1. Breastfeeding Support and Promotion Joan Younger Meek, MD, FAAP AAP Section on Breastfeeding
The American Academy of Pediatrics strongly supports breastfeeding for virtually all mothers and infants.
This presentation is designed to explain
 Why breastfeeding is important for babies and their mothers and families and results in optimal health outcomes
 How breastfeeding can be best be initiated and supported
 The role every health care professional can play in promoting breastfeeding in hospitals, clinics, offices, and the community
The author would like to acknowledge members of the Section on Breastfeeding Executive Committee and Rachel Meek for their review of the material in this slide set. The slides may be used for educational purposes with credit to the original source. 1

2. Management of Breastfeeding
Breastfeeding initiation
Recommended breastfeeding practices
Weight pattern
Hypoglycemia
Jaundice
Employment
This section will review the management of normal breastfeeding and breastfeeding in special circumstances.

3. Breastfeeding Promotion in Physicians’ Office Practices Curriculum
3 Key Educational Tools for Physicians to
Teach New Mothers
Nutritional parameters
Hand expression
Latch and positioning
Three key messages which physicians should be able to convey to mothers are the nutritional parameters that will be monitored to assure adequate milk production and milk transfer, the importance of learning hand expression, and appropriate latch and positioning.

4. 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.
To facilitate optimal breastfeeding, the first feeding should take place within about 1 hour after delivery. The newborn should be placed skin-to-skin with mother immediately after delivery. Unless there are unusual circumstances, the infant should remain with the mother throughout the recovery and post-partum period.
Repeated oral, nasal, or gastric suctioning may contribute to oral aversion in the infant. Traumatic procedures that are not essential should be delayed if possible to avoid interfering with the establishment of breastfeeding.
AAP Pediatrics 2012;129:e

5. Breastfeeding Initiation
Skin-to-skin contact
Promotes physiologic stability
Provides warmth
Enhances feeding opportunities
Infant crawls to breast and self-attaches
Delay weights and measurements, vitamin K and eye prophylaxis until after first feeding
Knowledgeable breastfeeding advocate in labor & delivery
Photo © Joan Younger Meek, MD, FAAP
The alert, healthy newborn can latch on to the breast within the first hour of life. If the infant is placed skin-to-skin immediately after the birth, the baby can often reach the breast and latch on with little or no assistance. If the mother has received medications that sedate the baby, then he/she may need more assistance. The newborn baby may be dried, have Apgar scores assigned, and be assessed while on the mother’s abdomen or chest. The mother helps to aid in newborn thermoregulation. Delaying weights, measures, bathing, vitamin K injection, and eye prophylaxis will encourage effective latch and maternal/newborn attachment. Unless there are unusual circumstances, the infant should remain with the mother throughout the recovery period. Vitamin K should be administered within 6 hours of birth. Labor and delivery personnel should be trained and knowledgeable in breastfeeding support. Lactation specialists, such as nurses or physicians with special breastfeeding training and expertise or International Board Certified Lactation Consultants (IBCLCs), should be available for consultation for special circumstances.

6. 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)
The manner in which the newborn suckles at the breast is very different from the way the newborn sucks on a pacifier or bottle. Babies should not need supplementation if they are allowed early and frequent access to the breast for feeding. Supplements may be counterproductive, filling up the baby’s small stomach and causing the baby to sleep for longer intervals and thus, not indicating interest in breastfeeding. Avoiding artificial nipples and formula feeding help to eliminate possible nipple confusion, encourage optimal milk production, and ensure that feeding cues result in the infant being placed at the breast to feed, instead of sucking on artificial nipples.
Pacifier use should be discouraged, because it may interfere with the establishment of good breastfeeding practices. Mothers need to learn to put the baby to the breast with early breastfeeding cues, such as rooting, or sucking on hands or fingers. These are signs to breastfeed, not to use a pacifier. In some cases, use of the pacifier may be a marker for breastfeeding problems which needs further evaluation. After about the first month, the pacifier can typically be introduced without causing an adverse effect on breastfeeding.
Pacifiers and artificial nipples should be avoided for at least the first 3 to 4 weeks of breastfeeding.

7. 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
Most healthy term infants require nothing but breast milk for optimal nutrition. In a few cases, alternative feedings are desired or necessary. These cases may include extreme prematurity, if mother’s milk or donor milk is not available; hypoglycemia, if the infant is unable or mother is unavailable to feed, although intravenous glucose should be administered to symptomatic hypoglycemic infants, including those refusing the breast and bottle; severe maternal illness when breastfeeding is not an option; and inborn errors of metabolism, such as classic galactosemia and cases of severe dehydration in which the infant needs immediate fluid resuscitation.
Intravenous fluids can be started as an alternative while lactation is being initiated, if donor milk is unavailable, or if the family or physician wishes to avoid exposing the infant to formula.
There only are a few maternal medications that are absolutely contraindicated during breastfeeding. These include chemotherapeutic agents, radioactive compounds agents (which typically only require a temporary interruption of breastfeeding), and illicit drugs. Medications were discussed in a previous segment of this presentation.
Academy of Breastfeeding Medicine Clinical Protocol #3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate.(

8. AAP Policy Statement Feeding Pattern
Encourage at least 8–12 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.
In the early weeks of life, the newborn should be fed at least 8 to 12 times per day, and preferably 10 to 12 times per day, or approximately every 2 to 3 hours. Some newborns may desire to be fed as often as every 1 to 2 hours. Feedings should not be timed, but the infant should be allowed to feed as long as desired from the first breast. The feeding should continue until the infant comes off the breast on his or her own or falls asleep at the breast. If the infant shows interest in further feeding after burping or changing the diaper, the second breast should be offered. Longer feedings at one breast provide a more “complete meal” with the higher fat milk being available to the infant towards the end of the feeding.
Nipple soreness does not result from the amount of time spent at the breast, but from improper positioning or latch.
Very young infants who fall asleep very soon after beginning to nurse can be stimulated to stay awake and continue nursing by tickling the feet or rubbing the back.

9. Infant Assessment Infant Weight Weight Loss Weight Gain
Average loss of about 6% over the first 3–4 days.
Loss greater than 8-10% mandates careful evaluation of breastfeeding.
Weight Gain
Begins with increase in mother’s milk production by at least day 4–5.
Expect gain of 15–30 g/day (1/2 to 1 oz per day) through the first 2–3 months of life.
All newborns are expected to lose weight in the early days of life. A newborn who is feeding frequently and effectively, in general, may lose an average of 6% of birth weight.
Any infant who loses more than 10% of birth weight should be carefully evaluated to make sure that the infant is being fed frequently enough and that the nursing technique is effective in transferring milk from the mother’s breast. Weight loss greater than 10% is not an automatic reason to supplement with formula. Formula administration may interfere with the baby’s interest in feeding at the breast and ability to learn appropriate breastfeeding techniques. If the mother has received excessive fluids during the intrapartum period, the newborn may be expected to have greater weight loss during the early days of life.
Once the mother’s milk production increases and the volume of milk consumed increases, most infants begin to gain 15 to 30 g or 1/2 to 1 oz per day. This rate of gain continues for the first several months of life.

10. 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.
Loss of excessive weight or failure to begin a steady pattern of weight gain indicates that either the mother is not producing adequate milk, the infant is not ingesting adequate milk, or, much less commonly, the infant has other organic problems. In general, correcting the latch and positioning will improve milk transfer from the breast to the baby.
In some cases, a mother may have low milk supply. Feeding the baby a minimum of 10 to 12 times per day and increasing the duration of the breastfeeding should increase the mother’s supply within several days.
Use of an electric breast pump or manual expression may be recommended as an adjunctive aid for additional nipple and breast stimulation.
When simple corrective actions are not effective, referral should be made to a breastfeeding specialist. Close follow-up is critical until the infant has achieved appropriate weight gain. In some cases, breastfeeding evaluation may include “test weights,” which involve weighing the infant on an accurate electronic scale, feeding the infant, followed by another weight check on the same scale with the same clothing and diaper to determine the intake of milk at the breast. For every 1 gram increase in weight, this is equivalent to approximately a milliliter of milk ingested.

11. 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 month—may indicate insufficient milk intake EVALUATE
Infrequent stools are common after the first month in the healthy breastfed infant.
In the first few days after delivery, the infant should have at least one urination and one stool per day. Over the next several days, the elimination pattern should gradually increase, with the stools changing from meconium to dark green by days 3 to 4. As mother’s milk volume increases, so does the number of stools and urine voids for the infant.
Generally, by at least day 4, the infant should produce between 4 to 6 pale, yellow, or colorless urine voids per day and at least 4 to 5 loose, yellow, seedy stools. This stool pattern continues until the infant is about 1 month of age, at which time the stools may become much less frequent.
Some older breastfed babies have a large stool once every few days to every week or so. As long as the baby continues to feed well, is gaining weight, and does not have abdominal distention, this is nothing to worry about. During the first few weeks of life, however, infrequent stools are very uncommon and may be a sign that the baby is not getting enough milk. These babies should be evaluated immediately.

12. Infant Assessment Breastfeeding evaluation
Proper positioning at the breast
Proper latch and lip closure
Sufficient areola in infant’s mouth
Tongue extends over lower gums
Adequate jaw excursion with suckling
Effective swallowing motion
Coordination of suck-swallow-breathe
While nursing, the baby should maintain a good seal and have regular movements of the tongue, which is cupped under the breast tissue.
The baby should have wide excursions of the jaw and should be heard to swallow during nursing, at least by the time the mother’s milk production increases.
Term infants should be able to coordinate their sucking, swallowing, and breathing during the feeding.
Occasionally, with high milk-flow rates, the infant may sputter or choke and pull off of the breast. The infant then can be properly reattached to resume the feeding. Babies who appear to have difficulty suckling, cause pain and trauma to the mother’s breast, or are not gaining weight appropriately should be evaluated carefully. A trained professional may need to perform a digital suck assessment with a gloved finger.
Lactation specialists and some speech and occupational therapists have special training to help breastfeeding infants improve their suckling technique.
Formal evaluation of breastfeeding should be undertaken by trained caregivers at least once per shift and documented in the hospital record. Encourage the mother to record the time and duration of each feeding. A documented plan for management should be clearly communicated to both parents and to the medical home.

13. AAP Policy Statement Recommended Breastfeeding Practices
Formal evaluation of breastfeeding during the first 24–48 hours and again at 3–5 days of age
Assess
Infant weight
General health
Breastfeeding
Jaundice
Hydration
Elimination pattern
The formal evaluation of breastfeeding technique and practices throughout the hospital stay, including documentation in the mother’s and infant’s charts, and again at 3–5 days of age are essential to promote successful breastfeeding.
During these evaluations, the health care professional can provide anticipatory guidance and help to prevent problems.
Close follow-up helps to provide a safety net to guard against the breastfeeding newborn developing significant dehydration or excessive jaundice.
The infant should be observed at the breast and assessed for weight pattern, jaundice, and hydration status, and the patterns of breastfeeding and infant elimination should be evaluated.

14. 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 cow’s milk before 12 months.
Water, juice, formula, and solids are not necessary in the first 6 months for breastfed infants.
All breastfed infants and children should receive 400 IU of vitamin D daily. This can be provided in the form of a multivitamin supplement, a combination of vitamins A, C, and D, or as a single supplement of vitamin D. Human milk does not contain sufficient vitamin D to prevent rickets. Adequate sun exposure is the usual way vitamin D is produced in the skin. Pediatricians and dermatologists are concerned about the long-term effects of sunlight exposure on children’s skin and recommend limited sunlight exposure. Furthermore, sunscreens prevent vitamin D production in the skin. 400 IU vitamin D daily by hospital discharge is recommended for exclusively breastfed infants (or those receiving less than one liter of infant formula or cow’s milk (after 12 months).
Most infants require a supplemental source of iron by about 6 months of life. This can be provided by iron supplements or by adding iron-rich foods, such as meats, or iron-fortified foods, such as infant cereal, to the diet. Premature babies may require additional supplementation of vitamins and iron prior to 6 months of age. Also, by 6 months, the family water supply should be evaluated to make sure that adequate fluoride is present to prevent dental caries.
The American Academy of Pediatrics does not recommend introduction of whole cow’s milk prior to the first birthday. Mothers who are not breastfeeding exclusively or who choose to wean their infants from the breast prior to the first birthday should feed iron-fortified infant formula.

15. Maternal Trouble Signs
Nipple pain
Nipple trauma
Breastfeeding should be pleasant and enjoyable for mother and baby. Pain during nursing is unusual and generally is a signal that latch and positioning should be evaluated and technique improved. In the first few days of breastfeeding, the mother may feel slight discomfort as the infant starts to latch, but this should rapidly subside as the infant begins to suckle. Pain should not last throughout the feeding. When improper latch is causing the nipple pain, correction of the latch typically results in immediate relief for the mother. Ideally, many of these problems can be prevented by proper technique, beginning with the first breastfeeding session.
Painful nursing also may result from infection of the nipple or breast, previous trauma due to poor latch, tight lingual frenulum, or tongue-tie in the newborn, as well as facial nerve palsy in the newborn. In all cases of maternal discomfort with breastfeeding, careful evaluation of breastfeeding technique by a qualified professional is indicated. Frenulotomy may relieve nursing discomfort related to tongue tie and can be performed by a trained physician as an outpatient procedure.
Photo © Joan Meek, MD, FAAP

16. 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
Neonatal hypoglycemia is a frequent reason reported for supplementation in the first postpartum day. Often, this supplementation is not necessary. The risk of underfeeding the term infant with no risk factors is not hypoglycemia, but instead, dehydration and possibly jaundice and hypernatremia.
For a clinical protocol on management of hypoglycemia in the neonate, see the Academy of Breastfeeding Medicine Web site at or the AAP Clinical Report on “Postnatal Glucose Homeostasis in Late-Preterm and Term Infants,” published in Pediatrics 2011; 127:
AAP; World Health Organization
Academy of Breastfeeding Medicine

17. 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 minutes of life and continue feeding on demand.
For those babies requiring supplementation due to persistent hypoglycemia which does not respond to breastfeeding or if the mother is not available to breastfeed, then supplements of expressed human milk or donor milk are ideal, but glucose water or formula can be considered. Supplements can be provided via a bottle and artificial nipple, however, a syringe, gavage tube, cup, or teaspoon can be used to provide a small volume of supplement in order to prevent nipple confusion by offering an artificial nipple. Alternatively, intravenous glucose can be offered, until the baby is able to breastfeed directly.
AAP; World Health Organization;
Academy of Breastfeeding Medicine

18. Maternal Trouble Signs
Engorgement
Severe prolonged engorgement is unusual and reflects inadequate milk removal from the breast. Continued engorgement can inhibit further milk production. Engorgement often occurs during the first few weeks of lactation because more milk is produced than the baby requires. Eventually, the milk production will be more in synchrony with the infant’s needs.
Engorgement can be prevented or minimized by frequent feedings or expressing milk by hand or using an electric or manual breast pump, expressing just enough milk to improve maternal comfort. Excessive pumping may exacerbate the problem. Cool compresses between feedings and analgesics may be necessary.
Use of warm compresses or a warm shower just before feeding or expressing milk may help to encourage milk flow.
Photo © Joan Younger Meek, MD, FAAP

19. 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
Due to increasing reports of bilirubin encephalopathy as breastfeeding rates have increased, all health care professionals should be vigilant in evaluating infants for jaundice. Infants less than 38 weeks should be considered at higher risk and should be closely monitored. Follow-up evaluation is important for all breastfed infants, particularly those with an early hospital discharge.
AAP Subcommittee on Hyperbilirubinemia Clinical Practice Guideline: Pediatrics 2004; 114:

20. 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
Published guidelines of the American Academy of Pediatrics Subcommittee on Hyperbilirubinemia provide guidance to health care professionals evaluating and managing infants with jaundice or risk factors for developing jaundice. The guidelines stress that successful breastfeeding should be promoted and supported. Nursery protocols that allow for the identification of jaundice are recommended. The guidelines indicate that all infants who become clinically jaundiced in the first 24 hours of life should have a serum bilirubin or transcutaneous bilirubin level measured. All bilirubin levels should be interpreted based on the infant’s age in hours and used to predict risk of the infant developing clinically significant levels of hyperbilirubinemia. Objective measurement of bilirubin is encouraged instead of visual estimation. The guidelines provide specific recommendations for initiation of phototherapy or exchange transfusion based on the age of the infant in hours.
AAP Subcommittee on Hyperbilirubinemia Clinical Practice Guideline: Pediatrics 2004; 114:

21. 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.”
It is a misconception that providing water, whether intravenous or orally, will help jaundice. What the jaundiced breastfeeding infant needs is frequent feeding, which will stimulate the gastrocolic reflex and stimulate stooling, which helps to decrease the serum bilirubin.
AAP Subcommittee on Hyperbilirubinemia Clinical Practice Guideline: Pediatrics 2004; 114:

22. 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)
Evaluation of every infant for jaundice is indicated daily, and especially prior to hospital discharge. Risk factors for jaundice should be noted. Objective assessment of jaundice by use of a transcutaneous bilimeter of a serum bilirubin determination is desirable. If the infant is discharged early at less than 48 hours or is clinically jaundiced, an early follow up appointment is indicated.
AAP Subcommittee on Hyperbilirubinemia Clinical Practice Guideline: Pediatrics 2004; 114:

23. AAP Clinical Practice Guideline
Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation
Plotting bilirubin levels by hour of life on the nomogram published by Bhutani and colleagues is recommended to determine need for further evaluation and management.
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;114:297–316

24. Management of Breastfeeding Jaundice
Increase caloric intake
Increase breastfeeding frequency to 10–12 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
Breastfeeding jaundice is managed by increasing the frequency and duration of breastfeeding to increase milk ingestion and improve caloric consumption.
This increases the stool output, decreases the enterohepatic reabsorption of bilirubin, and helps to lower the serum bilirubin.

25. Breast Milk Jaundice Definition Begins after day of life 5–7
Increased bilirubin reabsorption from intestine
Lasts several weeks to months
Breast milk jaundice often occurs as an extension of the normal physiologic jaundice of the newborn, beginning after days 5 to 7. It may last weeks to months and results from increased reabsorption of bilirubin from the breastfed infant’s intestine and decreased bilirubin conjugation.
Babies with breast milk jaundice should be feeding well, gaining weight, thriving, and have an elevated total serum bilirubin, but should not have an elevated direct bilirubin fraction, abnormal liver enzymes, or other signs of illness.

26. 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.
Breast milk jaundice can be managed in a variety of ways. Breastfeeding can be continued, with the bilirubin followed periodically until it normalizes.
If the bilirubin exceeds 20 mg/dL, phototherapy should be considered.
Other options that may be considered include temporarily supplementing with casein hydrolysate formula or temporarily interrupting nursing and feeding casein hydrolysate formula. Casein hydrolysate formula has been shown to be more effective in inhibiting intestinal bilirubin absorption. It also is less allergenic and a special formula, indicating to the mother that the infant did not need regular formula to handle the problem. If nursing is interrupted for any reason, the mother should be instructed to express her milk frequently to maintain her milk supply. Use of a nursing supplementer or other methods of alternative feeding with a cup, syringe, or gavage tube may help to prevent the infant from developing nipple confusion, if supplements are indicated.
Infants with prolonged jaundice should be evaluated for other causes of jaundice, such as ongoing hemolysis due to blood type or group incompatibility, glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, hypothyroidism, extrahepatic biliary atresia, genetic conditions, and intrinsic liver disease.

27. Nursing Supplementation
When supplements are indicated, the use of a nursing supplementer or other methods of alternative feeding with a cup, syringe, or gavage tube may help to prevent the infant from developing nipple confusion or nipple preference. With this method, the supplemental feeding, either expressed breast milk or infant formula, is placed in the container with a small tube taped in place so it extends just beyond mother’s nipple. As the infant nurses at the breast, the infant also receives the supplement. This method of feeding also can be used to reestablish a milk supply after weaning or induce a milk supply in the case of an adoptive infant.
Illustration by Tony LeTourneau

28. 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.
If a mother is separated from her infant because of premature birth, maternal or infant illness, or her return to work or school, she should be taught to express her milk so that she can maintain a milk supply and continue to provide her infant with milk.
Hand expression or a manual pump is effective for occasional expression. For regular expression because of mother’s return to work or school or to express milk for a premature infant who remains hospitalized or is unable to breastfeed directly, a good-quality electric breast pump is desirable.
Expressed milk can be stored in a clean container in the refrigerator for up to 4 days. For longer storage, the milk can be placed toward the back of the freezer, not on the door. Stored milk should be dated and, if it is stored at the workplace, carefully labeled.

29. Milk Expression
The mother on the left is demonstrating hand expression, which is done after gentle massage of the breasts by compressing the areola while pushing toward the chest wall. Many mothers become very adept at hand expression.
For prolonged or regular periods of milk expression, a hospital-grade pump, which can be rented or purchased, is desirable. Pumping is most effective and efficient when both breasts are expressed at the same time, as demonstrated on the right. The double pump set-up increases prolactin levels more effectively than expressing milk from one breast at a time. A hospital-grade pump will help to maintain a good milk supply when pumping for extended periods of time for a premature baby.
Photo © Jane Morton, MD, FAAP
Photo © Kay Hoover, MEd, IBCLC

30. 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 3–4 weeks.
When the mother plans to return to work or school after delivery, she should be encouraged to breastfeed and options for continued breastfeeding after resuming employment should be discussed. Ideally, plans for returning to work and breastfeeding should be discussed with the employer prior to maternity leave.
It is best to practice exclusive breastfeeding for at least the first 3 to 4 weeks to establish a good milk supply. After that time, bottles usually can be introduced without difficulty.
Someone other than the breastfeeding mother may be more successful at getting the infant to accept the bottle.
Continued breastfeeding allows the mother to have periods of closeness and relaxation with the baby after the mother’s schedule becomes more hectic.

31. Employed Mother Workplace support Breaks for feeding/ expressing
Private, clean place to pump
Refrigerator or cooler with ice packs to store and transport milk
After returning to work, many mothers continue exclusive breastfeeding/breast milk feeding, while other mothers breastfeed when they are with the baby and provide formula when they are not. For the baby older than 6 months, solids may be fed in the mother’s absence.
Plans for lactation should be discussed with the employer prior to returning to work so that adequate breaks and location for milk expression and storage are arranged. Some companies provide pumps, breastfeeding rooms, and even lactation specialists to assist their employees in maintaining lactation.
Illustration by Tony LeTourneau

32. 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
Adolescent births continue at a high rate in the United States. With good support, adolescent mothers are capable of establishing and maintaining a good milk supply while enjoying a close and nurturing relationship with their infants. Breastfeeding should be promoted actively for adolescent mothers since teens have the lowest incidence of breastfeeding in the US, even after considering other sociodemographic factors. Multidimensional adolescent parenting support programs, including home visits, family centered care, and peer support, are effective in increasing the initiation and duration of breastfeeding in teens.
Many high schools are providing assistance to teenage mothers, and community programs often are in place to make sure that the mother continues her education and is able to obtain basic infant supplies.
A reasonable diet; adequate fluids, calories, and protein; and a multi-vitamin supplement, with calcium from dietary sources or a supplement, will help to protect the nutritional status of the lactating adolescent.

33. 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.
Breastfeeding should be initiated within about one hour after birth. Supplementation is rarely indicated and interferes with successful lactation. Good breastfeeding practice helps to prevent breastfeeding problems. One of the most frequent reasons for mothers to stop breastfeeding or start supplementation is their perception that they do not have “enough milk.” Close follow-up and good education should help to minimize concerns about lack of milk. Physicians and other health care providers must be knowledgeable to provide the support that breastfeeding families need to be successful. All breastfed infants need an office visit by 3-5 days of life, or about hours after hospital discharge.