Breastfeeding
Basics
- Breast milk contains >200 active components that provide nutrition, immune protection, and gut microbiome support.
- Exclusive breastfeeding recommended for 6 months; continuation for ≥2 years as desired.
- Maternal benefits: rapid uterine involution, reduced postpartum bleeding, decreased postpartum depression, decreased risk of breast and ovarian cancer, type 2 diabetes, cardiovascular diseases.
- Infant benefits: ideal digestibility, reduced infections, lower risk of SIDS, obesity, diabetes, allergies, enhanced neurodevelopment.
Epidemiology
- US breastfeeding rates (2019):
- Any breastfeeding: 83.2%
- At 6 months: 55.8%
- At 12 months: 35.9%
- Exclusive at 6 months: 24.9%
Physiology
- Prolactin stimulates milk production; oxytocin mediates milk ejection (let-down reflex).
- Colostrum production starts ~5 months gestation.
- Milk production and ejection operate on supply-demand hormonal feedback.
- Conditions like diabetes, thyroid dysfunction, cystic fibrosis can delay lactation.
Prevention & Vaccinations
- Most vaccines (including COVID-19, Tdap, influenza, MMR) are safe in breastfeeding.
- Avoid live yellow fever and smallpox vaccines during breastfeeding.
Diagnosis and Physical Exam
- Assess breast anatomy, nipple status, prior breastfeeding difficulties, perinatal complications.
- Breast lumps during lactation require evaluation and may need imaging or biopsy.
Treatment & Management
Initiation
- Skin-to-skin contact immediately after birth promotes breastfeeding success.
- Proper latch: baby’s mouth covers areola, lips flanged, no nipple pain.
- Feeding frequency: 8+ times/day by day 2; 2-8 times in first 24 hrs.
- Avoid formula/water supplementation unless medically indicated.
Contraindications
- Maternal HIV (industrialized world), HTLV infection, untreated TB, active breast HSV lesions, substance abuse.
- Infant galactosemia and maple syrup urine disease contraindicate breastfeeding.
Support
- Referral to IBCLC or experienced providers for latch or supply issues.
- Frequent follow-up, especially for first-time breastfeeding parents.
Complementary Therapies
- Galactagogues: metoclopramide, domperidone, fenugreek, goat’s rue, milk thistle—efficacy not well-established.
- Breast lymphatic massage, acupuncture, cabbage leaves for engorgement.
Ongoing Care
- Monitor maternal milk supply and infant growth/output.
- Supplement if infant loses >10% birth weight but maintain milk stimulation.
- Avoid abrupt weaning; gradual introduction of solids from 4 months.
Diet
- Breastfeeding parents need ~500 extra calories/day.
- Hydration adequate; limit caffeine <300 mg/day; avoid alcohol.
- Vitamin D (400 IU/day) and iron supplementation recommended for infants.
Patient Education
- Exclusive breastfeeding for 6 weeks crucial for milk supply.
- Signs of adequate nursing: 6-8 wet diapers/day by day 6-8, appropriate weight gain (~1 oz/day).
- Educate on positioning, latch, and feeding on demand.
- Family planning options safe during breastfeeding include LAM, barrier methods, progesterone-only pills.
Complications
- Breast milk jaundice if prolonged neonatal jaundice >1 week.
- Plugged ducts: sore lump without fever, treat with warm compress and frequent feeding.
- Mastitis: fever, erythema, tenderness, requires antibiotics covering Staphylococcus aureus.
- Nipple soreness: evaluate latch, check for thrush or ankyloglossia.
- Engorgement: warm compress before feeding, pump if needed.
Clinical Pearls
- Support systems increase breastfeeding duration.
- Almost all can breastfeed successfully with correct information and support.
- Breast milk is optimal infant nutrition with benefits to both infant and lactating parent.