Breastfeeding

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 minutes 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. 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 feed on only one side; then the mother should alternate sides with each feeding. If the infant tends to fall asleep before adequately feeding, 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.

Infant Breastfeeding

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Mothers should be encouraged to feed on demand or about every 1½ to 3 hours (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 for long periods. 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.

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

Mothers who spend several hours or more apart from their infant (eg, for work, school) 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 hours and immediately frozen if it is to be used after 48 hours. Refrigerated milk that is not used within 96 hours should be discarded because risk of bacterial contamination is high (1). Frozen milk should be thawed by placing it in warm water; microwaving is not recommended due to uneven heating that can cause burns to the infant and the potential degradation of nutrients and other compounds (2).

The primary potential complication for infants of breastfeeding is underfeeding, which may lead to dehydration and hyperbilirubinemia. (See also breastfeeding jaundice and human milk jaundice.) There are many risk factors for and conditions that can contribute to breastfeeding difficulties and underfeeding, including small or premature infants and mothers who are primiparous, who become ill, or who have had difficult or operative deliveries (1–3).

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 weeks (at which time 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 and/or jaundiced; lethargy and sleepiness are extreme signs of dehydration and should prompt testing for hypernatremia.

Early referral to a certified lactation consultant can help with many breastfeeding problems that are not readily solvable with the help of the mother's and infant's physician or other clinician, and has been shown to reduce the risk of stopping breastfeeding (4, 5).

Classic galactosemia in the infant is an absolute contraindication to breastfeeding (6).

Certain maternal infections that can be transmitted to the infant through breast milk, including HIV infection, human T-cell lymphotropic virus type I or type II infection, untreated brucellosis, or suspected or confirmed Ebola virus disease. Recommendations vary about breastfeeding by mothers with HIV, depending on use of antiretroviral therapy and other factors. Breastfeeding with complementary feeding may continue until 24 months of age or beyond. For certain other maternal infections (active, untreated tuberculosis; varicella; active herpes simplex lesions on the breast or chest; cytomegalovirus [for preterm infants]), separation of mother and infant for the period of transmission may be recommended, but breast milk may be expressed and fed to the infant.

In addition, breastfeeding is contraindicated when there is maternal misuse of certain substances (eg, illicit opioids, cocaine, and phencyclidine) because of potential impacts on the infant's long-term neurobehavioral development. However, for pregnant patients with opioid use disorder who are stable on medication (eg, methadone, buprenorphine), breastfeeding may help mitigate neonatal opioid withdrawal syndrome. who are stable on medication (eg, methadone, buprenorphine), breastfeeding may help mitigate neonatal opioid withdrawal syndrome.

Common maternal complications include breast pain due to sore or cracked nipples, breast engorgement, plugged ducts, or mastitis, and anxiety.

For sore or cracked nipples, the mother should receive support and education to ensure optimal infant position and breastfeeding technique. After feedings, the nipples may be soothed by expressing a little milk and letting it dry on the nipples or by applying lanolin. If breast pain or cracked nipples persist or other lesions develop on the nipple or areola, the patient should be evaluated for other causes, including breast pump misuse, dermatologic conditions (eg, eczema, psoriasis), infections (candida, herpes simplex, herpes zoster), or infant ankyloglossia (the mother should receive support and education to ensure optimal infant position and breastfeeding technique. After feedings, the nipples may be soothed by expressing a little milk and letting it dry on the nipples or by applying lanolin. If breast pain or cracked nipples persist or other lesions develop on the nipple or areola, the patient should be evaluated for other causes, including breast pump misuse, dermatologic conditions (eg, eczema, psoriasis), infections (candida, herpes simplex, herpes zoster), or infant ankyloglossia (1).

Breast engorgement occurs most commonly during days 3 to 5 postpartum when mature milk (rather than colostrum) begins to be produced (1). Measures that may help relieve breast fullness and discomfort include frequent feeding, manually expressing milk when breasts are uncomfortable, wearing a supportive bra, applying cool compresses between feedings, and/or 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. Excessive expression of milk between feedings increases milk production and facilitates engorgement, so expression should be done only enough to relieve discomfort or facilitate feeding.). Measures that may help relieve breast fullness and discomfort include frequent feeding, manually expressing milk when breasts are uncomfortable, wearing a supportive bra, applying cool compresses between feedings, and/or 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. Excessive expression of milk between feedings increases milk production and facilitates engorgement, so expression should be done only enough to relieve discomfort or facilitate feeding.

Plugged milk ducts manifest as mildly tender lumps in the breasts of lactating women with 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 feeding positions because different areas of the breast empty better depending on the infant’s position at the breast. A supportive nursing bra is helpful; bras with underwires or other constrictions should be avoided because they may contribute to milk stasis in a compressed area. If a palpable lump does not resolve with conservative measures, the mass should be evaluated to exclude breast cancer.

Mastitis is common and manifests as a tender, warm, swollen area of breast. It is caused by milk stasis and occurs most commonly in women with oversupply of milk (often due to excessive breast pumping), latch difficulties, or skipped feedings (or pumpings) and may be preceded by engorgement or plugged milk ducts. Infection may occur secondarily, most often with penicillin-resistant Staphylococcus aureus and less commonly with Streptococcus or other species (2). With infection, fever ≥ 38.5° C, chills, and flu-like aches may develop.

Early recognition and treatment or mastitis may prevent complications, such as breast abscess or sepsis. Diagnosis of mastitis is by history and examination. First-line management is conservative and includes milk removal via breastfeeding or pumping, cold compresses, analgesics, and a supportive bra. If symptoms and signs do not improve in 12 to 24 hours, antibiotics that are safe for breastfeeding infants and effective against S. aureus (eg, dicloxacillin, cephalexin, or clindamycin) should be started; duration of treatment is 7 to 14 days. Community-acquired methicillin-resistant (eg, dicloxacillin, cephalexin, or clindamycin) should be started; duration of treatment is 7 to 14 days. Community-acquired methicillin-resistantS. aureus should be considered if patients do not respond promptly to antibiotics. Analgesics (eg, acetaminophen) may be helpful. Breastfeeding may continue during treatment.should be considered if patients do not respond promptly to antibiotics. Analgesics (eg, acetaminophen) may be helpful. Breastfeeding may continue during treatment.

Postpartum anxiety or depression may be caused by or contribute to difficulties with and cessation of breastfeeding. Common reasons for discontinuing breastfeeding earlier than planned include perceived insufficient milk supply, breast pain, latch difficulties, and return to work (3). Early follow-up with a pediatrician or consultation with a certified lactation specialist is helpful and effective for preventing early breastfeeding termination (4, 5).

(See also Postpartum Care and Associated Disorders.)

Breastfeeding mothers should avoid taking unnecessary medications. When medications are necessary, the mother should avoid medications that are not safe for infants and medications that suppress lactation (eg, bromocriptine, levodopa, trazodone), unless the benefits of the medication outweigh those of breastfeeding. Breastfeeding mothers should avoid taking unnecessary medications. When medications are necessary, the mother should avoid medications that are not safe for infants and medications that suppress lactation (eg, bromocriptine, levodopa, trazodone), unless the benefits of the medication outweigh those of breastfeeding.

Evaluating use of specific medications during breastfeeding is complex and involves weighing risks and benefits for both maternal and infant health. For example, in lactating patients, sertraline or paroxetine are typically considered to have the lowest risk of infant adverse effects. However, fluoxetine use may be considered if it is a better therapeutic choice for a particular patient, even though case reports have described growth and sleep problems as well as colic in breastfed infants (Evaluating use of specific medications during breastfeeding is complex and involves weighing risks and benefits for both maternal and infant health. For example, in lactating patients, sertraline or paroxetine are typically considered to have the lowest risk of infant adverse effects. However, fluoxetine use may be considered if it is a better therapeutic choice for a particular patient, even though case reports have described growth and sleep problems as well as colic in breastfed infants (1, 2).

The American Academy of Pediatrics suggests several resources to guide clinicians and patients in assessing these risks and benefits (3):

• The U.S. Department of Health and Human Services maintains the extensive LactMed® database for medications and breastfeeding, which can be consulted regarding use of or exposure to specific medications or classes of drugs (2).

• Mother to Baby Fact Sheets provides patient-oriented fact sheets about many common medications and their effects while breastfeeding.

• Infant Risk Center provides general information and articles about specific medications and other exposures while breastfeeding

When medications are necessary, the safest choice and dose of medication should be used; when possible, most medications 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 medications comes from case reports and small studies. Safety of some medications (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. When medications are necessary, the safest choice and dose of medication should be used; when possible, most medications 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 medications comes from case reports and small studies. Safety of some medications (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.

Breastfeeding may be continued as long as desired by both mother and child for 2 years or more. Gradual weaning over weeks or months after 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 months or longer.