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Breastfeeding

By Deborah M. Consolini, MD, Assistant Professor of Pediatrics;Chief, Division of Diagnostic Referral, Sidney Kimmel Medical College of Thomas Jefferson University;Nemours/Alfred I. duPont Hospital for Children

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(See also Nutrition in Infants.)

Breast milk is the nutrition of choice. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for a minimum of 6 mo and introduction of appropriate solid food from 6 mo to 1 yr. Beyond 1 yr, breastfeeding continues for as long as both infant and mother desire, although after 1 yr breastfeeding should complement a full diet of solid foods and fluids. To encourage breastfeeding, practitioners should begin discussions prenatally, mentioning the multiple advantages:

  • For the child: Nutritional and cognitive advantages and protection against infection, allergies, obesity, Crohn disease, and diabetes

  • For the mother: Reduced fertility during lactation, more rapid return to normal prepartum condition (eg, uterine involution, weight loss), and protection against osteoporosis, obesity, and ovarian and premenopausal breast cancers

Milk production is fully established in primiparas by 72 to 96 h and in less time in multiparas. The first milk produced is colostrum, a high-calorie, high-protein, thin yellow fluid that is immunoprotective because it is rich in antibodies, lymphocytes, and macrophages; colostrum also stimulates passage of meconium. Subsequent breast milk has the following characteristics:

  • Has a high lactose content, providing a readily available energy source compatible with neonatal enzymes

  • Contains large amounts of vitamin E, an important antioxidant that may help prevent anemia by increasing erythrocyte life span

  • Has a calcium:phosphorus ratio of 2:1, which prevents calcium-deficiency tetany

  • Favorably changes the pH of stools and the intestinal flora, thus protecting against bacterial diarrhea

  • Transfers protective antibodies from mother to infant

  • Contains cholesterol and taurine, which are important to brain growth, regardless of the mother’s diet

  • Is a natural source of omega-3 and omega-6 fatty acids

These fatty acids and their very long-chain polyunsaturated derivatives (LC-PUFAS), arachidonic acid (ARA) and docosahexaenoic acid (DHA), are believed to contribute to the enhanced visual and cognitive outcomes of breastfed compared with formula-fed infants. Most commercial formulas are now supplemented with ARA and DHA to more closely resemble breast milk and to reduce these potential developmental differences.

If the mother’s diet is sufficiently diverse, no dietary or vitamin supplementation is needed for the mother or her term breastfed infant. However, to prevent vitamin D deficiency rickets, vitamin D 400 units once/day beginning in the first 2 mo is given to all infants who are exclusively breastfed. Premature and dark-skinned infants and infants with limited sunlight exposure (residence in northern climates) are especially at risk of vitamin D deficiency. After 6 mo, breastfed infants in homes where the water does not have adequate fluoride (supplemental or natural) should be given fluoride drops. Clinicians can obtain information about fluoride content from a local dentist or health department.

Infants < 6 mo should not be given additional water because hyponatremia is a risk.

Breastfeeding Technique

The mother should use whatever comfortable, relaxed position works best and should support her breast with her hand to ensure that it is centered in the infant’s mouth, minimizing any soreness. The center of the infant’s lower lip should be stimulated with the nipple so that rooting occurs and the mouth opens wide. The infant should be encouraged to take in as much of the breast and areola as possible, placing the lips 2.5 to 4 cm from the base of the nipple. The infant’s tongue then compresses the nipple against the hard palate. Initially, it takes at least 2 min for the let-down reflex to occur.

Volume of milk increases as the infant grows and stimulation from suckling increases. Feeding duration is usually determined by the infant.

Some mothers require a breast pump to increase or maintain milk production; in most mothers, a total of 90 min/day of breast pumping divided into 6 to 8 sessions produces enough milk for an infant who is not directly breastfed.

The infant should nurse on one breast until the breast softens and suckling slows or stops. The mother can then break suction with a finger before removing the infant from one breast and offering the infant the other breast. In the first days after birth, infants may nurse on only one side; then the mother should alternate sides with each feeding. If the infant tends to fall asleep before adequately nursing, the mother can remove the infant when suckling slows, burp the infant, and move the infant to the other side. This switch keeps the infant awake for feedings and stimulates milk production in both breasts.

Mothers should be encouraged to feed on demand or about every 1½ to 3 h (8 to 12 feedings/day), a frequency that gradually decreases over time; some neonates < 2500 g may need to feed even more frequently to prevent hypoglycemia. In the first few days, neonates may need to be wakened and stimulated; small infants and late preterm infants should not be allowed to sleep long periods at night. Large full-term infants who are feeding well (as evidenced by stooling pattern) can sleep longer. Eventually, a schedule that allows infants to sleep as long as possible at night is usually best for the infant and family.

Mothers who work outside the home can pump breast milk to maintain milk production while they are separated from their infants. Frequency varies but should approximate the infant’s feeding schedule. Pumped breast milk should be immediately refrigerated if it is to be used within 48 h and immediately frozen if it is to be used after 48 h. Refrigerated milk that is not used within 96 h should be discarded because risk of bacterial contamination is high. Frozen milk should be thawed by placing it in warm water; microwaving is not recommended.

Infant Breastfeeding Complications

The primary complication is underfeeding, which may lead to dehydration and hyperbilirubinemia. Risk factors for underfeeding include small or premature infants and mothers who are primiparous, who become ill, or who have had difficult or operative deliveries.

A rough assessment of feeding adequacy can be made by daily diaper counts. By age 5 days, a normal neonate wets at least 6 diapers/day and soils at least 4 diapers/day; lower numbers suggest underhydration and undernutrition. Also, stools should have changed from dark meconium at birth to light brown and then yellow. Weight is also a reasonable parameter to follow (see Feeding problems); not attaining growth landmarks suggests undernutrition. Constant fussiness before age 6 wk (when colic may develop unrelated to hunger or thirst) may also indicate underfeeding.

Dehydration should be suspected if vigor of the infant’s cry decreases or skin becomes turgid; lethargy and sleepiness are extreme signs of dehydration and should prompt testing for hypernatremia.

Maternal Breastfeeding Complications

Common maternal complications include breast engorgement, sore nipples, plugged ducts, mastitis, and anxiety.

Breast engorgement, which occurs during early lactation and may last 24 to 48 h, may be minimized by early frequent feeding. A comfortable nursing brassiere worn 24 h/day can help, as can applying cool compresses after breastfeeding and taking a mild analgesic (eg, ibuprofen). Just before breastfeeding, mothers may have to use massage and warm compresses and express breast milk manually to allow infants to get the swollen areola into their mouth. After breastfeeding, cool compresses reduce engorgement and provide further relief. Excessive expression of milk between feedings facilitates engorgement, so expression should be done only enough to relieve discomfort.

For sore nipples, the infant’s position should be checked; sometimes the infant draws in a lip and sucks it, which irritates the nipple. The mother can ease the lip out with her thumb. After feedings, she can express a little milk, letting the milk dry on the nipples. After breastfeeding, cool compresses reduce engorgement and provide further relief.

Plugged ducts manifest as mildly tender lumps in the breasts of lactating women who have no other systemic signs of illness. Continued breastfeeding ensures adequate emptying of the breast. Warm compresses and massage of the affected area before breastfeeding may further aid emptying. Women may also alternate positions because different areas of the breast empty better depending on the infant’s position at the breast. A good nursing brassiere is helpful because regular brassieres with wire stays or constricting straps may contribute to milk stasis in a compressed area.

Mastitis is common and manifests as a tender, warm, swollen, wedge-shaped area of breast. It is caused by engorgement, blocking, or plugging of an area of the breast; infection may occur secondarily, most often with penicillin-resistant Staphylococcus aureus and less commonly with Streptococcus sp or Escherichia coli. With infection, fever 38.5° C, chills, and flu-like aching may develop. Diagnosis of mastitis is by history and examination. Cell counts (WBCs > 106/mL) and cultures of breast milk (bacteria >103/mL) may distinguish infectious from noninfectious mastitis. If symptoms are mild and present < 24 h, conservative management (milk removal via breastfeeding or pumping, compresses, analgesics, a supportive brassiere, and stress reduction) may be sufficient. If symptoms do not lessen in 12 to 24 h or if the woman is acutely ill, antibiotics that are safe for breastfeeding infants and effective against S. aureus (eg, dicloxacillin, cloxacillin, or cephalexin 500 mg po qid) should be started; duration of treatment is 7 to 14 days. Community-acquired methicillin-resistant S. aureus should be considered if cases do not respond promptly to these measures or if an abscess is present. Complications of delayed treatment are recurrence and abscess formation. Breastfeeding may continue during treatment.

Maternal anxiety, frustration, and feelings of inadequacy may result from lack of experience with breastfeeding, mechanical difficulties holding the infant and getting the infant to latch on and suck, fatigue, difficulty assessing whether nourishment is adequate, and postpartum physiologic changes. These factors and emotions are the most common reasons mothers stop breastfeeding. Early follow-up with a pediatrician or consultation with a lactation specialist is helpful and effective for preventing early breastfeeding termination.

Drugs and Breastfeeding

Breastfeeding mothers should avoid taking drugs if possible. When drug therapy is necessary, the mother should avoid contraindicated drugs and drugs that suppress lactation (eg, bromocriptine, levodopa, trazodone). The US National Library of Medicine maintains an extensive database regarding drugs and breastfeeding, which should be consulted regarding use of or exposure to specific drugs or classes of drugs. For some common drugs contraindicated for breastfeeding mothers, see Table: Some Drugs Contraindicated for Breastfeeding Mothers.

When drug treatment is necessary, the safest known alternative should be used; when possible, most drugs should be taken immediately after breastfeeding or before the infant’s longest sleep period, although this strategy is less helpful with neonates who nurse frequently and exclusively. Knowledge of the adverse effects of most drugs comes from case reports and small studies. Safety of some drugs (eg, acetaminophen, ibuprofen, cephalosporins, insulin) has been determined by extensive research, but others are considered safe only because there are no case reports of adverse effects. Drugs with a long history of use are generally safer than newer drugs for which few data exist.

Some Drugs Contraindicated for Breastfeeding Mothers

Drug Class

Examples

General Concerns and Specific Effects in Infants

Anticoagulants

Dicumarol

Warfarin

May be given cautiously but, in very large doses, may cause hemorrhage (heparin is not excreted in milk)

Cytotoxic drugs

Cyclophosphamide

Cyclosporine

Doxorubicin

Methotrexate

May interfere with cellular metabolism of a breastfeeding infant, causing possible immunosuppression and neutropenia

Unknown effect on growth and unknown association with carcinogenesis

Psychoactive drugs

Anxiolytics, including benzodiazepines (alprazolam, diazepam, lorazepam, midazolam, prazepam, quazepam, temazepam) and perphenazine

Antidepressants (tricyclics, SSRIs, bupropion)

Antipsychotics (chlorpromazine, chlorprothixene, clozapine, haloperidol, mesoridazine, trifluoperazine)

For most psychoactive drugs, unknown effect on infants, but because drugs and metabolites appear in breast milk and in infant plasma and tissues, possible alteration of short-term and long-term CNS function

Fluoxetine: Linked to colic, irritability, feeding problems and sleep disorders, and slow weight gain

Chlorpromazine: Possible drowsiness, lethargy, decline in developmental scores

Haloperidol: Decline in developmental scores

Individual drugs that are detectable in breast milk and pose theoretical risk

Amiodarone

Possible hypothyroidism

Chloramphenicol

Possible idiosyncratic bone marrow suppression

Clofazimine

Potential for transfer of high percentage of maternal dose

Possible increase in skin pigmentation

Corticosteroids

With large maternal doses given for weeks or months, can produce high concentrations in milk and may suppress growth and interfere with endogenous corticosteroid production in the infant

Lamotrigine

Potential for therapeutic serum concentrations in the infant

Metoclopramide

None described

Metronidazole

Tinidazole

In vitro mutagens

May stop breastfeeding for 12–24 h to allow excretion of dose when a mother is given a single dose of 2 g

Safe after the infant is 6 mo

Sulfapyridine

Sulfisoxazole

Caution required if infants have jaundice or G6PD deficiency or are ill, stressed, or premature

Individual drugs that are detectable in breast milk and have documented risk

Acebutolol

Hypotension, bradycardia, tachypnea

Aminosalicylic acid

Diarrhea

Atenolol

Cyanosis, bradycardia

Bromocriptine

Suppresses lactation

May be hazardous to the mother

Aspirin (salicylates)

Metabolic acidosis

With large maternal doses and sustained use, may produce plasma concentrations that increase risk of hyperbilirubinemia (salicylates compete for albumin-binding sites) and hemolysis only in G6PD-deficient infants who are < 1 mo

Clemastine

Drowsiness, irritability, refusal to feed, high-pitched cry, neck stiffness

Ergotamine

Vomiting, diarrhea, seizures (with doses used in migraine drugs)

Estradiol

Withdrawal vaginal bleeding

Iodides

Iodine

Goiter

Lithium

1/3to 1/2therapeutic blood concentration in infants

Phenobarbital

Sedation, infantile spasms after weaning, methemoglobinemia

Phenytoin

Methemoglobinemia

Primidone

Sedation, feeding problems

Sulfasalazine (salicylazosulfapyridine)

Bloody diarrhea

Nitrofurantoin, sulfapyridine, sulfisoxazole

Hemolysis in infants with G6PD deficiency; safe in others

Drugs of abuse*

Amphetamine

Irritability, poor sleeping pattern

Alcohol

With < 1 g/kg daily, decreased milk ejection reflex

With large amounts, drowsiness, diaphoresis, deep sleep, weakness, decrease in linear growth, abnormal weight gain in the infant

Cocaine

Cocaine intoxication: Irritability, vomiting, diarrhea, tremulousness, seizures

Heroin

Tremors, restlessness, vomiting, poor feeding

Marijuana

Components detectable in breast milk but effects uncertain

Phencyclidine

Hallucinogen

*Effects of smoking are unclear; nicotine is detectable in breast milk, and smoking decreases breast milk production and infant weight gain but may decrease incidence of respiratory illness.

Data from Committee on Drugs of the American Pediatric Association: The transfer of drugs and other chemicals into human milk. Pediatrics108(3):776–789, 2001.

Weaning

Weaning can occur whenever the mother and infant mutually desire, although preferably not until the infant is at least 12 mo old. Gradual weaning over weeks or months during the time solid food is introduced is most common; some mothers and infants stop abruptly without problems, but others continue breastfeeding 1 or 2 times/day for 18 to 24 mo or longer. There is no correct schedule.

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