Breastfeeding Guidelines for Healthcare Providers
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
The promotion of breastfeeding is an ongoing priority of the Women's Health and Education Center (WHEC). Exclusive and predominant breastfeeding rates in many developed countries often fall short of the practice recommended by the World Health Organization and the American Academy of Pediatrics. Both recommend exclusive breastfeeding for the first 6 months, followed by the introduction of suitable complementary foods and continued breastfeeding up to 2 years of age. Despite increasing awareness of the many advantages of breastfeeding, the challenge remains to implement programs that can effectively improve short- and long-term breastfeeding rates, especially of exclusive and predominant breastfeeding. In the United States a campaign is underway aimed at improving breastfeeding practice to meet the goals of Healthy People 2010, in which 75% of mothers initiate breastfeeding and 50% still breastfeed at 6 months postpartum. Evidence continues to mount regarding the value of breastfeeding for both women and infants. It is critical that women make an informed choice in deciding what is best for them, their families, and their babies. Women need to know that breastfeeding, like other aspects of having a new baby, has its demands as well as rewards.
The purpose of this document is to promote breastfeeding and work with national and international organizations dedicated to promoting the health of infants worldwide to formulate guidelines for breastfeeding. Where breastfeeding practices are suboptimal, simple one-encounter antenatal education and counseling significantly improve breastfeeding practice up to 3 months after delivery. Provision of printed or audiovisual material is not enough. Healthcare providers should make every effort to have at least one face-to-face encounter to discuss breastfeeding with expectant mothers before they deliver. Human milk provides developmental, nutritional, and immunologic benefits to the infant that cannot be duplicated by formula feeding. Obstetricians and gynecologists and other healthcare professionals caring for pregnant women should regularly impart accurate information about breastfeeding to expectant mothers and be prepared to support them should any problems arise while breastfeeding.
Many women make infant feeding decisions before delivery and before any contact with healthcare professionals. Although health promotion campaigns are influential in educating women about breastfeeding, they often do not dissuade women from formula feeding once the decision has been made. Antenatal preparation of pregnant women for breastfeeding raises awareness of the importance of breastfeeding, empowers them with practical knowledge and skills in breastfeeding techniques, and prepares them for possible difficulties. The U.S. breastfeeding initiation rate has improved from 53.6% in 1994 to 65.1% in 2001, continued breastfeeding in the 2001 survey was 27.0% at 6 months, with exclusive breastfeeding rates at only 7.9%, falling short of the Healthy People 2010 goals. Programs aimed at promoting breastfeeding through patient education and caregiver encouragement have delivered mixed results. With the development of iron-fortified formula, breastfeeding rates began to decrease in the late 1950s as formula feeding gained popularity. In 1971, only 24.7% of mothers left the hospital breastfeeding. The initiation rates are lowest among non-Hispanic black women, women younger than 20 years, women enrolled in WIC (Special Supplemental Nutrition Program for Women, Infants, and Children), and those who completed high school or less. In 2005, the rate of any breastfeeding at 6 months reached 39.1%, the highest rate in the nearly 35 years such data have been collected. The sharpest decrease in breastfeeding (approximately 20%) occurs within the first month after discharge. Accounting for this precipitous decrease, the most common reasons given for premature discontinuation are insufficient milk production, difficulty with attachment (latch-on and infant suckling), and lack of maternal confidence. Research in the United States and throughout the world indicates that breastfeeding and human milk provide benefits to infants, women, families and society.
Modern society has created obstacles to breastfeeding that may contribute to the low percentage of mothers (13.9% in 2005) breastfeeding exclusively at 6 months postpartum. Short hospital stays make the teaching of breastfeeding a challenge. Lack of spousal or partner support and family customs may discourage breastfeeding. Although some employers recognize that encouraging breastfeeding as a policy improves employee morale and decreases absenteeism, having to return to work may still be obstacle. An unfriendly social environment may also make it difficult to breastfeed in public. Although the effect of these obstacles can be mitigated by educating the families, employers, and society, some women will decide that the challenges outweigh the benefits for themselves and babies.
Potential Protective Effects & Benefits of Human Milk & Breastfeeding:
In 2005, the American Academy of Pediatrics (AAP) published a revised policy statement, "Breastfeeding and the Use of Human Milk". The statement summarizes established infant protective effects, as well as positive associations that require further study. Many of the benefits of breastfeeding for both the mother and infant are recognized to be enhanced by exclusivity and duration. Obstetricians and gynecologists in their practice should prepare women about the evidence for these benefits of human milk and breastfeeding. Systematic reviews conclude that educational programs are more effective at improving breastfeeding initiation and its short-term duration than literature alone.
Infant: Human milk provides species-specific and age-specific nutrients for the infant. Colostrum (the fluid secreted from breast immediately after delivery) contains a high level of immune protection, particularly secretory immunoglobulin A (IgA). During the first 4-7 days after birth, protein and mineral concentrations decrease, and water, fat, and lactose increase. Milk composition continues to change to match infant nutritional needs. However, human milk alone may not provide adequate iron for infants older than 6 months, infants whose mothers have low iron stores, and premature infants at all ages. Research in developed and developing countries of the world, including middle-class populations in developed countries, provides strong evidence that human milk feeding decreases the incidence and/or severity of a wide range of infectious diseases including bacterial meningitis, bacteremia, diarrhea, respiratory tract infection, necrotizing enterocolitis, otitis media, urinary tract infection, and late-onset sepsis in preterm infants. In addition, post-neonatal infant mortality rates in the United States are reduced by 21% in breastfed infants.
Some studies suggest decreased rates of sudden infant death syndrome in the first year of life and reduction in incidence of insulin-dependent (type 1) and non-insulin-dependent (type 2) diabetes mellitus, lymphoma, leukemia, and Hodgkin disease, overweight and obesity, hypercholesterolemia, and asthma in older children and adults who were breastfed, compared with individuals who were not breastfed. Breastfeeding has been associated with slightly enhanced performance on tests of cognitive development. Additional research in these areas is warranted.
Women: Benefits start in the immediate postpartum period with the release of oxytocin during milk let-down. This results in increased uterine contractions aiding with uterine involution and a decrease in maternal blood loss. Additionally, evidence exists that oxytocin and prolactin contribute to the mother's feeling of relaxation and of her attachment to her baby. Breastfeeding also is associated with a decreased risk of developing ovarian and breast cancer. Moreover, breastfeeding delays postpartum ovulation, supporting birth spacing. Although breastfeeding causes some bone mineralization, studies indicate that "catch-up" re-mineralization occurs after weaning. Importantly, clinical studies have demonstrated a protective effect of breastfeeding, such as a lower incidence of osteoporosis and hip fracture after menopause.
Families and Society: Studies indicate that the breastfed child has fewer illnesses and therefore fewer visits to the physician and hospital. This translates into lower medical expenses, and for women who work outside the home, less absenteeism from work. Because women now constitute a large portion of the workforce, the improvement in work productivity may be significant for society as well. More than 60% of all women return to outside employment during the first year after birth of a child. Breastfeeding while demanding maternal time and attention can save families and public programs considerable money compared with formula feeding. Society may benefit as well when the ecologic issues of disposal of formula, cans, bottles, and bottle liners are considered.
Preconception and Prenatal Education on Breastfeeding:
The obstetricians and gynecologists have many opportunities during periodic gynecologic examinations and prenatal visits to promote breastfeeding, allay a woman's anxieties, and suggest solutions or resources to make breastfeeding a practical choice for the patient and her family. Periodic gynecologic examination provides mentioning breastfeeding during the breast examination. Women whose breast anatomy appears to be normal can be told that if they decide to have a baby, there are no structural impediments to breastfeeding.
Prenatal Visits: The advice and encouragement of the obstetricians and gynecologists are critical in making the decision to breastfeed. Other health professionals, such as pediatricians, nurses, and certified lactation specialists, also play an important role. Alternatively, hospitals and other organizations, including mother-to-mother groups and other lay organizations, can provide education for pregnant women and their partners. Some women who choose to breastfeed were breastfed themselves or had a sibling who was breastfed, which established it as normal behavior in their household. These women would probably benefit from some education and reinforcement concerning breastfeeding. Guidance and consideration of life situations are important in helping these women and their families make a decision about feeding their infants. Information about the benefits and challenges of breastfeeding compared with the use of formula will help them make good decisions. The initial prenatal visit is an optimal time to encourage or reinforce the decision to breastfeed. Women should be reassured about her ability to breastfeed. The techniques to assist in nipple eversion, however, are not recommended during pregnancy because there is no evidence to support their effectiveness. Today, with shorter postpartum hospital stays, it is important for pregnant women to come to the hospital for delivery with a good foundation of knowledge gained during antepartum period.
Prenatal Breastfeeding Instructions: Prenatal education groups have been shown to be particularly effective in increasing duration of breastfeeding. Education in the hospital can then focus on operational aspects of breastfeeding such as latch-on and feeding techniques. UNICEF-WHO Baby Friendly Hospital Initiative should be adapted for use in the hospital practices and have been shown to increase rates of successful breastfeeding. These 10 steps are: 1) Maintain a (supportive) written breastfeeding policy that is communicated to all health care staff. 2) Train all pertinent healthcare staff in skills necessary to implement this policy. 3) Inform all pregnant women about the benefits of breastfeeding. 4) Offer all mothers the opportunity to initiate breastfeeding within 1 hour of birth. 5) Show breastfeeding mothers how to breastfeed and how to maintain lactation even if they are separated from their infants. 6) Give breastfeeding infants only breast milk unless medically indicated. 7) Facilitate rooming-in; encourage all mothers and infants to remain together during their hospital stay. 8) Encourage unrestricted breastfeeding when baby exhibits hunger cues or signals or on request of mother. 9) Encourage exclusive suckling at the breast by providing no pacifiers or artificial nipples. 10) Refer mothers to establish breastfeeding and/or mothers' support groups and services, and foster the establishment of those services when they are not available.
Postpartum Support for Breastfeeding: The immediate postpartum period should allow the woman and her newborn to experience optimal bonding with immediate physical contact, preferably skin to skin. The initial feeding should occur as soon after birth as possible, preferably in the first hour when the baby is awake, alert, and ready to suckle. The longer the interval between birth and first feeding, the more likely the use of supplementation. All hospitals should have trained personnel available and should offer 24-hour rooming-in to maximize the interaction between the woman and her newborn. Rooming-in and promoting skin-to-skin contact have numerous advantages for both the infant and mother. Infants cry less, sleep more, and become adept at breastfeeding sooner. Trained staff should assess breastfeeding behavior of the woman and newborn during the first 24-48 hours after birth for correct nursing positions, latch-on, and adequacy of newborn milk transfer. Generally, painful breastfeeding almost always results from poor positioning or latch-on, which should be immediately corrected, rather than from breastfeeding "too long". Before discharge the woman should be educated about indicators of adequate intake and informed that for most breastfeeding infants, no water is required. She also should be educated about age-appropriate elimination patterns of her newborn during the first week after birth. Before gaining weight, the breastfeeding newborn may lose 5-7% of birth weight in the first week. When the loss is greater than 5-7% of birth weight in the first or reaches that level in the first 3 days, a clinician should evaluate the breastfeeding process to address any problems before they become serious. A weight loss of up to 10% is the maximum that is acceptable only if all else is going well and the physical examination findings are negative for problems. Follow-up should confirm that the newborn is beginning to regain weight after the first week. Couples should be encouraged to discuss emotional adjustments to their new family status.
Neither inactivated nor live vaccines administered to a lactating mother affect the safety of breastfeeding for mothers or infants. Breastfeeding does not adversely affect immunization and is not a contraindication for any vaccine. Although live vaccines multiply within the mother's body, most have not been demonstrated to be excreted in human milk. Regular breastfeeding generally ensures adequate milk supply. As the baby grows and requires more milk, the woman's supply increases to accommodate the baby's needs.
Postpartum Nutrition & Contraception:
Well-balanced diet generally provides the nutrients their infants need. On average, it is estimated that women will need approximately 500 kcal per day more than recommended levels for non-pregnant and non-lactating women. Additional maternal food intake generally will provide additional needed vitamins and minerals (with the possible exceptions of calcium and zinc). One exception is that many individuals do not synthesize adequate amounts of vitamin D from the sunlight. Furthermore, unprotected exposure to sunlight is not recommended. For this reason vitamin D is added to milk for general consumption and to infant formula. Breastfed babies should also receive vitamin D supplementation (200 international units of oral drops daily) beginning in the first 2 months of life and continuing until daily consumption of vitamin D fortified milk or formula is 500 mL or vitamin supplemented foods are added. Vitamin D supplementation for a woman will not significantly increase the content of vitamin D in her breast milk. Women of childbearing age need to maintain a calcium intake of 1,000 mg per day at all times, including during pregnancy and lactation (1,300 mg for adolescents through 18 years of age). Dietary intake is the preferred source of all needed nutrients. Corrective measures can be suggested by a nutritionist for improving nutrient intakes of women with extreme or restrictive eating patterns. Women should be encouraged to drink plenty of fluids to satisfy their thirst and maintain adequate hydration.
Healthcare providers should address contraceptive needs, and the emotional adjustments, as well as physical problems of soreness, fatigue and vaginal dryness secondary to breastfeeding. The average time to first ovulation is 45 days postpartum (range, 25-72 days) for a woman who does not breastfeed. In contrast, ovulation in women who breastfeed exclusively can be delayed 6 months. Lactational amenorrhea method is most appropriate for women who plan to breastfeed exclusively for 6 months. Four prospective clinical trials of the contraceptive effect of the lactational amenorrhea method demonstrated cumulative 6-month life-table, perfect-use pregnancy rates of 0.5%, 0.6%, 1.0% and 1.5% among women who relied solely on it. If there is uncertainty regarding the extent to which a woman is breastfeeding, it would be prudent to recommend additional methods of family planning. Non- hormonal contraceptive options neither affect breastfeeding nor pose a risk to the infant. Such methods include intrauterine devices, condoms, diaphragms, or cervical caps. Female sterilization or vasectomy may be considered by couples desiring permanent birth control. Progestin-only oral contraceptives can be prescribed or dispensed at discharge from the hospital to be started 2-3 weeks postpartum. Depot medroxyprogesterone acetate can be initiated at 6 weeks postpartum. Hormonal implants can be inserted at 6 weeks postpartum. The levonorgestrel intrauterine system can be inserted at 6 weeks postpartum. Combined estrogen-progestin contraceptives, if prescribed, typically should not be started before 6 weeks postpartum, and only when lactation is well established and the infant's nutritional status is appropriate. Given the overall lack of data, healthcare providers may consider earlier initiation of progestin-only method (e.g., before hospital discharge) and initiation of estrogen-containing hormonal contraception after the period of hypercoagulability associated with pregnancy has resolved.
Women Who Should Not Breastfeed:
The contraindications to breastfeeding are few. Women who should not breastfeed are:
- Take street drugs or do not control alcohol use
- Have an infant with galactosemia
- Have certain infections, such as human immunodeficiency virus (HIV); human T-cell lymphotropic virus type I or type II; active or untreated tuberculosis; varicella; or active herpes simplex with breast lesions
- Are taking antineoplastic, thyrotoxic, and immunosuppressive agents
- Take certain medications like radioactive isotopes or are undergoing treatment for breast cancer
Hepatitis infections do not preclude breastfeeding. With appropriate immunoprophylaxis, including hepatitis B immune globulin and hepatitis vaccine, breastfeeding of babies born to women positive for hepatitis B surface antigen poses no additional risk for the transmission of hepatitis B virus. If a woman has acute hepatitis A infection, her infant can breastfeed after receiving immune serum globulin and vaccine. The average rate to hepatitis C virus (HCV) infection reported in infants born to HCV-positive women is 4% for both breastfed and bottle-fed infants. Therefore, maternal HCV is not considered a contraindication to breastfeeding.
Breast Pain and Infections:
Breast and nipple pain is a common problem for the breastfeeding woman, and is the second most common factor leading to cessation of breastfeeding. The cause should be diagnosed and treated promptly. Breast pain may result from engorgement, nipple pain, or mastitis. Sore nipples are the most common complaint raised by mothers and usually results from poor positioning or latch-on, trauma, plugged ducts, candidiasis, harsh breast cleansing or use of irritating cleansing products. The first-line treatment should be counseling about basic latch-on techniques. Purified lanolin cream and breast shells (to protect the nipples from friction between feeding) may be suggested to facilitate healing.
Engorgement: It results from ineffective or infrequent removal of milk from the breast and leads to full, hard, and tender breasts. Prevention involves ensuring proper latch-on and milk removal and encouraging on-demand feeding. Healthcare professionals should ensure that breastfeeding women can successfully express milk by hand. Because use of a breast pump is more efficient, rental or purchase of a pump can be considered. In general, electric pumps are more efficient than hand pumps. Pumping both breasts simultaneously is more effective and saves time. Human milk should be stored in a cool, safe place to maximize its preservation and minimize contamination. Breast milk can be stored in the refrigerator or on ice in glass or plastic containers. The use of refrigerated milk within 2 days is recommended, which is well before appreciable bacterial growth usually occurs. Frozen milk can be stored for 3-6 months.
Mastitis and Breast Abscess: It most commonly occurs between the second and third weeks postpartum but may be seen any time throughout the first year. Mastitis occurs in 2-9.5% of breastfeeding women. It is manifested by a sore, reddened area on one breast and often is accompanied by chills, fever, and malaise. The fever can be as high as 40° C. A segment of the breast becomes hard and erythematous. The most common causative agent in mastitis is Staphylococcus aureus, occurring in 40% of cases. It also is the most common cause of abscess. Other common organisms in mastitis include Haemophilus influenzae, H parainfluenzae, E. Coli, enterococcus faecalis, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens, Group B Streptococci, and Pseudomonas pickettii. The condition usually can be treated successfully with narrow-spectrum antibiotics (the first choice for women who are not allergic is dicloxacillin, 500 mg, four times daily for 10-14 days), hydration, bed rest, and analgesics such as acetaminophen or ibuprofen. Women who are allergic to penicillin may be given erythromycin. If the infection is caused by resistant, penicillinase-producing staphylococci, an antibiotic such as vancomycin or cefotetan can be used. All antibiotics should be continued until 2 days after the infection subsides, a minimum of 10-14 days. The mother should continue to breast feed or express the milk from both breasts because it is important to empty the affected breast. Discarding the milk from the affected breast is not recommended when a mother with mastitis is being treated, except in unusual circumstances. It does not pose a risk for the healthy, term infant. Breast milk from unaffected breast may be used under any circumstance. The antibiotics commonly used to treat mastitis and anti-inflammatory agents, such as ibuprofen, are safe to use when breastfeeding. If mastitis is not treated aggressively, it may become chronic or an abscess may develop.
An abscess is diagnosed by the presence of a palpable mass or fever that fails to abate within 48-72 hours of antibiotic therapy. Generally abscesses have been treated with incision and drainage. Multiple abscesses may require multiple incisions, with a finger inserted to break down the locules. Breast milk should be discarded for the first 24 hours after surgery, with breastfeeding resuming thereafter if there is no drainage into the breast milk. Recently, ultrasonographically guided needle aspiration is shown to be successful in treating abscesses.
There are no rules about when to wean. Various situations and preferences may influence the timing. Whenever possible, weaning process should be gradual. During the first 6 months of life, exclusive breastfeeding is the preferred feeding approach for the healthy infant born at term. Gradual introduction of iron-enriched solid foods in the second half of the first year should complement the breast-milk diet. Abrupt weaning can be difficult for the mother and the baby, but certain measures can be helpful. The mother should wear a support bra. She does not need to restrict fluids. She may manually express just enough milk to relieve the engorgement. Cool compresses will reduce engorgement. Hormonal therapy is not recommended.
Milk Banks: Some women who cannot breastfeed look to donor breast milk rather than formula to nourish their infants. Donor human milk is particularly beneficial for infants in neonatal intensive care units, primarily very low birth weight infants and those with gastrointestinal pathology. The Human Milk Bank Association of North America (HMBANA) is the only professional membership association for milk banks in Canada, Mexico, and the United States, and sets the standards and guidelines for donor screening, storage, sterilization of milk, and modern distribution methods.
Breast Cancer Detection: Clinical breast examination and breast self-examination are recommended for breastfeeding women, just as for all women aged 19 years and older. Because of normal changes in the breasts during pregnancy and lactation, cancer detection by palpation becomes more difficult. Increasing age is one of the many risk factors for breast cancer; this concern is especially important for women who are having babies in their late 30s and early 40s. Although regular breast examinations should continue during the 1- or 2-year period of pregnancy and lactation, detection of abnormalities may be more difficult during that time. Therefore, some women and their health care providers may consider a screening mammogram before age 40 years for women planning pregnancies in their late 30s. During lactation, mammograms are less reliable because of the associated increase in breast tissue density, which may make test more difficult to interpret. Ultrasound examination can provide further assistance in evaluating palpable breast masses (solid or fluid-filled) during lactation.
Although new mothers may be aware of breastfeeding benefits, they often lack practical knowledge about the technique and process of initiating and maintaining breastfeeding, and this may take them resort to infant formula instead. Obstetricians-gynecologists and other healthcare providers should be in the forefront of fostering changes in the public environment that will support breastfeeding, whether through change in hospital practices, through community efforts, or through supportive legislation. 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 or 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. Even if 75% of women initiate breastfeeding, two thirds of them will need to continue breastfeeding to reach the proposed target of 50% of all women breastfeeding at 6 months. The greatest benefits for mother and infant and the best continuation rates accrue with exclusive breastfeeding in approximately the first 6 months. Healthcare providers should ensure that women have the correct information to make an informed decision and together with pediatricians, they should ensure that each woman has the help and support necessary to continue breastfeeding successfully. The combined efforts of all healthcare providers will be necessary to meet these goals. The most useful intervention includes demonstration of breastfeeding techniques (educational video), one-to-one teaching by a trained lactation counselor, and a breastfeeding information booklet.
- World Health Organization
The optimal duration of exclusive breastfeeding: report of an expert consultation (pdf)
- UNICEF (United Nations Children's Fund)
Protecting, Promoting & Supporting Breastfeeding
- Centers for Disease Control and Prevention
Breastfeeding: data and statistics
- American Academy of Pediatrics
Ten steps to support parents' choice to breastfeed their baby (pdf)
- Academy of Breastfeeding Medicine
- Healthy People 2010
Maternal, infant, and child health.
- The Human Milk Bank Association of North America (HMBANA)
Human Milk Banking
Dedicated to Women's and Children's Well-being and Health Care Worldwide