32
Approach to Breast-feeding
Ruth Lawrence, MD
Robert M. Lawrence, MD
“Babies were born to be breast-fed” is the tag-
line for the national campaign to promote breast-
feeding.1
The health goals of our nation include a state-
ment regarding breast-feeding. By the year 2010,
75% of women will leave the hospital breast-
feeding, at least 50% will continue to breast-feed
for at least 6 months, and at 12 months at least
25% will still be breast-feeding. The goal particu-
larly addresses high-risk women, those from
minority, low-income, and undereducated groups.2
The Institute of Medicine issued a report on
nutrition during lactation as part of a review of
nutrition in the perinatal period that stated that
breast-feeding was ideal for all infants under
ordinary circumstances.3 It further stated that
even women without perfect diets could produce
good milk and nourish their young well.3 Profes-
sional medical associations such as the American
Academy of Pediatrics,4 the American College of
Obstetrics and Gynecology, and the Academy of
Family Practice have developed policies encour-
aging universal breast-feeding. The World Health
Organization and United Nations International
Children’s Emergency Fund (UNICEF) have
taken very strong positions in support of world-
wide breast-feeding, including the development
of the Baby Friendly Hospital Initiative.5,6
Human milk is specifically designed for the
needs of the human infant. Its nutritional advan-
tages have been noted to be especially important
for brain growth.7–9 In the first year of life, the
brain of the human infant doubles in size.10 The
myelinization of nerves is equally important
and occurs extensively in the first year of life.
Taurine, cholesterol, and omega fatty acids are
essential to brain growth and are uniquely present
in human milk.11
The presence of dozens of active enzymes,
the immunologic properties, infection protection
properties, and allergy protection are some of the
compelling reasons breast-feeding is superior for
human infants.12–15
The number of women who elect to breast-
feed has continued to increase, and the renais-
sance of breast-feeding is well established.16,17 It
is important for the clinician to be knowledgeable
about the value of human milk, the advantages of
breast-feeding, the clinical management of lacta-
tion, and the diagnosis and treatment of prob-
lems.18 The current scientific literature provides a
Compliments of AbbottNutritionHealthInstitute.org
large resource of information on these topics,
which will be summarized here.
ANATOMY AND PHYSIOLOGY
Lactation is the completion of the normal repro-
ductive cycle. It is a physiologic process triggered
by the termination of pregnancy, but anticipated
both anatomically and physiologically from early
development.11
The breast bud is present at birth in both
sexes, but remains dormant until early pubes-
cence, when growth is stimulated by the increase
in estrogen and progesterone in the female.19,20
The ductal system proliferates and the breast
matures. This maturation continues with stimulus
from each menstrual cycle until age 25. When
growth stabilizes, further proliferation does not
occur until pregnancy intervenes (Figure 1).
Changes in circulating hormones result in pro-
found changes in the ductular–lobular–alveolar
growth during pregnancy.21 There is marked
increase in ductular sprouting, branching, and
lobular formation evoked by luteal and placental
hormones (Figure 2). Placental lactogen, prolac-
tin, and chorionic gonadotropin have been identi-
fied as contributors to the accelerated growth.
From the third month of gestation, secretory
material resembling colostrum appears in the
alveoli. By the second trimester, placental lacto-
gen begins to stimulate the production of colos-
trum so that a woman delivering immaturely as
early as 16 weeks may secrete colostrum although
her baby is not viable. Until delivery, the produc-
tion of milk is suppressed by prolactin-inhibiting
hormone produced by the placenta. Progester-
one produced by the placenta has been recog-
nized as important in blocking milk production
in pregnancy. At delivery, the withdrawal of
placental and luteal sex hormones and the
infant’s sucking result in the loss of the inhibit-
ing hormones and the stimulation of prolactin-
releasing factors.22
The initiation of milk secretion at delivery
and the continued production of milk occur
because the breast has developed extensively
throughout pregnancy.11 The ductal system has
arborized to form an extended network of collect-
ing ducts. The alveoli are richly lined with epi-
thelial cells varying from flat to low columnar in
shape, all capable of producing milk. Some cells
With permission from Duggan C, et al. Nutrition in Pediatrics. 4th ed. Hamilton, Ontario, Canada: BC Decker Inc; 2008.
protrude into the lumen of the alveoli; others are
short and smooth. The lumen of the alveolus is
crowded with fine granular material and lipid
droplets (Figure 3). The division and differentia-
tion of the mammary epithelial cells and prese-
cretory alveolar cells into secretory milk-releasing
alveolar cells completes the preparation for milk
production. The biosynthesis of milk involves
this cellular site, where the metabolic processes
occur. There are stem cells and highly differenti-
ated secretory alveolar cells at the terminal ducts.
The stem cells are stimulated by growth hormone
and insulin, which is synergized by prolactin to
stimulate the cells to secretory activity. The breast
acts in response to the interactions of the pitu-
itary, thyroid, pancreatic, adrenal, and ovarian
hormones (Figure 4).
The process of milk synthesis involves apo-
crine secretion for the de novo production of fat
and protein and the merocrine secretion of lac-
tose synthesized from glucose.19 Ions diffuse
across the membrane and, in some cases, are
actively transported. The primary alveolar milk is
then diluted within the lumen to be isotonic with
plasma by water that diffuses from extracellular
fluid.22,23 The pathways for milk synthesis and
secretion into the mammary alveolus include22
(1) exocytosis of protein and lactose, (2) forma-
tion of the milk fat globule, (3) secretion of ions
and water, (4) pinocytosis–exocytosis of immu-
noglobulins, and (5) the paracellular pathway
(Figure 5).
Because lactation is anticipated, the body pre-
pares the breast during pregnancy and also devel-
ops additional nutritional maternal stores that will
be needed during lactation, in the form of 6 to
8 pounds of body weight apart from the uterus
and its contents. When lactation begins, there is a
redistribution of blood supply from the uterus to
the breast, where there is an increased demand
for nutrients and an increased metabolic rate to
accommodate the demands of milk production.
The mammary gland may have to produce milk at
the expense of other organs if stores are inade-
quate. There are cardiovascular adjustments as
mammary blood flow increases. The mammary
blood flow, cardiac output, and milk secretion are
suckling dependent. In addition, suckling induces
the release of anterior pituitary hormones, prolac-
tin and oxytocin, which act directly on the breast
tissue and on the uterus.22
364 PART III / Perinatal Nutrition

Figure 1 Female breast from infancy to lactation with corresponding cross-section and duct structure. A, B, C, Gradual development of well-differentiated ductular and peripheral
lobular-alveolar system. D, Ductular sprouting and intensified peripheral lobular-alveolar development in pregnancy Glandular luminal cells begin actively synthesizing milk fat and
proteins near term. Only small amounts are released into lumen E, With postpartum withdrawal of luteal and placental sex steroids and placental lactogen, prolactin is able to induce
full secretory activity of alveolar cells and release of milk into alveoli and smaller ducts. Reproduced with permission from Lawrence RA and Lawrence RM.10

In addition to glandular preparation, the nip- specimens in 1840.29 Imaging the actively secret-
ple and areola are also preparing for lactation. ing breast has revealed that only about 9 to 12
There is an increase in vascularization. The Mont- (range 4–18) ducts are at the base of the nipple,
gomery glands, which are sebaceous glands on not 15 to 25, as originally believed. The ducts
the areolae circling the nipple, become enlarged were measured to be 1.9 � 0.6 mm (1.0–4.4 mm)
and begin to secrete a substance that lubricates in diameter. The number of ducts and their
and protects the areola and nipple during preg- diameter did not correlate with nipple size or
nancy and lactation.11 radius of the areolae or actual milk production.
The use of ultrasound imagery24–28 to examine The amount of glandular tissue in the lactating
the working of the human breast has replaced some breast was about 64% (range 45–83%) of the
beliefs about the anatomy that were originally breast tissue, and the fatty tissue only accounted
Retromammary fat
derived from the dissection of formalin-prepared for 38% (16–51%). There was no correlation
Intraglandular fat
Subcutaneous fat
Areola
Intra-alveolar
Main milk duct milk fat and proteins
Cytoplasmic
striations
Milk duct Protein
Glandular tissue cap
Basal nuclei
Cooper’s ligaments

Resting cell Beginning milk Spontaneous Provoked Resting phase

Figure 2 Morphology of mature breast with dissection synthesis milk secretion milk secretion
to reveal mammary fat and duct system. Reproduced with Figure 3 Cycle of secretory cells from resting stage to secretion and return to resting stage. Reproduced with permission
permission from Lawrence RA and Lawrence RM.10 from Lawrence RA and Lawrence RM.10
Compliments of AbbottNutritionHealthInstitute.org With permission from Duggan C, et al. Nutrition in Pediatrics. 4th ed. Hamilton, Ontario, Canada: BC Decker Inc; 2008.
 CHAPTER 32 / Approach to Breast-feeding 365
30
Postpartum suckling of the infant. This suckling stimulates
Adenohypophysis the mechanoreceptors in the nipple and areola
that send stimuli along nerve pathways to the
Increased prolactin synthesis
PIF and release into the circulation Pr hypothalamus, which stimulates the posterior
g ola
sin cti pituitary to release oxytocin.31,32 Oxytocin, which
ea
rel n
is carried via the bloodstream to the breast and
c tin or(s)
ola fact uterus,33,34 stimulates the myoepithelial cells that
Pr
envelop the secretory alveoli and the collecting
ductules in the breast to contract, ejecting milk
Hypothalamus
Supportive metabolic Breast through the ductule. The oxytocin also stimulates
Withdrawal of placental and
luteal sex hormones and the hormones Milk synthesis and milk release the myoepithelial cells in the uterus to contract,
infant’s sucking result in Insulin, cortisol, thyroid- into mammary alveoli causing the “after pains” a mother associates with
depression of PIF and/or parathyroid hormone, lactation. Physiologically, this uterine contrac-
stimulation of prolactin growth hormone Milk ejection
tion enhances the uterine postpartum involution,
releasing factor(s)
so that the uterus of the lactating woman returns
to normal more quickly postpartum. Oxytocin
Ne release can also be stimulated by seeing or hear-
ur
og
en cin
ing the infant; thus a woman notices that her milk
ic to begins to drip when she sees her infant.34 Prolac-
sti xy
mu Neurohypophysis O
la tin, however, is only released when the breast is
tio
n Sucking induces synthesis stimulated by suckling or pumping.
and release of oxytocin Prolactin, which is also released from the
Figure 4 Hormonal preparation of breast postpartum for lactation. Reproduced with permission from Lawrence RA and hypothalamus during sucking, stimulates the pro-
Lawrence RM.10 duction of milk.30 Prolactin levels during early
lactation are increased 10 to 20 times greater than
normal. The technology required to obtain pro-
between milk production and the amount of INITIATION OF MILK SECRETION lactin levels has been available for clinical inves-
glandular tissue as measured by ultrasound24,25 tigation, but the role of prolactin in the volume of
(Figure 3). The nipple has many sensory nerve Withdrawal of placental and luteal sex hormones milk produced is still not clearly defined. It is
fibers but the areola does not: an important fact and stimulation of prolactin-releasing factor clear, however, that the surge in prolactin to about
in terms of comfort for the mother while nurs- result in the increased prolactin synthesis by the twice the baseline levels is critical to the success-
ing.26 The response to tactile sensation of the adenohypophysis, which stimulates milk synthe- ful production of an adequate supply of milk.
nipple increases dramatically at delivery as an sis in the mammary alveoli. The release of milk When evaluating prolactin during lactation, a
adaptation for lactation that enhances the from the alveolar collecting ductules depends on sample of blood is drawn at baseline and then a
nervous response to suckling by the infant the ejection or let-down reflex (Figure 6). The let- second sample is drawn after 10 minutes of
(Figure 6). down reflex is a simple arc that is initiated by the breast-feeding or pumping with an electric
pump.11 The baseline should be above normal
range for the laboratory and poststimulus should
be increased to almost double baseline.
I II III IV V

PRENATAL CONSIDERATIONS
Lactose Lipids H2O IgA Cells
Ca2+, PO4 Na other Na
Although the breast prepares for lactation inde-
Citrate K plasma ? Plasma protein?
Milk protein MFG Cl proteins pendent of the mother’s decision to breast-feed,
it is important to introduce the question of feed-
ing the infant as soon as possible during
pregnancy so that the mother can make an
SV
informed choice on behalf of her baby. 31
Although it has been suggested that well-educated
Closed, Open
? mothers have made up their minds about how
lactation pregnancy
they will feed their infants long before concep-
Golgi tion occurs, there are many women who need to
be informed about breast-feeding and need to
receive reinforcement from their physician.31
Many women, especially primiparas, will need
RER considerable assistance to lactate successfully.
The significant benefits of human milk to the
human infant have already been reviewed in pre-
Basement vious chapters. The psychological benefits are
membrane equally as important to both mother and child.32
Capillary
The nutritional benefits of human milk,
Figure 5 The pathways for milk synthesis and secretion in the mammary alveolus. (II) Exocytosis of milk protein and
although legion, can in part be substituted with a
lactose in Golgi-derived secretory vesicles. (III) Secretion of ions and water across the apical membrane. (IV) Pinocytosis-
exocytosis of immunoglobulins. (V) The paracellular pathway of plasma components and leukocytes. MFG � milk fat modern prepared formula, but the infection
globule; RER � rough endoplasmic reticulum; SV � secretory vesicle. Adapted from Neville MC.18 Reproduced with protection, immunologic properties, and the
permission from Lawrence RA and Lawrence RM.10 psychological benefits of human milk cannot be
Compliments of AbbottNutritionHealthInstitute.org With permission from Duggan C, et al. Nutrition in Pediatrics. 4th ed. Hamilton, Ontario, Canada: BC Decker Inc; 2008.
366 PART III / Perinatal Nutrition
Figure 6 (A) Normal nipple everts with gentle pressure. (B) Inverted or tied nipple inverts with gentle pressure.
Reproduced with permission from Lawrence RA and Lawrence RM.10
duplicated.14,15 In the mid–twentieth century, when
bottle feeding was rampant, the single, clear,
unchallenged advantage to breast-feeding that was
articulated was the special interrelationship
between the mother and her baby.32 The key ele-
ments of attachment are said to include early con-
tact, closeness, eye-to-eye contact, smell, and body
warmth. Breast-feeding includes these naturally. A
woman has a surge of oxytocin and prolactin dur-
ing each feeding, which has been demonstrated
biologically to stimulate mothering behavior.33,34
When a mother wishes to be free of the
responsibility of breast-feeding, it is often so that
she will not be tied down, will not always have to
be available, and can have others feed the infant,
thus depriving the infant of this special frequent
closeness with the mother.
Preparation of the Breasts
Nature prepares the breasts. It is not necessary to
manipulate the breasts and nipples prenatally in
Figure 7 Breast shell in place inside a brassiere to evert the nipple. Reproduced with permission from Lawrence RA and Lawrence RM.10
Compliments of AbbottNutritionHealthInstitute.org
preparation in the normal woman. Part of the pre-
natal physical examination should include the
breasts with respect to lactation so that any ana-
tomic variations that may interfere with lactation
can be discussed.31 The size of the breast is not
related to lactation success and is not a measure
of glandular potential.28 Women who have had
benign cysts removed can still nurse successfully.
Augmentation mammoplasty does not usually
interfere with lactation if the nipple and duct sys-
tem have been left intact, that is, the nipple has
not been realigned and the implant is placed
under the breast tissue on the chest wall. Unless
the implant has ruptured and has caused scarring,
lactation should be successful. When breast size
has been surgically diminished by reduction
mammoplasty, the duct system may have been
interrupted if the nipple was completely removed
and replaced central to the remaining tissue. This
may make lactation improbable, and this issue
should be discussed with the operating surgeon.
If the procedure was done leaving the nipple and
With permission from Duggan C, et al. Nutrition in Pediatrics. 4th ed. Hamilton, Ontario, Canada: BC Decker Inc; 2008.
areola on a pedicle, lactation may be successful.
Women who have had one breast removed surgi-
cally can successfully breast-feed, although when
the mastectomy is for malignant disease, it may
not be recommended because of the potential
effect of continued high levels of sex steroids in
the system if pregnancy occurs within 5 years of
treatment. It should be discussed with the oncolo-
gist. Women who are in the process of treatment
for breast cancer during lactation may pump and
discard their milk for a few days after chemo-
therapy and then resume feeding until the next
treatment. Length of time for discarding varies
with the drug employed. The time for complete
clearance can be calculated as 5 times the half-
life of the drug involved.11 Many of the cancer
drugs have very short half-lives, so the disruption
may be less than 24 hours.
Inverted nipples are the most common ana-
tomic problem identified (Figure 7). Although
there are stretching exercises that can be done,
to pull the nipple out, exercises require time,
considerable dedication, and a commitment on
the part of the mother to this daily manipulation.
Some mothers find nipple exercises distasteful.
Nipple stimulus prenatally may trigger uterine
contractions and premature labor. Another
method of treatment for inverted nipples is
wearing specially designed plastic shells inside
the normal brassiere daily during the last
6 weeks of pregnancy, beginning with a few
minutes a day and increasing time worn to 8 to
10 hours after about 2 weeks. The continued
gentle pressure on the areola, stretching the
fibrous tissue, will evert the nipple through the
central hole. After delivery, these shells can be
worn between feedings (but not during) until the
eversion is firmly established postpartum and
the nipple is easily grasped by the infant. A con-
trolled study by Alexander and colleagues found
that the technique was not very effective and it
often discouraged some women from even

initiating breast-feeding. 35 Inverted or small
nipples may best be everted by using a good
hand pump or an electric pump just prior to put-
ting the infant in position to latch on for a feed-
ing in the first few days postpartum. Usually, the
nipple will remain erect without pumping after a
week of these efforts. In subsequent pregnan-
cies, the nipples are more everted probably due
to the stretching of the fibers that were tying the
nipple down initially.
Only gentle face soap and clear water are
needed for breast care. No ointments or lotions
are advised prophylactically as they irritate the
skin and plug the natural pores, inhibiting the
natural secretions. The sebaceous secretions of
the glands of Montgomery on the areola are
intended to lubricate the areola and nipple. Buff-
ing the tissues briskly with a turkish towel or a
toothbrush is neither necessary nor recommended.
In a very dry climate where skin dryness is a
problem, a bland ointment such as a vitamin A
and D ointment or purified lanolin might be pre-
scribed in some cases.
Removing colostrum in the last few weeks
of pregnancy by manual expression is not
recommended as it may irritate the tissues and
cause an early mastitis. Because the colostrum is
discarded, it wastes a very valuable commodity,
which should be left for the infant. Such manipu-
lation of the breast may also stimulate premature
contractions of the uterus. Prior to delivery, the
mother should purchase and bring to the hospital
a well-constructed nursing brassiere to support
the breasts, especially as the milk first comes in.
This will alleviate the feeling of heaviness and
engorgement. Many women wear a nursing bras-
siere night and day, especially in the first few
weeks postpartum.
A new mother may find it helpful to attend
breast-feeding classes prenatally and actually see
an infant at the breast before she delivers if she is
totally unfamiliar with breast-feeding.36 Many
childbirth classes include breast-feeding in the
curriculum. If not, the physician may wish to
have the office staff provide that educational ser-
vice or refer the patient to a community breast-
feeding support group, such as La Leche League.
Initiating Lactation: The First Feed
As soon after birth as possible, preferably within
the first hour of life, the infant should be breast-
fed.5,6 Once the infant is stable, with the airway
clear and respirations established, he can be
offered the breast with the mother lying on her
side facing the infant, who is also lying on his
side. The infant should be held close to the breast.
The areola will be soft and compressible. If the
mother strokes the infant’s lower lip with the nip-
ple, he will quickly root, open the mouth wide,
grasp the nipple and areola, and begin to suckle.
The nipple and areola elongate to form a teat as
they are drawn into the mouth. The infant should
grasp well beyond the nipple so as to compress
the areola and ductules, which lie under the are-
ola (Figures 8 and 9). Because nipple size and
Compliments of AbbottNutritionHealthInstitute.org
Figure 8 (A) As the infant grasps the breast, the tongue
moves forward to draw the nipple in. (B) The nipple
and the areola move toward the palate as the glottis still
permits breathing. (C) The tongue moves along the nipple,
pressing it against the hard palate and creating pressure,
Ductules under the areola are milked and flow begins as
a result of peristaltic movement of the tongue. The glottis
closes. Swallow follows. Reproduced with permission
from Lawrence RA and Lawrence RM.10
areola size vary, the infant may not be able to get
the entire areola into the mouth. Even at the first
feeding, the infant will receive colostrum. The
mother should be further instructed in the art of
positioning herself comfortably and supporting
her breast with her hand. Changing her position
at different feedings allows the infant to grasp
from different angles.18,36,37 This will rotate the
point of greatest suckling pressure and will evenly
distribute the suckling pressure over the entire
areola. After the first feed, a mother may lie down
or sit up as she chooses. If the nipple is tender,
the baby can be held on the right breast as if he
were nursing on the left side, that is, facing the
mother’s right side with feet to her right (or the
reverse on the left breast, with the infant facing
the mother’s left side). The key to correct
positioning is having the infant face the breast.
The infant can be brought close by moving the
Figure 9 Latching on. In response to stimulating the
infant’s lower lip with the nipple, the mouth opens wide.
Reproduced with permission from Lawerence RA and
Lawerence RM.10
With permission from Duggan C, et al. Nutrition in Pediatrics. 4th ed. Hamilton, Ontario, Canada: BC Decker Inc; 2008.
CHAPTER 32 / Approach to Breast-feeding 367
mother’s arm that is holding the infant and not by
pushing the infant’s head toward the breast. Push-
ing the head toward the breast causes the infant to
arch back away from the breast, which is the nat-
ural arching reflex. This results when the back of
the head is held. This appears to the mother as if
the infant is rejecting the breast.
Initially, a mother may offer both breasts at
each feeding to stimulate each breast as often as
possible during the first weeks. The infant, how-
ever, should nurse long enough on the first side to
receive the hind milk, that is, over 5 minutes. In
reality, he may drift off to sleep before being
switched to the second side. At the next feeding,
he should be offered the other breast first. This
will balance the stimulus and, thus, milk produc-
tion. The infant should nurse every time he awak-
ens and is alert and hungry, which may be as
frequently as every 2 hours. Intervals between
feedings should not be greater than 4 to 5 hours in
the beginning when frequent stimulus is critical
to establishing a good milk supply. If the infant
sleeps 6 hours, he should be awakened in the first
few weeks of life. Having the mother and baby
cared for in close proximity as in rooming-in or
by mother–baby nursing staff assignments will
facilitate frequent appropriate feeding and will
enhance milk production. In programs where
infants are fed more than six times daily (average
10–12 times), the length of each feeding tends to
be shorter. With frequent feeding, there is better
milk production, less weight loss, earlier regain
of birth weight, and less neonatal jaundice.38–42
This increase in feeding frequency has not been
associated with an increase in sore nipples. Sore
nipples are associated with inappropriate posi-
tioning at the breast. Care should be taken not to
overwhelm the mother with many suggestions for
different positions, alternate hand grips, and other
angles for the infant. She should find a simple
way that works before leaving the hospital. If
there is a problem, then different approaches can
be suggested. The infant should feed when hun-
gry with no rules for timing or intervals. Crying
is a late sign of hunger. Every mother should be
observed feeding her baby by a skilled observer
before discharge.
Healthy mothers and their infants are being
discharged in 48 hours or less in sharp contrast to
the 4- to 5-day stay of the past. Mothers with
cesarean sections may leave in 36 hours. Having
a helpless newborn totally dependent on a mother
is an awesome, frightening, and sometimes dis-
couraging responsibility. The mother is no longer
an independent person. This responsibility may
be overwhelming unless care is taken to “mother
the mother,” because our culture does not auto-
matically provide maternal support.43 In fact, our
culture programs a superwoman concept in which
the new mother must return to her other house-
hold chores unless the health professional inter-
venes. Adequate rest should be prescribed.
Discussing the joint responsibilities of parent-
hood with both parents may facilitate a smoother
transition from the sheltered hospital environment
to home. Early discharge home also places a
368 PART III / Perinatal Nutrition
responsibility on the physician to see the breast-
fed infant in the first week of life at home. Provi-
sion for weight checks and assessment of jaundice
should involve a home visit or an office visit
within 2 days of discharge.4,41 Many offices have
a nurse practitioner skilled in newborn care and
breast-feeding who provides this service.
Nourishment for the lactating woman should
make sense, but nurturance while providing these
nutrients is equally important. Raphael has
expressed it as the need for a doula, which is
taken from the Greek language to mean “a help-
ful friend from across the street.”43 It means that
someone must care for the mother, support her
efforts to breast-feed, and make her feel confident
in her ability to mother her infant.
Supplementation with Milk or Water
Careful study of weight loss in breast-fed and
formula-fed infants in the first days of life indi-
cates that the breast-fed baby does not lose more
weight than the formula fed baby when breast-
feeding is adequately assisted. Furthermore,
infants who are fed frequently at the breast in
the first few days begin to gain weight at least
by the fourth day. Studies correlating the method
of feeding with the level of bilirubin show no
significant difference between breast-feeding
and formula feeding.40–42 Studies comparing fre-
quency of feeding in the breast-feeding group
show that infants who are fed seven or more
times per day have significantly lower bilirubin
levels than those fed six or less times per day.
Findings were independent of the total number
of minutes per day spent nursing.39,40 In terms of
lactation physiology, the breast produces milk
in response to suckling and the removal of milk
by suckling or pumping. The greatest volume of
milk is obtained in the first 5 to 10 minutes at
each breast. If the infant feeds more frequently,
he receives more milk, and the breast produces
more in response. Animal studies by Gartner
and Herschel suggest a relationship between
elevated bilirubin levels and starvation.41 Weight
loss of greater than 5% requires evaluation of
the breast-feeding, as does unexplained hyper-
bilirubinemia.4,38
If, on the other hand, the influence of giving
water or milk supplements to babies who are
breast-fed is scrutinized, it is noted that supple-
mentation, especially with water, is associated
with increased weight loss and increased bilirubin
levels in the first few days of life.39–41,44 If the influ-
ence of water or milk supplements on babies who
are breast-fed is investigated from the standpoint
of successful establishment of lactation, length of
breast-feeding, and reasons for early weaning, it is
also noted to be negative. Mothers who add sup-
plements have more difficulty establishing a good
milk supply, are more apt to wean early, and give
“insufficient milk” as a reason for weaning. Sup-
plements interfere with successful lactation.45
In the first few weeks of lactation, it is impor-
tant to encourage a feeding program that meets
the infant’s needs, that is, providing feeding when
Compliments of AbbottNutritionHealthInstitute.org
the infant is awake and hungry (so-called demand
or on-request feeding). This may be 12 to 16 times
per day. Most babies have a period of a few hours
when they want to nurse every hour and that is
appropriate for several feedings. There is, how-
ever, a relationship between the fatigue and stam-
ina of the mother that has to be balanced against
the true needs of the infant. A fussy breast-fed
infant who has been well fed may need to be com-
forted by someone else. This is an important role
for the father. Lactating women may not be able
to comfort their own infants without offering the
breast because the infant smells the milk and will
root even though he is well fed. This sometimes
leads to incessant nonnutritive suckling, which
may be a drain on the mother’s energy resources
and traumatic to the nipple. Nonnutritive comfort-
ing is a significant need of most infants and can be
provided by the father.
An additional side effect of supplementation is
the use of a bottle and a rubber nipple, which may
lead to nipple confusion on the part of the new-
born.46 The sucking mechanism utilized at the
breast is the sucking reflex present at birth. The
infant will have much of the areola in the mouth,
compressing it against the hard palate as it elon-
gates into a teat, maintaining the seal with the gum
and lips. The tongue undulates with a peristaltic
motion that also triggers the swallow and initiates
peristalsis in the esophagus and the stomach. The
nipple is a passive passageway for the milk to exit.
When a bottle is used, the infant’s jaws do little but
hold the nipple in place. There is little undulating
of the tongue, and milk flows easily with a little
suction created by the seal. The tongue may even
be thrust upward to control the flow from the
unyielding rubber nipple. Because this is a differ-
ent position and action, some babies are confused
by switching back and forth between breast and
bottle, especially in the first few weeks or when
the infant is slightly premature. When the tongue
thrusting of bottle-feeding is used with the breast,
it pushes the human nipple out of the mouth.
The position a mother assumes while nursing
should be comfortable and relaxing for her. A
rocking chair is often the best for the sitting posi-
tion. It is recommended that a mother may
increase her comfort if she varies the hold and
orientation of the baby to the breast. This includes
not only lying down and sitting up, but holding
the baby under the arm in a football hold or across
her body so he is held by the left arm at the right
breast or the reverse.11,37,47 The infant should
always be facing the breast directly regardless of
the position of the rest of the body and the back
of the head should not be handled.
Management at Home
Adjustments at home for a new baby are often
amplified when the mother is breast-feeding,
because any problem such as fussiness, colic,
wakefulness, or night feedings are assumed by
the mother to be due to a problem with breast-
feeding. Instilling confidence in the mother’s
ability to care for and nourish her infant is
With permission from Duggan C, et al. Nutrition in Pediatrics. 4th ed. Hamilton, Ontario, Canada: BC Decker Inc; 2008.
important. Closer surveillance by the physician in
the first few days, however, is necessary to be
certain that the new inexperienced mother does
not interpret long sleeping periods with little
feeding as adequate for proper growth. Success-
ful breast-feeding results in fewer problems and
illnesses later. Review of weight status, number
of wet diapers (at least six per day), stool pattern
(at least three per day in the first month), and
feeding pattern is a further check on successful
lactation. When a breast-fed infant does not stop
losing weight by 5 days, does not produce a stool
every day, does not void adequately, or does not
regain birth weight by 14 days, aggressive inter-
vention is indicated. The physician needs to eval-
uate infant and the breast-feeding.47
Maternal Nutrition
The nursing mother should have a nutrition check
to confirm her appropriate food intake. A lactating
woman should have 500 extra calories over the
pre-pregnancy baseline, 20 extra grams of pro-
tein, and a balanced diet. Mothers who are con-
cerned about losing weight should be counseled
to consume no less than 1,800 kcal per day and to
consume adequate vitamins and minerals. 3,48
Maternal weight loss after the initial drop should
not exceed 1 to 1.5 kg per month in the first 6
months of lactation. The most important dietary
increase is calcium and phosphorus, to a total of
1,200 mg per day.49 The neonatal calcium–phos-
phorus requirement exceeds that of the fetus in
the last trimester of pregnancy. Dairy products
are the best source, but if these products are not
tolerated by the mother, she needs to seek out
additional sources in dark green vegetables, nuts,
legumes, and certain dried fruits. Dark-green
leafy vegetables such as kale, cabbage, collards,
and turnip greens contain readily available cal-
cium, whereas the calcium in spinach, swiss
chard, and beet greens is bound to oxalic acid and
is unabsorbable.3,48 The amount of calcium in the
diet will not influence the amount in the milk, but
a deficiency will lead to leaching from maternal
bone and significant osteoporosis. A lactating
woman does not need added iron for milk but will
need to replace stores lost in pregnancy and
parturition. A balanced diet should provide all
other nutrients. The quality of the milk day by
day is balanced by intake and stores (Figure 10).
Figure 10 Energy use in lactation, showing availability
of body stores and dietary sources. Reproduced with
permission from Lawrence RA and Lawrence RM.10
 CHAPTER 32 / Approach to Breast-feeding 369

Table 1 Herbal Teas

Ingredient Botanical Source Pharmacologic Principle Use Effects

African yohimbe bark, Corynanthe yohimbe Yohimbine Smoke or drink as stimulant Mild hallucinogen
yohimbe
Catnip Nepeta cataria Nepetalactone Smoke or drink as marijuana substitute Mild hallucinogen
Gordolobo yerbal Senecio douglassi Pyrrolizidine alkaloids Drink Sore throat therapy,
? tranquilizer
Hops Humulus lupulus Lupuline Smoke or drink as sedative and marijuana substitute ? None
Kavakava Piper methysticum Yangonin, pyrones Smoke or drink as marijuana substitute Mild hallucinogen
Kola nut Cola spp. Caffeine, theobromine, kolanin Smoke, drink, or take as capsules as stimulant Stimulant
Lobelia Lobelia inflata Lobeline Smoke or drink as marijuana substitute Mild euphoriant
Mandrake Mandragora officinarum Scopolamine, hyoscyamine Drink as hallucinogen Hallucinogen
Mate Ilex paraguayensis Caffeine Drink as stimulant Stimulant
Mormon tea Ephedra nevadensis Ephedrine Drink as stimulant Stimulant
Nutmeg Myristica fragrans Myristicin Drink as hallucinogen Hallucinogen
Passion flower Passiflora incarnata Harmine alkaloids Smoke, drink, or take as capsules as marijuana Mild stimulant
Periwinkle Catharanthus roseus Indole alkaloids Smoke or drink as euphoriant Hallucinogen
Snakeroot Rauwolfia serpentina Reserpine Smoke or drink as tobacco substitute Tranquilizer
Thorn apple Datura stramonium Atropine, scopolamine Smoke or drink as tobacco substitute or hallucinogen Strong hallucinogen
Valerian Valeriana officinalis Chatinine, velerine alkaloids Drink or take as capsules as tranquilizer Tranquilizer
Wormwood Artemisia absinthium Absinthe Smoke or drink as relaxant Narcotic-analgesic
Adapted from reference 44. Reproduced with permission from reference 10.

The strict vegetarian is in jeopardy, however, of
causing B12 deficiency in her offspring, unless
she takes supplements, because B12 is not found
in nature except in animal protein.
The lactating woman does have increased
needs for fluids and thus increased thirst. If a
woman selects beverages that contain caffeine
or other active pharmacologic principles, it
could affect the infant. Beverages that either
contain no caffeine or have been decaffeinated
are appropriate. With the increasing interest in
herbal teas, attention should be given to the con-
tent of such teas.50 A partial list of products is
shown in Table 1. Many teas contain very potent
glucosides having pharmacologic properties,
others are benign and a few even nutritious, such
as rose hips, which contain vitamin C.
Documenting the consumption of herbal teas
by the mother or given to the infant directly should
be part of the medical history. Some herbs are
reputed to enhance lactation such as fenugreek.
The required dose is large and soon the milk and
all secretions and the infant smell like maple syrup.
It helps some women but not all. There can be a
cross allergy to peanuts and chickpeas that may
cause colic in the infant. Comfrey has been widely
used in midwifery and in lactation but is banned in
many countries. The FDA has also issued a warn-
ing as its use can cause veno-occlusive disease and
even be fatal, especially in infants.51
STAGES OF BREAST-FEEDING
Adaptation
Initially, there is a period of adjustment and
adaptation as the mother and baby settle into a
reciprocal relationship of supply-and-demand.
The infant can be exclusively nourished at the
breast for the first 6 months of life. During that
time there may be gradual changes in the feeding
pattern as the infant matures and sleeps longer
between feedings and also spends more time
Compliments of AbbottNutritionHealthInstitute.org
awake and socializing. Growth spurts are accom-
panied by a temporary increase in feeding
frequency. This may alarm the mother if she
has not been alerted to this possibility. Periods
of stress or illness in the infant may be marked
with temporarily increased suckling, especially
nonnutritive suckling for comfort. Human
milk meets all the nutrient needs of the infant for
the first 6 months except for a select group of
women who live in cold climates with little sun-
shine, have dark pigmented skin, wear occlusive
clothing, or use sunscreen frequently, who may
be vitamin D deficient.52 Concern about wide-
spread vitamin D deficiency has resulted in
reconsideration of vitamin D requirements. Rec-
ommendations from the Centers for Disease
Control and Prevention suggest supplementing
the infants with 400 units vitamin D daily by
mouth with a vitamin D–only preparation for
breast-fed infants. 53 Very-low-birth-weight
infants may need iron. Healthy exclusively
breast-fed infants do not need iron for the first 6
months of life. When weaning foods are added in
the second 6 months, they should be iron con-
taining, such as iron-supplemented cereal.54
Adding Solid Foods
The infant ideally is exclusively breast-fed for the
first 6 months. The single nutrient needed to add
to solid foods in an exclusively breast-fed infant is
the need for additional dietary iron; thus introduc-
tion of iron-fortified weaning foods at around 6
months is recommended, although the exact age is
poorly defined.54 At about 6 months of age, it is
appropriate to begin the addition of solid foods to
the infant’s diet for nutritional reasons (see Chap-
ter 28, “The Low Birth Weight Infant”). Learning
to take solid foods is also an important develop-
mental milestone that involves a new use of
tongue, jaw, and lips—a use that differs from
suckling.55 Beginning to take fluids from a cup is
also a developmental task that should be learned
With permission from Duggan C, et al. Nutrition in Pediatrics. 4th ed. Hamilton, Ontario, Canada: BC Decker Inc; 2008.
around 7 months of age. The infant who is exclu-
sively breast-fed to this point needs to explore
these activities and develop these skills just as a
bottle-fed infant would. The fluids can be water,
juice, or pumped breast milk. If a mother contin-
ues to provide her milk, there is no need to intro-
duce formula. Cow’s milk when the infant is
under 1 year of age is not recommended.
Weaning
To wean is “to transfer the young of any animal
from dependence on its mother’s milk to another
form of nourishment” or “to estrange from for-
mer habits or associations” according to the dic-
tionary.56 The weaning process takes many forms,
depending on the mother’s schedule and beliefs
and the needs of the infant. Some women plan to
breast-feed for only a few months “to give the
baby a good start”; other mothers wean as soon as
solid foods can be started, and some continue to
offer the breast for several years, even during a
subsequent pregnancy and while feeding a new
baby. The appropriate time for weaning should
be based on nutritional and psychological needs
and developmental milestones. Feeding is an
important social as well as nutritional encounter,
and eating solids and drinking from a cup are
important social accomplishments. This does not
mean the infant is taken completely off the breast.
In practice, the mother is usually the instigator of
weaning. The process ideally is gradual, replacing
one feeding at a time with solids and the intro-
duction of a bottle or cup, depending on the
infant’s age and stage of development. After the
adjustment has been made to substitute one feed-
ing, a second feeding is replaced, usually at the
opposite time of day. The process is continued
until there is only one nursing at night and one in
the morning. These two feedings may be main-
tained for many months or gradually discontin-
ued over weeks. A mother may be able to express
milk from the breast for weeks after the final
370 PART III / Perinatal Nutrition
feeding. An infant who has not weaned by 18 to
24 months usually does spontaneously wean until
4 or 5 years of age.11
Emergency weaning because of a crisis such
as illness or separation may be stormy for the
dyad. The infant may reject the bottle and refuse
all nourishment at first. The mother who abruptly
weans may experience severe engorgement, pain,
and systemic symptoms attributed to the resorp-
tion of milk, referred to as “milk fever.” Emer-
gency weaning is facilitated by the assistance of
another adult who can initiate the new feeding
method and is patient and understanding with the
child. Cup feeding with a small medicine cup
may be a helpful alternative.
Breast-Feeding and the Return to Work
Returning to work has been cited by epidemiolo-
gists as a major hurdle in the initiation and dura-
tion of breast-feeding.57,58 Because they need to
return to work or to school, women often think it
is best not to start. Before the industrial revolu-
tion, all women worked on the farm or in a cot-
tage industry, keeping their children with them.
In developing countries today, women carry their
infants with them to feed them whenever neces-
sary while working. It was the industrial revolu-
tion that separated home and work and made
parenting a separate role for women.
More women are employed today outside the
home than ever before.59 Women with children
under 6 years of age are the fastest-growing seg-
ment of the female workforce in 2000 (64.4% of
women with a child under 6 years old). Even
more startling are the number of working moth-
ers with children under 3 years of age (60.7%).60
Of the women who work during pregnancy, over
50% plan to return to work by 3 months postpar-
tum. These dramatic statistics make it clear that
the decision about infant feeding is an important
part of this issue.61 Child care also presents
another consideration for the women who may
well have to choose day care or some form of
child care that means her infant will be in close
contact with other children. In modern pediatrics,
“Day Care Syndrome” is real. It is the increase in
number of infections, especially diarrhea, respi-
ratory illness, and otitis media experienced by
young infants in day care.
The data are clear that breast-feeding impacts
these figures. These illness data predominantly
represent bottle-fed infants. A quantitative study
has shown that extending breast-feeding from 4
months of age to 6 months decreases the risk of
respiratory infection including pneumonia and oti-
tis media even further.12 The protective properties
in human milk (Chapter 30, “Human Milk: Nutri-
tional Properties”) are even more important for the
child exposed to other children early in life while
mother works or attends school. A comparison of
mothers’ absenteeism showed that those who were
breast-feeding had reduced absenteeism.62 Look-
ing at illness rates of children whose mothers work,
75% of children who were bottle-fed were ill and
only 25% of those breast-fed had any illness.
Compliments of AbbottNutritionHealthInstitute.org
The feeding pattern for mothers who work:
Ideally, the mother does not return to work for at
least 6 weeks so she is able to establish her milk
supply before having to add work to her sched-
ule. Mother will have to decide how she will
cope.63 If her job permits her to visit her child
several times a day, then she can just feed the
infant at the usual times. An employer who has a
day care center on the premises makes such an
arrangement possible. Professional women who
control their own schedules (lawyers, doctors,
consultants) may be able to keep the infant on
the premises under the care of a baby attendant
and feed on demand. For most women, however,
their jobs are more rigid and they may have to
settle for an opportunity to pump their milk every
3 or 4 hours on lunch or coffee breaks and store
the milk in a cooler to take home for the next
day’s feedings. Most women practice pumping
at home several weeks ahead of time and store
up a supply of milk in the freezer so they do not
run out.
Employers such as hospitals, health depart-
ments, and family-friendly industries like Amoco
Chicago, Dow Chemical of Midland, Michigan,
and the Los Angeles Department of Water and
Power, to name a few, have been recognized for
their support of “Healthy Mothers and Healthy
Babies” and their accommodations for nursing
mothers. They provide a room to pump, electric
pumps, refrigerators, and in some cases lactation
consultants to assist with any breast-feeding issues.
This support improves the incidence and duration
of breast-feeding for the working woman.63
Pumping and Storing Milk
If the employer does not provide pumps, a mother
should obtain a pump by either renting or pur-
chasing several weeks in advance of the return to
work. All pumps are not equal.64,65 There are,
however, several brands of good portable electric
pumps that provide disposable attachments for
those parts that contact the breast and the milk.
Attachments that allow pumping both sides
simultaneously save time and for some women
stimulate more milk release. Other women find
double pumping overwhelming and choose to do
one side at a time. Hand (manual) pumps are
good for stimulating milk release and relieving
engorgement but not for large-volume pumping
for most women. Many hospitals have lactation
consultants on staff and a shop or service that
rents pumps and sells other breast-feeding devices
such as breast pads and storage bottles. Informa-
tion about local resources should be available on
the postpartum floor. If not, a mother can call La
Leche League International, 1-800-LALECHE
(1-800-525-3243) for a local contact person.
After each pumping session, the disposable
flanges, tubing, and bottles used for pumping
should be rinsed with cool water first and then
washed in warm soapy water and thoroughly
rinsed and air dried. After rinsing with cold water
to remove the milk, the equipment may also be
washed in an electric dishwasher.
With permission from Duggan C, et al. Nutrition in Pediatrics. 4th ed. Hamilton, Ontario, Canada: BC Decker Inc; 2008.
The pumped milk should be placed in a glass
bottle or a firm plastic polypropylene nursing
bottle that can be capped with an airtight seal
without a nipple, and then used to feed the infant
later. Polyethylene bags are adequate for term
baby use. Storage temperatures and times have
been carefully studied.64 The container, which
should be labeled with name, date, and time,
should be placed in a refrigerator immediately or
in a cooling bag or container with freezer packs if
at work or school, where there is no refrigerator. It
is safe in a cooler bag as long as the packs remain
cold (24 hours). Upon arrival home, the bottles
should be placed in the refrigerator if it will be
used within 3 days or in the freezer if stored for
later use. When milk is pumped at home, it can be
placed in the refrigerator (4°C) immediately and
kept for 5 days. Actually, when there is no alter-
native or a bottle has been inadvertently left out,
milk can be kept in a sterile container at room
temperature for 8 hours and then used immedi-
ately or refrigerated for a day.11
If milk is placed in the freezer of the refrig-
erator that has a separate door, it can be stored
for 3 months if it is placed in the back to avoid
thawing and freezing when the door is opened. If
milk is placed in a deep freeze (�20°C), it can
be kept for 6 months, and if at �70°C, it is good
for a year or longer.59,63,65 The impact of freezing
on the milk is minimal, destroying only the cells
and their function. The effect of refrigeration is
also minimal, decreasing the cells and some of
their function. Nutrients are unchanged Preserv-
ing nutrition. Storing mother’s milk for her own
infant does not require pasteurization. Providing
donor milk to another infant does require pas-
teurization by regulation owing to the increase in
risk of infection in the present environment. Pas-
teurization does affect some properties, destroy-
ing cells and decreasing lipase activity and some
other enzymes (see Table 2).59,66
Day Care for the Breast-Feeding Infant
In choosing a day care service, care should be
taken to ensure that breast-feeding and breast
Table 2 Storage and Use of Pumped Milk for
Healthy Term Infants
Place Length of Time
Refrigerator (4°C) 5 d at home;
3 d in day care
Freezer section (separate door) 3 mo
refrigerator (–20°C)
Deep freeze (manual defrost) 6 mo
(–20°C)
Commercial deep freeze (–70°C) 1y
Sterile container at room 8h
temperature (23°C)
(not ideal but milk need not
be discarded)
Stored in cooler bag with frozen Less than 24 h
packs (as long as packs are
still cold)
Thawed, previously frozen in 24 h
refrigerator

milk are welcome. When taking an infant to day
care, a mother may wish to nurse the infant just
before she leaves her child or she may wish to
nurse the infant at day care when she has a break
from work. Further, she may wish to feed the
child before she sets out for home with the infant
in the afternoon. There needs to be a place to sit
quietly with the infant out of the mainstream of
activity. The staff should be prepared to make
these accommodations and delay a feeding if
mother is going to arrive shortly.
The mother will probably wish to provide her
stored breast milk for her infant to receive during
the day. It is not necessary for the caretaker to
wear gloves to handle the milk or feed the infant.
It is, however, appropriate to wear gloves to
change any babies’ diaper. If the milk was frozen,
it can be thawed in the refrigerator at day care or
thawed by swirling in a container of warm water.
It should not be warmed in the microwave
because of possible hot spots and scalding the
infant. Microwaving interferes with the anti-
infective properties as well as decreasing the
vitamin C content. If the infant does not empty
the container, it can be refrigerated and fed later
unless it has been microwaved.11 This is not true
of formula but the protective factors in human
milk will keep the bacterial count down. The day
care attendants should save the containers for
reuse by the mother. Thawed breast milk can be
maintained in the refrigerator for 24 hours.
The milk containers should be carefully
labeled with name and date of collection. The
attendant should carefully confirm the name on
the container before feeding. Mishaps of giving
the wrong milk to the wrong infant do occur. It
should be reported to both families and the day
care’s medical consultant with an incident report.
There are no reported cases of injury following
such an event.
FAILURE TO THRIVE WHILE
BREAST-FEEDING
Paralleling the increasing incidence of breast-
feeding, there has been an increase in the number
of clinical reports, including one in the Wall
Street Journal, describing a few cases of failure
to thrive while breast-feeding. 24,44,67,68 The
New York Times followed the dramatic story of a
teenage mother prosecuted for the death of her
8-week-old breast-fed son from starvation. The
event followed a series of misadventures and
refusal to see the child at a Medicaid clinic.70 The
majority of these cases have reflected a lack of
clinical knowledge on the part of the professionals
regarding the basic physiology of lactation and a
general failure of the health care system to pro-
vide an appropriate safety net for new and inex-
perienced mothers following the current early-
postpartum discharge practices (hospital stay
(�2 days). As cost drives the health care system to
earlier and earlier discharge, the risk of infant
problems increases since lactation will not be well
established prior to discharge.71,72 The American
Compliments of AbbottNutritionHealthInstitute.org
CHAPTER 32 / Approach to Breast-feeding 371
increase in weight compared to the erratic gain-
Table 3 Differential Diagnosis in Poor Weight Gain
ing and losing pattern in failure to thrive. The
Slow Gainer Failure to Thrive slow-gaining infant is alert and active, with good
skin turgor and muscle tone. It feeds frequently
Alert, healthy appearance Apathetic or crying
Good muscle tone Poor tone night and day, wets many diapers with pale dilute
Good skin turgor Poor turgor urine, and has a normal stool pattern. The infant
At least 6 wet diapers daily Few wet diapers looks scrawny but well.69
Pale unconcentrated urine “Strong” urine Because it sleeps long periods between feeds,
Stools frequent and seedy Stools infrequent the failure-to-thrive infant may be mistakenly con-
(or, if infrequent, large and scanty sidered satisfied when actually he has starvation
and soft)
8 or more nursings daily Fewer than 8
inanition. The infant often fed poorly in the first
lasting 15–20 min feedings, often few days or for various other reasons does not stim-
brief ulate good milk production. Since breast milk pro-
Well-established let-down No signs of duction depends on supply-and-demand
reflex functioning phenomenon, when the infant sucks weakly, he
let-down reflex receives little milk, and thus remains weak from
Weight gain consistent Weight erratic
some degree of starvation. This infant also has few
but slow (loss may occur)
wet diapers, the urine is concentrated and described
Reproduced with permission from reference 10. as “strong” by the mother. There are few and small
stools, often the green mucus of starvation. The
tone and turgor are poor, the cry is weak and infre-
Academy of Pediatrics has recommended that quent, and the infant looks sick. This may well be a
infants be seen by the pediatrician within a week medical emergency requiring hospitalization. The
of discharge but in 2 days if breast-fed.4 feeding pattern should be evaluated, especially
Failure to thrive in children has been thor- focusing on the length of time spent at the first
oughly reviewed in Chapter 43, “Failure to Thrive: breast during a feeding to be sure it is long enough
Malnutrition in the Pediatric Outpatient Setting” to allow the high-fat hind milk to be obtained.
however, there are some critical differential fac- Sometimes the pattern of slow gaining can be
tors when the infant is breast-fed. Most cases of reversed by limiting a feeding to a single breast to
significant failure to thrive in the breast-fed infant ensure high-fat, high-calorie feeds.73 Switching
manifest themselves in the first few weeks or back and forth between breasts several times dur-
months of life. There is also an important distinc- ing a feeding does not increase milk supply and can
tion between failure to thrive and the slow-gaining reduce the amount of high-calorie fat provided.
breast-fed infant.45,69 The weight curve of an ade- The diagnostic work-up of these phenomena
quately nourished breast-fed infant from birth may requires the same clinical assessment that is
well include a weight loss of 6 to 8% and the regain appropriate when the infant is not breast-fed and
of birth weight at 10 to 14 days in contrast to the for this, the reader is referred to Chapter 43,
formula-fed infant, who may lose only 3 to 4% of “Failure to Thrive: Malnutrition in the Pediatric
birth weight and quickly regain birth weight by Outpatient Setting.” Since the breast-feeding
5 to 7 days, often beginning on a path to obesity. infant is part of a synchronous dyad, there are
The critical clinical distinctions between fail- additional considerations in the differential diag-
ure to thrive and slow gaining are enumerated in nosis.11 A suggested schema for identifying the
Table 3. The salient points include the slow cause of the problem is presented in Figure 11.
Figure 11 Diagnostic flow chart for failure to thrive. Reproduced with permission from Lawrence RA and Lawrence
RM.10 CNS � central nervous system; SGA � small for gestational age.
With permission from Duggan C, et al. Nutrition in Pediatrics. 4th ed. Hamilton, Ontario, Canada: BC Decker Inc; 2008.
372 PART III / Perinatal Nutrition
The clinician should take a history oriented to the
process of lactation. This history should include
additional parameters that affect the success of the
breast-feeding dyad, such as the mother’s perina-
tal history, general health, diet, habits, psychoso-
cial state, social support system, and the attitudes
of the father and family about breast-feeding.
Parameters unique to the breast-fed infant include
any anatomic or physiologic conditions that would
interfere with sucking, which is a critical link in
the milk production process.
Difficulties with sucking include anatomic
abnormalities that result in mechanical interfer-
ence with sucking such as cleft lip, cleft palate,
hypoplasia of the jaw, macroglossia, ankyloglos-
sia (tongue “tie”) and tumors or cysts of the oro-
pharynx. These abnormalities can be identified
by physical examination, which includes obser-
vation of the infant’s suck. There may be neuro-
logic interference, resulting in a diminished or
absent suck. Events at birth, such as maternal
anesthesia or analgesia and fetal anoxia or
hypoxia, may contribute to poor suckling in the
immediate neonatal period and failure to provide
adequate stimulus to the breast to initiate lacta-
tion. The ensuing lack of nutrition for the infant
leads to hypometabolism and continued lack of
vigor. Congenital cardiac anomalies may present
in this manner. Other causes of neurologic deficit
in sucking include trisomy 13 to 15, trisomy 21,
and neuromuscular syndromes such as Werdnig-
Hoffmann, neonatal myasthenia gravis, and con-
genital muscular dystrophy. Hypothyroidism,
prematurity, and congenital intrauterine viral
infections contribute to poor suck and lack of
vigor. The greatest number of infants, however,
are entirely normal but have not had sufficient
assistance in establishing the proper grasp of the
breast, and possibly have been further confused
by being given a bottle supplement, which con-
tinues to confound their learning experience.46 In
addition to examining the infant and the maternal
breast, the clinician should observe the feeding
dynamics.71,72
All physicians who counsel breast-feeding
mothers should be knowledgeable about normal
sucking at the breast so that observation of lacta-
tion in a diagnostic situation can be constructive.
The style with which the mother approaches a
feeding, her body language, may be a clue. If she
is relaxed, confident, loving, and gentle with her
infant, it suggests it is not maternal inexperience
at fault. Her verbal interaction can be revealing. A
baby suckling at the breast brings reflexive eye-
to-eye contact, stroking, and verbal nuances that a
seasoned lactating woman utters without consid-
eration for the environment. The insecure, inexpe-
rienced mother will sit tensely, offering the breast
gingerly, with little or no verbal communication
to the infant. If the process is mechanical or punc-
tuated by unrealistic commands to the infant, it
may suggest an inability to help the infant root,
grasp, and suckle properly. Rigidly timed feed-
ings that are scheduled by the clock may result in
poor milk production. The treatment rests with
frequent on-request feedings that fit the infant’s
Compliments of AbbottNutritionHealthInstitute.org
Figure 12 Palmar grasp (C-hold). When the palm and
fingers cup the breast with support and the thumb rests
lightly above the areola, the nipple projects straight ahead
or slightly downward (correct). Reproduced with permis-
sion from Lawrence RA and Lawrence RM.10
biologic rhythms. Suggesting a quiet room, a
rocking chair, soft music, or a relaxing beverage
for the mother may all improve the situation.
The behavior of the infant when offered the
breast may indicate an infant with a suckling disor-
der, not associated with any other neurologic symp-
tom or long-range problem. Sucking inadequately
at the breast can be altered so the infant learns the
technique. The infant is identified when it is noted
the infant cannot maintain the breast in the mouth
unless his mother holds it there. In other words,
when she takes her hand away, the breast falls
away. A normal infant sucks without help from
his mother’s hands if the grip is proper and the
seal is adequate. When the infant does begin to
suck when the breast is held in position, the suck
may be a flutter or ineffective tongue actions.
This may be improved by having the mother hold
the breast between thumb and index finger, with
fingers under the breast (palmar hold) (Figure 12)
rather than with areolar compressed between the
middle and index finger (scissor hold) (Figure 13).
The infant’s position should be adjusted so his
body is turned toward the mother’s body (instead
of just turning his head). Thus, the breast is cen-
Figure 13 When the breast is offered to the infant, the
areola is gently compressed between two fingers and the
breast supported to ensure that the infant is able to grasp
the areola adequately. Reproduced with permission from
Lawrence RA and Lawrence RM.10
With permission from Duggan C, et al. Nutrition in Pediatrics. 4th ed. Hamilton, Ontario, Canada: BC Decker Inc; 2008.
tered toward the infant, and this position will
improve the effectiveness of the infant’s efforts.
The mother may have to continue to hold the
breast in place for weeks until the infant perfects
his technique. The mother may also have to pull
his lower lip down to keep infant from drawing
the lip into the mouth and moving it along the
lower surface breast. The lip should be held as
part of the seal holding the breast in place and
permitting development of some negative suck-
ing pressure. If the mother stimulates the rooting
reflex by stroking the center of the lower lip, the
infant will open wide and draw the nipple and
areola into the mouth to form a teat.
While the infant is learning to suckle prop-
erly, it is urgent to avoid introduction of a rubber
nipple on a bottle or a pacifier.71,72 This poses a
problem if adequate nutrition is critical and the
mother’s supply needs to be stimulated to be
adequate. A trial of frequent feeds, waking the
infant every 2 hours, may suffice. Extra calories
may be offered by medicine cup or Haberman
feeder. When the failure to thrive has reached
critical starvation, a more aggressive approach is
mandatory. If hospitalization is necessary, intra-
venous therapy to treat dehydration may also be
necessary. Hypernatremia and hypochloremia
have been described, and a complete work-up,
including pH, electrolytes, blood urea nitrogen,
and creatinine are essential.23,44,47,74,75 While the
infant receives intravenous therapy, the mother
should be assisted to pump frequently to develop
and increase her milk supply. When it is safe to
begin oral feedings, the infant should be exclu-
sively breast-fed as far as sucking is concerned,
and additional nourishment should be provided
by intravenous line, gastric tube, or medicine cup.
Thus, the infant avoids the introduction of a bot-
tle. When the crisis has abated and full breast-
feeding is appropriate but the milk production is
still inadequate, the use of a nursing supplementer
(Lact-Aid) may be useful. This device permits
the uninterrupted nursing at the breast while sup-
plementary nourishment is provided via a fine
capillary tube that runs along the breast into the
infant’s mouth (Figure 14). The tube brings the
supplementary fluid from a reservoir plastic bag
that hangs around the mother’s neck. The system
is carefully engineered. It provides fluid only
when the baby sucks; thus, it coordinates with the
infant’s swallowing mechanism. It is not a siphon
or a pump. When used to help establish or increase
milk production as with a premature infant first
going to breast, the infant is usually weaned from
the supplementer within 1 or 2 weeks by provid-
ing smaller and smaller volumes of supplement
as maternal production increases. The supple-
menting device may make the critical difference
when the degree of starvation is great and lacta-
tion is being preserved. It is important to point
out that all too often the infant is quickly weaned
to a bottle without any effort to solve the under-
lying lactation problem, which is unfortunate
(Figures 14 and 15).
In rare cases of failure to thrive while breast-
feeding, the underlying cause is actually metabolic

Figure 14 Lact-Aid Nursing Trainer System (Lact-Aid
International, Inc.). Reproduced with permission from
Lawrence RA and Lawrence RM.10
and the infant does even less well on formula
prepared from cow’s milk or soy protein. In that
case, it is quite possible to have the mother
re-lactate. It is an art practiced in most cultures
over the centuries and resorted to when the
biologic mother became ill or died and another
female (often the grandmother) had to assume the
nourishment of the baby. In the case of premature
weaning there has already been the biologic stim-
ulus of pregnancy and early lactation so reinsti-
tuting the milk supply occurs more easily. The
lactation supplementer may be of great value in
Figure 15 Lactation Supplementry by Medela, which
provides additional nourishment to the infant while it
suckles at the underproducing breast. Reproduced with
permission from Lawrence RA Lawrence RM.10
Compliments of AbbottNutritionHealthInstitute.org
CHAPTER 32 / Approach to Breast-feeding 373
this situation, as the infant can return to the breast Hypothalamus
and be nourished with donor human milk
while the mother builds up her own supply
(see Figure 15). Pituitary
gland
Maternal Causes of Failure to Thrive
Prolactin Oxytocin
Poor milk production may be the cause of the
failure. This is usually characterized by an alert,
active infant who cries hungrily and is very
Uterus
demanding but never satisfied. This baby demands
Myoepithelial
attention and is usually seen by the physician cell
because of his dissatisfaction. The quiet, sleepy, Lacteal
starved baby gets into serious trouble before he is
discovered because his sleeping is interpreted
as satiation. It is rare in the United States that diet
is the true cause of insufficient milk although it is
appropriate to evaluate the mother’s diet and
make recommendations for increases or adjust- Figure 16 Ejection reflex are. When suckling the breast,
ments where needed (see Figure 10).76 An addi- the infant stimulates mechanoreceptors in the nipple and
tional 600 kcal or a minimum of 1,800 kcal per areola that send a stimulus along nerve pathways to the
hypothalamus, which stimulates the posterior pituitary to
day, a balance of foods with 20 g extra protein
release oxytocin. It is carried via the bloodstream to the
and 400 mg extra calcium, is minimal for every breast and uterus. Oxytocin stimulates myoepithelial cells
mother. Many mothers feel better taking Brew- in the breast to contract and eject milk from the alveolus.
er’s yeast. “Mothering the mother” by caring It is secreted by the anterior pituitary gland in response to
about her diet may have a positive effect. How- suckling. Stress such as pain and anxiety can inhibit the
ever, the major factor in poor production is let-down reflex. The sight or cry of an infant can stimulate
fatigue. It is the single most important element in it. Reproduced with permission from Lawrence RA and
Lawrence RM.10
milk production. The present-day “super-mom”
model that has been developed by women may be
the actual destructive element. A postpartum
Although many women describe a tingling and
woman needs rest to recover whether she nurses
turgescence when the milk lets down, it is possible
or not. When she is also nourishing an infant she
to have an effective ejection reflex without these
needs more rest. This is often neglected when
sensations. As indicated in Figure 16, it is possible
the infant needs care every 3 to 4 hours around
for pain or stress to interfere with let-down. If
the clock, and only the mother is involved in the
mother has sore nipples or the infant has an
feeding of the infant. When her physician sug-
improper grasp at the breast, the pain may interfere
gests that the mother needs to reorder her priori-
with let-down.30 If the adjustments and remedial
ties and schedule naps for herself, it may be the
actions to avoid stress and enhance confidence do
necessary official approval she needs to do so. A
not result in a change in the release of milk, it may
mother may need to be told it is not only okay but
be necessary to temporarily provide the oxytocin
it is necessary for her to take care of herself in
needed for the let-down arc.11 Synthetic oxytocin
order to provide for her baby. The physician may
can be prepared by the pharmacist as a nasal spray
need to prescribe rest as well as nourishment.
for home use utilizing the injectable oxytocin. It is
There is a small number of women who are
packaged in a 5- to 10-mL nasal dropper bottles. It
unable to make sufficient milk. Some of these
contains 10 USP units (IU) per milliliter of oxyto-
women have inadequate glandular tissue. Mark-
cin, a polypeptide hormone of the posterior pitu-
edly asymmetric breasts, conical shaped breasts,
itary gland. A prescription is required. It is
and extremely small ones may be in this category.
destroyed in the gastrointestinal tract; therefore, it
Even extremely large breasts are occasionally
must be used nasally on the mucous membranes,
nonfunctional. Failure of the breasts to change
where it is rapidly absorbed. Four to six drops into
and enlarge during pregnancy and/or failure of
one nostril followed by having the infant suckle
the breasts to become engorged immediately
within 2 to 3 minutes is sufficient. This is repeated
postpartum are signs of inadequately functioning
using the second nares if the infant is switched to
tissue. These signs prenatally should alert the
the second breast. This may also be used when
medical team to extra vigilance as lactation is
using a breast pump and collecting for an infant
initiated.
who cannot nurse directly as in the case of a pre-
Failure to Let Down Milk mature baby. Usually, it is only necessary to use
the medication for a few days as the natural pro-
A woman may make milk abundantly but be cess will take over.
unable to release it. As the practitioner observes A rare finding in lactation failure is the lack of
the lactation process, evidence of successful let- a prolactin surge when the breast is stimulated by
down should be sought. If the sucking is inter- the suckling or pumping. The prolactin should
rupted by breaking the suction (by putting a finger double over baseline upon suckling. If prolactin
in the corner of the infant’s mouth), milk should levels are obtained, the samples should be care-
continue to flow in a steady drip if not a stream. fully timed so that the baseline sample is drawn
With permission from Duggan C, et al. Nutrition in Pediatrics. 4th ed. Hamilton, Ontario, Canada: BC Decker Inc; 2008.
374 PART III / Perinatal Nutrition
from a heparin lock after the mother has recov-
ered from the needle stick. Then she should feed
the infant or pump her breasts for 10 minutes, and
a second sample should be drawn. The percent-
age increase in prolactin over baseline should
approach 50%. The baseline should be above
normal for the laboratory. Replacement prolactin
is not clinically available although prolactin
stimulation with fenugreek or meclopromide or
other galactogues may increase milk supply while
the treatment is continued.11
Knowing When to Discontinue Breast-feeding
Although breast-feeding provides species-specific
nourishment, infection protection, immunologic
protection, and psychological benefits for both
mother and baby, there are times when it should
be discontinued. The role of the physician is a
delicate one, one in which true support of breast-
feeding is necessary for credibility. On the other
hand, the physician must recognize when other
alternatives are medically preferable. The moth-
er will need help in accepting this. Having to
wean prematurely or before the planned date is
not to be construed as maternal failure. It is still
possible to nurture the infant, to be a good mother,
and to have a good mother–infant relationship,
even though the mother may no longer be able to
breast-feed.
The indications for premature weaning are
rare but include severe illness in the mother,
severe galactosemia in the infant, and a few
maternal drugs such as therapeutic doses of radio-
active pharmaceuticals.11,77
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