Breastfeeding (Lactation)

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Chapter 193 Breastfeeding (Lactation)

THE CHALLENGE

To assist patients in successfully nursing their infant(s).

Scope of the Problem: In 2005, 72.9% of new U.S. mothers initiated breastfeeding; however, only about 41% of infants are breastfed after 6 months.

Objectives of Management: Encourage nursing as feeding strategy, assist patients to prepare for nursing and to deal with problems if they occur.

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.

Patient Education: Reassurance, support, specific suggestions; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP029 (Breastfeeding Your Baby).

IMPLEMENTATION

Special Considerations: Breastfeeding is contraindicated in patients with human immunodeficiency virus (HIV), cytomegalovirus, hepatitis B virus infections, and human T-cell lymphotropic virus type I or type II and in those who have active untreated tuberculosis or varicella or active herpes simplex virus with breast lesions. Substances of abuse (including alcohol) pass to breast milk, as do some medications. Breastfed infants often lose weight in the first few days and do not regain birthweight until as late as day 10. Growth spurts often occur at about 10 days, 6 weeks, 3 months, and 4 to 6 months. If the infant fails to thrive, support and evaluation are in order. Care must be taken to wash the hands (and any equipment used) well before breastfeeding or breast manipulation. The nipples and the infant’s face should also be clean before each feeding. Fresh breast milk may be safely kept for 6 to 10 hours at room temperature or 72 hours under refrigeration. Breast milk may also be frozen and kept for 6 months in a home freezer or 12 months at −20°C. Thawed breast milk should be used within 24 hours and may not be refrozen. Breast milk should never be warmed in a microwave oven. The volume of milk required for each feeding varies widely but is normally between 2 and 5 oz for newborns, 4 to 6 oz for infants 2 to 4 months of age, and 5 to 7 oz for babies 4 to 6 months old. One study found that 65% of women with augmentation mammoplasty have lactation insufficiency.

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