Chapter 193 Breastfeeding (Lactation)
THE CHALLENGE
TACTICS
Relevant Pathophysiology: Breastfeeding is the preferred method of feeding for newborns and infants. Evidence continues to mount regarding the value of breastfeeding for both women and their infants. Breastfed infants have fewer respiratory, gastrointestinal, and ear (otitis media) infections and fewer allergies. Breast milk is more easily digested, better absorbed, and less constipating than formula. Breastfeeding hastens uterine involution. Stimulation of the areola causes the secretion of oxytocin, which is responsible for the letdown reflex and ductal contraction that expels the milk. Suckling stimulates further milk production. Milk production is often not well established until day 3 of nursing. Patients should maintain adequate fluid intake and an increase of approximately 200 kcal/day in dietary intake. Prenatal vitamin supplementation should be continued. Blocked ducts and mastitis are the most common complications. Mastitis mimics blocked ducts (sore, firm lump or lumps) with the addition of erythema and fever. Warm, moist packs; analgesics; and antibiotics that are effective against Staphylococcus aureus are appropriate therapies. Infection comes from the infant’s nose and mouth. Other sources of fever must also be considered (endometritis).
Strategies: Preparation for nursing—encourage breastfeeding, discuss plans early, address issues such as work and weaning, discuss the role of supplementation, and introduce techniques. Involvement of the father and others increases the chance of success. Preparation of the nipples in advance is not required.
Nursing—initially the infant should nurse at least nine times in 24 hours to encourage milk production. Once milk production is established, the infant should dictate the frequency and duration of nursing—six or more wet diapers per day and a weight gain of approximately 1 oz/day indicate adequate feeding. The breasts should be hard before and soft after nursing.
Weaning—introduce the bottle by 3 to 4 weeks as an occasional supplement (may use pumped breast milk). Complete weaning may be done either gradually (substituting bottles for some feedings) or abruptly. If engorgement occurs, analgesia, ice, and compressive binding provide the greatest relief. Medication to suppress lactation is generally not effective.
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