General principles

  • Human milk is the preferred feeding for all infants.
  • Exclusive breastfeeding is recommended for the first six months of life.
  • All breastfeeding newborn infants should be seen by an experienced health-care professional at age 3-5 days.

           — Check for adequacy of feeding.

  • Normal pattern is eight to 12 feeds/day.
  • Weight loss >7% from birth weight suggests possible breastfeeding problems.
  • Gains of 30 g/day are expected after nadir.

           — Physical exam, especially for jaundice and hydration

           — Maternal history of breast problems (painful feedings, engorgement)

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           — Infant elimination patterns (expect passage of meconium by day 5 of life, three to five urines and three to
           four stools per day by age 3-5 days and four to six urines and three to six stools per day by age 5-7 days)

  • Breastfeeding infants should have a second visit at age 2-3 weeks for

           — Monitoring of weight gain

           — Providing additional support and encouragement to mother

  • Child should continue breastfeeding for at least the first year of life and as long as mutually desired by mother and child.
  • Infants weaned before age 12 months should receive iron-fortified infant formula (not cow’s milk).

Supplementation

  • Fluid supplements (water, glucose water, formula, and other fluids) should not be given to breastfeeding newborn infants unless medically indicated.
  • Medical indications for supplemental feeding in term healthy infants

           — Breastfeeding contraindicated

           — Infant unable to feed at breast (e.g., congenital malformation or illness)

  • Possible indications for supplemental feeding in term, healthy infants

           — Asymptomatic hypoglycemia unresponsive to frequent breastfeeding (symptomatic hypoglycemia treated
           with IV glucose)

           — Significant dehydration

           — Delayed bowel movements or continued meconium stools on day 5

           — Hyperbilirubinemia

           — Poor milk production

           — Other supplements

  • Start vitamin D drops 400 IU/day orally during first few days of life, and continue until daily intake of vitamin D-fortified formula or milk is one liter.
  • Supplementary fluoride should not be provided during first six months of life.
  • Iron supplementation

           — Introduce complementary foods rich in iron at about age 6 months.

           — Start iron supplementation earlier in preterm infants, low-birth-weight infants, and infants with
           hematologic disorders.

Cautions

  • Breastfeeding may be associated with pain and discomfort, especially with latching on, but this should resolve within one to two weeks.
  • Assume maternal medications will appear in breast milk.

           — Most medications can safely be given while breastfeeding.

           — Medication compatibility with breastfeeding can be checked at Toxnet

Contraindications

  • Breastfeeding contraindicated in:

           — U.S. mothers who are HIV-positive (but not necessarily mothers in developing part of world)

           — Mothers receiving selected medications including antimetabolites, chemotherpeutic agents, diagnostic or
           therapeutic radioactive isotopes. Clinicians should check risks associated with any other medications a
           mother is taking.

           — Mothers with exposure to radioactive materials (for as long as there is radioactivity in milk)

           — Mothers using drugs of abuse

           — Mothers who have herpes simplex lesions on a breast (infant may feed from other breast if clear of
           lesions)

           — Infants with classic galactosemia

           — Mothers with active untreated TB

           — If severe hyperbilirubinemia, breastfeeding may need to be interrupted temporarily

  • Breastfeeding not contraindicated in

           — Most newborns with nonsevere jaundice and hyperbilirubinemia

           — Infants born to mothers who are hepatitis B surface antigen-positive

           — Mothers infected with hepatitis C virus

           — Mothers who are febrile

           — Mothers exposed to low-level environmental chemicals

           — Mothers who smoke tobacco

           — Mothers with history of breast augmentation or breast reduction

  • Alcohol consumption can inhibit milk production, but an occasional single, small alcoholic drink is acceptable; avoid breastfeeding for two hours after drinking.

Medical aspects

  • Mastitis

           — Exclude noninflammatory conditions (i.e., engorgement, plugged ducts) that do not benefit from
           antibiotics.

           — Continued breastfeeding using both breasts is considered safe during mastitis except in an HIV-positive
           mother.

           — Treatment: Express milk to prevent milk stasis; emptying breast every six hours may shorten duration of
           mastitis; antibiotics to shorten duration of infectious forms (typical regimens include dicloxacillin [Dycill,
           Dynapen] 125-500 mg every six hours or cephalexin [Keflex] 250-500 mg every six hours for 10-14 days; 
           Supportive treatments may include analgesia, increased fluid intake, and rest.

  • Breast candidiasis findings include

           — Intense pain after period of pain-free breastfeeding

           — Pain in both nipples or breasts

           — Burning pain during or after feeds

           — No fever

           — No inflammation of breast

           — May have itchy, flaky, or shiny nipples, but rule out contact dermatitis

           —Signs of fungal infection may be present in baby’s mouth or diaper area.

  • Treatment of nipple candidiasis

           — Topical antifungal (miconazole [Monistat] or clotrima­zole [Lotrimin] cream) is the most common
           treatment. If nipple fissures are present, also treat with such topical antibiotics as mupirocin (Bactroban) or
           triple antibiotic ointment (Neosporin), because Staphylococcus aureus is significantly associated with nipple
           fissures.

           — Mid- or low-potency topical steroid cream if red, inflamed nipples

           — Simultaneous treatment of mother and baby is required.

           — Oral fluconazole (Diflucan) (not approved by FDA for mammary candidosis) is often used for persistent
           cases of nipple yeast or presumptive ductal yeast with a 200-400 mg loading dose and then 100-200 mg
           once daily for 14-21 days. Mothers can continue breastfeeding while taking fluconazole. Inform nursing
           mother of lack of data prior to prescribing. Be alert to drug-drug interactions.

Postpartum contraception

  • Women with exclusive breastfeeding and amenorrhea within the first six months postpartum have low (1%-2%) likelihood of pregnancy.
  • Indications to begin contraception

           — Menstruation resumes

           — Breastfeeding reduces in frequency or duration

           — Bottle feeds are started

           — Infant reaches age 6 months

  • Contraceptive options

           — First-choice methods: Natural family planning; barriers; intrauterine devices

           — Second choice: progestin-only methods; not recommended <6 weeks postpartum; recommended ≥6
           weeks postpartum

           — Third choice: estrogen-containing contraceptives such as combination hormonal contraceptives; not
           recommended <6 weeks postpartum; not recommended 6 weeks to 6 months postpartum. May be used ≥6
           months postpartum; diaphragms or cervical caps previously used should be refitted at 6 weeks postpartum.

Dr. Ehrlich is a family physician and deputy editor for DynaMed, a database of comprehensive updated summaries covering more than 3,200 clinical topics. Dr. Pettit is an assistant professor at the University of Arizona, medical director of the Tucson Family Advocacy Program, and a peer reviewer for DynaMed.

From the August 01, 2011 Issue of Clinical Advisor

Topics:

Hospital Medicine Obstetrics and Gynecology Pediatrics Practice Management Pregnancy Women's Health