Breastfeeding


Article Author:
Saieda Kalarikkal


Article Editor:
Jennifer Pfleghaar


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
6/17/2019 3:26:51 PM

Definition/Introduction

Breastfeeding is an important part of a newborn's life. Breastfeeding or lactation provides total nutritional and emotional dependency of the baby on the mother. The strong emotional bonding between the mother-child dyad is needed for successfully prolong breastfeeding.[1] Breast milk is recommended as the optimal and exclusive source of early nutrition for all infants from birth to at least 6 months of age. Maternal milk is crucial for development.[2]

Milk production is regulated by the maternal hypothalamus and pituitary gland-derived hormones. Oxytocin and prolactin are the main hormones that play the role of milk production and the resulting letting down reflex.[3]

There are distinct stages seen in milk production which start before the birth of the baby. The first milk is colostrum which is available after labor. Occasionally, there is pre-colostrum before the postpartum stage. 

Colostrum is high in protein, sodium, and immunoglobulins while being low in lactose, and this is the first milk produced for the baby.[4] After  30 to 40 hours postpartum, the milk composition changes by an increase of lactose and dilution of other constituents as the volume increases.

Subsequently, the maintenance of lactation follows an autonomous pattern wherein the sucking of the baby and emptying of the breast are the main factors regulating the milk flow.[5]

Issues of Concern

Establishment of smooth bonding between the mother and baby is essential for successful breastfeeding.[6]

Baby and maternal factors can influence this bonding. Skin-to-skin contact in the first 2 hours after birth is essential for successful initiation of lactation. The breast crawl, soon after birth, while the baby is alert will initiate the bonding, and it will be an assurance by giving comfort and calm to the mother. The breast crawl is when the baby is placed on the mother's abdomen after birth; the baby finds its way to the breast to suckle.[6][7]

Successful breastfeeding factors related to the baby include proper latching, alertness of the baby, rooting reflex, and active sucking reflex. Although lactation is a natural process, the mother needs support and education for proper positioning and latching.[8] The ability of the baby to empty the breast will determine the subsequent milk volume.[9][5]

Maternal factors like pain, anxiety, emotional instability, among others should be addressed before and after delivery. Lactation consultants or knowledgeable nurses can also be helpful with initiating of breastfeeding.[10]

Father and other supportive individuals, including physicians, also have an important role for the reassurance of the mother and the baby.[11][12]

Getting a correct latch on the nipple is important. If the latch is not correct due to issues such as lip tie or tongue tie, the mother can develop cracked nipples or pain while breastfeeding.[13] An evaluation by a lactation consultant or other health professional comfortable with diagnosing lip and tongue ties may be helpful.

The use of medications needs to be addressed while the mother is breastfeeding. Women should not be told to stop breastfeeding, but careful attention needs to be placed to find alternatives that are safe to use while breastfeeding. Some studies show women take more medication while breastfeeding compared to pregnancy.[14]

Clinical Significance

Colostrum is highly significant due to its immune-boosting effects because of the high amount of immunoglobulins.[15] It often referred to as the baby's first immunization. It produces mucosal immunity to the gastrointestinal (GI) tract via the secretory IgA (sIgA), IgM, and IgG. These vital immunoglobulins give barrier protection to the gut and also play a vital role in fighting the germs.

Milk contains microbiota like Bifidobacterium and Lactobacillus and this along with the oligosaccharides confer anti-bacterial activity to the gut.[16][17]  Furthermore, this results in the synthesis of essential nutrients such as vitamin B12, B6, folate, and vitamin K. Early introduction of breastfeeding will help in establishing the naturally sterile gut of the baby to colonize with these safe micro-organisms and also maternal organisms, rather than colonizing with the organisms of the hospital baby room and of the other caretakers. So early rooming in, where the baby is kept with the mother, is advisable.

Another component, lactoferrin, will act by increasing iron absorption and preventing its degradation by bacteria. Bacteria utilize this for its proliferation. It confers an immune protective action against bacterial, viral, fungal and parasitic infections.[18]

Milk produced can be classified as foremilk and hindmilk. Foremilk contains higher levels of lactose while hindmilk contains a higher proportion of proteins and fats. The baby's nutritional need controls the milk quantity and components. The knowledge of high lactose foremilk and high fat of hindmilk will help the mother to regulate the feed from both breasts.[19]

There is ample evidence showing that breastfeeding lowers the risk of upper respiratory tract infections and diarrhea in the newborn. Other postulated benefits include a lower risk of developing asthma, type 1 diabetes, food allergies, and obesity. Breastfeeding may also delay the return of menstruation. Also of importance is that breastfeeding is a lot cheaper than formula-which is of practical importance to women who are poor. In the United States,  about 75% of women start breastfeeding, but the majority stop the practice within a few months. The use of alcohol, smoking, or coffee is not valid reasons to stop breastfeeding. In general, breastfeeding can be stopped between 6 to 12 months, although some women breastfeeding until the child is 2 to 4 years.

A lactation consultant should provide emotional comfort to the mother. Empowering the mother is very important. The mother should have full confidence and full control of her baby‘s needs and feeds. She should have a positive attitude. Any negative comment, or even usage of negative words, like problem, difficulty, inadequate, improper, among others should be avoided entirely during the counseling of the mother. Presence of the postpartum disorders like depression and postpartum psychosis may be subtle in presentation and can rapidly deter breastfeeding. These emotional conditions should be kept in mind while managing the postpartum difficulties and breastfeeding failure. A lactation consultant should be provided during the hospital stay and after she leaves the hospital.[10]

Nursing Actions and Interventions

In Breast milk jaundice, addition of 5 ml of artificial baby milk (ABM) in every feed (minimum 6 feeds) prior to initiation of breast milk for 3 days will bring the bilirubin down to safe levels and tends to remain so. Mothers who recieve this regime should be counselled not to carry on with ABM afterwards.[20] 


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Breastfeeding - Questions

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Breastfeeding is safe with which drug?



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What is the best intervention for an infant having difficulty maintaining lip seal with a bottle and nipple?



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Which statement is true regarding breastfeeding?



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Approximately what percentage of newborns in the United States were breastfed in 2013?



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Which is the least appropriate contraceptive for women who want to continue breastfeeding?



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A 17-year-old woman was diagnosed with HIV while pregnant. What would be the feeding options recommended for her infant?



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A mother is breastfeeding her 1-month-old infant exclusively. She is wondering if she should supplement the infant diet with other foods. What advice should she be given?



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A postpartum mother is trying to breastfeed her baby. Her breasts feel engorged and do not empty as the baby feeds. Which of the following is the treatment of choice to relieve the breast engorgement?



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An anicteric, breastfed infant is losing weight since birth and has no signs of dehydration. What should the mother do?



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Which of the following drugs is contraindicated when breastfeeding?



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What is not true about breastfeeding?



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What is a good way to know the baby is getting enough milk through breastfeeding?



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Which of the following is a benefit of breastfeeding?



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What is not decreased by breastfeeding?



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Which of the following would not be appropriate patient education for breastfeeding?



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Which of the following is not a known benefit to providing breast milk to a newborn infant?



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A 33-year-old G2P2 mother comes to your office following the birth of her second child via normal spontaneous vaginal delivery. Her chief complaint is listed as "concerns about lactation". Which of the following is not a common concern for lactation?



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What senses are used by the neonate for successful breast crawl?



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A 3-month-old infant is brought to the clinic weighing 6 kg. His birth weight was 3 kg. Which of the following factors contributes most to this weight change?



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A young Asian couple presents to the clinic anxious about their first-born. The baby is seven days old, female, born normally with a birth weight of 2.55 kg. They report the baby has frequent loose stools and 7-8 episodes of urination per day. They show an earlier report taken two days back showing bilirubin of 9.4 mg%. On evaluation, weight is 2.4 kg, yellow discoloration is visible, and bilirubin is 14.5 mg%. Which of the following is the most appropriate advice for the couple?



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Breastfeeding - References

References

Alzaheb RA, A Review of the Factors Associated With the Timely Initiation of Breastfeeding and Exclusive Breastfeeding in the Middle East. Clinical medicine insights. Pediatrics. 2017     [PubMed]
Uvnäs-Moberg K,Widström AM,Werner S,Matthiesen AS,Winberg J, Oxytocin and prolactin levels in breast-feeding women. Correlation with milk yield and duration of breast-feeding. Acta obstetricia et gynecologica Scandinavica. 1990     [PubMed]
Żelaźniewicz A,Pawłowski B, Maternal breast volume in pregnancy and lactation capacity. American journal of physical anthropology. 2018 Nov 8     [PubMed]
Weaver SR,Hernandez LL, Autocrine-paracrine regulation of the mammary gland. Journal of dairy science. 2016 Jan     [PubMed]
Schwartz R,Ellings A,Baisden A,Goldhammer CJ,Lamson E,Johnson D, Washington 'Steps' Up: A 10-Step Quality Improvement Initiative to Optimize Breastfeeding Support in Community Health Centers. Journal of human lactation : official journal of International Lactation Consultant Association. 2015 Nov     [PubMed]
Zanardo V, Breast crawl: the attractive warmth of the mammary areola. Acta paediatrica (Oslo, Norway : 1992). 2018 Oct     [PubMed]
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Peaker M,Wilde CJ, Feedback control of milk secretion from milk. Journal of mammary gland biology and neoplasia. 1996 Jul     [PubMed]
van der Zee-van den Berg AI,Boere-Boonekamp MM,Groothuis-Oudshoorn CGM,IJzerman MJ,Haasnoot-Smallegange RME,Reijneveld SA, Post-Up Study: Postpartum Depression Screening in Well-Child Care and Maternal Outcomes. Pediatrics. 2017 Oct     [PubMed]
deMontigny F,Gervais C,Larivière-Bastien D,St-Arneault K, The role of fathers during breastfeeding. Midwifery. 2018 Mar     [PubMed]
Wang S,Guendelman S,Harley K,Eskenazi B, When Fathers are Perceived to Share in the Maternal Decision to Breastfeed: Outcomes from the Infant Feeding Practices Study II. Maternal and child health journal. 2018 Nov     [PubMed]
Verd S,Ginovart G,Calvo J,Ponce-Taylor J,Gaya A, Variation in the Protein Composition of Human Milk during Extended Lactation: A Narrative Review. Nutrients. 2018 Aug 20     [PubMed]
Dzidic M,Boix-Amorós A,Selma-Royo M,Mira A,Collado MC, Gut Microbiota and Mucosal Immunity in the Neonate. Medical sciences (Basel, Switzerland). 2018 Jul 17     [PubMed]
Toscano M,De Grandi R,Grossi E,Drago L, Role of the Human Breast Milk-Associated Microbiota on the Newborns' Immune System: A Mini Review. Frontiers in microbiology. 2017     [PubMed]
Telang S, Lactoferrin: A Critical Player in Neonatal Host Defense. Nutrients. 2018 Sep 4     [PubMed]
Mizuno K,Nishida Y,Taki M,Murase M,Mukai Y,Itabashi K,Debari K,Iiyama A, Is increased fat content of hindmilk due to the size or the number of milk fat globules? International breastfeeding journal. 2009 Jul 16     [PubMed]
Gertosio C,Meazza C,Pagani S,Bozzola M, Breastfeeding and its gamut of benefits. Minerva pediatrica. 2016 Jun     [PubMed]
Feenstra MM,Jørgine Kirkeby M,Thygesen M,Danbjørg DB,Kronborg H, Early breastfeeding problems: A mixed method study of mothers' experiences. Sexual & reproductive healthcare : official journal of the Swedish Association of Midwives. 2018 Jun     [PubMed]
Saha MR,Ryan K,Amir LH, Postpartum women's use of medicines and breastfeeding practices: a systematic review. International breastfeeding journal. 2015     [PubMed]
Flaherman VJ,Aby J,Burgos AE,Lee KA,Cabana MD,Newman TB, Effect of early limited formula on duration and exclusivity of breastfeeding in at-risk infants: an RCT. Pediatrics. 2013 Jun;     [PubMed]

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