3. The American Academy of Pediatrics (AAP) recommends that babies be exclusively breastfed for the first 6 months of life.

4. The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding. Grade: B Recommendation.

7.  Species-specific  Bio-active  Composed of: › Immunoglobulins (especially IgA) › Growth modulators › Protein › Carbohydrates › Minerals › Vitamins › Fats

8.  Cyclical process of milk synthesis and secretion  Activated by prolactin, oxytocin, TSH, and human placental lactogen (hPL) › Prolactin: milk production › Oxytocin: milk secretion  Inhibited by progesterone and estrogen

9.  Initiates milk production  Elicited by suckling  Produced by anterior pituitary gland  Stimulates mammary glandular ductal growth and epithelial cell proliferation

10.  Milk ejection or letdown  Suckling activates touch receptors that stimulate dorsal root ganglia via intercostal nerves (4, 5, 6) to release oxytocin in a pulsatile fashion  Secreted by posterior pituitary gland  Causes contraction of myoepithelial cells that line the ducts of the breast

12. Hypothalamus

14.  Moderate contraceptive effect › Dependent on suckling intensity and frequency › Equivalent to OCP (98%) only in amenorrheic women who exclusively breastfeed at regular intervals for first 6 months › With menstruation or after 6 months, chance of ovulation increases › Supplemental feeding increases chance of ovulation

15.  Intrauterine contraception › Does not affect milk volume or composition  Progestin-only contraceptives › Historically preferred method of hormonal contraception › Does not affect milk volume or composition  Estrogen-progestin contraceptives › Traditionally thought to suppress milk production › Recent study shows no effect on breastfeeding duration or infant growth

16.  Double-blind RCT examining the effect of progestin-only compared with combined hormonal contraceptive pills on rates of breastfeeding continuation  Similar breastfeeding continuation rate at 8wks, contraceptive continuation, and infant growth parameters

18.  Death  SIDS  Infectious disease  Diabetes  Obesity  Hypercholesterolemia  Asthma  Atopy  Lymphoma/leukemia/ Hodgkin’s disease  Cognitive development

19.  Case-control study examining association between breastfeeding and postneonatal death, N=1204  Ever breastfed, OR 0.79  Longer breastfeeding associated with lower risk  Decreased incidence of infectious cause (OR 0.76), injury (OR 0.59), and SIDS (0.84)

20.  Postpartum bleeding  Menstrual blood loss  Risk of Breast CA  Risk of Ovarian CA  Risk of osteoporosis and hip fractures (post- menopausal)  Type 2 DM  Postpartum depression  Postpartum weight loss

21.  Annual healthcare costs in United States  Cost for public health programs, i.e. WIC  Parental employee absenteeism  Environmental burden

23.  Maternal active, untreated TB  Maternal HTLV+  Maternal HIV (developed countries)  Maternal HSV lesions on breast  Maternal exposure to radioactive materials  Mothers receiving anti-metabolites or chemotherapy  Maternal drug use  Classic galactosemia

24.  Maternal +HepBsAg  Maternal Hepatitis C  Maternal seropositive CMV carriers  Febrile mothers  Mothers exposed to low-level environmental chemical agents  Maternal tobacco use  Maternal alcohol use – wait 2 hours

26.  The sooner, the better  Relaxed and supportive environment  Father’s assistance and support

27.  Positioning the infant › Cradle hold (most common) › Football hold

28.  Presenting the breast › Hand positions:  C-hold or palmar grasp  Scissor grasp › Ensure nipple is not tipped upward

29.  Achieving latch- on › Suck-swallow pattern › Bring nipple towards infant’s mouth

30.  Timing › 8-12 times a day during the first 4-5 days › Unrestricted breastfeeding based on infant’s demand

32.  Solutions: › Frequent breastfeeding every 1.5-2 hours during the first few days › Galactogogues (milk production enhancers):  Herbal: fenugreek, fennel seeds, milk thistle, goat’s rue  Medical: Reglan, Domperidone

33.  Solutions: › Frequent breastfeeding › Manual expression, breast massage › Cool compresses or ice (to relieve pain) › Frequent warm showers (to express milk) › Mild analgesics › Manual or electric pumping › +/- Cabbage leaves (to relieve pain)

34.  Sore nipples: due to improper latching › Encourage mother to place areola/nipple in infant’s mouth  Cracked nipples › Begin breastfeeding on less-affected side › Place a drop of milk on each nipple and allow to air-dry after breastfeeding › High-grade lanolin or nipple shields › Avoid coarse fabric, bras w/ seams

35.  More common in engorged breasts  Presents with flu-like symptoms  Most common pathogens: S. aureus, streptococcus, E. coli  Treatment: ibuprofen, dicloxacillin, cephalexin, clindamycin  Continue to breastfeed while taking antibiotics  Frequent emptying

36.  Rare – incidence of 0.1%  Requires incision and drainage, antibiotics  Pump affected side  Continue to breastfeed on unaffected side

37.  Centers for Disease and Control, Breastfeeding Report Card – United States, 2010. http://www.cdc.gov/breastfeeding/data/reportcard.htm. Accessed March 13, 2011.  Chen A, Roga, WJ. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics 2004; 113:5 e435-e439.  Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary care to promote breastfeeding: an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008 Oct 21;149(8):565-82.  Committee on Health Care for Underserved Women, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 361: Breastfeeding: maternal and infant aspects. Obstet Gynecol. 2007 Feb;109(2 Pt 1):479-80.  Dewey KG, Heinig MJ, Nommsen LA. Maternal weight-loss patterns during prolonged lactation. Am J Clin Nutr. 1993 Aug;58(2):162-6.  Gartner LM, Morton J, Lawrence RA, Naylor AJ, O'Hare D, Schanler RJ, Eidelman AI; American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005 Feb;115(2):496-506.  Kaunitz A. Postpartum and postabortion contraception. Up to Date, Inc. http://www.uptodate.com/contents/postpartum-and-postabortion- contraception?source=search_result&search=contraception+postpartum&selectedTitle=1%7E150#. Accessed Feb 8, 2012.  Merewood A, Mehta SD, Chamberlain LB, Philipp BL, Bauchner H. Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics. 2005 Sep;116(3):628-34.  Speroff L, Fritz MA (2005). The Breast. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 625- 633. Philadelphia: Lippincott Williams and Wilkins.  Wagner, C. Counseling the Breastfeeding Mother. Pediatrics: Cardiac Disease and Critical Care Medicine, Dec 14, 2010.  Wagner, C. Human Milk and Lactation. Pediatrics: Cardiac Disease and Critical Care Medicine, Dec 14, 2010.