue until an infant consumes 500ml of vitamin D fortified milk or formula daily.

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Common Early Post-partum Breastfeeding Issues

Pacifier Use in Breastfeeding Infants • Pacifiers can cause nipple confusion, which occurs when an infant has not had the

opportunity to establish the correct mouth movements for proper breastfeeding. • Frequent use of artificial nipples early in life has been shown to promote a less effective

mouth-movement, which can make breastfeeding difficult for infant and painful to mother. • Pacifiers have been shown to give infants protection against SIDS, however, breastfeeding

is also protective against SIDS. • Studies show a 4-fold increase in weaning by 6 months in pacifier users over non-users:

ineffective suckle ! less milk to infant ! pain in mother ! less let down ! less milk ! earlier weaning

• Pacifiers should not be given routinely to breastfeeding infants until 4 - 6 weeks of life, at which point breastfeeding is usually well established.

Breast Engorgement A very common breastfeeding scenario is a woman who breastfed without difficulty in the hospital and then is unable to latch her infant to breastfeed after lactogenesis 2. This is most commonly due to engorgement, where the breasts become large and firm and the nipple is often effaced making it difficult for the infant to latch. Engorgement is common in the first week post-partum; this is due to presence of milk in the breast, but also due to edema in the breast tissues. To soften the breasts and nipples and enable easier latch is to have the woman pump her breasts for 1-5 minutes; this often results in successful latch and breastfeeding. A mother can also experience engorgement during lactation when milk is not removed regularly. Common situations that lead to engorgement:

• infant sleeping through the night • separation of mother and infant • formula supplementation • infrequent feedings, or time-limited feedings

Management and Treatment • Instruct the mother to manually hand express or pump her breast milk prior to feedings

in order to release enough milk to better enable the infant to grasp the nipple. • Instruct the mother to use warm compresses prior to feeding to stimulate let down and

cold compresses upon completion of feeding to decrease inflammation. • Instruct the mother to feed or pump frequently (8 – 12 times per day). • The mother may need a pain reliever to relieve discomfort and symptoms of

engorgement; Tylenol, aspirin and ibuprofen are all compatible with breastfeeding. • Reverse pressure softening can also be used (see appendix.)

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Hyperbilirubinemia Jaundice is common in the newborn period. If an infant is jaundiced and bilirubin levels are below phototherapy guidelines, the infant is well, and the elevated bilirubin level cannot be attributed to any specific factor, it is considered “physiologic jaundice.” There are risk factors for potentially dangerous levels of bilirubin. One risk factor is hemolysis due to ABO incompatibility. However, the increasing number of cases of kernicterus in this country over the past few decades is postulated to be due to short hospital stays (24 - 72 hours) and the increase in breastfeeding rates. Education of the mother, adequate post-partum follow-up of the infant and proper management of breastfeeding can minimize the occurrence of dangerous hyperbilirubinemia. Late-preterm birth, primiparity, and exclusive breastfed status are risk factors for hyperbilirubinemia. Bilirubin levels should be plotted using the Bhutani curve (see appendix), with consideration of risk factors for hyperbilirubinemia, and infants should be risk-stratified. Infants should be admitted for phototherapy if levels indicate (see also appendix). Otherwise, a mother should be encouraged to continue breastfeeding but follow-up frequently for infant assessment.

Breastfeeding Jaundice Breastfeeding jaundice, also called “non-feeding jaundice,” is caused by a low intake of breastmilk. This can be due to delayed lactogenesis, poor latch and/or breastfeeding technique, or infrequent feedings in a newborn infant. Poor intake of breastmilk results in low stool output. Low stool production results in less excretion of bilirubin. Adequate stool output is essential in adequate excretion of bilirubin during the newborn period. When an infant cannot breastfeed adequately and/or there is a delay in lactogenesis 2, breastfeeding jaundice can occur. Management of Breastfeeding Jaundice: • Measure serum bilirubin; the physical exam is not an accurate method of determining

bilirubin levels. • Calculate weight loss of infant, and review feeding and elimination patterns of infant. • Educate mother if necessary about appropriate feeding frequency (8 – 12 times per 24

hours). • Evaluate breastfeeding success: evaluate position, latch and ensure milk transfer. • Encourage frequent feedings of infant to ensure adequate nutrition and continued milk

production in infant. • Use supplemental formula if medically indicated. • Consider a referral to a lactation consultant for assistance in evaluating proper

breastfeeding technique: positioning, latch and milk transfer. However, if an infant’s weight loss and elimination patterns are appropriate, encourage the mother to continue breastfeeding. A “trial” of formula is not indicated in this situation. Bili blankets are an option for home use; they are used as prophylaxis in infants where there is concern for significant hyperbilirubinemia. They are not a substitute for intensive / treatment phototherapy.

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Management of Breastmilk Jaundice: About 30% healthy newborns will still be jaundiced after 2 weeks of age. Bilirubin levels will be below those requiring phototherapy. The exact etiology of breastmilk jaundice is unclear, however, beta-glucuronidases and lipases in breastmilk may encourage reuptake of bilirubin in the intestine. In cases of breastmilk jaundice, the total bilirubin levels can range from 12 – 20 mg/dL and may be elevated for 1 – 3 months. It is important to evaluate the jaundice with direct and total bilirubin tests to avoid missing significant pathology. Pathology such as liver disease, congenital hypothyroidism and galactosemia are serious conditions associated with jaundice at this age. If the baby’s physical exam is normal and urine and stool output are normal, the infant can be observed and followed without intervention. A “trial” of formula is not necessary and may result in decreased breastmilk production, prompting the need for continued formula supplementation.

Ankyloglossia or “tongue-tie” • Perceived or actual short sublingual frenulum that prevents tongue from elevating or

extending anteriorly • Occurs in 3 – 5% of infants • Infants with ankyloglossia comprise 13% of infants with breastfeeding problems • Problems with breastfeeding include nipple trauma or failure of infant to breastfeed

effectively • Previous belief that ankyloglossia can cause speech defects has been proven to be

unfounded.

Management: • Determine breastfeeding success:

o Weigh infant, ensure adequate growth o Review feeding and elimination patterns o Observe breastfeeding and evaluate infant latch o Evaluate pain in mother with breastfeeding

• If breastfeeding is unsuccessful due to improper latch, or there is substantial pain in the mother despite lactation consultation, the clinician can consider the frenotomy procedure:

o “snipping” of frenulum o no local anesthesia o well-tolerated by infant, mother can breastfeed immediately after o usually done by ENT at KP LAMC

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Indications for Post-Partum Lactation Consultation Consider referring the mother to a lactation consultant when the following conditions are present:

• Mother in ICU or other complication • Breasts or nipples that require assistive devices for proper latch • Infant born at gestation <38 weeks / late - preterm • Absence of lactogenesis 2 by day 3 • Failure to thrive / excessive weight loss • Pain in mother while breastfeeding • Ankyloglossia / tongue tie • Mother of infant with congenital anomalies • Mother attempting to breastfeed multiple infants

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First month of life

Growth / Weight Gain of Healthy Full Term Infants

Pumping and Storing Breastmilk

Contraception and Breastfeeding

Lactation Amenorrhea Method of Contraception

Insufficient Milk Syndrome

Sore Nipples / Nipple Trauma

Mastitis / Breast abscess / MRSA / Candidal Infections

Co-sleeping / Bedsharing

Post-partum Depression

Return to Work

Weaning

Breast Cancer Detection in Breastfeeding Women

Environmental Toxins in Breastmilk

Breastfeeding Support for Patients / Patient Resources

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First Month Breastfeeding Essentials: • Encourage exclusive breastfeeding for all infants up to six months age, with

continuation of breastfeeding with complementary foods to one year of age and beyond. • Discourage use of artificial nipples (bottles) or pacifiers until 4 – 6 weeks of life or

until breastfeeding is well established. • Review normal weight gain and elimination patterns of neonates. • Discuss contraceptive planning with mother. • Discuss maternal current or future medication use, and investigate compatibility of

medicine with breastfeeding. • Assist mother in pumping and storing breastmilk, if desired by mother. • Discuss plans for mother’s return to work, if any; mother should plan on returning to

work after at least 4 weeks post-partum to ensure breastfeeding establishment. • Introduce a bottle of expressed breast milk beginning at 4 – 6 weeks of age If a

mother is planning on returning to work, or if other caregivers will feed the infant during the first year.

• Educate mother about growth spurts, where she can expect the infant to be hungrier and cry more often.

• Screen mother for postpartum depression, and offer referrals to a mental health provider or social worker if indicated.

• Ensure daily vitamin D supplementation for infant in exclusively breastfed infants. • Reassure mothers that their infants are thriving. Lack of maternal confidence in

breastfeeding or in her ability to produce milk is a common cause of early discontinuation of breastfeeding.

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Growth / Weight Gain of Healthy Full Term Infants • 8% weight loss from birthweight is considered acceptable in the first week of life. • Infants will usually regain birthweight by the second week of life. • Typical weight gain is 5 – 7 oz per week for first four weeks (10g/kg per day).

Growth spurts Growth spurts usually occur at standard intervals where an infant who was breastfeeding successfully will suddenly become fussy, appear hungrier and feed more frequently. Growth spurts are often accompanied by an increase in crying frequency and duration; often the mother will believe that she is “running out of milk.” Growth spurts most commonly occur at 2 – 3 weeks, 6 weeks, 3 months and 6 months of life, however, they can happen at any time. • Growth spurts usually resolve in 2-3 days. • Encourage mother to continue to breast feed her infant when based on feeding cues. • Avoid formula supplementation, which will decrease breast milk production. • Reassure mother that she is capable of producing enough milk for her infant. • Growth spurt behavior is the infant’s way to promote continued breast milk production in the

mother.

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Pumping and Storing Breast milk Infants of breastfed mothers are often cared for by others, and many women in this country will return to work soon after delivery. Expressing and storing breast milk is a means of providing breastmilk to infants when they are separated from their mothers.

Milk Expression Breast milk can be expressed via hand expression, manual pump, or automatic / electric breast pump. Hand expression can be cheap and convenient, as no extra materials are involved; however, electric pumps are more efficient, as pumping both breasts simultaneously is more effective and saves time.

Manual expression technique (please see appendix for diagrams): • Mother places hand on breast, with the thumb above and fingers underneath, about an inch

to an inch-and-a-half behind the nipple. If the breast was a clock, thumb would be at 12 o'clock and fingers would be at 6 o'clock. Breast should not be cupped; instead, thumb and fingers should be directly across the nipple from each other.

• Press thumb and fingers directly back into the breast tissue, towards the wall of the chest. • Fingers and thumb and rolled forward to squeeze milk out of the milk sinuses, which are

located under the areola behind the nipple. Fingers should not slide along the skin as this will make breasts sore. Milk will appear at the nipple when milk sinuses are compressed.

• Sequence is repeated--position, press, roll--until the milk flow ceases. Thumb and fingers are then repositioned at 11 and 5 o'clock and the sequence is done again. Both hands can be used to work one breast. The process is then transferred to the other side until the milk sinuses have been emptied.

• Lactation consultation can be very helpful in instructing women how to manually express breastmilk.

Manual Breast Pumps: • Hand and wrist operated hand-held device. • Requires practice, skill and coordination. • Useful for occasional pumping if mother is away from infant only occasionally. • Price range is $30 to $50; can be purchased at KP Women’s Center or local store Automatic / Electric Breast Pumps: • Run on batteries or plugs into electrical outlet. • Easy to use. • Can pump one breast or both breasts at the same time. • Need place to clean and store the equipment between uses. • Hands-free models are available. • Costs run $150 to over $250; can be purchased at KP Women’s Center or local store

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Home Storage of Breastmilk General Guidelines: • Milk may be kept at room temperature (up to 77 deg F) for 6-10 hours (hospital storage: 4

hours) • Milk may be kept in an insulated cooler bag with ice packs for up to 24 hours. • Milk may be refrigerated (39 deg F) for up to 8 days; store milk in back of main body of

refrigerator where it is coolest. • Freezer storage: generally store milk in the back of the freezer, where temperature is most

constant; if stored in other areas of the freezers, refer to following timetables: o Freezer compartment located inside refrigerator (5 deg F) ! two weeks o Refrigerator/freezer with separate doors (0 deg F) ! 3 – 4 months o Deep freezer that is opened infrequently (-4 deg F) ! up to 12 months

Storage containers: • Should be hard-sided, such as hard plastic or glass • Should have airtight seal • Plastic bags specifically designed for human milk storage can be used for short-term milk

storage (<72 hours); long term is not recommended as the bags may spill or leak, and milk components may adhere to the soft plastic

• Use containers that have been washed in hot, soapy water and rinsed. Cleaning in a dishwasher is acceptable.

• Do not fill container completely to the top as breast milk will expand as it freezes.

Thawing and warming milk: • Microwaves should be avoided as they can scald the milk and can denature valuable

proteins in the milk; stovetops should be avoided as well for similar reasons. • Milk that is thawed and warmed but not used should be discarded. • Oldest milk should be used first. • Thaw milk by placing it in refrigerator overnight or gently warm it by placing container under

warm running water or by placing it in bowl of warm water. • Swirl the container to mix the cream back in, and distribute heat evenly.

Miscellaneous breast milk storage guidelines: • Store milk in small portions to minimize waste. • Babies will often take between 2 – 4 oz every 3 – 4 hours when starting on an alternative

feeding method; storing 2 oz portions and offering additional amounts if baby is hungry will result in less waste.

• Several expressions a day may be combined to get desired volume in a container. • Expect that breast milk will separate during storage because it is not homogenized; the

cream will rise to the top; before feeding, gently swirl and blend the cream portion into the milk.

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Contraception and Breastfeeding Non-hormonal and hormonal contraception methods are compatible with breastfeeding. Non-hormonal methods are preferred, due to the concern that hormonal methods may decrease total breastmilk production. The average time to first ovulation is 45 days post partum, with a range of 25 – 72 days in non-breastfeeding women. When exclusive breastfeeding occurs, ovulation can be delayed via the lactation amenorrhea method.

Non-hormonal and hormonal methods of contraception • Non-hormonal methods are preferred methods of contraception in breastfeeding

women (condoms, IUDs, diaphragms, cervical caps). • Progestin-only contraception (Nor QD, Depo-Provera)

o Some sources recommend a delay of at least 6 weeks post-partum before starting progestin only pills; ACOG recommends waiting at least 2 - 3 weeks post-partum

o ACOG recommends waiting 6 weeks prior to using Depo-Provera o ACOG: Hormonal implants may be inserted 6 weeks post-partum

• Combined estrogen-progestin contraceptives o Some sources caution against any use of combined contraceptive pills (Hale) o ACOG: typically should not be started prior to 6 weeks post-partum, and only after

breastfeeding has been well established. • Infants are not exposed to clinically significant levels of hormones in women who use

hormonal contraception methods. • However, a woman should consider discontinuing her hormonal contraception

method if she notices a decrease in breast milk production. Per ACOG in their 2007 statement: “Due to absence of well-designed clinical trials proving an association of hormonal contraception and decreased breast milk production, a clinician may decide to initiate progestin-only methods before hospital discharge, and initiate estrogen-containing hormonal contraception after the period of hypercoagulability associated with pregnancy has resolved (2 – 4 weeks.)”

Lactation Amenorrhea Method of Contraception. • Provides more than 98% protection against pregnancy. • Only for mothers of exclusively breastfed infants! • If babies are supplemented with formula, or if solid foods have been introduced, there is a

chance of ovulation occurring. • Feeding intervals should be < 4 hours. • Supplemental feedings should be < 5 – 10% of total (less than one every 10 feeds). • Per ACOG in their 2007 statement: “If there is uncertainty regarding the extent to which a

woman is breastfeeding, it is prudent to recommend additional methods of family planning.”

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Insufficient Milk Syndrome Frequent, regular breastfeeding generally ensures adequate milk supply, and this extends to breastfeeding multiples and older siblings with newborn infants. Many times when breastfeeding women feel there is “not enough milk” there is in fact plenty of milk and baby is growing well. The most common cause of true decreased production of breast milk is supplementation with formula, infrequent feeds, separation of mother and infant, or improper latch. Other causes include:

Maternal causes • Endocrine problems including PCOS and hypothyroidism • Breast surgery, specifically breast reduction • Retained placenta • Unrelieved engorgement • Return of menstruation • OTC medications • Hormonal birth control • Obesity (thought to be due to increased circulating estrogen / androgens)

Infant causes • Infrequent feeding or frequent supplementation with formula • Pacifier use • Ineffective suck, prematurity, neuromotor problems • Oral anatomic problems such as cleft lip or palate

Evaluating a possible case of insufficient milk syndrome:

• Does mother have any risk factors for delayed lactogenesis? • What was the infant’s birth weight? What is the infant’s weight now, and is the

infant gaining weight appropriately? Infants should regain their weight by 2 weeks of life, and weight gain is 5 – 7 oz per week for the first four weeks (10g/kg per day).

• What are baby’s ins and outs? Are they appropriate for the infant’s age? Infants should put out 6 – 8 weight diapers per day after day of life 6. After day of life 5, stools should be yellow and seedy, and should total approximately 4 per day.

• How often does mother breastfeed and for how long? It is important for women to breastfeed “on demand” in the first few weeks of life. Usually, 20 minutes on each breast every 2 – 3 hours is adequate for a 0 – 14 day old baby. For older infants, breastfeeding every 3 – 4 hours, or taking 3 – 4 oz of expressed breast milk every 3 – 4 hours is considered adequate.

• If the infant is gaining weight appropriately, elimination patterns are adequate, and the infant appears well, it is appropriate to reassure the mother. Encourage her to continue breastfeeding on demand or at least every 3 hours, and arrange for a follow-up in 1 – 2 days to reassess her progress.

In cases of true insufficient milk supply, galactogogues may be used. See “Galactogogues” section in the appendix for more information.

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Sore Nipples / Nipple Trauma Breast and nipple pain is a common factor cited as a reason for breastfeeding cessation. Nipple sensitivity for the first 30 seconds to 60 seconds of breastfeeding is considered normal during the first and second weeks of breastfeeding. However, persistent or severe pain during breastfeeding is not normal and should be evaluated. Causes

• The most common cause is poor latch or position and attachment at the breast • Frictional trauma is caused by inadequate amounts of breast tissue being drawn into the

the infant’s mouth. • Infants that use pacifiers typically have a superficial sucking pattern which can cause

frictional trauma • Other causes: Nipple shape, engorgement, improper use of nipple shields or pumps. • The breast may also be tender from a candida infection/thrush, impetigo, eczema, or

herpes; irritation from laundry detergents; food particles in the toddler’s mouth; or dried colostrum or milk causing nipple to stick to bra or breast pads

• The infant’s oral structure: ankyloglossia, high or bubble palate, short tongue can also cause frictional trauma.

Treatment and Care Most early nipple discomfort and pain is due to the mechanics of breastfeeding (e.g. poor latch or positioning) and can be corrected. Counsel the mother on basic positioning and latch-on techniques.

• To facilitate healing begin purified lanolin cream or hydrogel pad and breast shells to keep clothing away from skin.

• Sore nipples without infection that don’t improve with the above regimen can be treated with a combination of mupirocin and triamcinolone 0.1% ointment applied BID. This is safe for the breastfeeding infant; cream can be applied immediately after feeding so possible effects are lessened at next feed.

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Mastitis Mastitis is an infection of the breast, not the breast milk. The most common cause of mastitis is bacterial overgrowth (staph aureus) from milk stasis. It is safe and appropriate to continue breastfeeding with mastitis.

• Occurs in 2-3 % of lactating women • Occurs most commonly in the second and third week post-partum • Flu-like symptoms occur with marked redness on the affected breast • Most common cause is non-MRSA staph aureus (40%); other causes include

haemophilus influenza, H parainfluenzae, E coli, enterococcus, klebsiella, enterobacter, serratia, group B streptocci, and pseudomonas.

Treatment

• Continue frequent, effective breastmilk removal, even after starting antibiotics! • Discarding the milk from the affected breast is not necessary or recommended;

the infant can safely breastfeed from affected breast. • Antibiotics for staph aureus: dicloxacillin 500mg QID for 10 days, or cephalexin for 10

days (clindamycin is indicated in pcn-allergic women); delayed initiation of antibiotics can result in abscess formation (see below).

• Warm or cool compresses on the sore breast. • Analgesics such as ibuprofen or Tylenol may be used for mother’s comfort and are safe

in breastfeeding. • Culture and sensitivity should be obtained if there is no response to antibiotics within

two days; consider treating for MRSA (trimethoprim-sulfa and vancomycin are safe and compatible with breastfeeding).

Breast Abscess • Abscess is indicated by presence of palpable mass and fever that persist for 48 – 72

hours after appropriate management is initiated. • Up to ~3% of mastitis cases will progress to abscess • Abscesses are generally treated with incision and drainage. Ultrasound guided

aspiration has also been successfully used. • Breast milk should be discarded for the first 24 hours after surgery, with

breastfeeding resuming if there is no drainage of exudate into breastmilk. Prevention of breast infections: frequent nursing; if a mother and infant are separated, mother can pump in between feedings with infant; sometimes mother may need to wake up and pump if infant is sleeping through the night and engorgement is uncomfortable or mastitis is recurrent. Consider: inflammatory breast cancer. The major feature that distinguishes mastitis from inflammatory breast cancer is knowledge of previous negative breast exam during pregnancy.

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Methicillin Resistant Staph Aureus (MRSA) Breast Abscess • Incidence is up to 50% in some studies • 95% are community acquired • Most are easily treated with oral antibiotics • Treatment also ensuring breast emptying via pumping and/or breastfeeding • Consider incision and drainage for refractory cases

Nipple Candidal Infections • Not common, but often misdiagnosed • Can present with nonspecific signs and symptoms, including:

o nipple pain o itching, o burning sensation o shooting breast pains that radiate back towards the chest wall

• Nipple and areola may appear erythematous or shiny or have white patches Risk factors • Diabetes • Steroid use • Immune deficiency • Antibiotic use • Nipple trauma • Use of plastic-line breast pads that trap moisture Management: • Candida is often difficult to prove as the causative organism in all situations, as milk and

skin cultures are not helpful. • Infant often has thrush in this context, and mother and infant should be treated together

Objects that contact breast or infants mouth should be sterilized, including pumping supplies, bottles, and pacifiers

• Antifungal treatment consists of: o Maternal treatment: nystatin suspension/ cream or clotrimazole applied after each

nursing; do not need to wash off before feeds. o Infant: nystatin (100,000 u/ml) 1 cc po qid inside mouth to breast after each nursing. o Oral fluconazole — may be prescribed if nipples are not significantly better after

several days of topical treatment, or in cases of reccurrence.

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Co-sleeping / Bed sharing Co-sleeping can help maintain a mother’s milk supply by encouraging regular and frequent feeding. However, bed sharing has become controversial in recent years, and some public health authorities have discouraged all parents from bed sharing. The concerns of these authorities focus around the risk of SIDS and asphyxiation with bed sharing. Critics of these recommendations, specifically the Academy of Breastfeeding Medicine, cite inconsistency of data and state that research showing increased risk of SIDS with bed sharing does not distinguish between unsafe sleep environments (such as sofas, recliners and waterbeds) from safer sleeping arrangements. They put forth that studies show that breastfeeding, specifically exclusive breastfeeding in the first four months of life, show a lowered risk of SIDS, and argue that there is currently not enough evidence to support routine recommendations against co-sleeping. General guidelines:

• Parents should be educated about risks and benefits of co-sleeping and unsafe co-sleeping practices.

• Safe sleeping practices include: o Placing babies to sleep in supine position o Using a firm flat surface for sleeping o Avoiding soft bedding, waterbeds, pillows, sofas or recliners o Ensuring that infant’s head will not be covered while sleeping o Never leaving infant alone in an adult bed o Ensuring that there are no spaces between mattress and headboard, or between

mattress and wall where infant can fall and become trapped. • Unsafe sleeping practices include:

o Environmental smoke exposure and maternal smoking o Sharing sofas or couches with sleeping infant o Placement of infant in side or prone position o Use of alcohol of drugs by adults who are bed sharing o Bed sharing with other children

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Post-partum Depression Most antidepressants are safe and compatible with breastfeeding. Postpartum depression is not uncommon. At least 10% to 20% of postpartum mothers suffer from depression, and 10% to 16% of pregnant women fulfill the American Psychiatric Association Diagnostic and Statistical Manual, edition 4 (DSM-IV) diagnostic criteria for major depression. These numbers are higher in mothers of multiples. The incidence of psychiatric illness is higher in the postnatal period than at any other period in a woman’s life. Children of mothers with post-partum depression can have lasting adverse health outcomes, including depressed mood, difficulty with social, cognitive and behavioral development, attachment difficulties, and are more likely to be victims of abuse and neglect. Many women experience the “baby blues,” up to 50% in some studies. This is a common, temporary condition which resolves in two weeks post-partum or less. However, post-partum depression is suggested by: • Feeling sad or depressed for most of the day, nearly every day, for 2 weeks or more • Mother has 4 or more symptoms of sleep disruption, concentration difficulties, poor energy,

excessive guilt, slowed or agitated motor movements, or thoughts of death or dying. • Post-partum depression can occur up to one year after birth. Women may not volunteer information regarding their depressed mood or negative feelings. Mothers may worry about being judged for having these feelings, or having feelings of harming their child. Also, normal post-partum period changes, including weight loss, sleep disruption, fatigue, concentration difficulties and guilt, are difficult to distinguish from symptoms of true depression. Mothers may also not identify their feelings as depression, but may describe themselves as being “worried” or “anxious.” Predictors of PPD include prenatal depression, low self-esteem, childcare stress, low social support and socioeconomic status, unplanned pregnancy, poor marital relationship, or multiple gestation. Mothers of infants with “difficult temperaments” are also at risk for PPD. Therefore, all clinicians, including obstetricians, pediatricians, and lactation consultants, are encouraged to offer non-judgmental, open ended inquiry regarding a mother’s mood and feelings during the post-partum period. Screening tools exist to assist clinicians in identifying women who may qualify for the diagnosis of post-partum depression, or who could benefit from counseling and/or antidepressants. One screening tool that is commonly used is the PHQ-9 Depression Screening Tool (available in appendix). Mothers may be relieved that their feelings of depression, anxiety or guilt have a diagnosis and a treatment option. Women should be encouraged to accept treatment for symptoms that suggest or qualify for post-partum depression. Cognitive therapy and counseling is helpful and indicated for all cases of PPD, however, many women do not have the time or resources for this treatment.

Treatment If an antidepressant is indicated for PPD treatment, women can be reassured about the safety and compatibility of most antidepressant medication with breastfeeding. Concern may arise

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over the demands of breastfeeding in depressed mothers; the decision to discontinue breastfeeding a part of a PPD treatment regimen should be made on an individual basis, with the mother aware of the benefits of continued breastfeeding and risks of formula.

• Selection of antidepressant medication must be individualized to the patient. • The risks and benefits of the medication, as well as the risks of untreated depression,

should be discussed with the mother. • For breastfeeding women with no prior history of antidepressant use, the first-

line antidepressants are paroxetine and sertraline due to research showing low levels in breast milk of these medications.

• After initiation of antidepressant medication, both mother and infant should be monitored for adverse effects.

• Routine serum monitoring of infants is not indicated. • If there is concern over infant exposure to maternal medication, a mother can take her

medication immediately after feeding, however, there is little evidence to support this practice.

Please see the medications tables in appendix for more information on selected anti-depressant use and breastfeeding.

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Return to Work A woman who wishes to return to work can continue to breastfeed her infant and provide her with breast milk via milk expression and storage. However, working outside the home is related to a shorter duration of breastfeeding, and intentions to work full time are significantly associated with lower rates of breastfeeding initiation and shorter duration. A breastfeeding plan can help the working mother anticipate logistic problems and devise a practical pumping schedule. Barriers to expressing milk at work include a lack of flexibility for milk expression in the work schedule, lack of accommodations to pump or store breast milk, concerns about support from employers and colleagues and real or perceived low milk supply. To ensure breastfeeding success, return to work should be delayed at least 4 weeks after delivery, longer if possible, to ensure establishment of breastfeeding. Women and clinicians may need to educate employers about the necessity of time and resources (i.e. suitable location) required to express milk during the workday. Employers can be reminded of the medical benefits of breastfeeding to infants, and the relationship between healthier infants and less missed days of work by parents caring for sick infants (see below). The influence of a clinician in this situation can be invaluable, and can be expressed in a letter or a phone call.

The Business Case for Breastfeeding Both employees and employers benefit from lactation programs in the workplace. Breastfed infants are healthier and have less illness than formula fed infants, resulting in less work-time lost for parents to care for ill infants. Benefits to the Employer:

• Reduced staff turnover and loss of skilled workers after the birth of a child. • Reduced sick time/personal leave for breastfeeding women and their partners because

their infants are more resistant to illness. • Lower health care costs associated with healthier, breastfed infants. • Higher job productivity, employee satisfaction and morale. • Added recruitment incentive for women. • Enhanced reputation as a company concerned for the welfare of its employees and their

families. For example: an employee absence of one day costs the Los Angeles Department of Water and Power average $360 (for a $15 per hour employee). From http://www.breastfeedingworks.org/econ.htm

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Weaning Weaning is the time of gradually transitioning infants from mother’s milk to complementary foods or an older child’s diet. Complete weaning, or complete cessation of breastfeeding, ideally should be a gradual process accomplished over a long period.. There is no evidence that a specific age of weaning is necessary or mandated. Some women may wish to continue breastfeeding during and after a subsequent pregnancy. Like other developmental milestones, children can wean themselves when they are ready, physically and psychologically. There are several weaning techniques that can be recommended when a mother wishes to encourage the process. In general, gradual weaning is preferred.

• Mother-initiated Weaning: gradually replacing one feeding at a time with solids or a bottle or cup is preferred.

• Infant-initiated Weaning: infants may attempt to wean due to inadequate milk supply or infant illness

• “Nursing Strike:” infant may suddenly refuse to nurse; usually this is temporary; possible causes include onset of menses in mother; maternal soap, deodorant or perfumes; stress in mother; infant may be teething, have an earache, or nasal obstruction; often time infant can be coaxed to begin breastfeeding again with a nursing strike.

• Sudden Weaning: This is not the ideal way to wean. Mother should express to relieve breast fullness, wear comfortable bra, and be alert to signs of plugged duct or mastitis

Hormonal therapy to assist in weaning or decreasing milk production is not recommended.

Breast Cancer Detection in Breastfeeding Women 3% of all breast cancers occur in the post-partum period. Studies show that there is a delay in breast cancer detection during pregnancy and lactation. Clinical breast exam and breast self-examination are recommended for all women, including breastfeeding women. If a mass is detected during lactation, it should be fully evaluated. If needed, a mammogram will not affect milk production. However, during lactation, mammograms are less reliable because of increased breast tissue density, which may interfere with adequate interpretation. ACOG suggests that providers consider performing a screening mammogram before age 40 years for women planning pregnancies in their late 30s.

Environmental Toxins in Breast milk Concern exists about excretion of environmental toxins into breast milk. To date, there is little to no evidence suggesting harm to nursing infants from these agents, even though many of these agents are detectable in breast milk.

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Appendix Breastfeeding Policies: AAP, AAFP, ACOG

The Baby Friendly Hospital Initiative

Healthy People 2010 Breastfeeding Goals

Medication Tables, Vaccines, Imaging / Radiocontrast Agents

Hyperbiilirubinemia Risk and Phototherapy Nomograms

Basic Lactation and Breastfeeding Physiology

Evaluation of Breastfeeding Technique: Positioning, Latch, Milk Transfer

Methods of Human Milk Expression

Alternative Methods to Bottle Feeding Infants

Reverse Pressure Softening for Breast Engorgement

Sample Breastfeeding Intake and Elimination Log

Galactogogues

Donor Breastmilk / Breastmilk Banking

CDC: Breastfeeding and Swine Flu (2009)

Travel Recommendations for the Nursing Mother

Online Clinician Breastfeeding Education and Training Options

PHQ9 Screening Tool for Depression

California Breastfeeding Laws and Legislation

KP and Community Patient Breastfeeding Resources

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Breastfeeding Policies of Medical Organizations

American Academy of Pediatrics From Breastfeeding and the Use of Human Milk, AAP, 2005:

• Exclusive breastfeeding for approximately the first six months and support for breastfeeding for the first year and beyond as long as mutually desired by mother and child.

• Mother and infant should sleep in proximity to each other to facilitate breastfeeding; • Self-examination of mother's breasts for lumps is recommended throughout lactation,

not just after weaning. • Clinicians should support efforts of parents and the courts to ensure continuation of

breastfeeding in cases of separation, custody and visitation. • Pediatricians should counsel adoptive mothers on the benefits of induced lactation

through hormonal therapy or mechanical stimulation. • Recognize and work with cultural diversity in breastfeeding practices. • A pediatrician or other knowledgeable and experienced health care professional should

evaluate a newborn breastfed infant at 3 to 5 days of age and again at 2 to 3 weeks of age to be sure the infant is feeding and growing well.

American Academy of Family Physicians Breastfeeding is the physiological norm for both mothers and their children. Breast milk offers medical and psychological benefits not available from human milk substitutes. The AAFP recommends that all babies, with rare exceptions, be breastfed and/or receive expressed human milk exclusively for the first six months of life. Breastfeeding should continue with the addition of complementary foods throughout the second half of the first year. Breastfeeding beyond the first year offers considerable benefits to both mother and child, and should continue as long as mutually desired. Family physicians should have the knowledge to promote, protect, and support breastfeeding. (From their policy statement 1989; revised in 2007.)

American College of Obstetricians and Gynecologists The American College of Obstetricians and Gynecologists strongly supports breastfeeding and calls upon its Fellows, other health professionals caring for women and their infants, hospitals and employers to support women in choosing to breastfeed their infants. All should work to facilitate the continuation of breastfeeding in the work place and public facilities. Breastfeeding is the preferred method of feeding for newborns and infants. Health professionals have a wide range of opportunities to serve as a primary resource to the public and their patients regarding the benefits of breastfeeding and the knowledge, skills and support needed for successful breastfeeding. (From their statement in 1994; revised in 2003.)

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The Baby Friendly Hospital Initiative The Baby-Friendly Hospital Initiative is a worldwide project of UNICEF and the World Health Organization (WHO). The goal of the initiative is to recognize hospitals and birth centers that take special steps to provide an optimal environment for breastfeeding. Approximately 18,000 hospitals worldwide have received this prestigious award. Notable hospitals in the US which have achieved Baby Friendly Status include Kaiser Permanente Riverside, Kaiser Permanente Honolulu, UCSD Medical Center, San Francisco General Hospital, and Glendale Memorial Hospital (the first Baby Friendly Hospital in Los Angeles County.)

10 Steps to Successful Breastfeeding 1. Develop a written breastfeeding policy and routinely communicate it to all health care staff. 2. Train all health care staff in skills necessary to implement the policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within half an hour of birth. 5. Show mothers how to breastfeed, and how to maintain lactation even if they should be

separated from their infants. 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. 7. Practice rooming-in: Allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial nipples to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on

discharge from the hospital or clinic.

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Healthy People 2010 Breastfeeding Goals

www.healthypeople.gov

U.S. Department of Health and Human Services: • To increase to 75% the proportion of mothers who breastfeed their babies in the early

postpartum period. • To increase to 50% the proportion of mothers who breastfeed their babies through five

to six months of age. • To increase to 25% the proportion of mothers who breastfeed their babies through the

end of the first year.

Added in 2007: • To increase to 60% the proportion of mothers who exclusively breastfeed their babies

for the first three months of life. • To increase to 25% the proportion of mothers who exclusively breastfeed their babies

for six months.

“Healthy People 2010 is a set of health objectives for the Nation to achieve over the first decade of the new century. It can be used by many different people, states, communities, professional organizations, and others to help them develop programs to improve health.

Healthy People 2010 builds on initiatives pursued over the past two decades. The 1979 Surgeon General's Report, Healthy People, and Healthy People 2000: National Health Promotion and Disease Prevention Objectives both established national health objectives and served as the basis for the development of State and community plans. Like its predecessors, Healthy People 2010 was developed through a broad consultation process, built on the best scientific knowledge and designed to measure programs over time.”

Healthy People 2020 goals were in development at the creation of this document.

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Medication Tables Information from these tables was obtained by TOXNET of the NIH, and Dr. Thomas Hale’s text “Medications and Mother’s Milk.”

Analgesics General Guideline for maternal analgesic use: If infant exposure is a concern, mothers can breast-feed their infants before taking the analgesics, and low to moderate dosages can be used. Maternal Medication Safe / compatible with breastfeeding? Acetominophen Yes NSAIDS

Ibuprofen, ketorolac Yes; preferred NSAIDs. Naprosyn, sulindac, piroxicam, indomethacin

Less preferred; probably safe for short-term use; longer half-life of these medications raise concerns of accumulation with prolonged use.

Aspirin Not recommended due to association with Reye Syndrome, however, transfer into milk is negligible.

Opiates Methadone Yes, transfer into milk is very low; however,

amount expressed in breastmilk is insufficient to prevent a withdrawal syndrome following chronic prenatal exposure of methadone.

Morphine Yes, very low transfer into milk following oral and IV dosing.

Fentanyl Yes Codeine Considered safe when used in moderate –

low doses. Hydrocodone Considered safe by AAP. Vicodin is the most

commonly used opiate analgesic immediately post-partum. Total exposure of infant to drug levels via colostrum in first 1 – 2 days is negligible; however, after lactogenesis 2 non-narcotic pain relievers are preferred; if used, max dose of 30mg of hydrocodone is recommended and monitor infant for drowsiness and appropriate weight gain.

Meperidine Not recommended; metabolite has very long half-life; increasing reports in literature of sedation, decreased Apgar scores, and lower oxygen saturations in newborns after perinatal administration.

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Anesthetics Maternal Medication Safe / compatible with breastfeeding? Epidural medications: bupivicaine, lidocaine, morphine, fentanyl, sufentanil

Yes

Propofol, thiopental sodium, enflurane Yes. Negligible amounts of these agents found in breast milk. In general, a healthy term infant can safely nurse as soon after surgery as the mother is awake and alert.

Antibiotics Maternal Medication Safe / compatible with breastfeeding? Penicillins Yes Cephalosporins Yes Erythromycin, azithromycin Yes Trimethoprim-sulfamethoxazole Yes, however, use should be avoided when

nursing infants less than two months of age due to potential for causing increased bilirubin levels.

Tetracycline Yes, however, for long-term use, other classes are preferred.

Doxycycline, minocycline Not recommended due to higher absorption by infants.

Ciprofloxacin Yes Metronidazole Topical and vaginal preparations are safe in

breastfeeding. With oral or IV use, no adverse effects have been reported, however, use of high maternal doses, such as 2 g for treatment of trichomoniasis, may produce higher milk concentrations, and mothers should be advised to interrupt breastfeeding for about 12 to 24 hours after administration; IV metronidazole mothers should be advised to discontinue breastfeeding for 2 to 3 hours until the plasma concentrations have dropped to values similar to those seen with oral dosing; metronidazole may impart a metallic taste to milk, and some infants may discontinue breastfeeding simply because they do not like the taste.”

Vancomycin Yes

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Antifungals Maternal Medication Safe / compatible with breastfeeding? Fluconazole (oral and topical) Yes Topical agents: clotrimazole, miconazole (Monistat), nystatin

Yes

Antivirals Maternal Medication Safe / compatible with breastfeeding? Acyclovir Yes Tamiflu Yes Relenza Yes Cardiovascular Medications Maternal Medication Safe / compatible with breastfeeding? Hydrochlorothiazide Yes Beta blockers Beta blockers vary widely in the amount

excreted into breastmilk. Propranolol, metoprolol, labetalol Yes Atenolol, nadolol, sotalol No. Reports of cyanosis, bradycardia and

hypotension exist in conjunction with use of these agents in breastfeeding women.

ACE inhibitors Caution in early post-partum; captopril and enalapril have lowest milk concentrations.

Calcium channel blockers Yes; nifedipine and verapamil are preferred. Hydralazine Yes Methyldopa Yes Magnesium sulfate Yes

Oral Hypoglycemic Agents Maternal Medication Safe / compatible with breastfeeding? Insulin Yes; insulin is not excreted into breastmilk. Sulfonylureas

First generation: tolbutamide Yes Second generation: glipizide, glyburide Data is limited; however, these agents are

highly protein-bound and passage into breastmilk is low. If used, monitor infant for signs of hypoglycemia (fussiness, lethargy.)

Metformin Yes; excretion is very low into breastmilk; no adverse effects have been reported. Caution when breastfeeding preterm, newborn (first week of life) and infants with renal impairment.

Thiazolidinediones: pioglitazone, rosiglitazone

No; no data is available on these agents with breastfeeding.

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Anti-allergy meds Maternal Medication Safe / compatible with breastfeeding? Pseudoephedrine (Sudafed) Yes, although may cause decreased milk

production. Antihistamines To reduce the small risk of adverse effects to

the infant (lethargy), the mother can take these medications immediately after breast-feeding.

Diphenhydramine (Benadryl) Yes Loratadine Yes Cetirizine “Small occasional doses of cetirizine are

probably acceptable during breastfeeding. Larger doses or more prolonged use may cause drowsiness and other effects in the infant or decrease the milk supply, particularly in combination with a sympathomimetic or before lactation is well established.” (Toxnet)

Nasal steroids, nasal cromolyn Yes

Asthma medications Maternal Medication Safe / compatible with breastfeeding? Albuterol Yes Ipatroprium No data currently available on this drug. Inhaled steroids Yes; fluticasone has lowest serum levels of

inhaled steroids. Oral steroids: prednisone, prednisolone Yes; if concern exists, withholding nursing for

four hours after taking the medication can minimize infant exposure.

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Anticonvulsants Maternal Medication Safe / compatible with breastfeeding? Topiramate (Topamax) Yes Phenytoin (Dilantin) Yes Carbamazepine (Tegretol) Yes Valproic acid (Depakote, Depakene) Yes Phenobarbital Generally yes. Per Toxnet: “there is a great deal

of inter- and intrapatient variability in excretion of phenobarbital into breastmilk. Phenobarbital in breastmilk apparently can decrease withdrawal symptoms in infants who were exposed in utero, but it can also cause drowsiness in some infants, especially when used with other sedating drugs. If phenobarbital is required by the mother, it is not necessarily a reason to discontinue breastfeeding. Monitor the infant for drowsiness, adequate weight gain, and developmental milestones, especially in younger, exclusively breastfed infants and when using combinations of psychotropic drugs. Sometimes breastfeeding might have to be limited or discontinued because of excessive drowsiness and poor weight gain. If there is concern, infant serum concentrations of phenobarbital can be obtained. Measurement of an infant serum level might help rule out toxicity if there is a concern.”

Lamotrigine Generally yes; amount transferred is moderate, however, no reports of ill effects on infants have been reported.

Medications for Migraine Headaches Sumatriptan Yes; levels in breast milk are low and

bioavailability is poor. Ergotamine No; because there is limited published

experience with ergotamine during breastfeeding and it might cause adverse effects in the infant, most authorities consider ergotamine to be incompatible.

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Psychotherapeutic Medications There is extensive research that shows the compatibility of breastfeeding with maternal use of most psychotherapeutic medications. Women should be reassured that they can continue treatment with most medications and still continue to safely breastfeed their infants.

General guidelines: Exercise caution with the use of these medications in breastfeeding mothers of newborns and premature infants, infants who have metabolic or renal disorders, infants with seizure disorders, and infants who are subject to apnea. The relative safety of antidepressants in breastfeeding is approximately:

sertraline = paroxetine > venlafaxine > citalopram = escitalopram > fluoxetine >> MAOI The relative safety of antipsychotics in breastfeeding is approximately:

risperidone = olanzapine > haloperidol >>> chlorpromazine

Antidepressants Maternal Medication Safe / compatible with breastfeeding? SSRIs Generally the first choice for treatment of

depression in breastfeeding mothers. Sertraline, paroxetine Yes, preferred SSRIs. Fluoxetine Less preferred SSRI; although it has been well

studied in pregnant women and is considered safe, it’s long half-life and potential for accumulation in breast milk makes it’s use controversial during breastfeeding, however, the relative risk of problems is low. 3 case reports of fussiness and tremulousness exist for breastfed infants of mothers taking fluoxetine.

Citalopram (Celexa), escitalopram (Lexapro)

Due to a few reports of somnolence in breastfed infants, caution recommended in breastfeeding infants less than 6 months old.

Venlafaxine (Effexor) Yes; small amount of metabolite is excreted in breastmilk but no untoward effects have been reported. Newborn and preterm breastfed infants should be monitored for sedation and adequate weight gain. Consider checking levels of metabolite in infant (desvenlafaxine).

Tricyclic antidepressants: amitriptyline, desipramine, nortriptyline, and amoxapine

Yes

Buproprion Yes, although some unconfirmed cases of reduced milk production have been reported; mothers of infants with seizure disorders should not take this medication and breastfeed.

Trazodone Yes Mirtazapine Yes

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Other Psychotherapeutic Agents Maternal Medication Safe / compatible with breastfeeding? Benzodiazepines: diazepam, midazolam, lorazepam

Yes, short term or intermittent use is preferred over long-term use due to risk of withdrawal symptoms in breastfed infants. Of note, the amount expressed in breast milk is insufficient to prevent a withdrawal syndrome following chronic prenatal exposure of these medications.

Phenothiazine sedatives: promethazine, chlorpromazine

Not recommended for use in women breastfeeding infants under 6 months of age due to possible induction of sleep apnea. If used, infant should be observed closely for sedative effects. A one time dose of these medications is probably safe.

Phenobarbital Yes Lithium Not recommended due to high levels of

excretion in breast milk. However, studies show that if levels in mother and infant are monitored closely, it is relatively safe. Caution is advised.

Valproic acid Yes, amount excreted in breast milk is very low. However, some sources recommend monitoring liver enzymes and platelet levels in breastfed infants.

Haldol Yes Risperidone Yes Olanzapine Yes References for Mediation Tables: 1. Hale. Pharmacology Review: Drug Therapy and Breastfeeding: Antidepressants, Antipsychotics, Antimanics

and Sedatives. NeoReviews 2004;5;e451 – e456. 2. Hale. Pharmacology Review: Drug Therapy and Breastfeeding: Antidepressants, Antipsychotics, Antimanics,

and Sedatives. NeoReviews, Oct 2004; 5: e451 - e456. 3. Hale. Pharmacology Review: Drug Therapy and Breastfeeding: Pharmacokinetics, Risk Factors, and Effects

on Milk Production. NeoReviews, Apr 2004; 5: e164 - e172. 4. NIH Toxnet: http://toxnet.nlm.nih.gov 5. AAP, Committee on Drugs. The Transfer of Drugs and Other Chemicals into Human Milk. Pediatrics 2001;

vol 108; No 3; pp. 776 – 789. 6. Spencer et al. Medications in the Breastfeeding Mother. Am Fam Physician 2001;64:119-26.

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Vaccines* In general, vaccines are safe for administration in breastfeeding women. Both inactivated and live viruses are safe and compatible with breastfeeding. Breastfeeding does not affect the immune response of the vaccine. Maternal Vaccine Safe / compatible with breastfeeding? Influenza Inactivated flu vaccine is preferred Yellow fever “Breastfeeding mothers in endemic areas of

the world should receive the vaccine, but mothers in other areas of the world should refrain from using this vaccine if possible while breastfeeding.” (Hale)

Radiocontrast agents Contrast agents have been studied and found not to enter milk in substantial amounts. Due to minimal transfer to milk and the poor oral bioavailability of these agents, discontinuation of breastfeeding is not necessary following an imaging study using contrast. Maternal Medication Safe / compatible with breastfeeding? Gadolinium Yes; this has been studied extensively and

virtually none passes into milk. Iodinated contrast Yes

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Bilirubin Management Tools Bhutani Curve: Nomogram for designation of risk in well newborns at 36 or more weeks’ gestational age with birth weight of 2000 g or more or 35 or more weeks gestational age and birth weight of 2500 g:

Phototherapy guidelines for infants more than 35 weeks gestation:

From Clinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Subcommittee on Hyperbilirubinemia. PEDIATRICS Vol. 114 No. 1 July 2004, pp. 297-316.

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Basic Lactation and Breastfeeding Physiology The final stage of breast development and preparation for lactation begins during pregnancy, when the breast grows larger, the size of the areola increases, and the breast veins become more prominent. The milk ducts and lobules contained in the breast grow and proliferate throughout pregnancy. After 16 weeks of pregnancy, lactogenesis 1 begins; this involves production of small amounts of milk and colostrum in the breast. This continues until approximately 60 hours post-partum, when lactogenesis 2 begins. Many hormones are involved in lactation. Prolactin and placental lactogen stimulate nipple and areolar growth and estrogen facilitates the proliferation and differentiation of the ductal system. Progesterone increases the size of lobes, lobules, and alveoli. Very small amounts of milk and colostrum are present in the breasts at delivery. The secretion of milk remains small until serum progesterone and estrogen concentrations fall; this process begins with the delivery of the placenta. The negative feedback by these hormones on pituitary prolactin release is then lost, which allows prolactin concentrations rise, leading to increased milk synthesis and the start of lactogenesis 2. When the infant suckles at the breast, oxytocin is released from the posterior pituitary which causes the milk-ejection reflex or “letdown,” which is accomplished through the effect of oxytocin on the myoepithelial cells surrounding the alveoli. Their contraction allows for the breastmilk to be expressed from the breasts. The rate of breast milk production can vary after each feed and is related to the degree of milk emptying of the breast. The more empty a breast is of milk, the faster it will replenish fully. If milk is left in the breasts after feeding, the presence of residual milk will negatively feedback on further breastmilk production. Certain medical conditions can inhibit lactogenesis 2, such as type 1 diabetes mellitus, obesity, polycystic ovary syndrome, hypothyroidism, placental retention, and stress, can delay or inhibit lactogenesis 2. Colostrum The first milk secreted into the breasts is colostrum, which differs from mature milk in its lower energy value (67 kcal/100 mL compared with the 75 kcal/100 mL of mature milk), and its higher percentage of protein, fat-soluble vitamins, and minerals. The volume of colostrum will vary with parity of the mother and the number of feedings of the infant in the early post-partum period. There is a large amount of antibodies in colostrum that provides protection to the newborn against infection, particularly bacteria and viruses present in the birth canal. Colostrum also facilitates the passage of meconium and helps establish beneficial bacteria (i.e. lactobacillus bifidus) in the infant’s gut.

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Mature Milk Triglycerides are the primary constituents of the fat in breast milk, which provide essential fatty acids and about 50% of its calories. Human milk is rich in long-chain polyunsaturated fatty acids, including docosahexanoic acid and arachidonic acid, which have been associated with higher visual acuity and cognitive ability in the infant.

Physiologic Basis of Health Protection from Breastmilk Breast milk has been shown to protect the infant against many infectious, allergic and autoimmune diseases in childhood and later in life. This is thought to be due to the anti-infective and immunologically active components in breast milk, including hormones, enzymes, growth factors, and many types of immunoprotective agents. • Many substances in the breast milk play a dual role of nutrition and immune protection /

activation • Infants do not begin making secretory IgA until 4 months of life, and the process is not fully

established until 12 months of life. • Fully breastfed babies receive about 0.5 to 1g of secretory IgA daily. • Human milk contains many immunomodulating agents which assist in developing an

infant’s immune system in the gut and to protect him against infection; these agents include interferon, growth hormone, lactoferrin, white blood cells, etc.

In women, breastfeeding has been shown to be protective against ovarian cancer, breast cancer, post-menopausal hip fractures, and cardiovascular disease. The exact mechanisms for these protections are unknown, but it is thought that decreased cycles of ovulation and possibly increased utilization of fat stores both play a role.

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Evaluate Breastfeeding Technique

Ensure Proper Positioning, Latch, and Milk Transfer

LATCH Score Tool The LATCH tool is by nurses and clinicians to evaluate the effectiveness of early breastfeeding. A numerical score of 0, 1, or 2 is assigned to the five letters of the acronym:

L - latching of infant onto the breast A - amount of audible swallowing T - type of nipple C - comfort of mother H - help needed by mother to hold baby to breast.

Lower scores (<5) can indicate the need for assistance for better success at breastfeeding.

Breastfeeding Positioning In particular, look for: • Maternal Comfort — Mother sits in comfortable chair or sits up in bed; pillows can provide

support; if she appears uncomfortable, you can suggest different positions, pillows, or a nursing stool for feet.

• Infant Position — head, shoulders, and hips should be aligned and the infant should face / be parallel to the mother’s body. The head should not be turned to the side.

• Infant should be brought to the breast (not the breast to the infant).

Cradle Hold

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Football Hold

Side-lying position

Breastfeeding position photos from Community Hospital of the Monterey Peninsula Hospital website: http://www.chomp.org/conditions/pregnancy/feeding/positioning.aspx

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Evaluate and Ensure a Correct Latch

Latch-On To begin, evaluate how the infant is brought to the breast. • Watch mother’s use of the C-hold to make a “breast sandwich” for the infant to latch on to:

o 4 fingers underneath and thumb on top of the breast. o Mother’s fingers are parallel to the infant’s jaw and well behind the areola.

• Watch how she encourages the infant’s rooting reflex. o Middle of infant’s lip stroked with nipple. o Infant opens his mouth wide.

• The infant is drawn to the breast, aiming the nipple toward the hard palate. • The infant will grab the nipple and as much areola as possible and continue to draw it into

his/her mouth. • The infant’s nose and chin will touch the breast and the lips will be flanged outward (infant

will be able to breathe through nose when it is touching breast due to nose structure). • The infant’s tongue will be cupped around the nipple. • When the infant is latched correctly, the mother will feel a gentle tugging with the wave-like

movements of the infants tongue and jaw, but should feel no pain. • Suckling should be fast at first as the let-down reflex is initiated, but once the milk is ejected

the suckling will slow into a rhythmic pattern with noted audible swallowing (if the room is quiet).

• Upon completion of nursing, the mother can release the suction by inserting a clean finger into the corner of the infant’s mouth.

from La Leche League International

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Signs of a Correct Latch

Signs of an Incorrect Latch

Immediate signs • Small amount of areola grasped by infant’s mouth. • Lips curled inward (indicating suction), not flanged out. • Infant’s cheeks indenting during suckling, clicking noises. • Frequent movement of the infant’s head. • Lack of swallowing sounds. • Maternal pain and discomfort. • Audible clicking noises. • Nose and chin not touching breast.

Areola grasp • Infant grasps the entire nipple and as much of the

areola as possible. • The nose and chin of the infant will touch the breast. • Lips will be flanged out. Mother should be comfortable: • Gentle undulating motion of infant mouth, not sucking. • No pain with feeding. • Mild pain for the first 30 seconds to one minute is OK;

if pain continues or is severe, remove infant and reposition and re-latch.

Later signs of incorrect latch • Trauma to mother’s nipples and

pain. • Poor infant weight gain. • Low milk supply.

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Ensuring Milk Transfer Watch the infant as she sucks and swallows and milk is transferred. Look and listen for: • Audible swallowing

o Sucking that begins with rapid bursts to stimulate milk let-down o A rhythm of sucking, swallowing, and pauses following establishment of milk flow o Approximately 1 suckle/swallow per second

• Undulating action of tongue— no stroking, friction, or in-and-out motion of the tongue

The Infant Breastfeeding Technique: The nipple is drawn well into the mouth, extending back to the junction of the hard and soft palate. The infant's jaw then moves his or her tongue toward the areola, compressing it. This process causes the milk to travel from the lactiferous sinuses to the infant's mouth. The infant then raises the anterior portion of the tongue to complete the process. Milk is extracted by a peristaltic action from the tip of the tongue to the base (not by negative pressure). Throughout the suckling cycle, the nipple should not move in the infant's mouth if it is correctly positioned.

Photo from Children’s Hospital of Wisconsin www.chw.org

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Methods of Human Milk Expression

Hand Expression Hand expression is an important skill for the breastfeeding women to learn. In the first few days of life, the manual/hand technique can often express more colostrum than a breast pump. This is because colostrum is high in proteins and antibodies; thus, these large negatively charged molecules make the colostrum “sticky.” Infants can get colostrum out via their mouth position and peristaltic action of their tongue. Hand expression can be done anywhere, anytime, and can be used to relieve engorgement. To manually express breast milk:

• Wash hands with soap and water. • Place clean container under breast to collect milk. • Massage breast gently towards nipple in a rotational manner. • Place thumb and index finger opposite each other outside the areola. • Press back towards chest and gently squeeze to express milk. • Repeat last step at different positions around areola. Step 1: Step 2:

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Expression with manual pump • Hand and wrist operated hand-held device. • Requires practice, skill and coordination. • Useful for pumping if mother is away from infant only occasionally. • Price range is $30 to $50. • Can be purchased at KP Women’s Center or local store.

Automatic / electronic expression

Medela Pump ‘n Style

• Runs on batteries or plugs into electrical outlet • Easy to use • Can pump one or both breasts at the same time • Hands-free models are available • Costs run $150 to over $250 • Unit can be used by another user; plastic

attachments seen in this photo can be purchased separately from the unit.

• Suction unit (housed in back pack) does not come into contact with breast milk.

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Alternative methods to bottle feeding Feeding infants with a bottle in the first few days and weeks of life can result in nipple confusion. Nipple confusion can occur when an infant has not had an opportunity to establish the correct mouth movements for breastfeeding. Early and frequent use of pacifiers can also result in nipple confusion. Nipple confusion negatively impacts breastfeeding success by producing an ineffective latch. This then results in inadequate milk delivery to infant and pain in mother. Eventually, milk production drops off in the mother and supplementation with formula is required. If supplementation is needed, nipple confusion can be avoided by using “alternative” methods for feeding infants.

Cup and Spoon Feeding A small glass or plastic cup is used to feed an infant a small amount of milk or formula. The infant is held in an upright position with his head supported and the milk is presented to his lower lip and tipped slightly, where he can lap at it and swallow small amounts at his own pace. Some nurseries have used cup feeding in infants with gestational ages as young as thirty weeks. Infants can be fed by a spoon using a similar technique: a spoon is used to offer small amounts of milk to the infant by placing the tip of the spoon on the lower lip. The child will take the milk at his own pace. The physiologic stability of an infant while cup-feeding has been confirmed in a number of studies.

Specialized cup for infant feeding. Cup feeding an infant. Cups made especially for infant feeding are available from lactation consultants and from La Leche League International (www.llli.org).

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Syringe feeding This method uses a syringe to drop milk into the infant’s mouth while being held and supported in an upright position (see cup-feeding picture on previous page.) A regular plastic syringe or one with a periodontal tip can be used. The technique involves angling the tip towards the infant’s cheeks and depositing a small amount of milk for the infant to swallow. This technique of feeding can also be accomplished with an eyedropper.

Periodontal syringe

Supplemental nursing system This device allows infant to receive supplements of milk and formula while suckling at the breast. A container for the milk hangs from a cord around mother's neck; silicone tubing runs from the container to the tip of mother's nipple and is secured with tape. When the infant latches onto the breast, he also takes the tubing into his mouth and receives supplement along with breastmilk. Supplementing this way helps stimulate milk production in the mother’s breasts.

Lactation consultation is advised when nursing this method, both for evaluation of appropriate method as well as proper teaching of system. Nursing supplementers can be used for premature infants and those infants who have trouble latching adequately to the breast i.e. infants with developmental or neurologic or neurologic problems. The supplemental nursing system is also used by mothers who are nursing adopted babies, as well as by mothers who are relactating (reestablishing a milk supply after weaning).

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Reverse Pressure Softening Reverse pressure softening is a way to soften the circle areola to make latching and expressing milk easier while an infant is learning to breastfeed. Reverse pressure softening can help in the first days after birth if women notice firmness of the areola, latch pain or breast fullness. Fullness in the early days after birth is due to tissue edema in the breast, as well as breast milk. Reverse pressure softening briefly moves some swelling backward and upward into the breast to soften the areola so it can change shape and the nipple can extend easily. It also helps elicit the milk-ejection reflex. It can also assist in manual milk expression. Delayed or skipped feedings may also increase edema in the breasts. Intravenous (IV) fluid or drugs such as pitocin may also increase edema, which can take 7-14 days to resolve. Reverse pressure softening is useful when a woman feels that her breast and areola are swollen and difficult to compress. Reverse pressure softening can be used prior to each feed. It is important to soften the areola in the entire one-inch area. Reverse pressure softening should cause no discomfort. To utilize the reverse pressure softening technique:

• Woman places the fingers or thumbs on areola. • Gentle, firm pressure is applied on areola towards ribcage. • Steady pressure is held for one to 3 minutes. • The infant is offered the breast when the areola is soft.

Sequence can be repeated as often as is needed. Pressure may also be applied by pressing with a ring made by cutting off the nipple part of an artificial nipple.

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Sample Breastfeeding Intake and Elimination Log

Date / Time

Right breast (min)

Left breast (min)

Formula (oz)

Wet diapers

Stool Notes

DOL 1 1:30pm 10 min 12 min None 0 0 baby sleepy 3:00pm 10 min 5 min None 1 0 5:15pm 12 min 7 min None 0 1 6:30pm 5 min 15 min None 1 0 Mild breast

pain 7:15pm 10 min 5 min None 0 0 10:00pm 10 min 12 min None 0 0 DOL 2 1:15am 12 min 5 min None 0 0 5:00am 5 min 7 min None 0 1 Crying 7:20am 10 min 15 min None 0 0 9:00am 10 min 5 min None 1 0 10:15am 12 min 7 min None 0 0 12:00pm 5 min 15 min None 0 0 ETC.

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Galactogogues Galactogogues are medications used to intitiate, maintain or augment breast milk production. Galactogogues generally increase the secretion of prolactin from the hypothalamus and therefore increase, but don’t necessarily maintain, maternal milk supply. The most important determinant of initiation and maintenance of an adequate breastmilk supply is early and frequent breastfeeding with complete emptying of the breasts at each feed. If the breasts are not emptied regularly and thoroughly, milk production declines. Likewise, more frequent and thorough emptying of the breasts typically results in increased milk production. Galactogogues are frequently used to augment breast milk production in mothers with infants in the neonatal intensive care unit. Other uses include relactation (e.g. reestablishing milk supply after weaning), adoptive nursing, increasing a mother’s milk supply due to maternal or infant illness or separation, or increasing milk production in women who have had a breast reduction. Use of galactogogues should only be used after a thorough evaluation for treatable causes of decreased milk production has been completed. Also, a trial of increasing the frequency of breastfeeding or breastmilk expression should also be attempted prior to galactogogue use. The assistance of a lactation consultant in these situations is very helpful. There is no research to suggest that starting galactogogues prenatally or within the first postpartum week is helpful in establishing or maintaining an adequate milk supply. Short-term use of galactogogues is advised (1-3 weeks). These substances are secreted in negligible amounts into breastmilk and are considered safe for use in breastfeeding. The effects of long-term use of domperidone and fenugreek are not known, but these substances are likely safe. Long-term (>6 months) usage of metoclopramide is associated with irreversible tardive dyskinesia, and earned the medication a black-box warning in 2009. Metoclopramide Metoclopramide (Reglan) is the most well studied and most commonly used galactagogue in the United States, and increases prolactin levels by antagonizing dopamine release, thereby promoting breastmilk production. The typical dose of metoclopramide, when used as a galactogogue, is 30 to 45 mg/day in three or four divided doses, with a dose-response effect up to 45 mg daily. It is usually given for 7 to 14 days at full dose with a taper off over 5 to 7 days. Occasionally the breastmilk supply will drop off as the dose is reduced; in these cases the lowest effective dose has been continued for longer periods successfully.

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Domperidone (Motilium) Like metoclopramide, domperidone is a dopamine antagonist that is routinely used outside the United States for the treatment of gastroesophageal reflux and emesis, as well as a galactogogue. Despite the fact that domperidone is approved for use in most of the developed world and has been used for many years with an excellent safety record, the U.S. Food and Drug Administration (FDA) issued a warning against its use based on safety concerns with IV use and risks associated with drug importation. There is no evidence that oral administration is associated with toxicity in either mother or infant. Domperidone is available from overseas pharmacies and from compounding pharmacies in the US. The quality of such products cannot be assured, and the FDA has warned against their use. The excretion of domperidone into breastmilk is negligible and no adverse effects have been reported in breastfed infants whose mothers were taking domperidone. Side effects in mothers taking domperidone are uncommon; they include dry mouth, headache and abdominal cramping. Domperidone is contraindicated in patients with known sensitivity to the drug and in situations in which gastrointestinal stimulation might be dangerous (e.g., gastrointestinal hemorrhage, mechanical obstruction, or perforation). When used as a galactogogue, the usual dosage of domperidone is 10 to 20 mg three to four times per day taken for 3 to 8 weeks. Most women respond within 3 to 4 days, but some require 2 to 3 weeks to get maximum effect. Fenugreek is the most commonly used herbal galactogogue. It is a member of the pea family listed as GRAS (generally regarded as safe) by the U.S. Food and Drug Administration. Usual dose is one to four capsules (580–610 mg) three to four times per day, although as with most herbal remedies there is no standard dosing. Alternatively, it can be taken as one cup of strained tea three times per day (1/4 tsp seeds steeped in 8 oz water for 10 minutes). Reported side effects are rare but include maple like odor to sweat, milk, and urine; diarrhea; and increased asthmatic symptoms. Use during pregnancy is not recommended due to its uterine stimulant effects.

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Donor Breastmilk / Breastmilk Banking The demand for banked human milk has been increasing over the past decade, in large part due to the research showing the many benefits of human milk feeding to infants. Effective screening and pasteurization techniques make donor breastmilk a safe option for infants whose mothers are unable to provide them with their own breastmilk. The pasteurization process does alter the structure of some beneficial proteins. However, much of the biologically active content of breastmilk is preserved, including most of the immunoglobulins present in breastmilk, particularly E and A. The benefits to infants consuming donor milk are similar to breastfed infants, including decreased rates of necrotizing enterocolitis, sepsis and possible support of long-term positive neurodevelopmental outcomes in very low- and extremely-low birthweight infants. Human milk banks in the United States follow the Human Milk Banking Association of North America (HMBANA) screening standards:

• Potential donors are cleared initially by their own physicians to assure that their health and welfare are protected.

• Potential donors undergo a screening history similar to the one used to screen potential blood donors.

Donor exclusion criteria include:

• A positive blood test result for HIV, human T-cell lymphoma virus (HTLV), hepatitis B or C, or syphilis.

• The donor or her sexual partner is at risk for HIV infection. • Use of illegal drugs. • Smoking or use of tobacco products. • An organ or tissue transplant or a blood transfusion in the last 6 months. • Regular consumption of more than two alcoholic drinks per day. • Residing in the United Kingdom for more than 3 months or in Europe for more than 5

years between 1980 and 1996. • Being born in or traveled to Gabon, Niger, Cameroon, Chad, Congo, or Equatorial

Guinea. • Use of medication or herbal supplements (with the exception of progestin-only oral

contraceptives or injections, levothyroxine, insulin, prenatal vitamins).

All donors undergo serologic screening, at milk bank expense, for: • HIV • HTLV I and II • Hepatitis B and C • Syphilis

Donors are taught carefully how to pump and collect their milk safely and cleanly and how to keep their pumps and collection systems sterile. Donor milk is frozen in sterile containers immediately after collection and maintained in the frozen state until processed by the receiving bank.

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Donor milk is cultured for bacterial contamination when received by the bank, and milk that has abnormal findings is not processed for distribution. Such findings include:

• Milk that has a high degree of bacterial contamination (ie, > 100 colony-forming units).

• Milk contaminated with specific problematic flora (eg, Staphylococcus aureus, Bacillus sp).

Donor milk that has passed all of the previous screening steps is then Holder pasteurized at 62.5°C for 30 minutes, a process demonstrated to eliminate known bacterial and viral pathogens.

Aliquots of milk are recultured after pasteurization to assure sterility; the presence of any bacterial growth at this point in the process requires discarding of the contaminated batch.

Of note, milk banks do not screen potential donors for cytomegalovirus (CMV). The prevalence of CMV seropositivity for pregnant women in North America ranges from about 40% to 60%, therefore, a large proportion of potential donors would be expected to be CMV-positive. Rather than screening and eliminating a very high percentage of potential donors, milk banks have relied on pasteurization to protect against transmission of CMV and other viruses. Pasteurization has been found to be effective in eliminating the virus from the milk. In the past, freezing had been used in an attempt to eliminate the virus but was found to be less effective. Case reports of infants being infected from their own mother’s milk have resulted in relatively mild infection, probably due to passive transfer of antibodies both in utero and through the mother's milk. In terms of CMV, pasteurized donor milk actually may be safer for babies than fresh maternal milk. The current price (as of 2010) of donor breast milk is approximately $3.50 per fluid ounce.

Donor Milk Banks in California: Mothers' Milk Bank 751 South Bascom Ave San Jose, CA 95128 Phone (408) 998-4550 FAX (408) 297-9208 [email protected] www.milkbanksj.org From Human Milk Banking Association of North America http://www.hmbana.org/

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CDC: Breastfeeding and Swine Flu (2009) From http://www.cdc.gov/h1n1flu/infantfeeding.htm “Infants who are not breastfeeding are particularly vulnerable to infection and hospitalization for severe respiratory illness. Women who deliver should be encouraged to initiate breastfeeding early and feed frequently. Ideally, babies should receive most of their nutrition from breast milk. Eliminate unnecessary formula supplementation, so the infant can receive as much maternal antibodies as possible. If a woman is ill, she should continue breastfeeding and increase feeding frequency. If maternal illness prevents safe feeding at the breast, but she can still pump, encourage her to do so. The risk for swine influenza transmission through breast milk is unknown. However, reports of viremia with seasonal influenza infection are rare. Expressed milk should be used for infants too ill to feed at the breast. In certain situations, infants may be able to use donor human milk from a certified milk bank. Antiviral medication treatment or prophylaxis is not a contraindication for breastfeeding.”

Excerpts from CDC “Novel H1N1 Flu (Swine Flu) and Feeding your Baby: What Parents Should Know” http://www.cdc.gov/h1n1flu/infantfeeding.htm#c

Does breastfeeding protect babies from this new flu virus? There are many ways that breastfeeding and breast milk protect babies’ health. Flu can be very serious in young babies. Babies who are not breastfed get sick from infections like the flu more often and more severely than babies who are breastfed. Since this is a new virus, we don’t know yet about specific protection against it. Mothers pass on protective antibodies to their baby during breastfeeding. Antibodies are a type of protein made by the immune system in the body. Antibodies help fight off infection. If you are sick with flu and are breastfeeding, someone who is not sick can give your baby your expressed milk.

Should I stop breastfeeding my baby if I think I have come in contact with the flu? No. Because mothers make antibodies to fight diseases they come in contact with, their milk is custom-made to fight the diseases their babies are exposed to as well. This is really important in young babies when their immune system is still developing. It is OK to take medicines to prevent the flu while you are breastfeeding. You should make sure you wash your hands often and take everyday precautions (http://www.cdc.gov/flu/protect/habits.htm). However, if you develop symptoms of the flu such as fever, cough, or sore throat, you should ask someone who is not sick to care for your baby. If you become sick, someone who is not sick can give your baby your expressed milk.

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Is it okay to take medicine to treat or prevent novel H1N1 flu while breastfeeding? Yes. Mothers who are breastfeeding and taking medicine to treat flu because they are sick should express their breast milk for bottle feedings, which can be given to your baby by someone who is not sick. Mothers who are breastfeeding and are taking medicines to prevent the flu because they have been exposed to the virus should continue to feed their baby at the breast as long as they do not have symptoms of the flu such as fever, cough, or sore throat.

If my baby is sick, is it okay to breastfeed? Yes. One of the best things you can do for your sick baby is keep breastfeeding. Do not stop breastfeeding if your baby is sick. Give your baby many chances to breastfeed throughout the illness. Babies who are sick need more fluids than when they are well. The fluid babies get from breast milk is better than anything else, even better than water, juice, or Pedialyte® because it also helps protect your baby’s immune system. If your baby is too sick to breastfeed, he or she can drink your milk from a cup, bottle, syringe, or eye-dropper.

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Travel Recommendations for the Nursing Mother From: http://www.cdc.gov/breastfeeding/recommendations/travel_recommendations.htm

Travel need not be a reason to stop breastfeeding. “A mother traveling with her breastfeeding infant or child may find that nursing makes travel easier than it would have been with a bottle-fed infant or child. And, by planning well before the travel date, a mother can overcome many potential obstacles. A mother planning a long separation from her nursing infant or child might wish to work with an International Lactation Consultant (IBCLC) or her pediatrician to obtain assistance and suggestions specific to her situation. Mothers can find an IBCLC in the United States online by visiting the websites for the International Lactation Consultants Association or The International Board of Lactation Consultant Examiners. Mothers may wish to identify breastfeeding support local to her destination. In this way, support may be only a phone call away at any time throughout the trip. Visit La Leche League International (www.llli.org) to find support groups and breastfeeding experts in other countries. To locate lactation consultants worldwide, visit The International Board of Lactation Consultant Examiners.”

Traveling With A Nursing Infant Less Than 6 Months of Age “A mother traveling with her nursing infant less than six months of age need not make provisions to supplement breastfeeding, even when traveling internationally. Breastfed infants do not require water supplementation, even in extreme heat environments. And, when accompanying their mothers, nursing infants and children may feed on demand. The most effective way to maintain a mother’s milk supply while traveling is to engage in frequent and unrestricted nursing opportunities. This is also the best way to meet the physical and emotional needs of the infant or child. The traveling mother may find it helpful to take along a sling or other soft infant carrier, which may be used to:

• Ease the burden of carrying a child for extended periods of time • Increase opportunities for unrestricted nursing, effective in maintaining an abundant milk

supply • Maintain skin-to-skin contact with the child, which helps in maintaining a milk supply • Protect the child from some environmental hazards”

When a Mother Travels Apart From Her Nursing Infant or Child

Prior to departure “A breastfeeding mother planning to be apart from her nursing infant or child may wish to express and store a supply of breast milk for use while she is away. Building one’s supply of breast milk takes time and patience, and is most successful when begun gradually over many weeks in advance of the planned separation. Infants who have never consumed milk from a bottle or cup will also need opportunities to practice this skill with another caregiver prior to the mother's departure. The woman who is unable to nurse for an extended period of time may notice her milk supply diminishing. However, she may take steps to preserve her milk supply while separated depending upon

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• The amount of time a mother has to prepare for her trip • The duration and destination of her travel • Her flexibility in the use of her time while traveling

Even if a woman’s milk begins to diminish, she may resume breastfeeding upon her return. Separation from the infant or child need not be a reason to stop breastfeeding. In many cases, after reuniting mother and baby, the suckling child will help return a mother’s milk supply to its prior level. Occasionally during prolonged separations, infants or children who have grown accustomed to using a bottle or cup may have difficulty transitioning back to the breast.”

How to Maintain Milk Supply While Traveling “A mother who has a flexible schedule while traveling may take regular breaks to express her milk. Milk expression approximating the frequency with which the infant or child typically nurses (generally every 2-3 hours for infants less than 6 months old) helps a mother maintain her milk supply. Certainly, the longer the separation between the nursing mother and child, the more difficult it is to maintain a full milk supply. In general, separation of a week or less usually poses no major problem for a mother wishing to maintain breastfeeding during separation from her child. This duration becomes more flexible and can be maintained for a longer period of time as the child grows older and complementary foods play a greater role in the child’s diet. In many cases, after returning from travel, a nursing infant or child will help bring her milk supply to its prior level. Depending on her destination, a mother may need to plan for alternative methods of milk expression. Intermittent milk expression can be done manually or with the help of a small battery or manual breast pump. However, to maintain an abundant milk supply over an extended period of time, a woman may have greater success using a hospital-grade double breast electric pump.”

Milk Storage and Handling While Traveling “Expressed milk should be stored in clean, tightly sealed containers. Any container may be used if it can be thoroughly cleaned with hot, soapy water and if it seals tightly. Many mothers choose to use infant feeding bottles with solid caps to store milk. Milk may be stored and transported in refrigeration, or frozen in dry ice. Freshly expressed milk is safe for infant consumption even when stored at room temperature for up to 6–8 hours. Fresh milk may be safely stored in an insulated cooler bag with frozen ice packs for up to 24 hours. Refrigerated milk can be stored for 5 days. Once milk is cooled, it should remain cool until the milk is consumed. Refrigerated milk can subsequently be frozen, however once frozen milk is fully thawed it should be used within one hour. Because of these requirements, a breastfeeding mother needs to consider access to safe storage options in making her decision whether to keep her expressed milk to bring back to her infant or child, or to discard it before returning home. Depending upon the destination, if no reliable milk storage is available, a mother traveling without her nursing infant or child may need to discard her expressed milk. In such a situation it is important to recognize the value of regular expression while separated to help her maintain her milk supply until she and her nursing infant or child can be reunited, regardless if milk is stored.”

Air Travel “No special precautions are necessary for airport security screenings while breastfeeding. A breastfeeding mother expressing her own milk while traveling does not need to declare her milk at U.S. Customs when returning to the United States. Electric breast pumps are

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considered personal items during air travel and may be carried on and stowed underneath the passenger seat, similar to a laptop computer, purse, or diaper bag.”

Immunizations during Breastfeeding

“Most nursing mothers may be immunized routinely, based on recommendations for the specific travel itinerary. Breastfeeding does not adversely affect immunizations considered routine for the United States, nor is the administration of most vaccines, including live virus vaccines, harmful to breast milk.”

The Traveler’s Health Kit During Breastfeeding “Most items included in traveler’s health kits are fully compatible with breastfeeding. In addition, breastfeeding mothers may wish to include an antifungal cream helpful in treating breast infections also known as thrush. An oral antifungal could be included as well to treat oral yeast in the infant. Breastfeeding mothers should consult the food-borne and waterborne illness recommendations (www.cdc.gov/breastfeeding/disease/index.htm) when choosing an anti-diarrheal. Breastfeeding mothers traveling to malarious areas should ensure the antimalarial included is compatible with breastfeeding before beginning travel.”

Source: NCID Yellowbook (www.cdc.gov/travel/contentYellowBook.aspx) From: http://www.cdc.gov/breastfeeding/recommendations/travel_recommendations.htm

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Online Breastfeeding Education and Training for clinicians Breastfeeding Training – a healthcare provider training project between the Virginia Department of Health and University of Virginia Health System. 7 CME credits are offered after completion of the course. www.breastfeedingtraining.org Wellstart International is a nonprofit organization that is active and influential in many global events related to the protection, promotion and support of optimal infant and young child feeding. They offer a free breastfeeding basics curriculum self-study course that can be downloaded from their website: www.wellstart.org American Academy of Pediatrics Breastfeeding Residency Curriculum – website with role-play situations, pre- and post-tests, and powerpoint presentations; suitable for pediatric, family medicine, internal medicine, preventive medicine and ob/gyn residency programs. www.aap.org/breastfeeding/curriculum

Textbooks on Breastfeeding for Clinicians Breastfeeding Handbook for Physicians, 2006 American Academy of Pediatrics and American College of Obstetricians and Gynecologists; Senior editor: Richard J. Schanler, MD, FAAP Provides physicians with a concise reference on breastfeeding and human lactation.

Breastfeeding for the Medical Profession, 2005 Ruth A. Lawrence and Robert Lawrence

Medications and Mother’s Milk, 2008 Dr. Thomas Hale !

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PHQ-9 screening tool for post-partum depression Over the last 2 weeks, how often have you been bothered by any of the following problems?

Not at all

Several days

More than

half the days

Nearly every

day

1. Little interest or pleasure in doing things

0

1

2

3

2. Feeling down, depressed, or hopeless

0

1

2

3

3. Trouble falling asleep, staying asleep, or sleeping too much

0

1

2

3

4. Feeling tired or having little energy

0

1

2

3

5. Poor appetite or overeating

0

1

2

3

6. Feeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family down

0

1

2

3

7. Trouble concentrating on things such as reading the newspaper or watching television

0

1

2

3

8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

0

1

2

3

9. Thinking that you would be better off dead or that you want to hurt yourself in some way

0

1

2

3

Add columns: ________ + ________ + ______ _ Total: ___________________________________ 10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

____ Not difficult at all ____ Somewhat difficult ____ Very difficult ____ Extremely difficult

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California Breastfeeding Laws and Legislation Available at the California Breastfeeding Coalition’s website at: http://www.californiabreastfeeding.org/Laws.html Lactation Accommodation Law (Assembly Bill 1025 - Legal Requirement)

Chapter 3.8, Section 1030, Part 3 of Division 2 of the Labor Code: 1030. Every employer, including the state and any political subdivision, shall provide a reasonable amount of break time to accommodate an employee desiring to express breast milk for the employee’s infant child. The break time shall, if possible, run concurrently with any break time already provided to the employee. Break time for an employee that does not run concurrently with the rest time authorized for the employee by the applicable wage order of the Industrial Welfare Commission shall be unpaid.

1031. The employer shall make reasonable efforts to provide the employee with the use of a room or other location, other than a toilet stall, in close proximity to the employee’s work area, for the employee to express milk in private. The room or location may include the place where the employee normally works if it otherwise meets the requirements of this section. 1032. An employer is not required to provide break time under this chapter if to do so would seriously disrupt the operations of the employer. 1033. (a) An employer who violates any provision of this chapter shall be subject to civil penalty in the amount of one hundred dollars ($100) for each violation

Jury duty

California Civil Code 210.5 (2000) Allows mother of breastfed child to postpone jury duty for one year and specifically eliminates the need for the mother to appear in court to request the postponement. The law also provides that the one-year period may be extended upon written request of the mother (Chap. 266 [AB 1814]

Breastfeeding in Public

California Civil Code 43.3 (1997) Allows a mother to breastfeed her child in any location, public or private, except the private home or residence of another, where the mother and the child are otherwise authorized to be present [AB 157]

Other Breastfeeding Legislation The United States Breastfeeding Committee has made available an inventory and analysis of state legislation on breastfeeding and maternity leave that includes legislation related to employment. This inventory can be viewed online or downloaded free of charge from http://www.usbreastfeeding.org.

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Breastfeeding Support for Patients / Patient Resources

Kaiser Permanente Los Angeles Medical Center

Inpatient Office located 4th floor, Post-partum East 323/783-1634 Allison Tyson, RN Employee pumping room located on 3rd floor east, room 3016 in main hospital

Outpatient: Women’s Center

4900 Sunset Boulevard, 5th floor Sandy Garcia, RN Monday to Friday 8:30 AM to 3:30 PM Perform 2-4 day weight checks, assess for jaundice, assist in breastfeeding technique, breastpump sales 323/783-7808, 783-4345

Kaiser Breastfeeding / Return to Work Class 323/783-4472

Online Neonatal and Perinatal Home Page: Southern California Region http://kpnet.kp.org/california/scpmg/NeoPeri/index.html

Breastfeeding Taskforce of Los Angeles

www.breastfeedingtaskforla.org/ Academy of Breastfeeding Medicine www.bfmed.org U.S. Centers for Disease Control www.cdc.gov/breastfeeding U.S. Department of Health and Human Services www.womenshealth.gov/breastfeeding/ United States Breastfeeding Committee www.usbreastfeeding.org La Leche League International www.llli.org

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Los Angeles Community Breastfeeding Resources More local resources can be found at www.breastfeedingtaskforla.org. The Pump Station Breastfeeding classes, support groups, breast pumps and accessories for rent and purchase; nursing and infantcare products.

Hollywood 1248 Vine St 323/469-5300 Santa Monica 2415 Wilshire Blvd 310/998-1981

Bellies, Babies and Bosoms Prenatal and post-partum classes, breastfeeding classes, support groups, breast pumps and accessories for rent and purchase; nursing and babycare products. Glendale 3461 N. Verdugo Rd. 818/541-1200 A Mother’s Haven Prenatal breastfeeding classes, pre- and post-natal yoga, post-natal breastfeeding support, breast pump sales, nursing accessories. After hours lactation support: 818/ 601-5381

Encino 15928 Ventura Blvd # 116 818/380-3111 Glendale Memorial Hospital 818/507-4191 Prenatal breastfeeding classes, Thursday support group; services by appointment only. Huntington Hospital Pasadena 626/397-3172 Prenatal and breastfeeding classes, sales and rentals of breastpumps, breastfeeding support group. La Leche League 24-hour hotline: 877/452-5324

US Department of Health and Human Services National Breastfeeding “Warm line”: 800/994-9662

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and Maternal and Infant Health Outcomes in Developed Countries, Evidence Report/Technology Assessment No. 153 (Prepared by Tufts New England Medical Center Evidence based Practice Center.) AHRQ Publication No 07 E007. Rockville, MD: Agency for Healthcare Research and Quality. April 2007

2. Schwarz EB, Ray RM, Stuebe AM, Allison MA, Ness RB, Freiberg MS, Cauley JA. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009;113(5):974-982.)

3. Ball TM, Wright AL. Health care costs of formula-feeding in the first year of life. Pediatrics. 1999;103(4 pt 2):870-876.

4. Weimer J. The Economic Benefits of Breastfeeding: A Review and Analysis. Washington, D.C.: Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture; 2001. Food Assistance and Nutrition Research Report No. 13. Weimer cited a savings of $3.6 billion annually if breastfeeding rates were increased from their current rates to those recommended by Healthy People 2010 goals. However, if one repeats Weimer’s calculations using the most current data on breastfeeding rates, updating the figures for inflation, the true figure would be over $14 billion today. This figure is an underestimation of the total savings because it represents cost savings from the treatment of only three childhood illnesses. Including chronic diseases in children and mothers would likely result in cost savings of many times that figure (from usbreastfeeding.org)

5. Moreland, Coombs. Promoting and Supporting Breastfeeding. Am Fam Physician 2000;61:2093-100,2103-4.

6. AAP, Section on Breastfeeding. Breastfeeding and the Use of Human Milk. Pediatrics 2005 115: 496-506.

7. Philipp BL . Baby Friendly Way, the Best Breastfeeding Start. Pediatr Clin North Am - 01-JUN-2004; 51(3): 761-83

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10. Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate. Academy of Breastfeeding Medicine, Vol 4, No 3;2009. http://www.bfmed.org/Resources/Protocols.aspx

11. Department of Health and Human Services; Healthy People 2010, www.healthypeople.gov. 12. Wendelin Slusser and Nancy G. Powers. Breastfeeding Update 1: Immunology, Nutrition,

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More Weeks of Gestation. Subcommittee on Hyperbilirubinemia. PEDIATRICS Vol. 114 No. 1 July 2004, pp. 297-316

16. Maria Fernanda B. de Almeida and Cecilia Maria Draque. Neonatal Jaundice and Breastfeeding. NeoReviews, Jul 2007; 8: e282 - e288.

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18. Foxman B, D'Arcy H, Gillespie B, Bobo JK, Schwartz K. Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol. 2002;155(2):103-114.

19. Stafford I, Hernandez J, Laibl V, Sheffield J, Roberts S, Wendel G, Jr. Community-acquired methicillin-resistant Staphylococcus aureus among patients with puerperal mastitis requiring hospitalization. Obstet Gynecol. 2008;112(3):533-537.

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20. Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110(5):e63.

21. Geddes DT, Langton DB, Gollow I, Jacobs LA, Hartmann PE, Simmer K. Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008;122(1):e188-e194.

22. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Breastfeeding handbook for physicians. Elk Grove Village (IL): AAP; Washington, DC: ACOG; 2006.

23. American College of Obstetricians and Gynecologists. Breastfeeding: maternal and infant aspects. Special report from ACOG. ACOG Clin Rev 2007;12(suppl):1S–16S.

24. Jennifer S. Read, MD, MS, MPH, DTM&H, and the Committee on Pediatric AIDS. Human Milk, Breastfeeding, and Transmission of Human Immunodeficiency Virus Type 1 in the United States, PEDIATRICS Vol. 112 No. 5 November 2003

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