Version May 2024
INTRODUCTION — Breastfeeding (or, when necessary, feeding expressed breast milk) is recognized as the normative standard for virtually all infants because of its health benefits to infants and their mothers. There is broad consensus recommending exclusive breastfeeding for approximately the first six months and continued breastfeeding, along with the introduction of solid foods, for at least one year after birth, as long as it is mutually desired by mother and infant [1-5]. The World Health Organization recommends continued breastfeeding through at least the child's second birthday.
Unfortunately, despite the strong recommendations, actual breastfeeding practice falls short of these goals in many countries and cultures. In the United States, more than 80 percent of mothers initiate breastfeeding, but less than 60 percent continue through six months postpartum and less than 40 percent are breastfeeding at 12 months [6]. Exclusive breastfeeding is practiced by less than one-half of mothers at three months postpartum and only one-quarter of mothers at six months. These observations call for collaboration among mothers, partners and families, communities, clinicians, health care facilities, and employers to actively support optimal breastfeeding [7].
Anticipatory guidance and ongoing counseling and education for mothers are discussed below. Detailed discussions of steps to initiate breastfeeding and address common problems of breastfeeding are presented separately. (See "Initiation of breastfeeding" and "Common problems of breastfeeding and weaning".)
FACTORS IN PARENTAL INFANT FEEDING DECISIONS — Mothers often make decisions about how they will feed their infant very early in pregnancy or before conceiving [8]. Understanding which factors affect parental decisions about infant feeding is essential to provide adequate education and support for families. In addition, an understanding of the common misconceptions and barriers that new mothers face and how to overcome them will facilitate counseling. Similarly, public resources and policy should be directed at addressing the common obstacles to breastfeeding in a population.
●Intention to breastfeed – Intention to breastfeed is a strong predictor of initiation and duration of breastfeeding [9-11]. Asking about intentions to breastfeed enables the clinician to provide extra counseling and support for those who are hesitant or undecided. Women are more likely to intend to breastfeed if they have prior successful experience with breastfeeding and if this decision is supported by their family and workplace. Women are less likely to intend to breastfeed if they face economic challenges (lower household income and/or need to return to work), have health problems or "hassles" during pregnancy, are pregnant with twins, are younger, and/or have limited access to health care [12,13].
●Clinician advice – Receiving advice from a health care provider to breastfeed is associated with a higher incidence of breastfeeding initiation [14]. Moreover, routine ongoing support and guidance during antenatal and postnatal care are associated with longer duration of breastfeeding (exclusive and partial) [15]. This support is optimally tailored to the setting and needs of the population and individual patient and may include a variety of professional or lay/peer counselors. However, breastfeeding advice is not universally provided, and when it is provided, it is not always consistent with recommendations to exclusively breastfeed [16].
●Common myths about breastfeeding – Several common myths about breastfeeding could hinder a mother's success [17-19]. These include a perception that breastfeeding is inherently painful, that many mothers are unable to produce sufficient breast milk, and that infants have poor weight gain with breastfeeding. Addressing each of these concerns is an important component of counseling while the mother makes her decision about breastfeeding during the antenatal and perinatal periods. (See 'Address common concerns' below.)
●Attitudes and social norms – Attitudes and social norms play a large role in a mother's decision about whether to breastfeed and her overall breastfeeding success [20]. This includes a mother's perception of whether or not it is acceptable to breastfeed in public. Mothers may need help feeling comfortable and empowered to feed their babies in public and may benefit from positive messages and learning strategies to maintain their desired level of modesty while doing so. Exposure to media images, advertising, and negative breastfeeding messages also influences a mother's initiation and continuation of breastfeeding [21,22].
•Lost generations – In the late 1970's and early 80's in the United States, breastfeeding initiation rates were as low as 25 percent [23]. This means that an entire generation of mothers, grandmothers, support people, and clinicians witnessed most mothers feeding formula to their infants and few mothers attempting breastfeeding. Now that the importance of breastfeeding is widely recognized [6], mothers and families need further education about why breastfeeding is recommended and what to expect, and clinicians who trained during that time need to develop skills to support the breastfeeding mother, especially in the first days and weeks postpartum.
•Self-efficacy – Breastfeeding self-efficacy (a mother's confidence in her ability to breastfeed) is one of the strongest predictors of breastfeeding initiation and duration [24]. Strategies and counseling techniques are needed that serve to boost a mother's confidence both prenatally and early postpartum to help her successfully breastfeed from the start. Counseling can help the mother learn to trust her body, which just grew a precious infant, and learn ways to confirm that breastfeeding is going well and that her baby is getting enough nourishment.
●Marketing of infant formulas – Marketing of artificial breast milk substitutes (formulas) often has a negative influence on breastfeeding initiation [25]. Marketing messages overtly or covertly intensify parents' anxieties and aspirations (eg, by claiming to solve common infant problems such as reflux or allergies), position formulas as close to or equivalent to breast milk, make health and nutrition claims based on marginal evidence, and encourage unnecessary use of toddler formula (after 12 months of age) [26-28]. Marketing is accomplished through a variety of platforms that effectively promote formula feeding, including targeted digital marketing methods to consumers and various methods that influence health professionals [29]. Countermeasures, such as professional education and baby-friendly hospital initiatives, are valuable but often insufficient. Marketing messages reach families in both low- and high-income countries, although the economic and structural drivers, market saturation and balance between marketing and countermeasures varies substantially [25,30].
PROGRAMMATIC APPROACHES AND PROFESSIONAL RESOURCES
●Baby-friendly hospital – The Baby-Friendly Hospital Initiative outlines 10 steps that hospitals and clinicians should take to facilitate successful breastfeeding (table 1) [31]. These include counseling to all pregnant women beginning in the first trimester about the benefits of breastfeeding, how to address any concerns, and hospital practices to encourage breastfeeding initiation. (See "Initiation of breastfeeding", section on 'Hospital policy and environment'.)
●Breastfeeding-friendly office environment – Several organizations have recommendations for how to make office practices more supportive or "friendly" for breastfeeding mothers. There are data indicating that these types of changes at the practice level can improve rates of breastfeeding initiation and duration [32-34].
●Professional support for breastfeeding mothers – The clinician and practice should develop familiarity and referral relationships with professional resources to support breastfeeding [1,35]. Mothers need to be aware of all of the ways in which she can receive in-the-moment professional help if and when she encounters a problem with breastfeeding. Timely help is crucial before either she or the infant develop a medical condition and/or before she starts supplementing when it is not medically necessary or stops breastfeeding completely.
Examples of professional support include:
•Advanced practice clinicians – Clinicians in a variety of medical fields may develop special expertise in breastfeeding medicine, through affiliation, education, and training with the following organizations:
-American Academy of Pediatrics Section on Breastfeeding
-Academy of Breastfeeding Medicine
•International Board-Certified Lactation Consultants (IBCLCs) – Certification as an IBCLC requires collegiate-level health sciences courses, over 90 hours of lactation-specific education, logging 300 to 1000 clinical practice hours, and successful completion of a criterion-referenced examination offered by an independent international board of examiners [36].
•Breastfeeding counselors – For families with basic breastfeeding concerns, breastfeeding guidance can be provided by a certified lactation counselor (CLC) or certified breastfeeding educator (CBE) [36]. Certification requires 20 to 120 hours of special training and passing a written examination offered by the training organization.
•Home visiting professionals – Home visits from a nurse, midwife, or postpartum doula with expertise in breastfeeding can help overcome some of the initial challenges with breastfeeding [37-39].
•Comprehensive postpartum follow-up programs – These programs are available in some health care systems and include nurses, pediatric specialists, obstetricians, lactation consultants, and sometimes psychologists. This wrap-around care has proven to be promising in helping new mothers and families get off to a good start [40,41].
•Telephone support – Telephone support for breastfeeding is available from hotlines such as the National Office on Women's Health Helpline: 1-(800)-994-9662.
●Peer support – The clinician can facilitate peer support by providing a list of available local resources and making referrals when appropriate. Peer support helps facilitate the success of new and expectant mothers by promoting breastfeeding as a social norm, enhancing self-efficacy, and encouraging them to reach out for social support and help with breastfeeding problems [42]. Examples of peer counseling include:
•Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in the United States offers breastfeeding peer counselors [43-48]
•La Leche League International groups
•Postpartum Support International
•Depending on locality, there are likely other breastfeeding or postpartum support groups
INITIAL CLINICAL ASSESSMENT AND SUPPORT — All mothers should have an initial assessment and discussion by a clinician with experience in breastfeeding. This could be an obstetrician or midwife, general practitioner or family medicine clinician, pediatrician, or lactation consultant. Ideally, this assessment and counseling should occur at several points during prenatal care and be reinforced in late prenatal or early postnatal visits.
Initial assessment — The initial assessment involves assessing the mother's knowledge about breastfeeding, identifying psychosocial and physiologic risk factors for breastfeeding problems, and providing tailored education to reduce these risks.
●Assess the mother's knowledge and concerns – To initiate counseling, it is helpful to start with an open-ended question such as "What have you heard about breastfeeding?" or "What are your thoughts about breastfeeding?" rather than asking "How do you plan to feed your baby?" The open-ended questions help to determine the mother's level of knowledge, comfort, and self-efficacy with breastfeeding, so that education may more resemble a conversation that is tailored to the mother's prior experiences and needs [49].
Assessing the mother's understanding of breastfeeding and identifying common concerns about breastfeeding, such as pain or concern for insufficient milk, ie, "perceived insufficient milk supply" [50], can help the clinician focus counseling and support. (See 'Address common concerns' below.)
All mothers and families deserve to be given accurate and current information about the health benefits, recommendations, and management of breastfeeding to make a truly informed decision about infant feeding and then receive all of the education and support needed to achieve their personal feeding goals. (See "Maternal and economic benefits of breastfeeding" and "Infant benefits of breastfeeding".)
●Identify mothers at risk for breastfeeding problems – Risk factors for breastfeeding problems and/or low milk supply are outlined in the table (table 2).
Women with risk factors for breastfeeding problems or low milk supply may benefit from extra lactation support, including prenatal consultation with a lactation consultant, and special education and attention during initiation of breastfeeding, as outlined below.
●Breast examination – The breast examination may identify anatomic features that predict increased risk for breastfeeding problems. Women with these features and their infants should be given extra support and monitoring during breastfeeding initiation.
•Insufficient glandular tissue – While it is rare, some mothers have insufficient glandular tissue. The breasts tend to appear misshapen, somewhat triangular in appearance, widely-spaced, and "less full" between the areolar complex and the chest wall (figure 1). These women are at risk of being unable to establish a full milk supply, but the likelihood of successful breastfeeding cannot be fully predicted from the physical examination.
For mothers with insufficient glandular tissue, the clinician should identify the problem to help manage her expectations and provide focused lactation counseling to optimize her chance of successful breastfeeding. This includes guidance to establish an effective latch from the very start and frequent expression of milk to maximize breast milk production. Even if a mother is unable to produce the quantity of milk needed for exclusive breastfeeding, it is likely that she can at least produce drops of colostrum, which have important health benefits for the baby. She can also have a breastfeeding relationship with her infant, offering suckling at the breast for comfort and possibly using a device that allows for supplementation at the breast while the infant is suckling.
•Other anatomic risk factors – Prenatal breast assessments are helpful to identify women with other anatomic conditions that may affect latching or milk supply, such as scar tissue, previous surgeries, or flat or inverted nipples (picture 1 and figure 2). It is difficult to predict whether these findings will interfere with breastfeeding. However, these mothers benefit from education and assistance during breastfeeding initiation to help them effectively feed their infants, remove milk frequently to help maximize their milk supply, achieve and sustain an effective latch, and avoid nipple trauma. (See "Nipple inversion" and "Initiation of breastfeeding", section on 'Flat or inverted nipples'.)
Contraindications to breastfeeding — There are very few contraindications to breastfeeding [5]. Contraindications may be permanent or temporary. In some cases, the infant may be fed expressed breast milk until it is safe to resume direct breastfeeding, as listed in the table (table 3).
Considerations for breastfeeding for a mother with coronavirus disease 2019 (COVID-19) are discussed separately. (See "COVID-19: Intrapartum and postpartum issues", section on 'Breastfeeding and formula feeding'.)
If one of these contraindications exist, the clinician should educate and support the mother on how to feed her infant safely and effectively in another manner. If the suspension of breastfeeding is temporary, she will need to express milk and signal her breasts frequently with either a breast pump or hand expression in order to maintain her milk supply until she can return to breastfeeding. A mother who is not able to breastfeed often experiences a sense of disappointment and even guilt. The clinician can help by recognizing and validating those feelings as well as helping her explore other ways to nurture and bond with her infant. (See 'Support for mothers who are not able to fully breastfeed' below.)
Support during breastfeeding initiation — Most mothers produce enough milk for their infants if they have appropriate education and support. To optimize milk supply and promote direct breastfeeding, key goals are:
●Avoid formula supplementation unless it is medically necessary
●Frequent feeding and emptying of the breast (including hand expression if needed) beginning immediately after birth and then at least 8 to 12 times in each 24-hour period until the breast milk supply is fully established
●Avoid artificial nipples
To achieve these goals, recommended practices include immediate skin-to-skin contact after birth, encouraging feeding in the first hour or two after birth and with every cue, 24-hour rooming-in with the infant to catch and respond to every feeding cue, working to achieve a comfortable position, and teaching an effective latch each time. Mothers should be encouraged to ask for help and hands-on assistance with positioning and troubleshooting problems such as nipple pain or if she has concerns that the baby is not feeding well. By observing a feeding and other clinical data, an experienced clinician can determine whether feeding and maternal milk supply are progressing as expected and provide appropriate guidance and reassurance. All new mothers should be taught techniques for hand expression of colostrum to provide signaling for her body in the case of a sleepy baby or if they are separated and to ensure optimal intake for the infant.
Details about how to support successful breastfeeding initiation are discussed in a separate topic review. (See "Initiation of breastfeeding".)
Address common concerns
Pain — Pain during breastfeeding is a common concern but usually can be addressed by making minor adjustments in the technique, particularly with regard to the angle that the infant approaches the breast. Pain is usually a signal that the baby is compressing or rubbing the nipple during suckling, which can impede milk flow. When a mother experiences pain during suckling, she should use a finger to help break the latch and reposition the baby, such that she and the baby are both comfortable. Pinching or rubbing the nipple during feeding can lead to more soreness and does not provide optimal signaling to mother's body. If the mother experiences pain while breastfeeding or latching the infant, even at the beginning of a latch, the clinician should directly observe breastfeeding and teach the mother techniques to achieve a good latch (figure 3). (See "Initiation of breastfeeding", section on 'Evaluating a latch for effectiveness'.)
Feeding a sleepy baby — Healthy babies wake easily and often to feed and ought to be fed with every feeding cue (eg, stirring, lip smacking, rooting, opening the mouth, turning the head, or sucking on fingers).
A newborn should eat at least eight times in 24 hours and more frequently if the baby is giving feeding cues. The feedings are not usually spaced out evenly throughout the day and night but rather may occur in "clusters" followed by "breaks" of up to four hours. It is common for a newborn to fall asleep at the breast because this is where they are most comfortable. To address this, the mother can try to arouse the infant by taking "burp breaks"; changing the diaper; or rubbing his or her head, back, arms, or feet. She can also encourage the infant to feed by using hand expression and breast compression.
Concerns about milk supply — Most mothers make enough milk to feed their baby without need for any supplementation. Understanding the normal progression of lactation after delivery will help a mother to focus on steps to enhance lactation and shape her expectations about milk volume. (See "Initiation of breastfeeding".)
In the first few days after birth, breasts will feel the same as before while mothers are producing colostrum, which is measured in drops rather than ounces. Colostrum is very concentrated with antibodies and other nutrients and is all that the baby needs. Because the volumes are small, babies will need to eat frequently. Mothers should not expect to produce significant milk volume (ounces) until day 3 to 4 after birth.
In the meantime, there are established ways to tell whether the baby is receiving sufficient amounts of milk by monitoring his or her weight, input and output, behavior, and other findings on the physical examination:
●Healthy infants typically lose weight during the first three to five days of life, and then their weight begins to increase by 15 to 30 g/day to regain their birth weight by 10 to 14 days. All healthy infants should regain their birth weight by three weeks of age [51].
●Infants should be evaluated more closely if they drop below the 75th percentile curve on the newborn weight loss tool (NEWT) nomogram within the first 48 to 72 hours after birth. (See "Initiation of breastfeeding", section on 'Assessment of intake'.)
●Other signs that warrant close monitoring include difficulty latching on or absence of effective suckling, maternal nipple pain or compression, presence of urate crystals in the diaper, or other signs suggesting dehydration [52,53].
Maternal exhaustion — Caring for a newborn is exhausting work, with a 24-hour/7-days-a-week schedule. Teaching mothers strategies for self-care may help them survive and thrive during this challenging and often overwhelming time. Suggestions to attenuate maternal exhaustion and facilitate self-care are summarized in the table (table 4).
In addition, all mothers should be screened for perinatal mood and anxiety disorders at each health maintenance visit for at least the first six months after birth. This can be done with a validated screening tool, such as the Edinburgh Postnatal Depression Scale. (See 'Perinatal mood and anxiety disorders' below.)
POSTNATAL MEDICAL SUPERVISION
Frequency of follow-up — Breastfeeding mother-infant dyads should have frequent follow-up with a clinician until breastfeeding is well established. For those who appear to have effectively initiated breastfeeding in the hospital and have no risk factors for breastfeeding problems (table 2), routine follow-up in the primary care office may be sufficient. The initial visit depends on the length of the birth hospitalization but usually should be within 24 to 48 hours after discharge. The timing of subsequent follow-up visits depends upon the infant's feeding and risk factors, such as prematurity or any other medical problems. Some infants may need to be seen one or more times again prior to the routine two-week visit. (See "Overview of the routine management of the healthy newborn infant".)
Patients with any problems with breastfeeding and/or poor infant weight gain should be seen more often and may benefit from professional breastfeeding assistance, such as a breastfeeding medicine clinician or a lactation consultant. (See 'Programmatic approaches and professional resources' above and "Initiation of breastfeeding", section on 'Assessment of intake'.)
Breastfeeding is well established when the infant has regained their birth weight, continues to gain weight well, and is cueing to feed appropriately; lactogenesis II has occurred; and the mother has no nipple pain or discomfort. Once these milestones are reached, follow-up can be performed in the form of check-ins about breastfeeding during routine well-child visits, with additional visits as needed should any problems arise.
Maternal diet — Maternal nutritional needs during lactation and frequently asked questions about diet and weight management are discussed in a separate topic review. (See "Maternal nutrition during lactation".)
Maternal alcohol use — A small percentage of alcohol is transferred into breast milk. The amount of alcohol considered to be "safe" while breastfeeding is controversial. We suggest that a breastfeeding woman avoid exposing the infant to alcohol by waiting to nurse for two hours after a single serving of alcohol (12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof liquor). If a woman drinks more than this amount, she should refrain from breastfeeding for an additional two hours for each serving of alcohol [54]. It is not necessary to express and discard milk after consuming alcohol, unless the breasts become uncomfortably engorged before enough time has elapsed for the alcohol to leave her system. Heavy alcohol intake can impair judgement and child care abilities and should be avoided, regardless of how the infant is fed. Further details about the pharmacokinetics and effects of alcohol use during lactation are available in the LactMed database.
Maternal cannabis use — Cannabis metabolites are secreted into breast milk; effects on the infant's neurodevelopment have been suggested but not established [5,55-59]. (See "Prenatal substance exposure and neonatal abstinence syndrome (NAS): Clinical features and diagnosis", section on 'Cannabis'.)
Maternal medications — Most medications are compatible with breastfeeding. Although most medications diffuse into and out of breast milk via their concentration gradient with the maternal serum, the amount transferred is usually quite small and unlikely to adversely affect the infant [5,60,61]. The following general considerations help to guide decisions:
●If the medication could otherwise be prescribed to the infant for a medical condition, it is generally considered safe for the mother to take while breastfeeding. The doses transferred via breast milk are generally much lower than the therapeutic doses given directly to an infant.
●The risk of medication toxicity is higher in preterm and ill infants and is rare in infants over six months of age [60].
●Infant medication exposure can be minimized by dosing maternal medications after nursing and before prolonged infant sleep, depending on the half-life of the medication.
●Medications that are highly protein-bound, have low lipid solubility, or have large molecular weights do not appreciably enter breast milk.
●Breastfed infants are generally not affected by medications with poor oral bioavailability, such as insulin or heparin.
●Some medications decrease breast milk volume, including dopamine agonists (eg, bromocriptine), decongestants, and estrogens (eg, in hormonal contraceptives). If a mother is taking these medications and has compromised breast milk supply, consider alternative medications if possible.
●Classes of drugs that are generally not compatible with breastfeeding are statins, amphetamines, ergotamines (antimigraine agents), and chemotherapy agents [5].
●Most analgesics are safe for breastfeeding women. Codeine and tramadol should be avoided, and oxycodone and aspirin should be used with caution. Management of pain in breastfeeding women is discussed separately. (See "Overview of the postpartum period: Normal physiology and routine maternal care", section on 'Safety of common analgesics in breastfeeding individuals'.)
The LactMed database, produced by the National Library of Medicine, is a free, authoritative reference for lactation compatibility for prescription and over-the-counter drugs. This resource provides data on potential adverse effects on breastfeeding infants and lactation, case reports of infant exposures, and recommendations for alternative medications. It incorporates data on maternal plasma concentration and protein binding of each drug, size of the molecule, degree of ionization, lipid solubility, and maternal pharmacogenomics.
Detailed discussions about specific classes of drugs can be found in the following UpToDate topics:
●(See "Safety of infant exposure to antidepressants and benzodiazepines through breastfeeding".)
●(See "Prenatal substance exposure and neonatal abstinence syndrome (NAS): Management and outcomes".)
●(See "Hyperthyroidism during pregnancy: Treatment", section on 'Breastfeeding'.)
Maternal anesthesia or radiographic procedures
●Anesthesia – There is no need to discard expressed breast milk after anesthesia. Guidance about perioperative care for breastfeeding women is discussed separately. (See "Preoperative evaluation for anesthesia for noncardiac surgery", section on 'Breastfeeding women'.)
●Imaging – Breastfeeding does not need to be interrupted when iodinated or gadolinium contrast is administered for radiologic imaging. However, if radiopharmaceuticals or radioactive medications are required, they may require interruption of breastfeeding [60].
Safe sleep and breastfeeding — Breastfeeding is associated with a reduction in the risk for sudden infant death syndrome (SIDS) and is recommended in addition to supine positioning and other safe sleep practices [62]. To facilitate breastfeeding while maintaining safe sleep practices, we suggest that the infant sleep in the mother's bedroom but not in the adult bed for at least the first six months. The infant should sleep in a separate sleep surface designed for infants, such as a crib or bassinet. Infants should never sleep in the adult bed or on a sofa, recliner, armchair, or other type of cushioned chair. Infants should always be placed supine for sleep. Due to exhaustion, it is not uncommon for mothers to fall asleep while feeding their infants. For this reason, if there is a risk of the mother falling asleep, feedings should occur in an adult bed (not a couch, sofa, or chair) without any pillows, blankets, or soft bedding and that the infant be returned to a nearby crib or bassinet when the mother awakens after the feeding, as recommended by the American Academy of Pediatrics [62,63]. (See "Sudden infant death syndrome: Risk factors and risk reduction strategies".)
Perinatal mood and anxiety disorders — It is important for mothers to be aware of the difference between postpartum blues and other more serious disorders such as depression, anxiety, and even postpartum psychosis since all of these are very treatable if recognized and diagnosed and can impact a mother's breastfeeding journey. Many of the risk factors for perinatal mood and anxiety disorders can also lead to breastfeeding problems such as extreme maternal exhaustion, history of infertility, and traumatic birth experience. (See "Postpartum blues" and "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis".)
Of note, perinatal mood and anxiety disorders are distinct from dysphoric milk ejection reflex, which is an uncommon condition characterized by unpleasant feelings that occur only with milk letdown and last a few minutes. (See "Common problems of breastfeeding and weaning", section on 'Dysphoric milk ejection reflex'.)
Breastfeeding during a subsequent pregnancy — It is generally safe to breastfeed during a subsequent pregnancy, as well as to "tandem" breastfeed an older infant along with a newborn [64-67]. In fact, these practices are common in many cultures. Mothers with risk factors for pregnancy loss or preterm labor who would like to continue to breastfeed their older child during the pregnancy should discuss the potential risks and benefits with their obstetrical clinician [68]. Once the newborn arrives, it is recommended that the mother feed the newborn first for each feeding before offering the breast to the older child to ensure that the newborn has adequate intake until a good weight gain pattern is established [65,69].
Special situations
Late preterm or early term infants — Mothers of late preterm infants (gestational age 34 to <37 weeks) and some early term infants may need additional support to establish effective breastfeeding and an adequate milk supply. These infants, despite appearing "normal" and not needing intensive care, are immature and should not be expected to be "good breastfeeders" until they reach approximately 40 weeks gestational age. Their mothers often require assistance with strategies to empty the breasts frequently and effectively to ensure adequate intake and signaling by the mother's body to promote sufficient milk production. Details are discussed in a separate topic review. (See "Breastfeeding the preterm infant", section on 'Late preterm infants'.)
Twins — Multiples pose a challenge for new mothers as they both/all require frequent feedings and often are born early. Mothers may need extra help with positioning the infants at the breast and with general infant care. Tandem nursing (breastfeeding two infants simultaneously) may be awkward and difficult for mothers to achieve without assistance at first but can help with synching the feedings for the infants, so that the mother may rest between feedings. As long as both/all of the infants are going to the breast with every feeding cue, the mother's body will adapt and produce the amount of milk that it is signaled to do so.
Infant jaundice — All newborns develop jaundice to some extent, which is considered physiologic and may even be protective because bilirubin is a powerful antioxidant. The baseline levels of bilirubin in breastfed infants are higher than in those who are formula feeding; however, unless there is inadequate intake, breastfeeding alone does not cause the bilirubin to rise to pathologic levels.
Early-onset pathologic jaundice has multiple potential causes, including hemolysis, infection, and underlying genetic disorders, and requires evaluation and management. Cessation of breastfeeding should only be considered in cases of extreme jaundice, in which the bilirubin levels come close to the threshold for an exchange transfusion. To reduce the risk of pathologic jaundice due to insufficient milk intake, all infants should receive optimal support of breastfeeding from birth to help ensure an adequate milk supply. Infants with jaundice should have focused feeding evaluations to ensure a comfortable, effective latch and milk transfer to ensure adequate intake. Unless there are signs of insufficient intake, infants who are breastfeeding should not require supplementation with anything other than mother's own milk [52,70]. (See "Unconjugated hyperbilirubinemia in neonates: Etiology and pathogenesis" and "Unconjugated hyperbilirubinemia in term and late preterm newborns: Initial management".)
Infant hypoglycemia — Similar to jaundice, most infants do not develop pathologic hypoglycemia. Measurement of infant blood glucose is recommended only for infants with risk factors for hypoglycemia, such as a diabetic mother, prematurity, or small for gestational age [71]. Strategies to prevent neonatal hypoglycemia include early breastfeeding within the first hour after birth and teaching the mother to hand express drops of colostrum in the first few days with each feeding. Evaluation and management of neonatal hypoglycemia are discussed separately. (See "Pathogenesis, screening, and diagnosis of neonatal hypoglycemia" and "Management and outcome of neonatal hypoglycemia".)
Relactation or induction of lactation — It is possible for a mother who has lactated before to reestablish and maintain a milk supply. It is also possible, although more challenging, to induce lactation in people who have never lactated. Protocols for inducing lactation are not well studied but typically include both hormonal preparation and breast signaling (nipple stimulation) with pumping [72-75]. The resulting milk production varies but is often sufficient to support at least partial breastfeeding.
Induced lactation may be particularly valuable for adopting families [5] or other non-gestational parents who wish to breastfeed/chestfeed [76,77]. This may include members of same-sex couples or transgender and nonbinary people, including transgender women [78-81]. Because the possibility of induced lactation is not widely recognized, particularly in the medical community, the clinician should specifically raise this question and offer assistance to parents with nontraditional family structures.
Support for mothers who are not able to fully breastfeed — Some mothers encounter problems with establishing breastfeeding that are beyond their control. The clinician's role is to provide accurate information in a culturally sensitive manner, so that the mother is able to make a truly informed choice about breastfeeding and to identify and remove barriers to breastfeeding if possible [82]. Mothers and other family members deserve the clinician's presence, listening skills, expertise, and guidance, so that they can participate in shared decision-making about breastfeeding.
If the mother cannot or chooses not to breastfeed, the clinician should guide her toward a plan for feeding, bonding, and interacting with her infant that will be as close as possible to meeting her personal breastfeeding goals. This process will help to minimize her experience of guilt or shame and ensure that she and her infant are safe, healthy, and have every opportunity to bond and thrive.
SUPPORT FOR MAINTENANCE OF BREASTFEEDING
Support to maintain milk supply — All lactating mothers need a technique to express milk, either by hand or with a manual or electric breast pump, in case they are ever separated from their infant. In general, maintenance of supply requires frequent signaling of the breasts, either with frequent feedings or with milk expression. Mothers should be instructed to pump at least once every time the infant does not drink directly from the breast or feeds anything other than her breast milk. If her supply is diminishing, increasing the frequency and amount of breastfeeding and/or milk expression for a day or two will usually increase the milk production within 24 to 48 hours, similar to when an infant feeds more frequently during a growth spurt. Further information on equipment and technique is discussed separately. (See "Breastfeeding the preterm infant".)
General support for ongoing breastfeeding — Infant feeding recommendations are for exclusive breastfeeding for the first six months, followed by continued breastfeeding with the introduction of complementary foods for at least one year (or two years according to the World Health Organization). However, many mothers are unable to meet these targets [6]. In the Infant Feeding Practices Study II, only 32.4 percent of mothers were able to meet their own personal feeding goals and most of those personal goals were shorter than the recommendations [83].
To help mothers come as close as possible to these goals for optimal infant feeding, clinicians can take the following steps:
●Remind mothers of the recommendations
●Encourage mothers to set a personal goal for breastfeeding duration
●Provide anticipatory guidance for the common obstacles to breastfeeding, such as pain, concern about supply, and return to work or school (see 'Address common concerns' above)
●Reassure mothers and families that the infant will have frequent checks and feeding evaluations to ensure that the infant is safe and healthy during the establishment of breastfeeding
●Become skilled at evaluation for a comfortable, effective latch and evidence of milk transfer (see "Initiation of breastfeeding", section on 'Principles of breastfeeding')
●Troubleshoot common problems such as latch difficulties or nipple pain and provide assistance if the mother encounters obstacles (see "Common problems of breastfeeding and weaning")
●Adhere to the recommendations for a breastfeeding-friendly office (see 'Programmatic approaches and professional resources' above)
●Collaborate and communicate with local obstetrical providers and maternity care centers to ensure that evidence-based best practices are in place
●Become a role model in the community and advocate for lactation support in the workplace, support mothers breastfeeding in public, and elicit community support
This guidance should ideally be part of each routine visit while the mother is breastfeeding. To maintain a positive therapeutic relationship, all discussions should be nonjudgmental, focused on problem-solving, include accurate information, and emphasize the importance of mothers being comfortable with the feeding plan for their infant. Evidence shows that with optimal education and support, the vast majority of mothers are able to breastfeed their babies.
Return to work — Returning to work is a known barrier for both initiation of breastfeeding and duration of continued breastfeeding [7,84]. Mothers should be given anticipatory guidance about strategies to continue breastfeeding while working, pumping and expressing milk, navigate workplace laws and accommodations, and problem-solve solutions for pumping and expressing in various different types of workplace environments [85].
Suggested guidance for mothers who plan to return to work includes:
●Suggest a gradual return to work, such as starting at the end of the week and then having the weekend to recover and troubleshoot any concerns, or working part-time for a period of time.
●Make sure she has an effective and efficient way to express her breast milk. A high-quality, dual-electric breast pump is ideal but not required. Some women may not have access to electrical outlets in the workplace or an expensive breast pump and can have success with manual pumps and/or hand expression; the mother will need to check with her insurance company to see what is available and what is covered.
●Encourage her to reach out to her supervisor to discuss plans about where and how often she will need to express her milk.
●Guide her to express her milk at least once every time the baby feeds when she is away.
●Suggest that she keep a blanket that smells like her baby nearby and a picture or video of her baby to view when pumping to help trigger the let-down reflex.
●Make sure she knows the current guidelines for milk storage. Recommend that she begin in advance to build a few days' supply of expressed breast milk to store in the freezer for emergencies. When possible, fresh refrigerated breast milk (pumped the day before) should be used rather than frozen breast milk because this helps to preserve some of the beneficial properties of breast milk, including some of the live cellular components that help to prevent infection. The composition of breast milk changes over the infant's different developmental stages, and using fresh refrigerated milk ensures that the infant receives the milk that the mother is making specifically for that time period.
●Refer her to other local resources and working mother support groups [86].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Breastfeeding and infant nutrition".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Weaning from breastfeeding (The Basics)" and "Patient education: Deciding to breastfeed (The Basics)" and "Patient education: Common breastfeeding problems (The Basics)" and "Patient education: Health and nutrition during breastfeeding (The Basics)" and "Patient education: Pumping and storing breast milk (The Basics)")
●Beyond the Basics topics (see "Patient education: Deciding to breastfeed (Beyond the Basics)" and "Patient education: Breastfeeding guide (Beyond the Basics)" and "Patient education: Common breastfeeding problems (Beyond the Basics)" and "Patient education: Pumping breast milk (Beyond the Basics)" and "Patient education: Health and nutrition during breastfeeding (Beyond the Basics)" and "Patient education: Weaning from breastfeeding (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Breastfeeding education – Routine ongoing support and guidance during antenatal and postnatal care is associated with longer duration of breastfeeding (exclusive and partial). This support is optimally tailored to the setting and needs of the population and individual patient and may include a variety of professional or lay/peer counselors. (See 'Factors in parental infant feeding decisions' above.)
●Initial assessment – During prenatal care or early postnatal visits, all mothers should have an initial assessment by a clinician with expertise in breastfeeding. This involves:
•Assessment of the mother's knowledge about breastfeeding, to identify psychosocial and physiologic risk factors for breastfeeding problems (table 2), and providing tailored education to reduce these risks.
•Breast examination to identify anatomic differences in the breasts that may complicate breastfeeding, including flat or inverted nipples (picture 1 and figure 2) or hypoplastic breasts, which are rare (figure 1). Women with these features can often breastfeed but will likely need extra support and guidance. (See 'Initial clinical assessment and support' above.)
●Contraindications to breastfeeding – There are very few contraindications to breastfeeding (table 3). In some cases, the contraindication is temporary and the infant may be fed expressed breast milk until it is safe to resume direct breastfeeding. (See 'Contraindications to breastfeeding' above.)
●Common concerns
•A common concern is that breastfeeding is inherently painful, which is not the case. "Tugging," "pressure," and an unfamiliar sensation are common. Nipple pain or compression are not normal and require immediate attention because they usually indicate that the latch is ineffective and that milk flow is impaired. The clinician should address this concern by observing a feeding and providing guidance and assistance during breastfeeding initiation to ensure proper technique, including an effective latch (figure 3).
•Counseling during breastfeeding initiation can also help with other common concerns, including feeding a sleepy baby, ensuring sufficient milk supply, and addressing maternal exhaustion (table 4). (See 'Address common concerns' above.)
●Postnatal supervision – Postnatal medical supervision for breastfeeding includes advice on safe infant sleep, monitoring for perinatal mood and anxiety disorders, and addressing any breastfeeding problems as they arise. (See 'Postnatal medical supervision' above and "Common problems of breastfeeding and weaning".)
●Maternal medications – Most, but not all, therapeutic drugs are compatible with breastfeeding. The safest medications are those that are safe to administer directly to an infant and those that are not orally bioavailable. The LactMed database is a free online database with reliable information about medication compatibility. (See 'Maternal medications' above and 'Maternal anesthesia or radiographic procedures' above.)
●Situations requiring additional attention – Early and focused guidance to optimize breastfeeding is particularly important for certain infants, including those born late, preterm, or early term; twins; or those with jaundice or hypoglycemia, as well as for mothers with risk factors for breastfeeding problems. The clinician should also be aware of the possibility of inducing lactation for a non-gestational parent, including adoptive parents, members of same-sex couples, or transgender and nonbinary people. (See 'Special situations' above.)
●Long-term support to maintain breastfeeding – A majority of mothers do not meet targets for sustained breastfeeding, which are exclusive breastfeeding for the first six months followed by continued breastfeeding with complementary foods for at least one year. To help mothers come as close as possible to these goals, the clinician should ensure that the mother has an effective technique for breast milk expression in order to maintain her milk supply when she is unable to breastfeed directly and provide anticipatory guidance about strategies to continue breastfeeding while returning to work or other activities. (See 'Support for maintenance of breastfeeding' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Richard J Schanler, MD, and Debra C Potak, MD, who contributed to earlier versions of this topic review.
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