Counseling the Breastfeeding Mother
Breastfeeding always has been the criterion standard for infant feeding. Prior to the advent of commercial formulas, breastfeeding was, in truth, the only way to feed an infant. The 20th century brought with it a dramatic change in the way an infant could be fed; for the first time in the evolution of man, nonhuman milk formulas were created and mass produced in such a way that allowed infants to survive and reach adulthood.
In the 21st century, despite marked improvements in the composition of such formulas, breastfeeding remains the superior form of infant nutriture and also serves as an extrauterine directive of immune development.  The issues relevant for lactation success have changed as the world has changed. The ability to counsel breastfeeding women and a multiprong approach significantly impact her success, particularly in urban, low-income women. [2, 3, 4, 5]
A Cochrane Database review of 52 studies of 56,451 mother-infant pairs supports this claim. Results of the review show that all forms of extra support showed an increase in the length of time women continued to breastfeed and the length of time women breastfed without introducing any other types of liquids or foods. Both professional and lay supporters had a positive impact on breastfeeding outcomes. Face-to-face support was significantly more effective compared with telephone support. 
Separately, in February 2015, results of an online survey of 12 World Health Organization Western Pacific offices revealed that the most commonly reported reason women did not breastfeed was return to work (44%). 
With the reemergence of breast milk as the ideal source of infant nutrition, more women are choosing to breastfeed. However, a lack of community knowledge about breastfeeding and shorter hospital stays has led to more breastfeeding failures, a phenomenon that continues to this day.
Women and their infants are now being discharged earlier (12-24 h postdelivery); therefore, the tradition of the first follow-up at age 2 weeks must be replaced with earlier, more carefully planned assessments of the breastfeeding mother–infant dyad. Such early follow-up makes lactation success more likely and leads to a healthier infant. Successful follow-up depends on the healthcare provider’s knowledge of the mechanics of breastfeeding, the evaluation of successful lactation, and the interventions required if difficulties develop.
A 2012 Cochrane review recommended exclusive breastfeeding for the first six months of life in both developing and developed countries. 
This article reviews the mechanics of breastfeeding, correct breastfeeding techniques, and sufficient versus insufficient milk supplies. A discussion of early follow-up of the breastfeeding mother–infant dyad and the warning signs of difficulties in that dyad are also included. Emphasis is placed on assessing the breastfeeding neonate and determining when neonatal jaundice, more common in breastfed infants, is pathologic. Finally, common breastfeeding problems are discussed, with emphasis on their early recognition and management.
For more information about the physiology of lactation and about the structure and biochemical features of human milk, please see the Medscape Drugs & Diseases article Human Milk and Lactation. Another good resource is the following: Lawrence RA, Lawrence RM. Breastfeeding. A Guide for the Medical Profession. 6th ed. St. Louis, MO: Mosby, Inc; 2005.
Understanding the actual mechanism of how babies get milk into their bodies is important. Suckling and breastfeeding are often areas that are taken for granted because of their seemingly instinctive nature. However, the mechanics should not be forgotten or deemphasized because they are essential for a successful and uncomplicated breastfeeding experience. This understanding is helpful in ensuring the use of proper breastfeeding technique.
When breastfeeding begins, the nipple, surrounding areola, and underlying breast tissue are brought deeply into the infant’s mouth, with the baby’s lips and cheeks forming a seal (see the image below).
During feeding, the suction created within the baby’s mouth causes the mother’s nipple and areola mammae to elongate to 2-3 times their resting length and to form a teat. The nipple and areola extend as far as the junction between the baby’s hard and soft palates. The baby’s jaw then moves his or her tongue toward the areola, compressing it. This process causes the milk to travel from the lactiferous sinuses to the infant’s mouth. The baby then raises the anterior portion of the tongue to complete the process.
Afterward, the baby depresses and retracts the posterior portion of his or her tongue in undulating or peristaltic motions. This motion forms a groove in the tongue that channels milk to the back of the oral cavity and stimulates receptors that initiate the swallowing reflex. This backward movement creates a negative pressure, allowing milk to travel into the baby’s mouth. Throughout the suckling cycle, the nipple should not move in the infant’s mouth if it is correctly positioned.
When the volume of milk is sufficient to trigger swallowing, the back of the infant’s tongue elevates and presses against the posterior pharyngeal wall. The soft palate then rises, closing off the nasal passageways. The larynx then moves up and forward to close off the trachea, allowing milk to flow into the esophagus. The infant then lowers his or her jaw, the lactiferous sinuses refill, and a new cycle begins. A rhythm is created in which a swallow typically follows every 1-3 sucks.
Distinct differences between suckling from a breast and sucking from an artificial nipple are important to note. Suckling from the breast is an active process that involves participation of both the mother and her infant. In contrast, bottle-feeding is a more passive activity that results in the creation of a partial vacuum in the infant’s mouth through sucking. The artificial teat taken into the infant’s mouth has a distinct oral/tactile stimulation. When an infant sucks on an artificial nipple, the nipple fills his or her mouth and prevents the peristaltic tongue action that occurs with suckling at the breast. Milk flows from the artificial nipple into the mouth without tongue action; flow occurs from the rubber nipple even if the baby’s lips are not sealed around the nipple. Because of these differences, an infant is more likely to have a desaturation episode during bottle-feeding than during breastfeeding.
Lawrence and Lawrence (2005) discuss the phenomenon of human imprinting or stamping, which occurs early in the postnatal period.  Comfort sucking and the formation of a nipple preference are genetically determined behaviors that affect imprinting to the mother’s nipple. The baby’s initial recognition of his or her mother involves the distinctive features of the nipple. If an infant who is learning to breastfeed receives supplementation via a bottle or a pacifier, the nipple-recognition signals are mixed. Although some dispute the existence of nipple confusion, numerous documented cases support its existence. Certainly, studies have shown that supplementation and the introduction of a foreign nipple, such as a pacifier, are associated with decreased rates of continued breastfeeding.
Before the common breastfeeding positions and techniques are reviewed, an understanding of the importance of timing in initiating breastfeeding is essential. Studies show that a woman’s likelihood of continuing breastfeeding beyond the first month is related to the initiation of breastfeeding immediately after delivery.
Oxytocin levels at 15 minutes, 30 minutes, and 45 minutes after delivery are significantly elevated, coinciding with the expulsion of the placenta. Studies have linked maternal bonding and oxytocin levels. Therefore, encouraging the mother to have contact with her infant at a time when suckling is paired with high oxytocin levels and better letdown seems appropriate. In addition, the infant is alert soon after delivery and has not entered the deep sleep period that ensues approximately 6-12 hours after birth. Finally, personnel are more available to assist the mother in initiating breastfeeding during this immediate postpartum period.
Successful latch-on of the infant during this period enhances a mother’s confidence that she can breastfeed. If a mother received narcotic analgesics during delivery, the infant may be sleepy and less able to breastfeed; if so, the mother may need to wait until the infant is in a more alert state. The use of relaxation techniques during labor and other forms of anesthesia, such as epidural anesthesia, allows the infant to be delivered in a more fully awake state. This early breastfeeding session typically helps instill confidence in the mother. Early problems can be identified, and the mother can be offered assistance to facilitate the lactation process.
A 2012 review supports the practice of early initiation of breastfeeding that includes skin-to-skin contact between the mother and infant. Skin-to-skin contact is associated with a higher success of breastfeeding in the first one to four months. In addition, it is associated with improved infant homeostasis in the immediate postpartum period as well as decreased crying behavior. 
The mother and infant should be allowed to breastfeed in a relaxed and supportive environment. Personnel should be readily available to facilitate the process. Constant interruptions and a deluge of visitors may disrupt the early breastfeeding experience. The father’s assistance and support are strongly associated with the success of breastfeeding. In a study of 224 mothers who were interviewed regarding their feeding choice, the father was a key factor in the initiation of breastfeeding.  When the father supported breastfeeding, more than 75% of the mothers chose to breastfeed; in contrast, when the father did not support breastfeeding, only 2% of the mothers chose to breastfeed.
Often, the father can assist the mother with the positioning of the infant, particularly if she is recovering from a cesarean delivery. Thus, the father’s approval and involvement in the breastfeeding process is helpful in creating a supportive environment. Grandparents who support breastfeeding also facilitate the process; however, if they are not supportive of breastfeeding, their attitude can adversely affect the breastfeeding mother. Therefore, the mother who is breastfeeding and learning to know her newborn should be surrounded by a supportive caring team of healthcare providers and family members. 
Positioning the infant is one of the most fundamental components to successful breastfeeding. If no maternal or neonatal contraindications (eg, heavily medicated mother, low Apgar scores, known congenital anomalies of the GI tract, respiratory distress, prematurity) are present immediately after birth, the mother should be helped into a comfortable position. This position may be lying on her side on the hospital bed or sitting in a comfortable chair. The most common position involves cradling the infant next to the breast from which he or she will feed, with his or her head propped up by the mother’s arm. The infant should be placed with his or her stomach flat against the mother’s upper abdomen, in the same plane. This close contact also helps the infant maintain a normal body temperature. As noted above,  skin-to-skin contact is associated with a greater chance of successful breastfeeding.
Another holding position is the football hold, in which the infant is cradled in the mother’s arm with his or her head in the mother’s hand and the feet oriented toward the mother’s elbow. Mothers recovering from cesarean delivery may prefer this position because less pressure is placed on her abdomen. The mother then presents her breast to the infant, and the suckling process is initiated.
Two basic hand positions that the mother typically uses are the palmar grasp or C-hold and the scissor grasp. With the palmar grasp, the mother places her thumb above the areola, and she places her remaining fingers under the breast to form a “C” or “V.” The scissor grasp involves the placement of her thumb and index finger above the areola with the remaining 3 fingers below. The mother should ensure that the nipple is not tipped upward when she presents it to the infant because improper latch-on and nipple abrasion may result. In addition, the grasp should not impede the infant’s ability to place a sufficient amount of the areola into his or her mouth, which is necessary for adequate latch-on and suckling.
Infants instinctually open their mouths wide when the nipple touches their upper or lower lip. The tongue extends under the nipple, and the nipple is drawn into the mouth, initiating the suckling reflex. The mother’s nipple and areolar should be maneuvered to the infant’s open mouth instead of pushing the infant’s head toward the breast. Although this maneuver may appear simple, it may seem impossible to a first-time mother. Care should be taken to assist the mother not only with the positioning of her infant relative to her breast but also with understanding the importance of putting the nipple and areola into the infant’s mouth when it is open.
The suck-swallow pattern should be evaluated while the infant is breastfeeding. Proper latch-on is evident by the infant’s suckling and then swallowing. One can hear an infant’s feeding rhythm, which produces a characteristic sound. During the early postpartum period, the mother typically reports that she feels her uterus contracting while her infant is breastfeeding.
Simply asking a mother if breastfeeding is going well is not enough. Many women report that everything is fine, but when further questioned about nipple pain, hearing the infant suckle, or the frequency of breastfeeding, problems often surface. The best way to know if breastfeeding is going well is to observe the mother-infant dyad. This observation allows the staff to assist the mother with immediate feedback and corrective measures when necessary. The observation checklist by Lawrence and Lawrence (2005) is adapted below. 
Key observation checkpoints of the breastfeeding mother-infant dyad include the following:
Observe the position of the mother, her body language, and her level of tension. Offer pillows to support the mother’s arm or the infant. Help reposition the mother if necessary.
Observe the position of the infant. The mother and infant should be positioned ventral surface to ventral surface (ie, stomach to stomach). The infant’s lower arm, if not swaddled, should be around the mother’s thorax. The infant cannot swallow if he or she has to turn to face the breast because the infant’s grasp of the areola is poor in this position. The infant’s head should be in the crook of the mother’s arm and moved toward the breast by the mother’s arm movement.
Observe the position of the mother’s hand on the breast and ensure that it is not impeding proper grasping by the infant.
Observe the position of the infant’s lips on the areola. Typically, the lips should be 1-1.5 inches (2.5-3.8 cm) beyond the base of the nipple.
Observe the lower lip. If folded in, suckling does not occur. The lips should be flanged.
Observe the presentation of breast to the infant and the mother’s assisting the infant to latch-on.
Observe the response of the infant to lower lip stimulus. The infant should open his or her mouth wide to allow the insertion of the nipple and areola.
Observe the motion of the masseter muscle during suckling, and listen for sounds of swallowing.
Observe the mother’s comfort level, and ensure that she is not having breast pain.
One should reinforce a mother’s own physiologic cues during breastfeeding. A mother’s letdown is the interplay of her physiologic response to suckling and her emotional state. Prolactin, the hormone responsible for letdown, is inhibited by stress (mediated by dopamine, norepinephrine, and epinephrine). The mother’s relaxation ensures adequate letdown and the continued adequacy of breastfeeding.
Putting the infant to breast 8-12 times a day during the first 4-5 days after birth ensures the creation of an adequate milk supply, which the infant’s use later regulates. A mother who responds to her infant’s cry with letdown and who breastfeeds her infant on demand (ie, unrestricted breastfeeding) is more successful with continued lactation than the mother who breastfeeds according to the clock. The recommendation for mothers to use systematic or controlled timed feedings to help regulate the baby’s cycles is fraught with misinformation. A mother should be empowered to follow the internal schedule that is appropriate for her and her baby.
True difficulties in supplying milk to the infant are most commonly related to the irregular or incomplete removal of milk. In the human mammary gland, lactation is under autocrine control, in which the frequency and degree of milk removal appears to regulate an inhibitory peptide present in the milk. In other words, if the milk is not removed, this inhibitory peptide accumulates and subsequently decreases the synthesis of milk. If the milk is frequently removed, this inhibitory peptide does not accumulate, and milk synthesis increases.
Although most women are capable of producing more milk than their infants require, more than half of breastfeeding mothers perceive that their milk supply as inadequate. Results of an online survey of 12 World Health Organization Western Pacific offices revealed that the second most commonly reported reason women did not breastfeed was “not having enough milk” (17%). 
A mother may state that her milk is not “in” and that her infant is not getting enough milk. This misperception is most common during the immediate postpartum period. The neonate’s requirements for fluid gradually increase over the first few days; ideally, the neonate frequently ingests milk in small volumes. As the baby’s GI tract becomes more regulated and functional and as the stomach volume increases, the baby’s milk intake increases.
The composition changes of the milk from colostrum to mature milk, which has a higher energy density (ie, caloric density) because of its higher fat content. Mothers should be encouraged to breastfeed at least 8-12 times during the immediate postpartum period to increase their milk supply. If a mother breastfeeds only 4-5 times during those early days, her milk production is delayed. Infrequent breastfeeding is associated with neonatal jaundice (referred to as breastfeeding jaundice or dehydration jaundice) and the early cessation of breastfeeding.
Another perception of inadequate milk supply is related to the infant’s growth spurts. During periods of enhanced growth, the infant may be more irritable and may seek the breast more often. These growth spurts usually resolve in about 1 week. Growth spurts should be explained to the mother to prevent undue stress or interruptions in breastfeeding.
Near-term infants, those 35-38 weeks’ gestation who are mature enough to be discharged with mother, may not feed well initially; however, once breastfeeding is established, they may seem to feed “on the hour.” If an infant has increased milk intake (eg, during periods of catch-up growth), the breast should be emptied fully to allow the transfer of hind milk, with its higher fat content. Those infants who receive only foremilk receive higher concentrations of lactose, which allow the infant to grow well but may lead to gaseous distension and irritability, with explosive, watery stools. This phenomenon is sometimes called hyperlactation syndrome.
As mentioned above, one should counsel the mother to empty her breast fully. A feeding with pumped milk that has both the fore and hindmilk in combination may also alleviate some of the gastrointestinal symptoms. During such potentially stressful times for both the mother and infant, consultation with a breastfeeding medicine expert is warranted.
Because the milk supply is directly related to its removal and ongoing synthesis, factors that hinder milk removal affect milk production. Factors that could disrupt the complete removal of milk are numerous (see Recognition and Management of Common Breastfeeding Problems). For example, stress and fatigue in both parents may have an impact on the mother’s milk production. Evaluating for these risk factors in the mother-infant dyad is essential to ensure that the milk supply is sufficient and that breastfeeding difficulties are not perpetuated.
If an infant is ill, a mother typically uses a breast pump to remove and store her milk. Early on, the mother may have difficulty extracting colostrum using a breast pump. Manual expression is seen as a viable option in the days following delivery, with a transition to the use of electric breast pumps. Premature infants who are first learning to breastfeed may be ineffective at milk removal.
Some infants have neurologic disabilities or suck-swallow incoordination (common among premature infants born at < 34 weeks’ gestation). In those situations, a mother may need to pump her breasts after breastfeeding to maintain adequate lactation while her infant learns to more effectively breastfeed. By facilitating complete removal of the milk by using a pump, the mother’s supply remains abundant and thus easier for the infant to consume. Marianne Neifert, MD, uses this simile: “With an increase in a mother’s milk supply, feeding is like drinking from a fire hydrant; the infant cannot miss.”
In summary, factors affecting maternal milk supply include the following: (1) irregular or incomplete milk removal, (2) growth spurts, (3) maternal fatigue and stress, and (4) the infant’s medical condition (eg, prematurity, neurologic injury).
In accordance with recommendations from the American Academy of Pediatrics, breastfed neonates should be evaluated for breastfeeding performance within 24-48 hours after delivery and again at 48-72 hours after they are discharged from the hospital. At this follow-up visit, the newborn’s weight and general health assessment are determined. The assessment of breastfeeding performance includes a direct observation of the baby latching on and suckling. The neonate should be evaluated for jaundice, adequate hydration, and age-appropriate elimination patterns when he or she is aged 5-7 days.
Evaluate the infant’s breastfeeding performance in the hospital within 24-28 hours after delivery, as well as before the newborn is discharged.
If the infant was born late preterm (between 35-37 weeks’ gestation), the mother-infant dyad must be closely followed to ensure adequate hydration and breastfeeding to prevent breastfeeding jaundice. This group is particularly at risk for developing hyperbilirubinemia. Therefore, if discharged from the hospital at 24 hours after delivery, these infants require a follow-up visit at 48 hours for a weight and bilirubin check.
For term infants, follow-up with telephone contact or an office visit 48-72 hours after the neonate is discharged from the hospital is essential. Perform the following:
Visually inspect the mother breastfeeding her newborn.
Check the baby’s weight.
Assess the neonate’s general health status.
Ask the mother if latch-on and suckling at breast are good.
Ask the mother if she has sore or painful nipples.
Ask the mother about support or help at home.
Follow-up with an office or clinic visit when the neonate is aged 5-7 days. Perform the following:
Evaluate baby for jaundice, adequate hydration, and age-appropriate elimination patterns.
Assess maternal well-being. For example, evaluate for fatigue, stress, postpartum depression, sore nipples, and engorgement.
The options for early follow-up assessment of the breastfeeding mother-infant dyad are numerous and can include a home health visit, a consultation with a lactation specialist, a hospital follow-up program, or an appointment at a doctor’s office or clinic. Telephone counseling should be viewed as an additional support, but it should not replace a visit in person.
This degree of follow-up may seem excessive, but ensuring the well-being of the breastfeeding mother-infant dyad is imperative. Such follow-up helps eliminate the rare but tragic cases of death caused by dehydration secondary to inadequate breastfeeding. Most morbidity associated with poor breastfeeding, such as failure to thrive, hypernatremic dehydration, and jaundice can be prevented with early follow-up and an assessment of maternal and neonate risk factors for inadequate feeding. This follow-up also increases the rate of successful breastfeeding.
Numerous warning signs of ineffective breastfeeding are noted. For example, if milk production is inadequate secondary to poor latch-on or infrequent breastfeeding, the infant may become dehydrated with a concurrent increase in the sodium level. Prolonged hyperbilirubinemia may accompany the dehydration. Dehydration may occur over days, depending on the milk supply and the frequency of breastfeeding. In rare cases, the sodium concentration may be as high as 180 mmol/L. Nothing may be inherently wrong with the mother’s milk, but if it is not adequately removed from her breasts, either by suckling or by pumping, the milk becomes weaning milk with a higher sodium concentration. Another sign of dehydration in the newborn is listlessness, decreased tone and activity, and increased sleepiness.
The main reason that the sodium level increases in the infant is volume contraction secondary to dehydration and insufficient transfer of milk to the infant. Human milk is 87% water, but its composition changes if an insufficient amount of milk is removed from the breast. The treatment of an infant with hypernatremic dehydration is to replace the free water losses slowly because an abrupt decrease in the sodium level can trigger seizures secondary to cerebral edema and the rapid flux of sodium concentrations. This treatment involves giving the infant intravenous fluid with decremental concentrations of sodium to achieve a normal serum sodium level.
Another warning sign of ineffective breastfeeding is failure to thrive in the breastfeeding infant, which also results from an insufficient milk supply. An infant can have both hypernatremic dehydration and failure to thrive. These disorders occur along a spectrum depending on whether the milk produced is adequate to maintain the infant’s hydration state but insufficient to allow adequate growth. The primary care provider must assess the growth of the breastfeeding infant over time. Neonates typically regain their birth weight by 2 weeks of age, and their weight should increase by 50% at age 6-8 weeks. At 4-5 months of age, the baby’s weight should be double his or her birth weight. Also, the infant’s head circumference and length should be assessed. The monitoring of subcutaneous fat deposition also aids the clinician in assessing the adequacy of growth. An infant’s growth should follow the growth curve.
Failure to thrive in an infant should not be attributed to breastfeeding without an exploration of other differential diagnoses. The mother whose infant is failing to thrive should be encouraged to breastfeed with close assistance and, possibly, short-term supplementation. Daily visits for weight checks and overall health assessments are often necessary. In rare cases, hospitalization may be indicated.
The assessment of the breastfed infant includes an evaluation of its voiding and elimination patterns; feeding routines; jaundice; and, most importantly, weight. In addition, the mother should be examined for pain or irritation of her breast and nipples and for signs and symptoms of undue stress or fatigue.
Healthy breastfed neonates should not lose more than 5-10% of their birth weight and should regain birth weight by the time they are aged 10-14 days. One factor that may impact initial weight loss in the first 24 hours is maternal intravenous fluid just prior to delivery. Some infants have a brisk diuresis if mother was given fluid over the course of several hours. The weight at 24 hours may be more reflective of the true “birth weight.” However, care must be taken to ensure that weight loss is not from poor feeding and lack of milk transfer, especially in late preterm infants (35-37 weeks’ gestation).
Newborns should have a minimum average weight gain of 20 g/d between age 14 days and 42 days. The average weight gain during this time is 34 g/d for girls and 40 g/d for boys. In addition, breastfed neonates tend to gain weight faster than formula-fed neonates for the first 2-3 months, and the rate begins to slow at 6-12 months. Breastfed infants also tend to have leaner bodies than those of formula-fed infants. In preterm, formula-fed infants, a recent study concluded that preterm formula aided growth and mineralization better than term formula. 
In the first 48 hours after birth, the neonate may void as infrequently as a couple times a day. Once the mother’s milk supply is established, the baby voids after most feedings, usually 6-8 times a day.
As the mother’s milk supply is established, the infant’s stool changes from green-black meconium to yellow yogurtlike stools with seedy curds. This transition usually occurs by the infant’s fifth day of life. Compared with formula-fed infants, breastfed infants tend to have more frequent and higher-volume bowel movements during their first 2 months of life. At weeks 4-6, an infant should pass at least 3 yellow stools of sufficient volume per day; if not, the possibility of inadequate milk intake must be considered. The number of stools gradually decreases after this time; by 2-3 months, several days or a week may pass before an infant has a stool.
As discussed in Factors Affecting the Maternal Milk Supply, incomplete breast emptying frequently causes insufficient milk production. An inadequate frequency or duration of breastfeeding is a common preventable cause of decreased milk production and thus intake. The expected frequency of breastfeeding in newborns is once every 2-3 hours. Breastfeeding should last approximately 10-15 minutes per breast and should include active suckling with short pauses and frequent audible swallows.
Early follow-up of the mother-infant dyad supports breastfeeding and the continued good health of the neonate. Although assessing the infant’s weight and state of hydration (skin turgor, capillary refill, hydration of mucous membranes) is vitally important, the interaction between infant and mother must also be assessed. Early breastfeeding is fatiguing and possibly overwhelming, especially for the primiparous mother. In addition to the physiologic assessment of the infant, the staff should encourage the mother and discuss ways to decrease her fatigue (eg, napping when the infant is napping, waking the infant during the day if his or her day-night cycle is switched, taking walks, talking with other mothers and friends).
Postpartum depression may occur in the early postpartum period. Early recognition is essential for appropriate treatment. Women often do not see their obstetricians until 6 weeks after delivery; therefore, the physician who is caring for the infant and mother becomes an important link in the care of the infant and mother. A mother who has depression often has difficulties with her daily activities, including breastfeeding. The early follow-up visit helps with the early identification of problems and with the initiation of appropriate intervention.
Hyperbilirubinemia occurs in nearly all newborns and can be classified in several categories, including pathologic jaundice, physiologic jaundice of the newborn, breastfeeding jaundice, and breast milk jaundice.
Jaundice in the first 24 hours after birth is not normal and causes, such as sepsis and blood type incompatibility, should be sought.
Physiologic jaundice is due to a higher erythrocyte circulating volume, a larger amount of precursors that undergo early degeneration, and a shorter life span of the newborn’s erythrocytes. In addition to these physiologic considerations, the newborn hepatic uptake and conjugation of bilirubin are reduced, and the reabsorption of bilirubin is relatively enhanced due to a process called enterohepatic recirculation. These factors can lead to an early elevation in unconjugated bilirubin levels, which typically become normal adult values when the neonate is aged 2-3 weeks.
In addition to physiologic jaundice, breastfeeding jaundice or dehydration jaundice may develop in infants who breastfeed. Breastfeeding jaundice is due to inadequate milk intake, regardless of the cause. This condition occurs in the neonate’s second or third day of life, usually before the mother’s milk supply is in. The treatment is to put the infant to the breast more frequently, and the mother-infant dyad should be observed for proper latch-on. Maternal pumping with supplementation should be considered only if increasing the breastfeeding frequency does not lead to an increased milk supply. Evaluation of the overall nutritional status and breastfeeding technique of the mother-infant dyad is essential for successful lactation and the resolution of breastfeeding jaundice.
Breast milk jaundice is different from breastfeeding jaundice in that unconjugated bilirubin levels in the serum continue to increase during the first 2 weeks. With breast milk jaundice, the unconjugated bilirubin level typically peaks between days 5 and 15 after birth, and they usually return normal levels by the end of the third week. However, elevated levels that persist into the third month are not uncommon.
Interrupting breastfeeding in an otherwise healthy infant is not recommended unless the serum bilirubin concentration exceeds 20-22 mg/dL. The cause of breast milk jaundice is still not clear. Potential causes include an inhibitor of hepatic glucuronyl transferase and/or an increase in the enterohepatic circulation of bilirubin. The differential diagnosis includes glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, especially in black and Asian infants. Other more rare forms of unconjugated hyperbilirubinemia, such as Crigler-Najjar syndrome (ie, glucuronyl transferase deficiency), should be considered if the bilirubin level remains elevated after the infant’s first month of life.
Mother-infant pairs who are at risk for breastfeeding difficulties should have closer follow-up care. Risk factors in the mother include a history of poor breastfeeding with a previous newborn, flat or inverted nipples, abnormal breast appearance, previous breast surgery, previous breast abscess, extremely sore nipples, minimal prenatal breast enlargement, failure of the milk to come in abundantly after delivery, and chronic or severe medical problems, including diabetes. Breastfeeding risk factors in the infant include small size or prematurity, poor sucking, any oral abnormality, multiple gestation, medical problems, or neurologic or muscle-tone problems.
Risk factors in the infant include premature birth, neurologic abnormalities, hyperbilirubinemia (sleepy baby), shortened frenulum (“tongue-tie”), and having been fed with a bottle prior to breastfeeding.
Common breastfeeding problems and their solutions include the following:
Engorgement: The treatment is prevention with frequent breastfeeding.
Areolar engorgement: Treatment involves the manual expression or pumping of milk to soften the areola and allow better latch-on
Mammary vascular engorgement: Treatment involves frequent breastfeeding around the clock, the application of cabbage leaves, and manual or electric pumping.
Sore nipple: This problem is commonly associated with improper latch-on. Help the mother with positioning and encourage her to insert the areola and nipple into the infant’s open mouth.
Cracked nipple: The mother should begin the breastfeeding session on the less-affected side. Placing a drop of milk on each nipple and allowing this to air dry after breastfeeding may help. The use of high-grade lanolin or nipple shields should be considered if bleeding occurs. Correcting the cause of the cracked nipple, such as incorrect positioning/latch or contact of the nipple with coarse fabric or use of a bra with a seam (as opposed to a nursing bra), is essential.
Mastitis: This problem is more common in engorged breasts. If engorgement is not effectively treated, the mother is at greater risk of developing mastitis in one or both breasts. If diagnosed with mastitis, the mother should continue to breastfeed while taking antibiotics. Common antibiotics include cephalosporins and dicloxacillin. Frequent emptying of the breast is essential for relief and recovery. The mother may also take acetaminophen or ibuprofen for relief. Mastitis can present with flulike symptoms, with fever, malaise, and chills. However, evaluation of the mother’s breasts relieves the main cause of symptoms.
Abscess: This problem typically requires surgical incision and drainage, as well as antibiotics. The mother should continue to breastfeed on the unaffected side and pump the affected side to relieve pressure and facilitate recovery. The infant may be breastfed on the affected side when the breast is no longer painful to touch. Analgesia is essential for mother’s comfort.
Yeast infection of the breast: Candida albicans, which causes thrush in infants, may infect the nipple and intraductal system. Complaints of the mother include pain during breastfeeding or a diminution of her milk supply. Culture samples obtained from the skin. Treatment may begin with topical nystatin, but systematic therapy may be required for eradication.
“Nipple confusion:” So-called nipple confusion is really flow confusion. The infant becomes accustomed to receiving milk from a bottle, with immediate flow of milk upon sucking. With breastfeeding, especially in the beginning, the infant must “work” to achieve milk let-down. Have the mother pump or use hand expression for a few minutes prior to putting the infant to breast. If the infant is frantic and hungry, a caregiver may feed the infant a few milliliters of expressed milk via syringe or cup to calm the infant. The mother should then put the infant to breast with a syringe of milk handy to place droplets of her milk on her nipple to facilitate latch.
Premature infants: Preterm infants lack the fat pads in the mouth that allow a good seal around the nipple and areola. They also have difficulties with suck, swallow, and breath. Putting an infant to an emptied breast first to learn to suckle without a deluge of milk may be necessary. Gradually, as the infant matures over days to weeks, the mother can pump her breasts less and put the infant to breast earlier. Some infants benefit from the use of a nipple shield (silicon) that creates a negative pressure around the nipple facilitating milk flow and latch. As the infant develops oral motor control, the nipple shield is discontinued.
Infants with neurological issues: Infants with neurological issues may require an approach similar to that of the preterm infant. Unlike the preterm infant who is likely to gain oral motor skills over time, some infants with neurological issues do not show oral motor improvement. Each case must be assessed to adapt the breastfeeding process to the skills of the infant and mother.
Shortened frenulum: As more women have chosen to breastfeed, the importance of a shortened frenulum has surfaced. Older physicians who were skilled at frenotomy (“clipping” the frenulum) are training a new generation of physicians to perform this simple technique. In areas where no one is skilled at this procedure, an ear, nose, and throat specialist may be consulted.
Engorgement is a common breastfeeding problem, and its prevention is important. A mother should be encouraged to breastfeed several times a day to establish her milk supply and to ensure relief after her milk has come in. If a mother’s breasts are so distended that the nipple is obscured, the infant may have difficulty in latching on. A mother may manually express or pump her milk to relieve the tension and distortion of the breast, which makes the nipple available for suckling by the infant. The mother should continue this cycle frequently as her breasts regulate to the requirements of her infant.
Cabbage leaves, either whole or as a minced paste, have been shown to relieve the swelling and pain of engorgement within 12-24 hours of application. The use of lanolin is not helpful in engorgement. Recommending that the mother discontinue breastfeeding is not appropriate because breast milk is the preferred source of nutrition for the infant and because the mother has shown that she desires to breastfeed with her action of initiating breastfeeding.
The misperception of an insufficient milk supply is common, particularly with first-time mothers. A mother who plans to breastfeed should undergo a prenatal assessment to evaluate her breast development during pregnancy: Does she have sufficient glandular tissue? Are her breasts tubular? Do you see milk veins and pigment changes in the nipples/areola? Is colostrum visible at the nipple when pressed by 20-24 weeks’ gestation? One should assess the condition of her nipples (eg, are they inverted?) and discuss strategies to achieve successful lactation. These strategies include frequent breastfeeding every 1.5-2 hours during the first few days. If a mother does not breastfeed frequently enough, her milk production is delayed.
The first-line treatment for an insufficient milk supply is to have the mother breastfeed frequently because any milk removed is quickly replaced. If a mother has been too ill to breastfeed or pump her milk or if her infant is too ill to breastfeed, the mother may have an insufficient milk supply. Again, the mother should be encouraged to breastfeed, if her infant is able, or to pump her breasts to stimulate milk production.
Women who have had breast reduction surgery are at greater risk of insufficient milk supply, especially if the innervation to the nipple has been compromised. Along with the excised fat tissue of the breast, the woman have also lost a fraction of her ductules/ducts, decreasing the potential production of milk. Despite the history, a woman should be supported to attempt breastfeeding. If her milk supply is insufficient, she may still breastfeed with the use of a supplemental nursing system.
Women who have undergone breast augmentation typically fare better than those who have had breast reduction—as long as the nipple and areolar have not been surgically altered. If a woman had insufficient glandular tissue to begin with, then she would still be at risk of a lower milk supply. Every attempt should be made to support these mothers and optimize breastfeeding for that woman.
Galactagogues or milk production enhancers may facilitate milk production. Probably the best known agent with the fewest adverse effects is fenugreek, a herb used in Indian curries and cooking. It is well tolerated by most women. It can be taken as a tea (2-3 cups of tea per day) or as a capsule (two 500-mg capsules 3 times daily for a total of 6 caps per day). Milk production should increase within 48-72 hours.
Other herbal remedies include fennel seeds brewed as a tea (1 tsp boiled in water and steeped for 10 min, served 2-3 times per day), milk thistle, and goat’s rue. Contraindications to these herbal remedies include the current use of antiepileptic agents, Coumadin, or heparin because the herbs may affect drug levels or clotting parameters.
Metoclopramide (Reglan) acts as a potent stimulator of prolactin release and has been used to treat lactation insufficiency. Although the US Food and Drug Administration (FDA) has not approved metoclopramide for this indication, a dose of 10 mg orally 3-4 times daily has been shown to increase milk production. An increase of milk letdown response was experienced by as many as 60% of women within 3-7 days. Limit use to a maximum of 10-14 days, with a gradual taper. Rarely, a woman may experience a dystonic reaction early on. Prolonged use is associated with clinical depression in some women, but differentiating this from postpartum depression may be difficult. Coadministration of opioid analgesics with metoclopramide may increase CNS toxicity.
Domperidone is used as a galactogogue worldwide. It is not approved for use in the United States, and the FDA cautions against its use because of reports of arrhythmias when intravenously administered. Despite this caution, thousands of women acquire the drug at local pharmacies where the drug is compounded. Many women report fewer side-effects with domperidone because it does not cross the blood-brain barrier and its prolonged use is not associated with postpartum depression. Documentation in the medical record must state why the drug is prescribed and that the potential risks have been discussed with the mother. The dose prescribed is the same as metoclopramide (ie, 10 mg orally 3-4 times daily for 3-7 d and then gradually tapering the regimen over days to weeks).
Large trials of galactagogues are lacking. Available data come from small studies and case reports.
The American Academy of Pediatrics (2008) recommends universal vitamin D supplementation (400 IU/d) starting a few days after delivery.  This recommendation follows in the wake of widespread vitamin D deficiency in the United States and other countries in all age groups. The reason that breastfed infants are deficient in vitamin D is not because human milk is deficient in vitamin D per se but because mothers who are deficient in vitamin D have vitamin D–deficient milk, which leads to vitamin D deficiency in the infant.
Studies are underway to determine if higher maternal vitamin D supplementation doses will safely and effectively increase milk vitamin D levels that will lead, in turn, to optimal vitamin D status in the breastfeeding infant.  In this way, both mother and infant could be replete. Until such studies are completed and published, a safe alternative is for infants to receive a vitamin D-only supplement to provide 400 IU vitamin D/d.
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Carol L Wagner, MD Professor of Pediatrics, Medical University of South Carolina
Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Womens Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Nutrition, Massachusetts Medical Society, National Perinatal Association, Society for Pediatric Research
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Brian S Carter, MD, FAAP Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Attending Physician, Division of Neonatology, Children’s Mercy Hospital and Clinics; Faculty, Children’s Mercy Bioethics Center
Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Pediatric Society, American Society for Bioethics and Humanities, American Society of Law, Medicine & Ethics, Society for Pediatric Research, National Hospice and Palliative Care Organization
Disclosure: Nothing to disclose.
Ted Rosenkrantz, MD Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Eastern Society for Pediatric Research, American Medical Association, Connecticut State Medical Society, Society for Pediatric Research
Disclosure: Nothing to disclose.
The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors Nikki Hughes, MD; Eric M Graham, MD; and William W Hope, MD, to the original writing and development of this article.
George Cassady, MD Clinical Professor, Department of Pediatrics, Stanford University School of Medicine
George Cassady, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Society for Pediatric Research, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.
Counseling the Breastfeeding Mother
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