Breastfeeding Support

and Promotion
Joan Younger Meek, MD, FAAP
AAP Section on Breastfeeding

Management of Breastfeeding
Breastfeeding initiation
Recommended breastfeeding
practices
Weight pattern
Hypoglycemia
Jaundice
Employment

Breastfeeding Promotion in Physicians

Office Practices Curriculum
3 Key Educational Tools for Physicians to
Teach New Mothers
Nutritional parameters
Hand expression
Latch and positioning

AAP Policy Statement

Recommended Breastfeeding Practices
Initiate in the first hour.
Keep newborn and
mother together in
recovery and after.
Avoid unnecessary oral
suctioning.
Avoid traumatic
procedures.
AAP Pediatrics 2012;129:e827-841.

Breastfeeding Initiation
Skin-to-skin contact
Promotes physiologic
stability
Provides warmth
Enhances feeding
opportunities
Infant crawls to breast
and self-attaches

Photo Joan Younger Meek, MD, FAAP

Delay weights and measurements, vitamin K

and eye prophylaxis until after first feeding
Knowledgeable breastfeeding advocate in
labor & delivery

AAP Policy Statement

Recommended Breastfeeding
Practices:
Avoid the routine use of supplements
unless there is a true medical indication
and the physician has ordered the
supplement
Avoid the use of pacifiers in healthy, term
infants, until breastfeeding is well
established (approximately 3-4 weeks of
age)

Medical Indications for

Supplementation
Very low birth weight or some premature infants
Hypoglycemia that does not respond to
breastfeeding
Severe maternal illness
Inborn errors of metabolism
Acute dehydration not responsive to routine
breastfeeding or excessive weight loss
Maternal medication use incompatible with
breastfeeding
Academy of Breastfeeding Medicine Clinical Protocol #3: Hospital
guidelines for the use of supplementary feedings in the healthy
term breastfed neonate.(www.bfmed.org)

AAP Policy Statement

Feeding Pattern
Encourage at least 812 feedings per day.
Alternate the breast that is offered first.
Allow infant to nurse on at least one side until
infant falls asleep or comes off the breast to
increase fat and calorie consumption.

Infant Assessment
Infant Weight
Weight Loss
Average loss of about 6% over the first 34 days.
Loss greater than 8-10% mandates careful
evaluation of breastfeeding.

Weight Gain
Begins with increase in mothers milk production by
at least day 45.
Expect gain of 1530 g/day (1/2 to 1 oz per day)
through the first 23 months of life.

Infant Assessment
Poor Weight Gain
Problem
Inadequate milk supply or milk transfer.
Solution
Weigh infant, feed infant, weigh again.
Evaluate infant at the breast.
Correct latch and positioning.
Improve milk production and transfer.
Increase frequency and duration of
feeding.

Infant Assessment
Elimination Pattern
Expect
4-6 pale or colorless voids/day by day 4
3-4 loose, yellow, curd-like stools after most
feedings by day 4, continuing through the first
month
Constipation is unusual in the first monthmay
indicate insufficient milk intake.
EVALUATE
Infrequent stools are common after the first
month in the healthy breastfed infant.

Infant Assessment
Breastfeeding evaluation

Proper positioning at the breast

Proper latch and lip closure
Sufficient areola in infants mouth
Tongue extends over lower gums
Adequate jaw excursion with suckling
Effective swallowing motion
Coordination of suck-swallow-breathe

AAP Policy Statement

Recommended Breastfeeding
Practices
Formal evaluation of breastfeeding

during the first 2448 hours and again at

35 days of age
Assess
Infant weight
General health
Breastfeeding
Jaundice
Hydration
Elimination pattern

AAP Policy Statement

Recommended Breastfeeding
Practices
Do not give water, juice, or solids in the

first 6 months.
Initiate iron supplements only if indicated
clinically in the first 6 months.
Include iron-rich foods or supplements after
6 months of age.
Supplement with 400 IU vitamin D daily.
Provide fluoride after 6 months if household
water supply is deficient (< 0.3 ppm).
Avoid cows milk before 12 months.

Maternal Trouble Signs

Nipple pain
Nipple trauma

Photo Joan Meek, MD, FAAP

Neonatal Hypoglycemia
No need to monitor asymptomatic low risk
infants for hypoglycemia
Routine monitoring of healthy term infants
may harm the mother-infant breastfeeding
relationship
Early, exclusive breastfeeding meets the
nutritional needs of healthy term infants
and will maintain adequate glucose levels
AAP; World Health Organization
Academy of Breastfeeding Medicine

Neonatal Hypoglycemia
Routine supplementation of healthy, term
infants with water, glucose water or
formula is unnecessary and may interfere
with establishing normal breastfeeding
and normal metabolic compensatory
mechanisms.
Healthy term infants should initiate
breastfeeding with 30-60 minutes of life
and continue feeding on demand.
AAP; World Health Organization;
Academy of Breastfeeding Medicine

Maternal Trouble Signs

Engorgement

Photo Joan Younger Meek, MD, FAAP

Jaundice and Breastfeeding

Infants <38 weeks gestational age and breastfed
are at higher risk
Systematic assessment of all infants before
discharge for the risk of severe hyperbilirubinemia
is warranted
Provide parents with written and verbal
information about newborn jaundice
Provide appropriate follow-up based on the time of
discharge and the risk assessment

AAP Subcommittee on Hyperbilirubinemia Clinical

Practice Guideline: Pediatrics 2004; 114: 297-316.

Management of
Hyperbilirubinemia
Promote and support successful breastfeeding
Perform a systematic assessment before
discharge for the risk of severe
hyperbilirubinemia
Provide early and focused follow-up based on
the risk assessment

AAP Subcommittee on Hyperbilirubinemia Clinical

Practice Guideline: Pediatrics 2004; 114: 297-316.

Primary Prevention of Jaundice

Recommendation 1.0
Clinicians should advise mothers to nurse their
infants at least 8 to 12 times per day for the first
several days.

Recommendation 1.1
The AAP recommends against routine
supplementation of nondehydrated breastfed
infants with water or dextrose water.
Supplementation with water or glucose
water will not prevent hyperbilirubinemia or
decrease total serum bilirubin levels.
AAP Subcommittee on Hyperbilirubinemia Clinical
Practice Guideline: Pediatrics 2004; 114: 297-316.

Risk Assessment for Jaundice

before Discharge
Recommendation 5.1
Before discharge assess risk for severe
hyperbilirubinemia
Every nursery should have formal protocol
Essential for infants discharged before 72 hrs
Best method: measure serum or
transcutaneous bilirubin in every infant
before discharge
Plot on Bhutani curve (perform at same time
as metabolic blood sampling)
AAP Subcommittee on Hyperbilirubinemia Clinical
Practice Guideline: Pediatrics 2004; 114: 297-316.

AAP Clinical Practice Guideline

Management of Hyperbilirubinemia in the
Newborn Infant 35 or More Weeks of
Gestation

Nomogram for designation of risk in 2840 well newborns at 36 or more weeks

gestational age with birth weight of 2000 g or more or 35 or more weeks gestational
age and birth weight of 2500 g or more based on the hour-specific serum bilirubin
values.

AAP Subcommittee on Hyperbilirubinemia. Pediatrics.

2004;114:297316

Management of Breastfeeding
Jaundice
Increase caloric intake
Increase breastfeeding
frequency to 1012
feedings/day
Increase duration of
breastfeeding
Improve latch and
positioning
Provide supplements
only when medically
indicated

Enhances milk
production
and transfer
Decreased
enterohepatic
reabsorption
Increased stool
output
Lower serum
bilirubin

Breast Milk Jaundice

Definition
Begins after day of life 57
Increased bilirubin reabsorption from
intestine
Lasts several weeks to months

Breast Milk Jaundice

Management

Avoid interruption of breastfeeding in

healthy term babies.
No routine indication for water or
formula supplementation.
If bilirubin >20 mg/dL, consider
phototherapy.
Rule out other causes of prolonged
jaundice.

Nursing Supplementation

Illustration by Tony LeTourneau

Milk Expression
Wash hands before manual or hand
expression.
Use a good-quality electric pump for
regular expression.
Milk storage
Chill as soon as possible.
Refrigerate milk for up to 4 days.
Freeze for longer storage.

Milk Expression

Photo Jane Morton, MD, FAAP

Photo Kay Hoover, MEd, IBCLC

Return to the Workplace or

School
Continued breastfeeding is feasible and
desirable for mother and infant.
Prepare ahead by discussing with the
employer or school personnel.
Delay introduction of bottles until milk
supply well established at 34 weeks.

Employed Mother
Workplace support
Breaks for
feeding/
expressing
Private, clean
place to pump
Refrigerator
or cooler with
ice packs to
store and transport
milk

Illustration by Tony LeTourneau

Adolescents and Breastfeeding

Highly recommended for adolescent mothers
Prenatal education and postpartum support
are essential
Arrange with school personnel to express
milk at school or use on-site child care
program, if available
Maintain healthy diet with adequate calories,
1,300 mg calcium per day, 15 mg iron, and a
daily multivitamin

Summary
Breastfeeding is the preferred feeding for
almost all infants.
Skin-to-skin contact should be initiated
immediately after delivery.
Supplementation is rarely indicated and
interferes with successful lactation.
Good breastfeeding technique can help to
minimize problems.
Close follow-up in the early days and
weeks is essential for breastfeeding
success.