Self Study Module Breastfeeding
Self Study Module Breastfeeding
Self Study Module Breastfeeding
Management
Self-Study Modules
Level I
Fourth Edition
2014
2013
The Third Edition (Revised) and the Fourth Edition of the document was developed entirely by Wellstart
International. Permission from Wellstart is required to reproduce these editions in part or in full. Wellstart
intends these documents to be available at low (production and shipping costs only) or no cost.
Permission is also required from Wellstart International to charge for these documents or any part thereof
by anyone other than Wellstart International.
Wellstart International also welcomes requests to translate this Fourth Edition in part or in full but
permission must be granted by Wellstart before such translation is undertaken as well as before any
translated version is published or distributed.
Wellstart International
E-mail: info@wellstart.org
This Fourth Edition of the Wellstart International Self-Study Modules, Level I
may be downloaded without charge from the Wellstart Web site: www.wellstart.org
Wellstart International is nonprofit organization (501)(C)(3) and is compliant with the International Code of
Marketing of Breastmilk Substitutes.
Dedication
This Edition of Wellstart Internationals Lactation Management SelfStudy Modules, Level 1 is dedicated to all of the mothers, fathers
and families who are raising the next generation of the
worlds citizens. Whether they live in urban or
rural settings, developed or developing
nations, are rich or poor, they
deserve our respect and
well prepared services
and support at
all times.
Gabriele Mistral
Section I
Contents
Section I
About Wellstart
About the authors
Acknowledgements
Foreword
Faculty Guide
Module Two
Basics of Breastfeeding: Getting Started
Objectives
Introduction: Case Exercise
Anatomy
The Physiology of Milk Secretion
Getting Together: Position and Attachment
Evaluation of a Breastfeed
Length (Duration) and Frequency of a Feeding
Anticipatory Guidance
Early Hospital Routines
International Code of Marketing of Breastmilk Substitutes
Discharge Planning
Conclusion
References
Module Three
Common Breastfeeding Problems
Objectives
Introduction
Common Problems
Case #1 : Inverted Nipples
Case #2 : Sore Nipples
Case #3 : Engorgement
Case #4 : Obstructed Lactiferous Duct
Case #5 : Mastitis
Case #6: Not Enough Milk
Case #7 : Jaundice in the Breastfed Baby
Breastfeeding the Infant with Special Medical Problems
Late Preterm Infants
Maternal Medical Problems
Breastfeeding During Emergency Situations
Contraception during Breastfeeding
Separation of Mother and Infant
Resources
Conclusion
References
Section V: Annexes
A.
B.
C.
D.
E.
F.
G.
H.
I.
Highlights
Acceptable Medical Reasons for Use of Breast-milk Substitutes
Infant Feeding in Emergency Situations
Ten Major Provisions of the International Code of Marketing
ABM Protocol #8: Storage of Human Milk
Guidelines for Hand Expression
Web Sites of Interest
Alphabetic Listing of References
Additional References Suggested by Reviewers for the 4th Edition
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Acknowledgements
First Edition, 2000
A First Edition is always the inspiration of all future editions. The creation and development of the First
Edition of the Wellstart International Lactation Management Self-Study Modules, Level I in 2000 would
not have been possible without the input and effort of a number of talented people. We would like to
express our continuing gratitude to the following individuals who assisted with that document:
Eyla Boies, MD, Clinical Associate Professor of Pediatrics, University of California, San Diego
Elizabeth Creer, RN, FNP, MPH, Wellstart International faculty
Pamela Deak, MD, Division of Obstetrics and Gynecology, University of California, San Diego
Donata Eggers, BS, RD, Instructor, Department of Pediatrics, Southern Illinois University
Stephanie Gabela, MPH, RD, Wellstart International faculty
Helen Moose, MS, CNM, Instructor, Department of Family and Community Medicine, Southern Illinois
University
Victoria Nichols-Johnson, MD, Associate Professor, Division of General Obstetrics and Gynecology,
Southern Illinois University
Janine Schooley, MPH, Wellstart International, Project Manager
Kirsten Searfus, MD, Assistant Professor, Division of Family Medicine, University of California, San Diego
Kim Solis, Wellstart International Assistant Project Manager
Yvonne Vaucher, MD, MPH, Clinical Professor of Pediatrics, Division of Neonatal/Perinatal Medicine
In addition, the medical students from Southern Illinois University and University of California, San
Diego and nursing students at St. Johns College in Springfield, Illinois deserve thanks for their useful
feedback.
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Acknowledgements
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Acknowledgements
These colleagues have done an outstanding job of helping to assure that this tool is current and
international in scope. They have our most sincere and heartfelt thanks.
We also want to thank Alison Blenkinsop, DipHE (midwifery studies), Aldershot, United Kingdom and
Andrea Herron, RN, MN, CPNP, San Louis Obispo, California, United States for their additional
corrections and suggestions. Their help is greatly appreciated.
Finally, once again, thanks goes to Maria Elena Sandoval for helping to prepare this Third Edition of
Wellstarts Lactation Management Self-Study Modules, Level I. Without her dedicated assistance, this
tool would probably not have been finished.
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Acknowledgements
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Acknowledgements
Shelburne, Vermont
June 2013
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Acknowledgements
Foreword
In a series of articles published in Lancet in 2003 it is noted that some 13% of the 9.5 million
annual deaths in the world among children under 5 years can be prevented or significantly
decreased in severity by breastfeeding exclusively for six months and then adding appropriate
nutritious complimentary foods. The majority of these deaths occurred in the less economically
developed nations of the world. In addition, breastfeeding is now well accepted as a very
effective evidenced based primary health care strategy in developed nations for improving both
the immediate health and well being of mothers, infants and children as well as lowering the risk
of a significant number of chronic diseases of older children and adults. (Figure 1)
Figure 1
Benefits of Breastfeeding1
Adapted from Breastfeeding and the Use of Human Milk, Pediatrics, March 2012(1)
Condition
% Lower Risk
Breastfeeding
Odds Ratio
Otitis Media
Recurrent OM
Upper Respiratory trct infect.
Lower Respiratory trct infect
NEC (NICU stay)
Gastroenteritis
Obesity
Type 1 diabetes
Type 2 diabetes
Leukemia (ALL)
Leukemia (AML
50
77
63
77
77
64
24
30
40
20
15
0 .50
1.95
0.30
4.27
0 .23
0.36
0.76
0.71
0.61
0.80
0.85
SIDS
36
Any > 1 mo
Thus when breastfeeding, a biologically normal reproductive process and way to feed human
infants and young children, is supported as a basic component of optimal infant and young child
feeding (OIYCF, Figure 2) individual, family and community health can be significantly improved
globally.
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Forward
Figure 2
C = conception
B = birth
There are, of course, many influences on achieving OIYCF. Among these are health care
providers with knowledge and skill of lactation management and breastfeeding support.
Unfortunately many health care providers have only a limited knowledge of this topic. An
important reason for this lack of knowledge is that many schools of medicine and nursing as
well as nutrition programs have not included lactation management education in their curricula.
Forward
III is designed for those who will specialize in breastfeeding medicine and will serve as key
faculty in leadership positions. (Figure 3)
Level I
Content Focus
of
Basic Knowledge
Needed by All Health
Care Providers
Level II
Level III
Breastfeeding Medicine
Specialists and Faculty
Modules
Module 1
Scientific Basis
Module 2
Clinical Management
Module 3
Professional Practice
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Forward
Though the LMCG achieved considerable success, limitations of available time in a preservice
health provider curriculum led to a recommendation by early users that a level I tool be
developed that could be completed in a few hours and at a time and place of the students
choosing. With further support from The Maternal Child Health Bureau of the Health Resources
and Services Administration, a set of three clinically oriented, competency based, self-study
modules was developed to help students achieve Level I knowledge. Initially published in 2000,
the Lactation Management Self-Study Modules, Level I have been revised and updated twice
(2005 and 2009) to incorporate important new evidenced based knowledge and skills.
These modules are particularly focused on the breastfeeding component of optimal infant and
young child feeding. Scientific evidence regarding the importance of breastfeeding, a review of
the physiology and basic management strategies to support lactation and breastfeeding and
solutions to common problems are included. They provide a self-contained unit of basic
knowledge that can be utilized by faculty, students, and other health care professionals in a
variety of settings. They can be assigned during clinical rotations in pediatrics, family medicine,
nutrition, obstetrics, and community health or as an elective course. Each institution can decide
where the modules would have the most impact in their curriculum. They can also be used by
those already in practice whose professional training did not include these topics or wish to
have a review of the basics.
As additional learning tools, pre-tests and post-tests have also been included. Users are urged
to take the pretest before beginning a review of the modules and compare their scores with the
post test taken after completion of all three modules. Answer sheets have also been provided
for both pre-test and post-tests. The answer sheet for the post-test includes a brief explanation
of the answer.
For this Edition an annex has been added which provides a number of useful reference
documents. These include an updated summary of key clinical points from the Modules called
Highlights, The Ten Steps to Successful Breastfeeding,WHOs 2009 Acceptable Medical
Reasons for Use of Breastmilk Substitutes, Infant feeding in Emergencies, Ten key points of
The International Code of Marketing of Breastmilk Substitutes and Relevant World Health
Assembly Resolutions, How to Store Human Milk (Protocol #8 from The Academy of
Breastfeeding Medicine), Guidelines for Hand Expression, Websites of Interest, an Alphabetic
Listing of References used in this tool and resources suggested by the reveiwersof the 4th
edition.
As was said in the opening paragraph of this Foreword to this Edition of the Self- Study
Modules, establishing breastfeeding as a biologically normal reproductive process and way to
feed human infants and young children will have a major impact on improving individual family
and community health globally. Knowledgeable health care providers are fundamental to
achieving this goal and preservice education is the foundation to this knowledge. In order to
encourage this revolution in preservice education, Wellstart International has made a decision
to provide this Edition on its web site as a downloadable teaching/learning tool without charge.
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Forward
We only ask that users take this opportunity seriously: read the material carefully and assume
responsibility for providing the evidence based care that is explained and recommended.
Become part of the solution that will help of children and their families survive and live life to the
fullest.
References
1. AAP. Policy Statement: Breastfeeding and the Use of Human Milk. PEDIATRICS.129, 3,
March 2012
2. Black, RE, Morris, SS, Bryce, J. Where and why are 10 million children dying every
year? (2003) The Lancet; 316;2226-2234
3. Horta, BL. Bahl, R, Martines, J, Victora, CG. (2007) Evidence on the long-term effects of
breastfeeding: Systematic Reviews and Meta-analyses. WHO, Geneva
4. Ip. S, Chung, M, et al. (2007) Breastfeeding and Maternal and Infant Health Outcomes in
Developed Countries. Evidence Report/Technology Assessment No 153. AHRQ
Publication No 07-E007. Agency for Healthcare Research and Quality.
5. Wellstart International and the University of California San Diego (1999). Lactation
Management Curriculum: A Faculty Guide for Schools of Medicine, Nursing and
Nutrition, Fourth Edition. San Diego,California; Wellstart International
6. World Cancer Research Fund/American Institute for Cancer Research (2007). Food,
Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective.
Washington, DC: AICR, 2007
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Forward
Faculty Guide
These Level I Modules are designed to be used during the beginning of clinical
assignments of students of the health professions (i.e.medical, nursing, nutrition) or by
those who have not had previous exposure to Level I content. They have also been
useful as a review of the basics. They can be used as the entire content of a course or
as a part of a course. For example, this material may be assigned as part of required
clinical experiences in newborn and/or maternal care or as part of an elective or
independent study. The manner in which these tools are used is up to the responsible
faculty. Faculty are encouraged to incorporate local or regional concerns into the
experience of the participants. For example, in some areas of the world, HIV and AIDS
are a major concern and may warrant more detailed special attention. Or perhaps the
most commonly used human milk substitute is not commercial formula but cow or goat
milk requiring appropriate information and comparisons.
Regardless of whether they are used as a course or are part of a course, the Modules
can be studied by the users at a time and place most convenient for the user. Though
faculty involvement is not required, experience with the first and second editions
suggests that users are likely to gain greater knowledge when guided by an interested
faculty member. Experience has also indicated that medical students and residents are
most responsive when the responsible faculty member and role model is a physician.
For nursing students, a faculty member from the school of nursing is most effective.
While the modules can be completed independent of one another, they are best
reviewed in sequence. Thus a student may have time to complete Module 1 and later
undertake Module 2 and even later, Module 3. A pre-test of knowledge is included
before beginning Module 1 as well as a pre-test with answers and where an explanation
of the answers can be found in the modules. Because many faculty have found it useful
to have students take both a pre-test and a post test for comparison with the pre test
scores, a post-test as well as a post-test with the answers briefly explained is also
included following Module 3 . In addition, each module has a set of references that can
be utilized for selecting assigned readings if so desired by responsible faculty.
The format of the modules provides application of the material by means of short case
exercises. The information in the modules and the case exercises will be enhanced by a
structured clinical experience such as bedside rounds where students can apply their
new knowledge to a realistic setting. A clinical instructor, experienced in lactation
management, should help the student carry out the breastfeeding assessment and
problem solving steps. If time is available, additional assignments in prenatal clinics,
delivery rooms, follow-up clinics, home visits and mothers support groups can also be
useful.
Experience with previous editions has indicated that the three modules can be
completed within a 6 to 7 hour time frame including reviews of two or three short DVDs
or videos. Additional time will be required for the clinical experiences, essential to
enhance application of the knowledge to real mother/infant situations. Welltart does not
give CME's. However many hospitlals throulgh their educational office have arranged
for CMEs to be given for completion of the Self-Study Modules.
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Faculty Guide
Faculty Preparation
Faculty members who will direct or coordinate this self-study learning experience
need to work through the modules to become familiar with the content, exercises,
and accompanying materials. Ideally responsible faculty who plan to use this tool
should be prepared at Level II or III. If faculty do not feel adequately prepared,
enrollment is recommended in one of the workshops frequently provided by
several organizations including the Academy of Breastfeeding Medicine (ABM),
American Academy of Pediatrics (AAP), or other faculty development workshops.
For those who will be working with students who intend to pursue certification by
the International Board of Lactation Consultant Examiners, the workshops carried
out by International Lactation Consultant Association (ILCA) workshops would be
helpful. These workshop opportunities are announced by the sponsors on their
organizational websites provided in annex G.
Recently the AAP made their Residency Curriculum available on their web site
(www.AAP.org/breastfeeding). Much of the material is available without charge,
though some recommended items such as training videos/DVDs must be obtained
for a fee from non AAP sources. This would also help prepare faculty at Level II.
Though the AAP Residency Curriculum material is not intended to be a self-study
course, it offers information and tools that can be helpful to someone who is
already reasonably knowledgeable.
Teaching Resources
1. Textbooks
It is also recommended that faculty assigned to direct or coordinate an experience
using the Wellstart Self-Study Modules, have the following references available.
The first three texts are particularly intended for physicians. The reference by Jan
Riordan is also very often used in physician training but especially useful in
programs focused on nursing students.
a. American Academy of Pediatrics and the American College of
Obstetricians and Gynecologists (2006) Breastfeeding Handbook for
Physicians. AAP, Elk Grove Village, IL and ACOG, WDC.
b. Hale, TW. Hartman, PE. (2007) Textbook of Human Lactation, First
Edition, Amarillo, TX. Hale Publishing, L.P.
c. Lawrence RA and Lawrence RM (2011) Breastfeeding, A Guide for the
Medical Profession, SeventhEdition, St. Louis, MO: Mosby, Inc.
d. Riordan J and Wambach K (2010) Breastfeeding and Human Lactation,
Fourth Edition, Boston, MA: Jones and Bartlett Publishers, Inc
e. Walker,M (2014) Breastfeeding Management for the Clinician: Using the
Evidence. 3rd Edition
2. References
At the end of each of the three modules a list of relevant references for the content
of the particular module is provided. These have also been put together as an
alphabetized list in the annex included at the end of this tool.
The World Health Organization has developed and made available a Model Chapter
on Infant and Young Child Feeding for textbooks for medical students and allied
health professionals. This material is intended for perinatal health professionals.
The chapter can be reviewed and downloaded without charge at the following
website:
www.who.int/nutrition/publications/infantfeeding/9789241597494/en/index.html
3. DVDS
Having an opportunity to visualize some of the techniques and skills described in
Modules 2 and 3 of this Level I Self-Study tool can be particularly helpful to user of
this tool. Several short DVDs regarding immediate breastfeeding at birth and how
to assist a new mother-baby couple with achieving an effective, comfortable
attachment or latch-on are available. Medical and nursing schools frequently
maintain a library of teaching tools and may already have something appropriate in
their collections. If that is not the case, faculty responsible for directing a program
in which the Self Study Modules will be utilized are urged to consider reviewing and
possibly obtaining one or two of the several relevant DVDs that are currently
available. Titles and web sites where further information may be obtained include:
a. Initiation of Breastfeeding by Breast Crawl
http://breastcrawl.org/video.htm
b. Delivery Self Attachment with Dr. Lennart Righard
www.geddesproduction.com/breast-feeding-deliveryselfattachment.php
c. Baby-Led Breastfeeding: The Mother Baby Dance with Christina M. Smiley, MD
www.geddesproduction.com/breast-feeding-baby-led.php
d. Making Enough Milk, the Key to Successful Breastfeeding: Planning for Day
One with Jane Morton, MD
www.breastmilksolutions.com/making_enough.html
e. Latch 1,2,3: Troubleshooting Breastfeeding in the Early weeks
www.healthychildren.cc
(note: to find information regarding this DVD, select Breastfeeding Information
Links from left hand column)
Section II
Pre-Test
1. Identify the component of human milk that binds iron locally to inhibit bacterial growth:
a.
b.
c.
d.
e.
taurine
secretory IgA
macrophages
lactoferrin
oligosaccharides
2. Identify the component of human milk that provides specific immunity against many
organisms:
a.
b.
c.
d.
e.
taurine
secretory IgA
macrophages
lactoferrin
oligosaccharides
3. The most important criterion for assessing the milk transfer during a feeding at the breast
is:
a. visible areola compression
b. audible swallow
c. proper alignment
d. proper attachment
vitamin D
iron
lipase
vitamin A
none of the above
progesterone
prolactin
estrogen
oxytocin
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Pre -Test
6. A mother with a three-day old baby presents with sore nipples. The problem began with
the first feeding and has persisted with every feeding. The most likely source of the
problem is:
a. feeding too long
b. poor attachment
c. babys suck is too strong
d. lack of nipple preparation during pregnancy
a.
b.
c.
d.
Use breast shells with guidance from her health care provider
Cut holes in the bra to allow the nipples to protrude; wear it day and night
Encourage everting the nipples four times a day to permanently evert her nipples
Do nothing because the natural changes in the breast during pregnancy and the
infants suckling postpartum may evert the nipples
9. Which of the following is most likely to have the greatest effect on the volume of milk a
woman produces?
a.
b.
c.
d.
e.
10. Infants exclusively breastfed for about six months will have:
a.
b.
c.
d.
2 months
4 months
6 months
8 months
10 months
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Pre -Test
12. Signs of adequate breast milk intake in the early (first 4-6) weeks include all EXCEPT:
a.
b.
c.
d.
e.
13. It is especially important that an infant with a strong family history of allergy should be
exclusively breastfed for:
a.
b.
c.
d.
e.
2 months
4 months
6 months
8 months
10 months
15. The most common cause of poor weight gain among breastfed infants during the first four
weeks after birth is:
a.
b.
c.
d.
e.
16. A breastfeeding mother with a 3-month old infant has a red tender wedge-shaped area on
the outer quadrant of one breast. She has flu-like symptoms and a temperature of 39qC.
Your management includes all of the following EXCEPT:
a.
b.
c.
d.
extra rest
interrupt breastfeeding for 48 hours
moist heat to the involved region
antibiotics for 10 to 14 days days
17. Studies have indicated that the Lactational Amenorrhea Method (LAM) of contraception
is less reliable under which of the following circumstances:
a.
b.
c.
d.
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Pre -Test
18. Which of the following statements is not true of The International Code of Marketing of
Breastmilk Substitutes approved as a resolution in the World Health Assembly (WHA) in
1981:
a.
b.
c.
d.
e.
19. Nipple candidiasis can be associated with all of the following EXCEPT:
a.
b.
c.
d.
a.
b.
c.
d.
22. Reasons for including breastfeeding support for mother infant in planning for or responding
to major emergencies where clean water,sanitation and power are disrupted do not include:
a. It is less expensive than providing for infant formula
b. With support even mothers who have already weaned can be assisted to
relactate
c. Breastmilk provides immunoglobulins that actively prevent infection.
d. In a stressful emergency situation breastfeeding provides a secure environment for
infants and young children
.
23. Hospital policies that promote breastfeeding include:
a.
b.
c.
d.
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Pre -Test
24. through 28. Label the structures of the breast by inserting next to the appropriate pointer
the number of the structure listed below:
26
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Pre -Test
taurine
secretory IgA
macrophages
lactoferrin
oligosaccharides
(Module 1)
2. Identify the component of human milk that provides specific immunity against many
organisms:
a.
b.
c.
d.
e.
taurine
macrophages
secretory IgA
lactoferrin
oligosaccharides
(Module 1)
3. The most important criterion for assessing the milk transfer during a feeding at the breast
is:
a. visible areola compression
b. audible swallow
c. proper alignment
d. proper attachment
(Module 2)
4. Compared to formula, human milk contains higher levels of:
a.
b.
c.
d.
e.
vitamin D
iron
lipase
vitamin A
none of the above
(Module 1)
5. The hormone considered responsible for milk ejection is:
a.
b.
c.
d.
progesterone
prolactin
estrogen
oxytocin
(Module 2)
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Pre-Test
6. A mother with a three-day old baby presents with sore nipples. The problem began with
the first feeding and has persisted with every feeding. The most likely source of the
problem is:
a.
b.
c.
d.
(Module 3)
a.
b.
c.
d.
Use breast shells with guidance from her health care provider
Cut holes in the bra to allow the nipples to protrude; wear it day and night
Encourage everting the nipples four times a day to permanently evert her nipples
Do nothing because the natural changes in the breast during pregnancy
and the infants suckling postpartum may evert the nipples
(Module 3)
9. Which of the following is most likely to have the greatest effect on the volume of milk a
woman produces?
a.
b.
c.
d.
e.
(Module 2)
10. Infants exclusively breastfed for about six months will have:
a. Fewer episodes of lower respiratory infection
b. fewer episodes of diarrhea
c. none of the above
d. both a and b
(Module 1)
11. The addition of complementary foods to breastfed infants is recommended at about:
a.
2 months
b.
4 months
c.
6 months
d.
8 months
e.
10 months
(Module 1)
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Pre-Test
12. Signs of adequate breast milk intake in the early (first 4-6) weeks include all EXCEPT:
a.
b.
c.
d.
e.
(Module 2)
13. It is especially important that an infant with a strong family history of allergy should be
exclusively breastfed for:
a.
b.
c.
d.
e.
2 months
4 months
6 months
8 months
10 months
(Module 1)
14. Severe engorgement is most often due to:
a.
b.
c.
d.
(Module 3)
15. The most common cause of poor weight gain among breastfed infants during the first four
weeks after birth is:
a.
b.
c.
d.
e.
(Module 3)
16. A breastfeeding mother with a 3-month old infant has a red tender wedge-shaped area on
the outer quadrant of one breast. She has flu-like symptoms and a temperature of 39qC.
Your management includes all of the following EXCEPT:
a.
b.
c.
d.
extra rest
interrupt breastfeeding for 48 hours
moist heat to the involved region
antibiotics for 10 to 14 days days
(Module 3)
17. Studies have indicated that the Lactational Amenorrhea Method (LAM) of contraception
is less reliable under which of the following circumstances:
a.
b.
c.
d.
(Module 3)
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Pre-Test
18. Which of the following statements is not true of The International Code of Marketing of
Breastmilk Substitutes approved as a resolution in the World Health Assembly (WHA) in
1981:
a. is updated every two years by the WHA
b. provides guidelines for the ethical marketing of infant formula
c. is incorporated into the Baby Friendly Hospital assessment
d. was approved by all WHA member countries
e. includes bottles, nipples, and breastmilk substitutes
(Module 2)
19. Nipple candidiasis can be associated with all of the following EXCEPT:
a. oral thrush in the infant
b. burning pain in the breast
c. fever and malaise
d. pink and shiny appearance of the nipples and areola
(Module 3)
20. Jaundice in a normal full term breastfeeding infant is improved by:
a.
b.
c.
d.
(Module 3)
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Pre-Test
24. through 28. Label the structures of the breast by inserting next to the appropriate pointer the
number of the structure listed below:
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Pre-Test
Section III
Self-Study Modules
Module One
Breastfeeding: A Basic Health Promotion Strategy in
Primary Care
Objectives
After completing this module, you will be able to:
1.
2.
3.
Introduction
All mothers want to provide whats best for their babies and often turn to their health
care provider for advice. This module will help prepare you for this discussion by
reviewing human milk composition and some of the major benefits of breastfeeding for
infant, mother, family and the community. Some of the factors that influence how
women make their infant feeding choice will also be described.
Case Exercise
Veronica, a 26-year-old woman, has come for a prenatal visit. You join
her in the consultation room and begin to review the history form she filled out in
preparation for her visit with you. You note that she has not answered the question
regarding how she plans to feed her new baby. When you inquire about this, she
responds that she hasnt thought about it as yet and would like to talk about what
would be best. Many of her friends have told her that it really doesnt matter how
she feeds her baby
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Module 1 - Importance
TABLE 1-1
Comparison of Colostrum (day 1) and Mature Human Milk*
Constituent (per liter)
Colostrum
Mature Milk
Energy (kcal/deciliter)
Lactose (g)
Protein (g)
Fat (g)
57.0
20.0
32.0
12.0
65.0
35.0
9.0
29.0
*Data adapted from Lawrence and Lawrence (2011), pp 105 and tables 4-5 and 4-8, pp105
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Module 1 - Importance
TABLE 1-2
Immunoglobulins in Human Milk
Day Postpartum
1
3
7
8 50
IgG
80
50
25
10
11,000
2,000
1,000
1,000
Adapted from: Remington JS and Klein JO (2001) Infectious Diseases of the Fetus and Newborn, Fifth Edition. Philadelphia, WB
Saunders Co.
UNICEF Chile
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Water - As is true of most mammal milks, water is the major constituent of human
milk. Even in hot climates, human milk, which is 87% water, provides sufficient
water for the exclusively breastfed infant to remain adequately hydrated. Only if the
infant is unable to nurse effectively as needed or has an unusual health problem
diabetes insipidus) would additional fluids be required.
Lipids - About 50% of the calories in human milk come from lipids. The primary fats
identified in human milk are phospholipids and triacylglycerols. Some 167 fatty
acids have been identified in human milk, many of which are long chain,
polyunsaturated fatty acids unique to human milk. Human milk contains omega-3
fatty acids, including docosahexaenoic acid (DHA), important for brain and retinal
development and function. Cholesterol, important to the development of
membranes, is also present in significant quantities.
While the content of milk fat in mature human milk usually ranges from 3.5% to
3.8%, it is important to recognize that these figures represent an average fat content.
In reality, the fat content is variable and influenced by a number of factors. Of
particular clinical importance is the significant increase which occurs during a
feeding from the low fat content of the milk of about 1.5 to 2.0 % which has
accumulated in the breasts since
the previous feeding (known as
Figure 1.1
foremilk) to the higher fat levels
Fat Protein
present in milk secreted during a
feeding. Fat content in milk
~5.5%
available near the end of a
feeding (hindmilk) can be as
much as 5 or 6% (Figure 1.1).
~1.7%
Allowing an infant to nurse until
there is an indication of satiation
~0.7%
~0.9%
is important if full
fat (and thereby caloric and fatForemilk
Hindmilk
soluble vitamin) intake is to be
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achieved.
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Proteins - The total protein content of human milk, 0.9%, is the lowest amount
identified among the many mammal milks which have been studied to date. This
low protein content is well matched with the still developing renal function of the
neonate and young infant. The low renal solute load of human milk places less
excretory burden on the immature system while providing optimal growth and
development.
Milk protein can be divided into two major components, whey and casein. Milk curd,
which forms from the casein when the milk pH (normally ranging from 6.7 to 7.4)
drops below 5.0, is an insoluble calcium caseinate-calcium phosphate complex. The
liquid that remains after the curds are formed is whey. Whey contains water,
electrolytes and important proteins that contribute to disease resistance including
alpha-lactalbumin, lactoferrin, lysozyme and the immunoglobulins. Human milk
protein is predominantly whey. When acidified (such as occurs in the stomach),
human milk results in a flocculent suspension allowing for easy digestion and
absorption of nutrients as well as rapid transit through the intestinal tract of the
human infant. This results in the normal pattern of frequent feeding and stooling
characteristic of breastfed infants.
In commercial substitutes for human milk the ratio of casein to whey has been
adjusted from the predominant casein of cows milk. Even with this adjustment, the
feeding frequency, stools and stool patterns of formula-fed infants are not the same
as breastfed infants. In addition, stools of formula fed infants are firmer than those
of breastfed infants.
It is important to note that there are a number of nitrogen containing compounds in
human milk with bioactive roles important to the newborn and young infant. These
include:
epidermal growth factor - contributes to the development and function of the
intestinal mucosa
taurine - a free amino acid associated with bile acid conjugation and
neurotransmission
nucleotides - metabolic and immune functions
carnitine - needed in the lipolysis of long-chain fatty acids
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TABLE 1-3
Minerals in Mature Human Milk
Mineral (per deciliter)
Sodium (mg)
Potassium (mg)
Calcium (mg)
Phosphorus (mg)
Iron (microgram)
Zinc (microgram)
15
57
35
15
100
120
Adapted from table 4-19, pp 127 and description of zinc in human milk,
pp 130-131, Lawrence and Lawrence (2011)
Is the iron content of human milk sufficient to meet the needs of the growing
infant?
Although the quantity of iron in human milk is not large (100 g/liter), studies have
demonstrated that the absorption from human milk is superior compared to cow milk
and iron fortified formula (Table 1-4). Lactoferrin contributes to iron bioavailability in
human milk. It is a complex protein found in whey where it binds iron and makes it
available for digestion and absorption by the infant. (This binding of iron also inhibits
bacterial growth by making the iron unavailable to iron dependent organisms.) Normal
full-term infants can be exclusively breastfed (no other foods or fluids) for six months
without becoming iron deficient. After six months, with the continuation of breastfeeding
and the
gradual addition of appropriate iron-containing complementary foods, term infants
continue to have normal iron stores and hemoglobin. Preterm infants or term infants
with perinatal blood loss may need additional Fe while still exclusively breastfed.
Zinc is another essential mineral for humans
and is important to enzyme activity. Like iron,
it is well absorbed from human milk (Table 1-4).
Zinc deficiency, demonstrated in the form of
intractable diaper and perioral rash, is very rare
in breastfed infants whose mothers have
adequate Zn intake. Both iron and zinc are
important to normal brain development and
function.
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TABLE 1-4
Iron and Zinc Absorption
Iron
Human milk
49%
Iron fortified formula
4%
Cow milk
10%
Zinc
41%
31%
28
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Vitamins - Human milk, particularly colostrum and early transitional milk, is a major
source of vitamin A, betacarotene, and vitamin E (Table 1-5). As previously
mentioned, vitamin A is important for protection against infection and for early retinal
development. Vitamin E protects the red cell against hemolysis. The quantity of
vitamin D in human milk, which occurs in both fat-soluble and water-soluble forms, is
sufficient when maternal diet is adequate and there is sufficient maternal and infant
exposure to sunlight. Maternal deficiency during pregnancy can result in newborns
with reduced stores of Vitamin D. In recent years, cases of rickets have been
reported in breastfed infants with limited exposure to sunlight. Infants with darker
skin pigment seem to be at greater risk. In order to assure that no infants develop
rickets, the American Academy of Pediatrics currently recommends that all breastfed
infants should receive 400 IU/day beginning in the first few days of life and
continuing until they are ingesting or exposed to sufficient Vitamin D from other
sources..
The Vitamin K is poorly transported prenatally via the placenta to the fetus and is
also limited in human milk. Newborns whether breastfed or not are at risk for
hemorrhagic disease, a life threatening disease. Thus it is recommended that all
newborns receive an intramuscular injection of 0.5 to 1.0 mg of vitamin K. Where an
oral form is available the first dose (2.0 mg) is given at birth and repeated at 1 to 2
weeks and again at 4 weeks of age. The United States has no approved form of oral
vitamin K.
Table 1-5
Selected Vitamins in Colostrom and Mature Human Milk
Micrograms per liter
Colostrum
Mature Milk
Fat Soluble
A
Beta carotene
D
E (mg)
K
151
112
--1.5
---
75
23
0.04
0.25
1.5
Water Soluble
B1
B6
C (mg)
1.9
--5.9
14
15
5
Food and Nutrition Board National Research Council, National Academy of Sciences, Recommended
th
Dietary Allowances, 10 ed. Washington, DC 1989
Enzymes - Over 20 bioactive enzymes have been identified in human milk. Some
enzymes function in the synthesis of milk, some compensate for digestive enzymes
needed but not yet produced in adequate quantity by the newborn, some help
transport minerals, and others are anti-infective. For example, lipase in breast milk
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works synergistically with lingual lipase and gastric lipase to form an efficient system
for complete digestion of human milk fat. This is particularly important during the
months after birth when pancreatic enzyme and bile salt levels are low.
Other Important Components - Human milk contains numerous peptide and nonpeptide bioactive hormones: thyroxine, prolactin, erythropoetin, epidermal growth
factor, insulin, leptin and gastrin. Prostaglandins, also present, influence
gastrointestinal motility.
Cellular Components - Human milk is a living tissue. It contains about 4000 cells
per cubic mm including neutrophils, macrophages, and lymphocytes. These cells
are most concentrated in colostrum but continue to be present in transitional and
mature milk. Neutrophils help prevent infection of the breast tissue while
macrophages (2000 to 3000 per cubic mm) and lymphocytes (400 per cubic mm)
are actively involved in providing immuno-protection for the newborn and young
infant. Macrophages secrete lysozyme, kill bacteria, and are active in phagocytosis.
Enteromammary Pathway - Maternal lymphocytes, both T and B cells, synthesize
immunoglobulins and are thought to originate in lymphoid tissue located along the
maternal gut and bronchial system. The developing lymphoblasts are sensitized by
the antigenic material (bacteria, viruses) ingested by the mother and coming into
contact with the particular mucosal surface. As the lymphoblasts mature they
migrate into the lymphatic system and are ultimately distributed throughout the body
including breast tissue. During lactation these cells and the immunoglobulins they
Maternal
Breast tissue
Maternal gut
Antigens
Other
Infant gut
mucosal
Lymphoblast
Blood
Mesenteric
node
Thoracic duct
Enteromammary Pathway
secrete become components of the milk and are transferred to the nursing infant.
Thus the infant is provided with a nearly continuous passive immunization to protect
against whatever organisms are present in the environment shared by the mother
and infant. While the concentration of cells and immunoglobins is greatest in
colostrum, significant bioactive amounts are present throughout lactation.
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Table 1-6
Summary of Major Differences Between Human Milk and
Commercial Substitutes Marketed for Normal Term infants
Human milk
Commercial
Substitutes
Protein
Corrected in
quantity but not in
quality ( not species
specific)
Fat
Appropriate quality/quantity of
essential fatty acids, lipase present
Lipase absent
Vitamins
Vitamins added
Minerals
Correct amount
Partly corrected
Anti-infective
properties
Present
Absent
Growth
factors
Present
Absent
Digestive
enzymes
Present
Absent
Hormones
Present
Absent
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Because of the clear biologic differences in growth patterns, the World Health
Organization sponsored an international collaboration to develop appropriate standards
of growth for healthy breastfed infants. The results of this collaboration were completed
in 2006 and indicate how healthy breastfed infants should grow. A comparison of the
resulting WHO and CDC growth charts (for boys) is given in Figure 1.4. As is evident in
the figure, the WHO charts (healthy breastfed infants) are quite different from the CDC
charts. In the United States the CDC now recommends the use of the WHO growth
grids for the first two year of life. A full set of the new WHO growth standards for boys
and girls may be obtained from the WHO web site: www.who.int/childgrowth/en.
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Figure 1. 4
Comparison of WHO and CDC Weight
for Age Z-score curves for boys
2006
Figure 1.2
Prevalence of Diarrheal Illness
among Breastfed
2.5
2
1.5
1
0.5
0
0-6 m
6-12 m
12-18 m
18-24 m
3.5
6
5
4
3
2
1
0
0-6 m
6-12 m
12-18 m
18-24 m
Formula Fed
Breastfed
Formula Fed
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Oxytocin secreted during breastfeeding not only brings about milk let-down but also:
decreases postpartum blood loss
results in more rapid uterine involution
enhances bonding, attachment and maternal parenting behaviors
reduced vulnerability to stress
Mothers who do not breastfeed are likely to lose their prenatally acquired weight
more slowly than mothers who do breastfeed.
Recent studies suggest an increased risk of type 2 diabetes and ovarian and breast
cancers among women who have not breastfed. The explanation for these risk
relationships is not yet clear.
Breastfeeding plays a role in child spacing. Whereas non-lactating women may
ovulate by 6 weeks postpartum, women who exclusively or predominantly
breastfeed usually do not ovulate until at least 6 months after delivery. Full nursing
during the first 6 months with no signs of menstruation reduces the likelihood of
pregnancy to less than 2%. Exclusive breastfeeding with those conditions reduces
the likelihood even further to 0.5%.
Breastfeeding has also been reported to decrease the risk of serious postpartum
depression and maternally caused child abuse and neglect.
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In the United States the Affordable Care Act requires some breastfeeding services to
be covered by insurers under preventive services. .Many countries have legislation
requiring employers to provide time for nursing breaks and/or time and space for
milk expression. Several states in the U.S. have recently passed similar legislation.
Restriction on Activity - Mothers these days are involved in many activities, and in
some cultures women feel breastfeeding will tie them down. They fear a loss of
freedom if they are the only ones who can feed their child. In fact, infants are very
portable and can be easily taken along on most outings. It is possible to feed
discretely with a light blanket or shawl draped to preserve modesty if necessary. In
some countries, laws specifically protect the right of mothers to breastfeed in public
locations. In the United States some states have similar laws in place.
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Illness and other health conditions - There are no nutritional reasons to deny
infants breast milk unless they have special health problems such as classic
galactosemia. Infants with other inborn errors of metabolism like
phenylketonuria (PKU) and maple syrup urine disease, very rare metabolic
conditions can receive breastmilk with very close monitoring.
Mothers may be advised to discontinue breastfeeding, either permanently or
temporarily, in a few circumstances:
In the U.S., the Centers for Disease Control and Prevention (CDC)
recommends that mothers infected with HIV not breastfeed because of the risk
of transmission of HIV to the infant through human milk.
The World Health Organization recognizes the impact that anti-retroviral
medications (ARVs) have made during the breastfeeding period. It
recommends that national authorities in each country decide which infant
feeding practice, (i.e. with ARV intervention) to reduce transmission or
avoidance of all breastfeeding, should be promoted and supported by their
Maternal and Child Health services. Regardless, breastfeeding should be
exclusive for six months.
The reader is encouraged to follow the international research and watch for
updated WHO information and guidelines at:
www.who.int/entity/nutrition/publications/hivaids
In the case of active maternal tuberculosis the mother and infant should be
separated only until the mother is considered noninfectious. The infant should
be placed on preventive therapy immediately. The infant can continue to
receive expressed breast milk while separated. Medications used to treat
tuberculosis, including INH, are compatible with breastfeeding.
Hepatitis often brings up questions about beginning or continuing
breastfeeding. Breastfeeding is acceptable with all three major types (A, B, and
C). In the case of Hepatitis B, the infant can begin breastfeeding before
receiving HBIG and the first dose of the Hepatitis B vaccine series which can
be given up to 7 days after birth preferably within 12 hours.
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should be selected if possible. Sometimes one drug can be substituted for another.
Drugs of abuse are contraindicated. Mothers maintained on the proper dose of
methadone or a long acting opioid can usually breastfeed. Infant withdrawal
symptoms are usually less severe if breastfeeding is allowed. Both mother and baby
should be monitored closely. Most radioactive compounds used for diagnostic
purposes often require a temporary cessation of breastfeeding, while those used for
therapeutic purposes may preclude breastfeeding.
Because of frequent additions to available drugs as well as changes in
recommendations, readers should consult the following sources regarding specific
recommendations:
(1) Hale T (2012) Medications and Mothers Milk, Fifteenth Edition, Amarillo: Hale
Publishing. LP.
(2) LactMed, National Library of Medicine data base. A free frequently updated
internet service accessed at:
http://www.toxnet.nlm.nih.gov/cgi-bin/sis/html.gen?LACT
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woman breastfeeds. Concerns about body image should be addressed as they are
identified.
Fitness There are usually no contraindications to exercise in moderation during
lactation. Breastfeeding prior to exercise and wearing a supportive bra is
recommended. There have been reports that increased lactic acid in the milk for
about 30 90 minutes following strenuous exercise has led to a temporary rejection
of the milk by some babies. This has been attributed to a change in the taste of the
milk. If it occurs, mothers could postpone feeding or offer previously expressed milk.
Diet - Some women feel that in order to breastfeed they must eat a perfect diet.
Breastfeeding mothers like everyone else need to eat a nutritious diet and consume
enough additional calories (approximately 300 to 500 calories per day depending on
the size and activity level of the mother) to provide energy and make milk. It is also
recommended that prenatal vitamins be continued during lactation. There are no
lists of foods to avoid. Poor maternal nutrition is not a contraindication to
breastfeeding.
9 Mothers make nourishing milk for their infants from all kinds of food.
9 There are no foods that must be avoided, unless mother or baby develops an
allergic reaction.
9 Breastfeeding mothers have an increased thirst that usually maintains an
adequate fluid intake; no data support the assumption that increasing fluid intake
will increase milk volume.
9 Mothers do not need to drink milk to make milk; thirst can be satisfied from a
variety of nourishing beverages, including water.
9 Calcium is available not only in milk and milk products but in many other foods,
such as broccoli, spinach, kale, bok choy, and collard, mustard and turnip green,
almonds, and canned fish.
Returning to Veronica at her first prenatal visit
You recall she left blank the question about how she plans to feed her baby.
This is your chance. Are you convinced about the importance of breastfeeding as a primary
health care strategy? For each of us there are different features of human milk and
breastfeeding that capture our interest.
What are the three most important things you would like Veronica to know about
breastfeeding?
1.
____
2.
3.
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You may have included the fact that breast milk and formula are not the same, that
breastfeeding provides many benefits to both mother and baby, and that there are very
few contraindications. You may have mentioned details within each of these categories.
Have you thought about how you will feed your baby?
What have you heard about breastfeeding?
Many mothers would like to know the current recommendations for the duration
of breastfeeding so they can think about how to fit it into their lives. If mothers will
be returning to work or school they can be advised in general terms that it is
possible to continue breastfeeding and that more detailed information will be
available when they are ready to consider it. Many countries (and states in the
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US) now have maternity protection laws that provide time for milk expression at
work. The local situation should be investigated.
Are your family (your mother, the babys father and the fathers mother)
and friends supportive of breastfeeding?
Were you breastfed?
Was the babys father breastfed?
Mothers history:
Mothers may be concerned there is something wrong with their breasts that will
make breastfeeding difficult. If the mother has had problems with her breasts,
she may need some help with breastfeeding. Alerting mothers to ask for
assistance as soon as possible postpartum will be helpful. Most medications are
compatible with breastfeeding and the mother can be reassured; the few
medications that are not compatible could be reviewed and an alternative
chosen.
Augmentation and reduction surgery are not always revealed in prenatal history.
Neither are contra-indications to breastfeeding. Implants are rarely a problem.
Reduction surgery may result in increasing the risk of low milk production. In both
situations, lactation progress and indicators of adequate milk intake need close
monitoring.
It is very helpful to give the patient either a brochure with information about
available classes (date, time, location) or to write out this information for sharing
with the father of the baby or other family members.
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Community Resources
Many hospitals provide childbirth education classes and printed information as part of
their maternity services; often breastfeeding is discussed as part of the childbirth
preparation class or there may be a separate breastfeeding class available. In addition,
organizations with local offices, such as Red Cross, YWCA and local NGOs offer
classes. In the United States many communities have an active Breastfeeding Coalition
which gives classes and other support services. It is important for health care providers
to investigate the classes and review the literature offered by the hospital and other
organizations in order to ensure that consistent, up-to-date information is being offered
to families.
Note: Although educational resources offered by formula companies on the topic
of breastfeeding do not always include clear advertisements for the company, it
is important to remember that a formula companys goal is to sell formula. They
are skilled at implying that substitutes are as good as breastmilk. It is best to
seek other materials that do not have this conflict of interest.
In the United States the Special Supplemental Nutrition Program for Women, Infants
and Children (WIC) for lower income families encourages breastfeeding by counseling
about nutrition and offering practical lactation management advice to WIC clients.
Breastfeeding clients also receive special supplemental foods.
La Leche League International has long been a source of information and support for
breastfeeding mothers. Their mother-to-mother approach provides individual problem
solving, classes, written information, videotapes, and equipment.
Several international professional organizations with a specialized interest in lactation
and breastfeeding promotion can also be helpful such as the Academy of Breastfeeding
Medicine (ABM) and the International Lactation Consultant Association (ILCA). These
organizations can be contacted for information for local specialists and consultants.
(see Annex G for web site contact information.)
There are numerous web sites that address the topic of breastfeeding available to
families on-line. Prior to recommending one, be sure to review it for accuracy. Not
everything on the Internet is up-to-date and accurate.
Bookstores may carry a selection of breastfeeding books in their Parenting Section.
You may wish to review the choices and have one or two recommendations in mind for
parents.
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What resources for breastfeeding information and support are available in your
community?
1.
2.
3.
You may have investigated the patient breastfeeding education opportunities within your
hospital, used the Yellow Pages to find breastfeeding resources, or inquired about
classes offered by community organizations.
Conclusion
Each woman brings her own frame of reference to the pregnancy and motherhood
experience. Asking, Have you thought about breastfeeding? during the prenatal
phase of care provides the opportunity to present information, elicit concerns, solve
potential problems and refer the mother to resources in the community. Asking about
breastfeeding during prenatal visits provides the opportunity to give anticipatory
guidance, recognize problems early and assist the mother to initiate and continue
breastfeeding for as long as she wishes. If she indicates that she is not interested, it
may be best to postpone this discussion and bring it up again at a later visit.
Getting mother and newborn off to a good start in the postpartum period is covered in
Module Two: Basics of Breastfeeding.
References
1. American Academy of Pediatrics (2008) Prevention of Rickets and vitamin D
Deficiency in Infants, Children and Adolescents. Pediatrics 122(5) 11421152.
2. American Academy of Pediatrics (2012) Breastfeeding and the use of
human milk. Pediatrics. Vol 129: e827-e841.
3. American Academy of Pediatrics (2009) Red Book: The Report of the
Committee on Infectious Diseases, 28th Edition.
4. Anderson, P (1998) Drugs in Pregnancy and Lactation, Fifth Edition,
Baltimore, MD: Williams & Wilkins.
5. Bachrach, V, Schwartz, E, Backrach, L (2003) Breastfeeding and the risk
of hospitalization for respiratory disease in infancy, Arch Pediatr Adolesc
Med,
157:237-243.
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6. Black, RE, Morris, SS, Bryce, J.(2003). Where and why are 10 million children
dying every year? The Lancet; 316; 2226-2234.
7. Briggs, GG, Freeman, RK, Yafee SJ (2005). Drugs in Pregnancy and Lactation
7th Edition . Baltimore Lippincott Williams and Wilkins.
8. Chen, A and Rogan, W.J. (2004) Breastfeeding and the risks of postneonatal
death in the United States. Pediatrics, 113: e435-e439.
9. CDC (2000) CDC Growth Charts: United States, Advance Data #314, May 30
http://www.hhs.gov/news/press/2000pres/2000530.html.
10. de Onis,M, Garza,C, Onyango,AW, Martorell, R. (2006) WHO Child Growth
Standards. Acta Paediatrica Supplement 450, April 2006, 95:7-101.
11. de Onis, M, Garza,C, Onyango, AW, Borghi (2007) Comparison of the WHO
child growth standards and the CDC 2000 growth charts. J.Nutr. 137:144-148.
12. de Onis, M et al . Comparison of the WHO child growth standards and the
National Center for Health Statistics/WHO international growth reference:
Implications for child health programs. Public Health Nutrition: 9(7), 942-947.
13. Dewey K, Heinig J, Nommsen-Rivers L (1995) Differences in morbidity between
breast-fed and formula-fed infants, J Pediatr 126(5), Part 1: 696-702.
14. Food and Nutrition Board, National Research Council, National Academy of
Sciences: Recommended Dietary Allowances, 10th ed. Washington, DC, U.S.
Government Printing Office, 1989.
15. Hale, TW. Hartman, PE. (2007) Textbook of Human Lactation, First Edition,
Amarillo, TX. Hale Publishing, L.P.
16. Hale T(2012) Medications and Mothers Milk, Fifteenth Edition, Amarillo: Hale
Publishing. LP.
17. Hamosh M (2001) Bioactive Factors in Human Milk, Pediatric Clinics of North
America 48(1): 69-86.
18. Himelright, I et al (2002) Enterobacter sakazakii infections associated with the
use of powdered infant formula --- Tennessee, 2001. CDC MMWR Weekly April
12, 2002/51(14);298-300
19. Horta, BL. Bahl, R, Martines, J, Victora, CG. Evidence on the long-term effects of
breastfeeding: Systematic Reviews and Meta-analyses. WHO, Geneva, 2007.
20. Ip. S, Chung, M, et al. (2007) Breastfeeding and Maternal and Infant Health
Outcomes in Developed Countries. Evidence Report/Technology Assessment
No 153. AHRQ Publication No 07-E007. Agency for Healthcare Research and
Quality.
21. Kramer, MS et al Breastfeeding and child cognitive development: new evidence
from a large randomized trial (2008) Arch Gen Psychiatry 65 (5):578-584.
22. Lawrence RA and Lawrence RM (2011) Breastfeeding, a guide for the medical
profession, Seventh Edition, St. Louis, MO: Mosby, Inc.
23. Perez, A, etal.(1992) Clinical study of the lactational amenoarrhea method for
family planning.Lancet 1992; 339: 968-970.
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24. Remington JS and Klein JO (2001) Infectious Diseases of the Fetus and
Newborn, Fifth ed. Philadelphia: WB Saunders Co.
25. Riordan J and Wambach K (2010) Breastfeeding and human lactation, Fourth
Edition, Boston, MA: Jones and Bartlett Publishers, Inc.
26. Strathearn, L, Mamun, AA, Najman, MJ, OCallaghan (2009) Does breastfeeding
protect against child abuse and neglect? A 15-Year cohort study. Pediatrics (2),
123;483-493.
27. World Cancer Research Fund/American Institute for Cancer Research (2007).
Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global
Perspective. Washington, DC: AICR, 2007
28. WHO (2009) Infant and Young Child Feeding: Model Chapter for Textbooks for
Medical Students and Allied Health Professionals. WHO Geneva.
www.who.int/nutrition/publications/infantfeeding/9789241597494/en/index.html
29. WHO Working Group on Infant Growth (1994) An Evaluation of Infant Growth
Geneva: World Health Organization. WHO/NUT/94.8.
30. WHO.(2010). Guidelines on HIV and infant feeding 2010: Principles and
recommendations for infant feeding in the context of HIV and a summary of
evidence.
31. Banta-Wright SA, Shelton,KC,et al.(2012). Breastfeeding success among infants
with phenylketonuria. J Pediatr Nurs, 2012 (4): 319-327.
32. Huner,G,Baykal,T, et al (2005).J Inherit Metab Dis 28(4):457-465.
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Module Two
Basics of Breastfeeding: Getting Started
Objectives
After completing this module, you will be able to:
1.
2.
3.
4.
Introduction
Although the mothers body produces milk as a normal part of the reproductive cycle,
the technique of breastfeeding is a learned skill enhanced by practice and support.
While parents need helpful information prenatally to know what to expect, the
opportunity postpartum to practice attaching the baby to the breast and assessing the
babys breastfeeding effectiveness can provide the family with confidence as they
embark on this particular experience of parenthood.
The key to helping new breastfeeding families is an understanding of the basic anatomy
of the breast and physiology of the milk production and removal process. This module
will focus on the science of lactation and practical clinical skills to help mothers get
started. The module is applicable to both the obstetric and pediatric sides of the
equation, as the management of the peripartum course and newborn care can
profoundly affect the early breastfeeding experience and later infant feeding outcomes.
As far as breastfeeding is concerned, the mother and baby are a biologic unit; whatever
influences one affects the other.
Case Exercise
As a result of the prenatal discussions of the benefits of breastfeeding,
Veronica, our 26 year-old first-time mother, has chosen to breastfeed her
baby. She experienced a normal spontaneous vaginal delivery (NSVD)
about 24 hours ago, producing a healthy term infant male weighing 3.5 kg.
She will be going home within the next 24 hours. You encounter her in the
postpartum unit on your regular morning rounds. She has attempted to
breastfeed three times. Her baby fell asleep each time she tried to nurse. She
says she doesnt have any milk and she is afraid her baby isnt getting enough to
eat. She is asking for formula to give her baby.
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Anatomy
Major structures of the breast include the nipple and areola, subcutaneous tissue,
alveoli (divided into lobules), ducts, myoepithelial cells, blood and lymphatic vessels,
Coopers ligaments and fat. Fat gives the breast size and shape as well as supplying
the metabolic fuel for milk fat production. Recent studies indicate that infants of
mothers with smaller breasts tend to feed more often than those with mothers who have
larger breasts. The sensory innervation originating primarily from the 3rd, 4th, 5th and 6th
intercostal nerves is also essential to the milk producing function of the breast.
Early in pregnancy, the mother notes changes in her breasts, including fullness,
tenderness, and a more prominent venous pattern. As the pregnancy progresses, she
sees the areola enlarge and darken in color. Montgomerys tubercles, small nodules
within the areola, become more prominent and prepare to secrete a lubricating
substance that protects and conditions the nipple and areola (Figure 2.1). The nipple is
located in the center of the areola and contains about 5-9 milk duct openings.
Figure 2.1
Areola
Montgomerys
Tubercle
Nipple
Each duct extends beneath the areola and into a mammary lobule where milk is
produced in the alveoli. The nipple contains smooth muscle fiber and sensory nerve
endings. The size and shape of nipples vary from woman to woman. The areola also
varies in size from woman to woman.
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Figure 2.2
The mammary lobules are composed of alveoli, the grape-like clusters where milk is
produced in response to prolactin. The alveoli are surrounded by myoepithelial cells,
string-like structures that respond to oxytocin by contracting and squeezing the milk out
of the alveoli into the ducts toward the nipple (Figure 2.2).
Module 2 - Basics
The total amount of colostrum available the first day is small (40-50 ml). It is well
matched to the newborns small stomach capacity of about 20 ml (about 4 teaspoons)
or 5 ml/kg (Figure 2.3).
Figure 2.3
Fullterm Newborn Stomach
5 ml
~20 ml
= about 4 Teaspoons
Milk will begin to appear a few days postpartum (lactogenesis stage II) whether the
woman breastfeeds or not, but the stimulus of the infant suckling at the breast builds and
maintains milk production. Breast milk production is baby driven, that is, the normal
full term baby indicates when he is hungry and when he has had enough. Breast milk is
easily digested, so the infant signals his need to eat about every two to three hours
(sometimes more often), or at least eight times every 24 hours, in the early weeks.
Some normal babies cluster their feedings into one particular part of the 24 hours and
feed less frequently during the remaining 24.
Breastfeeding involves a set of reflexes and hormones that also drive the milk supply.
Milk production is influenced positively by early frequent and effective milk removal and
negatively by late infrequent feeds or by the feeding the baby other liquids or foods
before six months of age.
As illustrated in Figure 2.4 each time the baby suckles at the breast he stimulates the
release of prolactin (milk production hormone) from the anterior pituitary and oxytocin
(milk ejection hormone) from the posterior pituitary. It is the oxytocin that stimulates the
myoepithelial cells to contract around the alveoli, making the milk flow, sending the milk
down through the ducts. The milk ejection reflex, or let-down reflex, may be noticeable
to the mother as a physical sensation such as pins and needles or a flush of heat.
Some women do not describe feeling anything, but they may see the milk dripping from
the nipples. When milk starts to flow the baby changes the way he moves his mouth,
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Module 2 - Basics
going into a pattern of wide excursions of his jaw and downward motion of the posterior
tongue resulting in a lowering of pressure in the infants oral cavity and increase in milk
flow. The flow of milk causes the baby to swallow in a slower rhythmic, audible manner
that sounds like a quiet cuh. Swallowing is a good indication the milk is being
effectively removed by the baby.
The baby may stimulate several ejection reflexes during the feeding. Each time the milk
is ejected it contains a little more fat. As noted in module 1, the milk that is present in
the breast at the beginning of the feed (foremilk) contains about 1.5 to 2% fat while the
milk present at the end of the feed contains about 5-6% fat. Allowing the baby to feed
without time limits enables him to get more of the higher fat hindmilk, providing fatsoluble vitamins, calories to gain weight, and the ability to wait 2-3 hours from the start
of one feeding to the start of the next.
Figure 2.4
Anterior Pituitary
Prolactin
Posterior Pituitary
Oxytocin
Myoepithelial Cell
Oxytocin > Milk Ejection
Suckling
= Afferent Arc
Uterus
= Efferent Arc
(Contractions)
Module 2 - Basics
The frequency of feeding regulates milk supply. The more often a baby removes the
milk the greater the milk supply. Conversely, a baby who sleeps many hours at a time
in the early weeks or feeds less than an average of eight times in 24 hours does not
have the opportunity to stimulate the breast, causing the milk supply to drop. This is
referred to as the law of demand and supply. Because each breast responds to the
amount of milk demanded by the infant, it is possible to exclusively breastfeed more
than one baby at a time or to use only one breast. Initially, if the milk is not removed the
breast becomes full and eventually engorged. At that point, a local factor known as the
feedback inhibitor of lactation (FIL) begins to decrease milk secretion. The exact
mechanism of FIL is still under study. There some evidence that FILS is Serotonin.
The Importance of Skin to Skin Contact
Evidence has been accumulating indicating that mother-baby pairs who have an
opportunity for the unclothed newborn infant to be placed on the skin of the mother
beginning immediately after birth, skin to skin (S2S), experience fewer breastfeeding
problems (Figure 2.5). Milk production is enhanced and infants are more contented.
Unmedicated newborns exhibit crawling behavior that helps them reach their mothers
breast and some, though not all will feed within the first hour. Studies also suggest that
extending S2S beyond the immediate newborn period continues to support successful
breastfeeding. Even babies born by cesarean section can be allowed S2S experience
on the chest area as soon as the mother is alert. Babies who are placed S2S after
delivery also have less difficulty with subsequent attachment.
Figure 2.5
Continuing S2S contact in hospital and after discharge improves milk output. Hospitals
can help encourage S2S by supporting continuous rooming-in. Prenatal and discharge
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counseling should include this topic. Fathers and other adult family members can also
participate in holding the infant S2S, allowing the mother time to sleep, bathe or take
care of other needs.
Infant should be in light sleep or in a quiet alert state but not crying. A crying baby
will need calmed before encouraging the baby to begin breastfeeding. A sleepy
baby may not respond with a rooting reflex and may not take the breast. Unwrapping
and undressing a baby may help awaken a sleepy baby. A gentle massage of the
infants back or the soles of the feet may also help.
Mother should sit or lie down comfortably, with her back well supported, and bring
baby in close to her. She offers her breast to the baby in a way that promotes good
attachment of the babys mouth to the breast. She may support her breast with all
four fingers below and thumb resting lightly atop the breast.This is often called a C
hold. The baby should approach the breast with his/her nose towards the nipple, so
that he has to tip his head back and reach up to the nipple with his chin going close
into the breast and well under the areola.
Her thumb and fingers should be away from the areola so
that baby can grasp the nipple and areola area without
interference. Often we see mothers offering the breast to
the baby using a scissors hold, with the nipple between
the forefinger and middle finger. If her fingers block the
areola, the baby cannot attach properly. (Figure 2.6)
With the mother seated in this position, the infant should be
held on the same level as mother's breast, turned so the
babys abdomen faces the mothers abdomen (tummy to
tummy), held close and well supported with pillows.
Figure 2.6
(C)
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For baby led or biological positioning mothers are encouraged to lie back rather
be in a more sitting position. The baby is placed on the mothers chest and allowed
to use infant reflexes and natural behaviors to find either breast and self-attach.
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Cradle (cross-chest):
The baby lies across mothers lap;
babys head lies on her forearm or
in her hand on the side from which
she is feeding. His head should not
be in the crook of her arm because
that takes him too far out to the side
and he has to bend his head forward
and cannot get his chin and tongue
underneath the nipple.
E.Helsing
Figure 2.8
Modified cradle:
The baby lies across the
mothers lap; mothers opposite
arm and neck. This position is
very useful for newborns and very
small babies, giving the mother
better control of the babys head
and neck than the cradle hold.
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Figure 2.9
Side-sitting (football):
In the Side-sitting position:
baby and mother sitting up; baby sits facing
mother with his legs under mothers arm;
mothers hand supports babys back and neck.
This position is comfortable after a cesarean
delivery because the babys weight is away from
the incision. Sleepy babies may stay awake and
feed better in this more upright position.
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Figure 2.10
Side-Lying:
The mother and baby lie side by
side with mothers lower arm
extended as shown in the picture.
v.valdes
Attachment
The way the baby grasps the nipple/areola area and pulls it into his mouth for feeding is
referred to as "attachment or latch. Attachment is consider to be the MOST
important factor for preventing early problems that lead to premature weaning.
As noted earlier, normal term infants are born with a number of reflexes and behaviors.
These reflexes include a rooting reflex that prompts him to open his mouth and turn
toward the breast when hungry. A light touch to the middle of the infants upper lip will
help elicit this reflex. The mother should aim the nipple towards the roof of the babys
mouth. The infant opens his mouth wide and brings his tongue down and forward over
the lower gum to pull the nipple into his mouth. A crying baby will need to be calmed,
since the tongue is usually elevated during crying and the babys tongue needs to be
down in order to breastfeed. When properly attached the babys lips are flanged
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UNICEF Chile
Figure 2.11
With effective positioning, the infants tongue presses the nipple/areola against the hard
palate and then lowers the posterior area of the tongue and soft palate, creating a
vacuum. This lower intra oral pressure results in milk flowing into the babys mouth from
the areola stimulating swallowing and further suckling actions in a rhythmical pattern.
Assisting a mother to learn how to help her baby attach or latch-on effectively is very
important to preventing problems and achieving breastfeeding success. (Note: Always
observe breastfeeding before intervening. Mothers and babies may be doing fine and
need only encouragement.)
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2-1
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Good Attachment
(Lips widely flanged out,
nose touching breast)
UNICEF Chile
Poor Attachment
(Lower lip curled in, nose
not touching breast)
no sounds of swallowing
short, quick (flutter)sucking movements only
mother may feel pain
If someone is assisting the mother with getting the baby attached, the helpers hand
should support the head, neck and shoulders below the infants occiput. Forward
pressure to the back of the head causes the baby to arch making it difficult for the baby
to attach effectively.
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Breastfeeding
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Bottle Feeding
Evaluation of a Breastfeed
How do we know if the baby is suckling effectively ?
Mothers breastfeed successfully without knowing all of the following details, but these
details may be helpful if the mother is experiencing problems or if the baby is not
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a few rapid sucks at the beginning of a feed with no active swallows of milk
stimulating the oxytocin reflex and milk flow (call-up suckling),
nutritive suckling: deeper, slower sucks (1:1 suck per swallow) with a brief pause
when the milk starts flowing
audible swallowing (a quiet cuh sound) shows that milk is being transferred
3 or 4 good sized bowel movements/ 24 hours.
25 30 grams weight gain per day after the milk comes in.
Breastfeeding is baby led. The baby asks to feed when hungry and stops when it is
satisfied. Feeding on demand allows the infant to indicate when he or she is
hungry. Crying is a late sign of hunger. Breastfeeding should be initiated in
response to early hunger cues rather than waiting until the baby is crying. Early
cues include:
waking up
bringing hands to his or her mouth
rooting
mouthing movements
Breastfeeding should also reflect the needs of the mother and she may try to get the
baby to feed if her breasts are becoming uncomfortably full.
Feeding patterns vary greatly among babies; some feed quickly, others slowly. The
important thing is to feed long enough to obtain the hindmilk. Milk has slightly more
fat with each let-down ejection.
Infants usually signal by spontaneously releasing the breast, falling asleep with the
nipple in its mouth, or discontinuing suck/swallow patterns when they are either
finished or ready to change sides. If necessary burp baby to see if displacing air
makes baby interested in taking more, then offer the second side. Sometimes one
breast is sufficient. Switch starting sides at each feeding.
Mothers have variable amounts of milk fat and total milk volume throughout the day,
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so the baby may feed for different lengths of time from one feeding to the next.
Every mother/infant pair is different. The babys style of feeding and the flow of the
mothers milk vary from pair to pair. Very long or very short feeds may indicate a
problem and should be evaluated. The best way to evaluate the babys
effectiveness is to observe a feeding. Look at how the baby is attached, listen for
swallows, and assess whether the mother is comfortable throughout and baby is
content after the feed.
If a mother needs to release her baby from the breast during a feeding, she can
break the suction created by feeding using a finger to press on her breast at the
junction of the babys lips or by putting a clean finger into the corner of the babys
mouth. This gentle manner of helping the baby off the breast can help prevent sore
nipples. The nipples should appear as they did before the feeding; i.e., round, not
reshaped or flattened.
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ovulation.
Some babies will cluster feed that is feed very frequently at times and extend the time
between other feedings. If the baby is gaining well this is a normal variation.
Frequent, soft bowel movements (3-4 or more/24 hours by day three, yellow
stools by day four) during the early weeks. After 5 or 6 weeks some normal
breastfed babies do not stool for several days.
Wet diapers: 6 or more/24 hours by day three. Diaper count may not be accurate
if newer absorbent diapers are used but a normal infant will urinate at least 6
times in 24 hours.
Sounds of swallowing during a feed
Contented between feeds
Average weight gain of 20 30 gm. ( - 1 ounce) per day or 100 200 gm (5-7
oz) .per week. Recent studies indicate that velocity of weight gain varies with
birth weight, smaller babies gaining more slowly than larger babies. Full term
infants should start to gain weight by the third to fifth day of life; most infants
regain birth weight by about seven to ten days after birth. Infants who lose 7-8%
or more of their birth weight need careful evaluation and follow-up to be sure
there isnt really a problem. Babies who breastfeed early regain their birth weight
earlier,
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Anticipatory Guidance
It is helpful to talk to mothers about their knowledge of breastfeeding and about their
individual situation in order to know best how to provide information and support. Open
ended questions allow a mother to express her concerns and worries.
Whatinformationaboutbreastfeedingdoyoualreadyhave? Itishelpful
to know her baseline breastfeeding knowledge and if she is aware of the risks of not
breastfeeding. A prenatal breastfeeding class provides the foundation for the
mother and baby getting off to a successful breastfeeding experience. Then the
short time from delivery to discharge can be utilized for skilled staff to help with
breastfeeding and with newborn care. Also a mother may have watched
breastfeeding videos, read books, and talked to family and friends. Some women do
not avail themselves of prenatal breastfeeding information because they think its a
natural process so what is there to learn? Health care providers can be
instrumental in this situation.
a new
confidence.
Though there are a few drugs that are contraindicated during breastfeeding (see
module I) most medications are compatible with breastfeeding. The mothers regular
medications should be reviewed and alternative selections made if necessary.
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Have you had any breast problems or surgery in the past (to increase or
decrease breast size, biopsies etc) Previous surgery does not necessarily
indicate that there will be any difficulties with breastfeeding but more careful followup may be warranted.
In addition to the questions listed above, a multipara who has some breastfeeding
experience should be asked the following:
How long did you breastfeed before? Why did you stop at that time?
A mother may have begun breastfeeding a previous infant but stopped because she
experienced problems. This is a good time to let her know that most problems are
preventable and there are resources in the hospital and community to help. She should
be praised for choosing to breastfeed this new baby. This mother should be given extra
attention to make sure things are going well in the hospital and beyond. A consult with
a lactation specialist may be indicated.
Of course, as a part of thorough prenatal care, a careful examination of breasts should
be done. In addition to the usual evaluation for possible masses, observations should
include variations in breast or nipple shape and breast changes consistent with
pregnancy. The examination offers a good opportunity to discuss any concerns that the
Mother may have about her ability to successfully breastfeed her baby and provide
reassurance.
Module 2 - Basics
the basis for the international Baby-Friendly Hospital Initiative (BFHI), a UNICEF/WHO
sponsored hospital centered voluntary program of training and policy development to
support the breastfeeding mother and newborn. At the time of the preparation of the 3rd
Edition of the Self-Study Modules, nearly 20,000 hospitals around the world had been
designated as Baby Friendly. In addition, many hospitals, though not as yet designated,
are now working on policies that include the Ten Steps.
The first two of the Ten Steps provide the foundation by requiring a hospital policy
that supports breastfeeding and trained staff who can assist the mother. Specific
clinical practices are then delineated:
Step 2: Train all health care staff in skills necessary to implement this
policy.
A course to provide basic training for health care staff has been designed by
WHO and is available for downloading without charge from the WHO website
(see Annex G: Web Sites of Interest)
Step 3: Inform all pregnant women about the benefits and management of
breastfeeding.
Women need to know early in pregnancy the importance of breastfeeding in
order to make an informed choice about infant feeding.
A mother who has had a cesarean birth should start to breastfeed within one
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Every mother should be shown how to hand express her milk. If she is
separated from her baby she can maintain her milk supply and in many cases
the milk can be saved and given to the baby.
Step 6: Give newborn infants no food or drink other than breast milk,
unless medically indicated.
Supplementation with breast milk substitutes should be given only if medically
indicated*.If supplements are necessary, human milk is best either from the
babys own mother or donor milk.
If substitutes for human milk are introduced, there is a risk of allergies. Soybased formula is probably no better than cows milk -based formula. If a nonhuman milk supplement is required, hydrolyzed cows milk is best to decrease
the risk of allergy.
Even in hot, dry climates, human milk contains sufficient water for a young
infants needs. Additional water, sweet drinks, or teas are not needed.
If the baby is supplemented, there is a missed opportunity to practice
breastfeeding skills and baby ingests less breast milk.
With less human milk intake there is less immunological protective effect.
*Note: In early 2009 WHO and UNICEF completed an updated statement of Acceptable Medical Reasons
for Use of Breast- milk Substitutes. A copy is included in the annexes of this Self-Study tool as annex B.
It may also be obtained from WHO, the Departments of Child and Adolescent Health and Nutrition for
Health and Development. www.who.int/child_adolescent_health and www.who.int/nutrition.
Module 2 - Basics
needs.
*Note : The Section on Perinatal Pediatrics of the American Academy of Pediatrics believes that there are evidenced-based medical
indications for pacifier use including pain reduction and calming effect in a drug exposed infant.
Encourage mothers to get help from family and friends during the early
postpartum period. Rest and relaxation are helpful both to recover from birth
and for successful lactation and breastfeeding.
Further information regarding BFHI can be obtained from UNICEF or WHO via their web
sites provided in Annex G.
Module 2 - Basics
Discharge Planning
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2.
3.
Find out how breastfeeding has gone so far by talking to the mother, to the staff,
and reviewing the medical records (check urine and stool output, weight).
Examine the baby. The baby should be beyond the normal postpartum sleepy
period now. The fact that he is stirring may indicate a readiness to feed. Your
exam will also stimulate him.
3.
When the infant is awake, request that the mother feed her baby. Observe a
feeding, noting position, attachment, and whether the baby is effectively feeding
(listen for swallows). Make adjustments to improve position/attachment as
needed.
4.
Review with the mother the landmarks for good attachment and point out the quiet
sounds of swallowing.
5.
Review with the mother the signs of adequate milk intake (contented baby, weight
gain, stooling and urination).
6.
Review with the mother the basics of building and maintaining a milk supply
(frequent breastfeeding, milk removal stimulates milk production, leave baby on
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Module 2 - Basics
first side until he signals he is full then offer second side). Without a clear medical
indication, formula use can interfere with building a milk supply.
7.
8.
Conclusion
An understanding of the anatomy and physiology involved in the natural process of
breastfeeding is essential in order to provide care that supports optimal breastfeeding
practices. The basic breastfeeding routines are based on evidence-based physiologic
principles, and adhering to them prevents problems from developing. Helping a mother
and infant off to a good start is one of the best investments in time and effort.
References
1. American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists (2006) Breastfeeding Handbook for Physicians. AAP, Elk Grove
Village, IL and ACOG, WDC.
2. American Academy of Pediatrics. (2012). Breastfeeding and the use of human
milk. Pediatrics 129 (3) e827-841
3. Balkam,JAJ,Cadwell,K,Fein,SB.(2011) The effect of components of the J
lactation program on breastfeeding duration among employees of a public-sector
employer. Matern Child Health J (15):677-683.
4. Colson,SD, Meek, JH, Hawdon, JM. (2008). Optimal positions for the release of
primitive neonatal reflexes stimulating breastfeeding. Early Hum Dev (2008),
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Module 2 - Basics
doi:10.1016/j.earlhumdev.2007.12.003
5. Declercq, E et al (2009). Hospital practices and womens likelihood of fulfilling
their intention to exclusively breastfeed. AJPH 99 (5) 929-935.
6. Geddes, DT,Kent, JC, Mitoulas,LR, Hartmann,PE. Tongue movement and intraoral vacuum in breastfeeding infants. (2008) Early Hum Dev. 2008:84: 471-477.
7. Hale, TW. Hartman, PE. (2007) Textbook of Human Lactation, First Edition,
Amarillo, TX. Hale Publishing, L.P.
8. Kean, YJ, Allian, A. (2009) Code Essentials 3: Responsibilities of Health
Workers under the International Code of Marketing of Breastmilk Substitutes and
subsequent WHA resolutions. ICDC Penang, Malaysia.
9. Lawrence RA and Lawrence RM (2011), BreastfeedingA Guide for the Medical
Profession, Seventh Edition, St. Louis, MO: Mosby, Inc
10. Naylor, AJ. (2001) Baby-Friendly Hospital Initiative: Protecting, Promoting, and
Supporting Breastfeeding in the Twenty-First Century. Pediatric Clinics of North
America 48(2) 475-483.
11. Ramsay DT, Kent JC, Hartmann RA, Hartmann PE. Anatomy of the lactating
human breast redefined with ultrasound imaging. (2005) J.Anat 206, pp525-534,
12. Riordan J and Wambach K (2010) Breastfeeding and Human Lactation, Fourth
Edition: Jones and Bartlett Publishers, Inc. Boston
13. Walker, M.(2014) Breastfeeding Management for the Clinician: Using the
Evidence T h i r d E d i t i o n Jones and Bartlett Publishers, Inc. Boston
14. WHO (2009). Infant and Young Child Feeding: Model Chapter for Textbooks for Medical
Students and Allied Health Professionals. WHO Geneva.
www.who.int/nutrition/publications/infantfeeding/9789241597494/en/index.html
15. WHO/UNICEF (2006) Promotion and Support in a Baby-Friendly Hospital, 20
hour Course WHO Geneva
16. WHO/UNICEF (1989), Protecting, Promoting and Supporting Breastfeeding: The
Special Role of Maternity Services. A Joint Statement. WHO Geneva.
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Module Three
Common Breastfeeding Problems
Objectives
After completing this module, you will be able to:
1.
2.
3.
4.
Introduction
From time to time, mothers encounter problems with breastfeeding. Most problems are
preventable with good breastfeeding practices: correct positioning and attachment,
frequent unlimited feeds, and attention to the effectiveness of the infants suckling.
When problems do occur, early recognition and treatment enable a mother to begin or
continue to enjoy breastfeeding and help reach the recommended goals of exclusive
breastfeeding for six months and continued breastfeeding for a year and beyond.
Maternal Problems
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Module 3 - Problems
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Inverted Nipple
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As a last resort, an ultra-thin silicone nipple shield can be temporarily used. It is best to
avoid bottles and pacifiers in the case of inverted nipples because the baby can get
used to the feel and flow of the longer artificial nipple and may refuse the breast.
Can Ann do anything during pregnancy to evert her nipples?
Until recently women with inverted nipples were told to use a variety of exercises and
devices to try to evert the nipple. The latest clinical trials demonstrated that these
strategies are ineffective. Women who did nothing to prepare their nipples prepartum
had the best results. Current advice, then, is to alert the mother that she should request
assistance with breastfeeding at the time of delivery and postpartum until the baby is
feeding well.
2.
3.
Women with inverted nipples can breastfeed but they may need more help
postpartum.
After delivery a breast pump might be useful to help evert the nipples.
If a pump is not available, a 20 ml syringe with the adaptor end cut off
and plunger inserted backwards is used to help draw out a nipple.
4.
Avoid bottle and pacifier use so the baby does not become accustomed to the
longer artificial nipple which feels and flows differently.
5.
When all else fails, an ultra-thin silicone nipple shield can be tried temporarily.
Note that nipple preparation during pregnancy in no longer recommended.
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Module 3 - Problems
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Nipple Trauma
Transient Pain
Nipple tenderness and sensitivity will usually subside
within a few days if positioning and attachment are
corrected.
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Module 3 - Problems
prolonged pushing
traumatic delivery
forceps or vacuum delivery
intra-partum drugs transferred from mother to infant before delivery.
Examine the breasts before and after a feeding. The first step in a breastfeeding
assessment is to diagnose the reason for the trauma.
Observe a breastfeeding to evaluate and correct position and attachment. With
correct position pain will often decrease and mother can continue to breastfeed
while nipples heal.
Check babys mouth for ankyloglossia. Clipping of a short lingual frenulum
(frenotomy) by an experienced health care giver may be necessary to allow
appropriate tongue movements and avoid chronic nipple trauma.
Ensure frequent feeding to avoid engorgement.
Changing position of the baby at each feeding may help to avoid friction on the
sore area of the nipple.
Use of emollient such as purified lanolin may improve rates of healing. Avoid
the development of crusts (scabs) on nipple lesions. The use of hydrogel pads
may increase comfort for some women with nipple wounds. Breastmilk to the
nipples after feeding may help some mothers.
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2.
3.
2.
Helped the mother and her baby make adjustments to the position and
attachment. If these changes ease Janes pain ask her to practice helping her
baby attach a few times so she is more comfortable and confident that she can
do this at home. In the commonly used cradle hold the baby should be lying on
his side facing the mother (so called tummy to tummy) His body should be on
about a 45 degree angle and well supported in his mothers arms. You may also
have elected to encourage the mother to lie back and allow baby led or biologic
positioning to occur.
Assisted the mother and baby to achieve an effective
and comfortable attachment by:
9
9
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9 stimulating the babys upper lip with mothers nipple which will cause the baby to
open its mouth wide
9 gently encouraging the baby to attach while the mouth is
open
3. Checked for effective attachment:
9
9
9
9
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Breast Engorgement
The treatment is milk removal, and the most sensible strategy is for the baby to attach
and feed! Sometimes engorgement and areolar edema may be so severe that the
areolar area becomes swollen and hard and the nipple flattened. The infant has a
difficult time pulling the nipple into his mouth.
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A warm shower or warm moist packs to the breasts may help the mother relax and
enhance milk flow.
Gentle massage, hand expression or minimal use of a breast pump (hand or
electric) are often used to soften the areola around the nipple to facilitate
attachment. Some lactation specialists recommend using finger pressure to
minimize the edematous areolar swelling around the nipple. This is known as areolar
compression or reverse pressure softening.
If the baby is unable to latch, judicious use of a thin silicone nipple shield may
facilitate latch until the areola is softened.
More frequent and effective feedings (every 2-3 hours or more frequently if the baby
is willing).
If baby will not nurse frequent and effective emptying of breasts by hand or breast
pump until engorgement is resolved.
If available, cold packs can be applied after feeding to help relieve congestion, and
pain. Evaporation from the moist cloths adds to the cooling effect.
Anti-inflammatory drugs may also be useful.
There is not sufficient evidence for other complimentary therapies to evaluate their
effectiveness.
2.
3.
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2.
Applied warm, moist compresses, such as washcloths wrung out in warm water
before feedings to help with milk ejection.
3.
Ask her to gently massage and use finger pressure on the areola as well as hand
express milk to soften the area so the baby can attach. Helped with position and
attachment and observe the baby for signs of effective nursing.
4.
5.
Encouraged frequent feeding or pumping (about every 2-3 hours) will prevent
reoccurrence of engorgement.
6.
If the baby is not able to suckle effectively, the mother may need to use hand
expression or a breast pump until the engorgement is resolved. (The expressed milk
can be given to the baby some other way.) If expression is effective the baby should be
able to feed directly from the breast as soon as the areola is softened.
If engorgement persists longer than 24 hours or if the infant cannot attach and
nurse effectively, refer the mother to a health care professional with
expertise in lactation and breastfeeding issues.
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Infrequent nursing
Ineffective milk removal (usually caused by poor attachment)
Local consistent pressure on the breast, caused, for example, by tight clothing
Rarely but important, an obstructed duct may be caused by a tumor (benign or
malignant)
2.
3.
By now you get the driftyou will examine the mothers breasts and watch a feeding.
During the visit you may have made the following suggestions:
1.
Have the mother gently massage the breast over the lump.
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2.
3.
Observe the feeding noting position and attachment; make suggestions as needed.
4.
Advise the mother to continue feeding frequently, every two or three hours, until the
lump is resolved. In this case, the new longer sleep pattern of the baby may have
contributed to the development of the obstructed duct. The breasts will adjust to
minor changes in frequency; in the meantime Maria could continue with the
treatment you have discussed.
5.
Note the appearance of the breasts. Are there marks on the skin that would
suggest the bra is too tight? Suggest she remove the underwire in the bra if it
appears to be a mechanical obstruction.
6.
If the lump does not resolve after a few days of the treatment described above, she
should return for reassessment of the situation because an unresolved blocked
duct may lead to mastitis. Additionally if the lump does not resolve or recurs,
consider referral to rule out other causes such as tumors.
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Mastitis
The portal of entry is often through a break in the nipple skin. Recurrent mastitis may
also be associated with an over-abundant milk supply. The mother usually complains of
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breast pain, fever, and headache. She may also notice a red wedge-shaped area on
the affected breast.
Can a mother with mastitis breastfeed?
Yes! The inflammation is mammary cellulitis. Even when due to a bacterial infection,
the organism is rarely in the milk and infants do not become ill from sporadic mastitis in
the mother. Continued breastfeeding or breast milk removal will avoid engorgement,
facilitate vascular and lymphatic drainage and is an important part of treatment.
Inadequate treatment of mastitis may lead to a breast abscess, a complication usually
requiring surgical intervention.
There is a saying that flu-like symptoms in a breastfeeding mother should be
considered mastitis until proven otherwise. To differentiate the diagnosis, ask the
mother if she has nasal discharge, cough, or other symptoms of respiratory illness. If
she does not, her symptoms are most likely due to mastitis.
There is some evidence that stress plays a role in the development of mastitis, because
it seems to occur around especially hectic times in the mothers life when there is an
increase in activities, such as in Amandas case, getting ready for a visit from a relative.
It may also be because she may miss a feeding or may breastfeed for only a short time
due to preparations for the visit.
How do you manage a case of mastitis?
Continue breastfeeding
Apply warm, moist compresses to the area 3 to 5 minutes before feeding or pumping
breast.
Frequent milk removal (every 2 to 3 hours or sooner) by feeding, hand expression
or pumping of the effective side is most important.
Encourage mother to enlist family and friends to help while she goes to bed for 24
hours. This will also facilitate feeding.
Encourage the mother to rest as much as possible for 24 hours.
Encourage the mother to drink extra nourishing fluids and water to meet her thirst
needs.
Treat nipple trauma as described above in Case #2.
A mild analgesic, such as acetaminophen or ibuprofen is helpful in relieving pain if
needed.
Prescribe antibiotic therapy as appropriate usually for 10 to 14 days:
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Remind the mother to finish the full course of antibiotics. Most antibiotics are
safe for the baby but when in doubt, check with one of the suggested sources
given on page 17 of Module 1.
Many clinicians will send a mother home with a prescription but suggest that she
be diligent about going to bed, applying warm moist compresses and frequent
emptying of the breasts. If she is not feeling better after 24 hours, she should fill
the prescription and take all of the antibiotic. If she is not better in 24 hours after
starting antibiotics, she should call her health care provider.
Instruct the mother to continue breastfeeding frequently. If her breast or nipples are
too sore to breastfeed directly, she should hand express or use a pump to ensure
effective milk removal and lower the risk of developing an abscess.
Ensure proper positioning and attachment of the baby to the breast to be sure he is
effectively removing milk.
2.
3.
Examination of the breasts confirms the diagnosis of mastitis. You may have
recommended the following:
1. Continue frequent breastfeeding, or at least milk expression, at least every 2
hours or sooner.
2. Rest as much as possible for 24 hours and have a relative or friend help with
meals and household activities. Emphasize that rest is an important part of the
treatment
3. Antibiotics for 10 to 14 days and an analgesic as needed. (Recent reports
suggest that if milk is removed effectively antibiotics may not be needed)
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The most common cause of low milk supply is ineffective suckling and/or infrequent
feeding routines that do not adequately stimulate milk production and milk removal.
Early introduction (before three weeks of age) of bottles which require that the baby
use a different type of feeding effort or suckling technique and may cause the baby
to have difficulty nursing or refuse to breastfeed.
Introduction of formula supplements, while calming the infant, decreases the number
of times the baby breastfeeds thereby reducing breast stimulation and thus milk
supply.
Conditions of the baby, such as illness or ankyloglossia may cause ineffective
suckling (ineffective suckling reduces the milk supply).
Condition of the mother such as fatigue, stress, use of certain medications (i.e.,
estrogen-containing oral contraceptives that inhibit milk production), psychological
inhibition, pregnancy, and smoking.
At around 4 weeks postpartum, normal lactating breasts may no longer become very
full before a feed; this change leads mothers to believe they have lost their milk.
Mother lacks confidence in her ability to produce enough milk because her baby
begins to be fussy or cry more and feed more frequently for several days. This
seems to occur several times during the first 3 months. Mothers often think they
have lost their milk supply because the baby suddenly wants to feed more often
(perceived low milk supply). On examination the infant is judged to be normal.
These transient periods of time when the baby demands to feed more frequently
have been called growth or activity spurts. As yet there are no published studies to
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confirm that either growth or activity are responsible for this behavior. Because more
frequent feeding stimulates a larger milk supply and babies usually return to less
frequent breastfeeding after a few days, it is assumed that the babies have
increased the supply to meet their needs.
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2.
3.
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The most likely cause of Monicas problem is lack of adequate breast stimulation
because of the introduction of formula (without extra milk removal by hand or a pump).
Your advice may have included the following:
Reassure Monica that she can build up her milk supply by breastfeeding more
frequently, 8 or more times in 24 hours; review with her the principles of demand and
supply that drive breast milk supply.
Feed the baby frequently, day and night, to stimulate milk production. Studies show
that prolactin levels are higher at night, and night feeding is important to maintaining
a good milk supply. Around six to eight weeks of age some babies start to sleep
longer at night and will feed more often during the day to maintain about 8 or more
feedings in 24 hours.
Review with Monica the possibility of an appetite spurt or growth spurt in a baby
Johns age, and reassure her Johns requests for more frequent feeding are normal,
temporary, and will likely result in an increased milk supply.
Module 3 - Problems
enzyme, which is very active in the newborn, resulting in large amounts of bilirubin that
is reabsorbed and flows back to the liver via the portal circulation. The very limited
capacity of the liver to conjugate bilirubin results in retention of significant amounts of
bilirubin in the circulation, which if it reaches a concentration in excess of 5 mg/dl will
produce jaundice. Exaggerated hemolysis due to RH or ABO incompatibility or
decreased hepatic conjugating capacity due to prematurity or inherited abnormalities of
the conjugating enzyme will further increase serum bilirubin concentrations and the
frequency and intensity of jaundice.
In the great majority of breastfed newborns serum bilirubin concentrations remain
elevated above the adult normal level of 1.5 mg/dl for at least three weeks and
sometimes as long as three months due to a factor in transitional and mature human
milk which further increases the intestinal absorption of unconjugated bilirubin. The
specific factor(s) in human milk increasing intestinal absorption has not been identified,
but is part of a mechanism for efficient retention of many nutritional and hormonal
components that are in the intestines of the newborn infant. The resulting prolongation
of Physiologic Jaundice of the Newborn in the breastfed infant, known as Breastmilk
Jaundice, is believed to be part of a protective mechanism. Bilirubin has been shown
to be a very effective antioxidant, preventing excessive injury during the critical
transition of the fetus to independent existence. During the first five days of life, the
optimally breastfed infant and the artificially-fed infant have identical serum bilirubin
concentrations. The serum bilirubin concentration of the artificially-fed newborn will
decline to adult normal levels by the tenth or eleventh days of life, reducing antioxidant
protection prematurely.
Suboptimal breastfeeding or reduced caloric intake in the artificially-fed newborn will
result in an increase in serum indirect bilirubin concentrations and more intense
jaundice due to a further increase in intestinal bilirubin absorption. This phenomenon
occurs to a mild degree in older children and adults as well and is known as starvation
jaundice. When it occurs in the neonate, it is known as Starvation Jaundice of the
Newborn, and was previously known as Breastfeeding Jaundice and Breast NonFeeding Jaundice.
While mild and moderate levels of hyperbilirubinemia are not harmful, serum bilirubin
concentrations that exceed certain levels can cause both transient and permanent brain
damage, known as Kernicterus. Unconjugated bilirubin which is not retained within the
circulation can enter the brain permanently destroying neurons in the basal ganglia and
cerebellum. In the newborn period this type of injury is manifest initially as lethargy and
poor feeding, progressing to movements which look like seizures, extensor stiffening
and arching of the back and neck (opisthotonus). Hearing loss, loss of upward gaze of
the eyes, and moderate to severe loss of movement control (choreoathetoid cerebral
palsy) are the later and permanent consequences of bilirubin damage to the brain.
Prevention of excessive rises in serum bilirubin concentration and close monitoring of
jaundice and serum bilirubin concentrations are essential in the prevention of
kernicterus. Thus, early and effective initiation of breastfeeding without water or other
supplementation, frequent breastfeeding of at least ten to twelve feeds per day starting
with the first day of life, and close monitoring of the nursing mother and infant to detect
and correct problems promptly can assure adequate caloric intake which minimizes
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jaundice and serum bilirubin concentrations. Close monitoring of the infant for the
appearance of jaundice is critical. The appearance of any jaundice, even just on the
face, during the first 24 hours of life is almost always evidence of a pathologic process
which may well progress to more intense hyperbilirubinemia. As serum bilirubin
concentrations increase, the jaundice progresses downward on the body, and may be
evident on the lower trunk and legs at levels in excess of 15 to 20 mg/dl. Competent
observation of jaundice in the newborn requires very strong and well balanced light,
best achieved at a window in daylight and some experience. Jaundice in the first 24
hours of life and anywhere below the face afterward requires measurement of a serum
bilirubin concentration by laboratory or use of the newer transcutaneous methods.
Many hospitals are now routinely performing bilirubin measurements before discharge
on all newborns using either serum drawn during the metabolic screen or a
transcutaneous method at either 24 hours of age or just prior to discharge. These
bilirubin values should be graphed on the age-specific charts which provide predictive
guidance on future bilirubin concentrations and risk for kernicterus (see AAP guidelines:
Pediatrics 2004;114:297-316). Infants with serum bilirubin concentrations in excess of
12 mg/dl need to have additional laboratory studies to rule out pathologic conditions
such as RH and ABO erythroblastosis, spherocytosis, glucose-6-Phosphate
dehydrogenase (G-6PD) deficiency, hypothyroidism, etc. Careful monitoring of jaundice
after discharge is also critical. Every newborn should be examined by a licensed health
practitioner at 3 to 5 days of age for jaundice and feeding, as well for many other
system problems. Infants with significant risk factors for excessive jaundice may be
seen even sooner after discharge or kept in the hospital an additional day. The
presence of any jaundice below the face or intense jaundice on the face at the time of
scheduled post-discharge examination or later requires a serum bilirubin measurement.
Treatment is determined by the level of the serum bilirubin as described in the
guidelines from the American Academy of Pediatrics (Pediatrics 2004;114:297-316 and
Pediatrics 2009;124:1193-1198). These treatments may include improvements in
breastfeeding management, additional feeding with expressed or banked human milk,
elemental formula, or phototherapy and/or exchange transfusion. These may be used
in combination. At no time should an infant be allowed to continue to have inadequate
caloric intake.
The lethargy induced by moderately elevated serum bilirubin concentrations, usually in
excess of 15 mg/dl, often leads to reduced frequency and efficacy of breastfeeding.
The resulting reduction in feeding and caloric intake increases intestinal bilirubin
absorption and the concentration of serum bilirubin. This increase in serum bilirubin
further depresses feeding. This vicious cycle can lead to severe increases in serum
bilirubin and to kernicterus. Every effort needs to be made to prevent this progressive
increase in serum bilirubin.
To minimize jaundice:
The infant should receive adequate fluid and caloric intake. Effective
breastfeeding 8 or more times in 24 hours is the ideal way for the baby to have
adequate fluid and caloric intake.
If an infant is not suckling well, consider having the mother pump after feeds and
give the baby supplements of this expressed milk which provides nutrients and
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hydration. Supplemental water or glucose water does not lower serum bilirubin
and should not be given.
Early follow-up should be arranged, particularly in cases of early discharge.
Note that any jaundice on the first day of life is not normal.
Alice and her son Andrew are ready for their visit with you. The baby is 11%
below birth weight. His temperature is normal. His skin looks jaundiced to about the
level of his legs. He is sleepy but roots when aroused. You ask Alice to feed the baby.
He is dressed and is wrapped in a blanket. He attaches to the breast and nurses with
only a few audible swallows for about 3 minutes before falling asleep.
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2.
3.
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You will want to check the bilirubin level and evaluate the jaundice; but whatever the
cause, this baby needs more oral intake. Increase the frequency of effective
breastfeeding.
Ask mother if her milk has come in and how she is doing. Arrange for mother to
receive care if needed.
Since the baby does not appear to be feeding well, Alice must express her milk and
give it to the baby. Alternatives to using an artificial nipple for giving the baby breast
milk include syringe feeding, supplemental nursing units or cup feeding. A bottle
may be used if any of these methods are not appropriate for the mother. If adequate
breast milk cannot be expressed or otherwise provided from a milk bank, formula
supplementation will be needed.
Provide Alice with a plan for feeding the baby and recording intake and output for the
next 24 hours. This may include putting the baby to the breast every 3 hours or
sooner and offering supplemental expressed breast milk or formula after nursing.
Arrange for follow-up in your office or by a home health provider the following day to
check the babys weight and assess his ability to feed effectively.
Since jaundiced babies are often sleepy, offer Alice suggestions for stimulating the
baby such as less bundling, side sitting position for feeding, burping, and changing
the diaper.
Consider referral to an experienced professional knowledgeable in management of
lactation problems.
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*LAM Guidelines
Baby less than six months old
No return of menstruation (no bleeding after the 56th day postpartum)
No regular supplements
Feeding at least 8 times in 24 hours
Night feedings
Module 3 - Problems
closable container with an airtight lid. Specific milk storage bags may be used but for
short periods of time as they may leak, spill or become contaminated or some of the
components of the milk may be lost in long time storage. Milk should be stored in
amounts that the baby would take. The newly expressed or warm milk needs to be
chilled before adding to cold, refrigerated milk. Several expressions with-in the same
day can be combined and used within 24 hours. For details regarding storage see
Annex E and the 2010 version of the Academy of Breastfeeding Medicine protocol #8.
Thaw milk overnight in the refrigerator or place the milk container in a bowl under warm
running water. Warm milk to room temperature. Never use a microwave to thaw or
warm milk. Offer only the amount of milk that baby is likely to take at a feeding. Once
a bottle of milk has been in the babys mouth the remaining milk must be discarded.
In the case of a hospitalized infant, the mother should follow the policies of the
institutions to label and store the milk. (see Annexes E and F for additional information
regarding expressing and storing of human milk )
Resources
When mothers encounter problems with breastfeeding they often turn to their physician
or other health care provider. The amount of knowledge and experience among
physicians and nurses is quite variable. Identify knowledgeable and experienced
colleagues in your community.
Your community may have lactation specialists and consultants available to mothers
through organized health systems or through individuals in private settings. Identify and
familiarize yourself with the lactation service providers as you would any other
specialists to whom you would refer your patients. Provide information as part of the
referral and request feedback in order to build your own experience with lactation
management. If your medical center provides lactation services, try to arrange a clinical
learning experience in prenatal, postpartum and outpatient health care settings.
Conclusion
Most breastfeeding problems can be prevented by providing women with helpful
information during the prenatal period so they know what to expect and providing
perinatal care for mother and infant that follows physiologic principles. In spite of
providing information and good care, problems do occur. Information about when and
how to seek assistance if problems develop is essential. Early intervention can help
breastfeeding families on the path toward exclusive and continued breastfeeding.
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References
1. Academy of Breastfeeding Medicine (2010). Protocal #8: Human Milk Storage
Information for Home use for Healthy Full-Term Infants. Breastfeeding Medicine
5(3):127-130.
2. Academy of Breastfeeding Medicine (2008). Protocol #4: Mastitis. Breastfeeding
Medicine, 3 (3)177-180.
3. Academy of Breastfeeding Medicine (2005). Protocol #13: Contraception during
Breastfeeding. Breastfeeding Medicine .(being revised)
4. Academy of Breastfeeding Medicine (2009). Protocol #20: Engorgement.
Breastfeeding Medicine 4(2) 111-113
5. American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists (2006) Breastfeeding Handbook for Physicians. AAP, Elk Grove
Village, Il and ACOG, WDC.
6. American Academy of Pediatrics (2004). Management of Hyperbilirubinemia in
the Newborn Infant 35 or More Weeks of Gestation. Pediatrics July; 114(1): 297316.
7. Briggs, GG, Freeman, RK, Yaffe SJ. (2005) Drugs in Pregnancy and Lactation.
7th ed, Baltimore Lippincott Williams & Wilkins
8. Geddes, DT, Langton, DB, Gollow, I Jacobs, LA, Hartmann, PE , Simmer, K
(2008) Freunlotomy for breastfeeding Infants with ankyloglossia: effect on milk
removal and sucking mechanism as imaged by ultrasound. Pediatrics 2008;
122;e188-e194
9. Hale T (2012) Medications and Mothers Milk, Fifteenth Edition. Amarillo: Hale
Publishing. LP
10. Hale, TW. Hartman, PE. (2007) Textbook of Human Lactation, First Edition,
Amarillo, TX. Hale Publishing, L.P.
11. Smith, LJ (2010) Impact of Birthing Practices on Breastfeeding. Second Edition
Jones and Bartlett Publishers, Inc. Boston
12. Labbok, M. Cooney, K, Coly S (1994) Guidelines: Breastfeeding, family
planning, and the Lactational Amenorrhea Method LAM. Washington,DC:
Institute for Reproductive Health, Georgetown University
13. Lawrence RA and Lawrence RM (2011), BreastfeedingA Guide for the Medical
Profession,Seventh Edition, St. Louis, MO: Mosby.
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14. LactMed, National Library of Medicine data base. (A free frequently updated
internet service accessed at: www.toxnet.nlm.nih.gov/egi-bin/sis/html.gen?LACT
15. McClellan,HL, Hepworth,AR, et al.(2012) Breastfeeding frequency, milk volume,
and duration in mother-infant dyads with persistent nipple pain. Breastfeed Med
(7) pp 275-281.
16. Mohrbacher,N. (2010) Breastfeeding Answers Made Simple: A Guide for
Helping Mothers. Hale Publishing Co. Amarillo, Texas
17. Noonan,M. Breastfeeding: Is my baby getting enough milk? BJ Midwifery
19(2)pp82-89.
18. Riordan J and Wambach K(2010) Breastfeeding and Human Lactation, Fourth
Edition: Jones and Bartlett Publishers, Inc. Boston
19. Truitt ST, Fraser AB, Grimes DA, Gallo MF, Schulz KF. Cochrane Database
Syst Rev. 2003; (2):CD003988. Combined hormonal versus nonhormonal versus
progestin-only contraception in lactation.
20. Walker, M (2014) Breastfeeding Management for the Clinician: Using the
Evidence. 3rd Edition Jones and Barlett Publishers Inc. Boston
21. WHO (2009) Infant and Young Child Feeding: Model Chapter for Textbooks for
Medical Students and Allied Health Professionals. WHO Geneva.
www.who.int/nutrition/publications/infantfeeding/9789241597494/en/index.html
22. S. Pokhrel, MA Quigley, J Fox-Rushby et al. Potential Economic impacts from improving breas
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Section IV
Post-Test
1. Identify the component of human milk that binds iron locally to inhibit bacterial growth:
a.
b.
c.
d.
e.
taurine
secretory IgA
macrophages
lactoferrin
oligosaccharides
2. Identify the component of human milk that provides specific immunity against many
organisms:
a.
b.
c.
d.
e.
taurine
secretory IgA
macrophages
lactoferrin
oligosaccharides
3. The most important criterion for assessing the milk transfer during a feeding at the breast
is:
a. visible areola compression
b. audible swallow
c. proper alignment
d. proper attachment
vitamin D
iron
lipase
vitamin A
none of the above
progesterone
prolactin
estrogen
oxytocin
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6. A mother with a three-day old baby presents with sore nipples. The problem began with
the first feeding and has persisted with every feeding. The most likely source of the
problem is:
a. feeding too long
b. poor attachment
c. babys suck is too strong
d. lack of nipple preparation during pregnancy
a.
b.
c.
d.
Use breast shells with guidance from her health care provider
Cut holes in the bra to allow the nipples to protrude; wear it day and night
Encourage everting the nipples four times a day to permanently evert her nipples
Do nothing because the natural changes in the breast during pregnancy and the
infants suckling postpartum may evert the nipples
9. Which of the following is most likely to have the greatest effect on the volume of milk a
woman produces?
a.
b.
c.
d.
e.
10. Infants exclusively breastfed for about six months will have:
a.
b.
c.
d.
2 months
4 months
6 months
8 months
10 months
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12. Signs of adequate breast milk intake in the early (first 4-6) weeks include all EXCEPT:
a.
b.
c.
d.
e.
13. It is especially important that an infant with a strong family history of allergy should be
exclusively breastfed for:
a.
b.
c.
d.
e.
2 months
4 months
6 months
8 months
10 months
15. The most common cause of poor weight gain among breastfed infants during the first four
weeks after birth is:
a.
b.
c.
d.
e.
16. A breastfeeding mother with a 3-month old infant has a red tender wedge-shaped area on
the outer quadrant of one breast. She has flu-like symptoms and a temperature of 39qC.
Your management includes all of the following EXCEPT:
a.
b.
c.
d.
extra rest
interrupt breastfeeding for 48 hours
moist heat to the involved region
antibiotics for 10 to 14 days days
17. Studies have indicated that the Lactational Amenorrhea Method (LAM) of contraception
is less reliable under which of the following circumstances:
a.
b.
c.
d.
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18. Which of the following statements is not true of The International Code of Marketing of
Breastmilk Substitutes approved as a resolution in the World Health Assembly (WHA) in
1981:
a.
b.
c.
d.
e.
19. Nipple candidiasis can be associated with all of the following EXCEPT:
a.
b.
c.
d.
a.
b.
c.
d.
22. Reasons for including breastfeeding support for mother infant in planning for or responding
to major emergencies where clean water,sanitation and power are disrupted do not include:
a. It is less expensive than providing for infant formula
b. With support even mothers who have already weaned can be assisted to
relactate
c. Breastmilk provides immunoglobulins that actively prevent infection.
d. In a stressful emergency situation breastfeeding provides a secure environment for
infants and young children
.
23. Hospital policies that promote breastfeeding include:
a.
b.
c.
d.
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24. through 28. Label the structures of the breast by inserting next to the appropriate pointer
the number of the structure listed below:
26
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2.
3.
4.
5.
Identify the component of human milk that binds iron locally to inhibit bacterial growth:
a.
lactoferrin
b.
macrophages
c.
oligosaccharides
d.
secretory IgA
e.
taurine
(Module 1)
6.
Identify the component of human milk that provides specific immunity against many
organisms:
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a.
lactoferrin
b.
macrophages
c.
oligosaccharides
d.
secretory IgA
e.
taurine
( Module 1)
7.
Which of the following would you suggest that a woman with inverted nipples do during
the third trimester?
a.
b.
cut holes in the bra to allow the nipples to protrude; wear it day and night
do nothing because the natural changes in the breast during pregnancy
and the infants suckling postpartum may evert the nipples
c.
use breast shells with guidance from her health care provider
d.
encourage everting the nipples four times a day to permanently evert her nipples
( Module 3)
8.
The most important criterion for assessing the milk transfer during a feeding at the
breast is:
a.
audible swallow
b.
proper alignment
c.
proper attachment
d.
visible areola compression
(Module 2)
9. A mother with a three-day old baby presents with sore nipples. The problem began with the
first feeding and has persisted with every feeding. The most likely source of the problem is:
a.
babys suck is too strong
b.
feeding too long
c.
lack of nipple preparation during pregnancy
d.
poor attachment
( Module 3)
10.
Signs of adequate breast milk intake in the early (first 4-6) weeks include all EXCEPT:
a.
at least 3-4 stools in 24 hours
b.
at least 6 diapers wet with urine in 24 hours
c.
baby gains weight
d.
baby sleeps through the night
e.
sounds of swallowing
( Module 2)
11.
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c.
infrequent feedings
d.
postpartum depression
( Module 3)
12.
13.
A breastfeeding mother with a 3-month old infant has a red tender wedge-shaped area
on the outer quadrant of one breast. She has flu-like symptoms and a temperature of
39qC. Your management includes all of the following EXCEPT:
a.
antibiotics for 10 to 14 days days
b.
extra rest
c.
interrupt breastfeeding for 48 hours
d.
moist heat to the involved region
( Module 3)
14.
Which of the following is most likely to have the greatest effect on the volume of milk a
woman produces?
a.
maternal caloric intake
b.
maternal fluid intake
c.
maternal weight for height
d.
supplementation of the infant with formula
e.
both a and c
( Module 2)
15.
16.
It is especially important that an infant with a strong family history of allergy should be
exclusively breastfed for:
a.
2 months
b.
4 months
c.
6 months
d.
8 months
e.
10 months
( Module 1)
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PostTest
17.
The most common cause of poor weight gain among breastfed infants during the first
four weeks after birth is:
a.
infant metabolic disorders
b.
infrequent or ineffective feedings
c.
low fat content of breast milk
d.
maternal endocrine problems
e.
maternal nutritional deficiencies
( Module 3)
18.
19.
20.
21.
Studies have indicated that the Lactational Amenorrhea Method (LAM) of contraception
is less reliable under which of the following circumstances:
a. is given no regular supplements
b. continues with night feedings
c. is less than 8 months old
d. feeds 8 or more times in 24 hours
( Module 3)
22.
Reasons for including Breastfeeding support for mother infant pairs in planning for or
responding to major emergencies where clean water,sanitation and power are disrupted
do not include:
a. Breastmilk provides immunoglobulins that actively prevent infection.
b. It is less expensive than providing for infant formula
c. In a stressful emergency situation breastfeeding provides a secure environment
for infants and young children
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PostTest
d. With support even mothers who have already weaned can be assisted to
relactate.
( Module 3)
23.
Which of the following statements is not true of The International Code of Marketing of
Breastmilk Substitutes approved as a resolution in the World Health Assembly (WHA) in
1981:
a. provides guidelines for the ethical marketing of infant formula
b. is incorporated into the Baby Friendly Hospital assessment
c. was approved by all WHA member countries
d. is updated every two years by the WHA
e. includes bottles, nipples, and breastmilk substitutes
( Module 2)
24. through 28. Label the structures of the breast by inserting next to the appropriate pointer
the number of the structure listed below:
24. Alveoli
25. Areola
26. Montgomerys glands
27. Duct
28. Supporting fat and other tissues
( Module 2)
24
26
27
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Possible Score: 28
Post-test score:
PostTest
Section V
Annexes
Annexes
A.
B.
C.
D.
E.
F.
G.
H.
I.
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Counseling Points
First 2 weeks:
Problems such as sore nipples Attachment assessment and
help
Lack of Support
Where to go for help
Support groups
At 3-4 weeks:
Mothers breasts no longer
feel firm between feedings
At 3-6 weeks:
Appetite spurt or growth
spurt
At 5-7 months
Eruption of teeth
6 months
Introduction of solids
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Correct
quality/quantity,
easier to digest
Appropriate
quality/quantity of
essential fatty acids,
lipase present
Commercial
Substitutes
Partly corrected
Lipase absent
Vitamins
Vitamins added
Minerals
Correct amount
Partly corrected
Anti-infective
properties
Present
Absent
Growth
factors
Present
Absent
Digestive
enzymes
Present
Absent
Hormones
Present
Absent
Permanent
.
Temporary
*note: these medical reasons for supplementation are consistent with the
Mastitis
Common cause:
Nipple abrasions
Milk stasis
Treatment:
Treat nipple abrasions and assure effective suckling.
Nurse more frequently (mastitis is an infection of the breast, not
the milk).
Apply moist heat for several minutes before each feeding
Relieve inflammation, pain and fever.
Take appropriate antibiotics as prescribed for 10 to14 days.
Rest as much as possible for at least 24 hours.
Drink more fluids to meet thirst needs.
WHO/NMH/NHD/09.01
WHO/FCH/CAH/09.01
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Preface
A list of acceptable medical reasons for supplementation was originally developed by WHO and
UNICEF as an annex to the Baby-friendly Hospital Initiative (BFHI) package of tools in 1992.
WHO and UNICEF agreed to update the list of medical reasons given that new scientific
evidence had emerged since 1992, and that the BFHI package of tools was also being updated.
The process was led by the departments of Child and Adolescent Health and Development (CAH)
and Nutrition for Health and Development (NHD). In 2005, an updated draft list was shared with
reviewers of the BFHI materials, and in September 2007 WHO invited a group of experts from a
variety of fields and all WHO Regions to participate in a virtual network to review the draft list.
The draft list was shared with all the experts who agreed to participate. Subsequent drafts were
prepared based on three inter-related processes: a) several rounds of comments made by experts;
b) a compilation of current and relevant WHO technical reviews and guidelines (see list of
references); and c) comments from other WHO departments (Making Pregnancy Safer, Mental
Health and Substance Abuse, and Essential Medicines) in general and for specific issues or
queries raised by experts.
Technical reviews or guidelines were not available from WHO for a limited number of topics. In
those cases, evidence was identified in consultation with the corresponding WHO department or
the external experts in the specific area. In particular, the following additional evidence sources
were used:
-The Drugs and Lactation Database (LactMed) hosted by the United States National Library of
Medicine, which is a peer-reviewed and fully referenced database of drugs to which breastfeeding
mothers may be exposed.
-The National Clinical Guidelines for the management of drug use during pregnancy, birth and
the early development years of the newborn, review done by the New South Wales Department of
Health, Australia, 2006.
The resulting final list was shared with external and internal reviewers for their agreement and is
presented in this document.
The list of acceptable medical reasons for temporary or long-term use of breast-milk substitutes is
made available both as an independent tool for health professionals working with mothers and
newborn infants, and as part of the BFHI package. It is expected to be updated by 2012.
Acknowledgments
This list was developed by the WHO Departments of Child and Adolescent Health and
Development and Nutrition for Health and Development, in close collaboration with UNICEF
and the WHO Departments of Making Pregnancy Safer, Essential Medicines and Mental Health
and Substance Abuse. The following experts provided key contributions for the updated list:
Philip Anderson, Colin Binns, Riccardo Davanzo, Ros Escott, Carol Kolar, Ruth Lawrence, Lida
Lhotska, Audrey Naylor, Jairo Osorno, Marina Rea, Felicity Savage, Mara Asuncin Silvestre,
Tereza Toma, Fernando Vallone, Nancy Wight, Anthony Williams and Elizabeta Zisovska. They
completed a declaration of interest and none identified a conflicting interest.
Introduction
Almost all mothers can breastfeed successfully, which includes initiating breastfeeding within the
first hour of life, breastfeeding exclusively for the first 6 months and continuing breastfeeding
(along with giving appropriate complementary foods) up to 2 years of age or beyond.
Exclusive breastfeeding in the first six months of life is particularly beneficial for mothers and
infants.
Positive effects of breastfeeding on the health of infants and mothers are observed in all settings.
Breastfeeding reduces the risk of acute infections such as diarrhoea, pneumonia, ear infection,
Haemophilus influenza, meningitis and urinary tract infection (1). It also protects against chronic
conditions in the future such as type I diabetes, ulcerative colitis, and Crohns disease.
Breastfeeding during infancy is associated with lower mean blood pressure and total serum
cholesterol, and with lower prevalence of type-2 diabetes, overweight and obesity during
adolescence and adult life (2). Breastfeeding delays the return of a woman's fertility and reduces
the risks of post-partum haemorrhage, pre-menopausal breast cancer and ovarian cancer (3).
Nevertheless, a small number of health conditions of the infant or the mother may justify
recommending that she does not breastfeed temporarily or permanently (4). These conditions,
which concern very few mothers and their infants, are listed below together with some health
conditions of the mother that, although serious, are not medical reasons for using breast-milk
substitutes.
Whenever stopping breastfeeding is considered, the benefits of breastfeeding should be weighed
against the risks posed by the presence of the specific conditions listed.
INFANT CONDITIONS
Infants who should not receive breast milk or any other milk except specialized
formula
Infants with classic galactosemia: a special galactose-free formula is needed.
Infants with maple syrup urine disease: a special formula free of leucine, isoleucine
and valine is needed.
Infants for whom breast milk remains the best feeding option but who may need
other food in addition to breast milk for a limited period
&O Infants born weighing less than 1500 g (very low birth weight).
&O Infants born at less than 32 weeks of gestation (very preterm).
&O Newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic
adaptation or increased glucose demand (such as those who are preterm, small for
gestational age or who have experienced significant intrapartum hypoxic/ischaemic
stress, those who are ill and those whose mothers are diabetic (5) if their blood sugar
fails to respond to optimal breastfeeding or breast-milk feeding.
MATERNAL CONDITIONS
Mothers who are affected by any of the conditions mentioned below should receive treatment
according to standard guidelines.
&OMaternal medication:
- sedating psychotherapeutic drugs, anti-epileptic drugs and opioids and their
combinations may cause side effects such as drowsiness and respiratory depression and
are better avoided if a safer alternative is available (7);
- radioactive iodine-131 is better avoided given that safer alternatives are available - a
mother can resume breastfeeding about two months after receiving this substance;
- excessive use of topical iodine or iodophors (e.g., povidone-iodine), especially on open
wounds or mucous membranes, can result in thyroid suppression or electrolyte
abnormalities in the breastfed infant and should be avoided;
- cytotoxic chemotherapy requires that a mother stops breastfeeding during therapy.
Breast abscess: breastfeeding should continue on the unaffected breast; feeding from the
affected breast can resume once treatment has started (8).
Hepatitis B: infants should be given hepatitis B vaccine, within the first 48 hours or as soon
as possible thereafter (9).
Hepatitis C.
Mastitis: if breastfeeding is very painful, milk must be removed by expression to prevent
progression of the condition(8).
Tuberculosis: mother and baby should be managed according to national tuberculosis
guidelines (10).
Substance use 2 (11):
- maternal use of nicotine, alcohol, ecstasy, amphetamines, cocaine and related stimulants
has been demonstrated to have harmful effects on breastfed babies;
- alcohol, opioids, benzodiazepines and cannabis can cause sedation in both the mother
and the baby.
Mothers should be encouraged not to use these substances, and given opportunities and
support to abstain.
The most appropriate infant feeding option for an HIV-infected mother depends on her and her infants individual circumstances, including her health
status, but should take consideration of the health services available and the counselling and support she is likely to receive. Exclusive breastfeeding is
recommended for the first six months of life unless replacement feeding is AFASS. When replacement feeding is AFASS, avoidance of all breastfeeding
by HIV-infected women is recommended. Mixed feeding in the first 6 months of life (that is, breastfeeding while also giving other fluids, formula or
foods) should always be avoided by HIV-infected mothers.
2
Mothers who choose not to cease their use of these substances or who are unable to do so should seek individual advice on the risks and benefits of
breastfeeding depending on their individual circumstances. For mothers who use these substances in short episodes, consideration may be given to
avoiding breastfeeding temporarily during this time.
References
(1) Technical updates of the guidelines on Integrated Management of Childhood Illness (IMCI). Evidence
and recommendations for further adaptations. Geneva, World Health Organization, 2005.
(2) Evidence on the long-term effects of breastfeeding: systematic reviews and meta-analyses. Geneva,
World Health Organization, 2007.
(3) Len-Cava N et al. Quantifying the benefits of breastfeeding: a summary of the evidence. Washington,
DC, Pan American Health Organization, 2002 (http://www.paho.org/English/AD/FCH/BOB-Main.htm,
accessed 26 June 2008).
(4) Resolution WHA39.28. Infant and Young Child Feeding. In: Thirty-ninth World Health Assembly, Geneva,
516 May 1986. Volume 1. Resolutions and records. Final. Geneva, World Health Organization, 1986
(WHA39/1986/REC/1), Annex 6:122135.
(5) Hypoglycaemia of the newborn: review of the literature. Geneva, World Health Organization, 1997
(WHO/CHD/97.1; http://whqlibdoc.who.int/hq/1997/WHO_CHD_97.1.pdf, accessed 24 June 2008).
(6) HIV and infant feeding: update based on the technical consultation held on behalf of the Inter-agency
Task Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers and their Infants, Geneva,
2527 October 2006. Geneva, World Health Organization, 2007
(http://whqlibdoc.who.int/publications/2007/9789241595964_eng.pdf, accessed 23 June 2008).
(7) Breastfeeding and maternal medication: recommendations for drugs in the Eleventh WHO Model List of
Essential Drugs. Geneva, World Health Organization, 2003.
(8) Mastitis: causes and management. Geneva, World Health Organization, 2000 (WHO/FCH/CAH/00.13;
http://whqlibdoc.who.int/hq/2000/WHO_FCH_CAH_00.13.pdf, accessed 24 June 2008).
(9) Hepatitis B and breastfeeding. Geneva, World Health Organization, 1996. (Update No. 22).
(10) Breastfeeding and Maternal tuberculosis. Geneva, World Health Organization, 1998 (Update No. 23).
(11) Background papers to the national clinical guidelines for the management of drug use during
pregnancy, birth and the early development years of the newborn. Commissioned by the Ministerial Council
on Drug Strategy under the Cost Shared Funding Model. NSW Department of Health, North Sydney,
Australia, 2006.
http://www.health.nsw.gov.au/pubs/2006/bkg_pregnancy.html
Further information on maternal medication and breastfeeding is available at the following United States
National Library of Medicine (NLM) website:
http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
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infant. The solution to helping malnourished women and infants is to feed the
mother not the infant. The mother will be less harmed by pathogens and she
obviously needs more food. By feeding her, you are helping both the mother and
child and harming neither. Remember that giving supplements to infants can
decrease milk production by decreasing suckling. The treatment for true milk
insufficiency is increased suckling frequency and duration.
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careful consideration and full awareness of the problems that may result. Human
milk substitutes must be:
9 limited to the special circumstances of the emergency;
9 guaranteed for the lifetime of emergency;
9 accompanied by additional health care resources, clean water, fuel, and
means to treat diarrhea;
9 include plans for the re-establishment of optimal feeding from the
outset of the emergency.
9 supervised by the local public health authorities.
9 be provided in accordance with the International Code of Marketing of
Breastmilk Substitutes
These guidelines should be disseminated and followed by all agencies working
in emergency situations.
1. Optimal Feeding Practices in Emergencies:
9
9
9
9
9
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MOTHER ACCOMPANYING
CHILD
Mother BF
child before
Lactation OK
Breastfeeding
support
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Wet nursing
acceptable
and available
Mother not
BF child
Lactation
Interrupted/reduced
Relactation
Support
Lactation possible
and acceptable
Lactation not
possible or
acceptable
Temperature
Room Temperature
16 29 C(60 85 F)
3 4 hours optimal
Refrigerator
< 4 C (39 F)
72 hours optimal
5 8 days under very
clean conditions
Freezer
< - 17 C (0F)
6 months optimal
12 months acceptable
__________________________________________________________________
Thumb here
Areola
Index finger here
X
5. Gently press your fingers and thumb back toward your rib cage and then gently compress
your thumb and fingers together just behind the areola.
6. Rotate the position of your fingers and thumb around the areola to express all areas.
7. Alternate breasts every few minutes or when the flow slows. Repeat the massage and
stroking of the breast and express cycle several times on each breast.
8. The appearance of the milk will change during the expression. At first the milk may appear
thin and alsmost clear. After the let-down reflex begins the milk appears more creamy
white. Some medications, foods and vitamins may slightly alter the color of the milk.
9. Note that the amount of milk obtained may vary at each expression. Dont worry this is
normal. It does not indicate that your milk production is declining.
10. You can express directly into clean glass or plastic bottles. Remember to not use plastic
bottles that contain Bisphenol A.
Wellstart International
www.waba.org.my
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Implications for child health programs. Public Health Nutrition: 9(7), 942-947.
(1)
21. de Onis, M, Garza, C, Onyango, AW, Martorell, R. (2006) WHO Child Growth
Standards. Acta Paediatrica Supplement 450, April 2006, 95:7-101 (1)
22. de Onis, M, Garza, C,Onyango, AW, Borghi (2007) Comparison of the WHO
child growth standards and the CDC 2000 growth charts. J.Nutr. 137:144148.(1)
23. Declercq, E et al (2009). Hospital practices and womens likelihood of fulfilling
their intention to exclusively breastfeed. AJPH 99 (5) 929-935.(2)
24. Dewey K, Heinig J, Nommsen-Rivers L (1995) Differences in morbidity
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(1)
25. Food and Nutrition Board, National Research Council, National Academy of
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26. Geddes, DT, Langton, DB, Gollow, I Jacobs, LA, Hartmann, PE , Simmer, K
(2008) Freulotomy for breastfeeding Infants with ankyloglossia: effect on milk
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28. Hale T (2012) Medications and Mothers Milk, Thirteenth Edition. Amarillo:
Hale Publishing. LP (1,3)
29. Hale, TW. Hartman, PE. (2007) Textbook of Human Lactation, First Edition,
Amarillo, TX. Hale Publishing, L.P. (1,2,3)
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