Initiation of breastfeeding

INTRODUCTION — Human milk is the optimal source of nutrition and protection for newborn infants because of its proven health benefits for infants and their mothers. The World Health Organization and major medical societies recommend breastfeeding exclusively for approximately the first six months of life and then continued with the addition of complementary foods for as long as mutually desired by mother and child, potentially for two years or more [1-5].

The routine care and support of the initiation of breastfeeding for typical mother-infant dyads during the birth hospitalization are discussed below. Other aspects of breastfeeding are discussed in the following topic reviews:

●(See "Breastfeeding: Parental education and support".) – Including considerations for maternal infectious diseases and medications.

●(See "Maternal nutrition during lactation".)

●(See "Common problems of breastfeeding and weaning".) – Including a diagnostic approach to the dyad with inadequate milk intake or nipple pain.

●(See "Breastfeeding the preterm infant".)

In this topic review, we use the term "mother" to refer to the lactating person and "breastfeeding" to refer to feeding an infant at the breast or chest.

RATIONALE — Supported by the evidence of the importance of breastfeeding and the recommendations from major organizations, breastfeeding rates continue to rise in many countries [1-5]. In the United States, breastfeeding rates have met some Healthy People 2020 goals, but breastfeeding duration remains suboptimal [5]. While more than three-quarters of mothers initiate breastfeeding, there is a notable steep decline in the proportion of mothers who continue to breastfeed during the first year of life. As an example, for infants born in 2018, almost 82 percent of mothers initiated breastfeeding; by six months, 61 percent were breastfeeding and 26 percent exclusively breastfeeding. Another study revealed that two-thirds of the women who gave birth in the United States were not able to achieve their own personal breastfeeding goals, although those personal goals were shorter than the recommended durations [6]. Because accumulating evidence suggests benefits of prolonged breastfeeding, the American Academy of Pediatrics now encourages breastfeeding beyond the first year of life, for as long as mutually desired by mother and child [5]. (See "Infant benefits of breastfeeding" and "Maternal and economic benefits of breastfeeding".)

These observations call for additional support for breastfeeding provided during the birth hospitalization in order to help mothers achieve their personal breastfeeding goals. The United States Surgeon General released a Call to Action in 2011, imploring all health care systems, clinicians, and communities to examine their policies and practices in order to provide better education and support to mothers to improve these rates and thereby improve the health for mothers and infants [7].

HOSPITAL POLICY AND ENVIRONMENT

Ten steps to successful breastfeeding — The key strategies to support breastfeeding are captured in the World Health Organization's Ten Steps to Successful Breastfeeding (table 1), which includes hospital policies and key clinical practices for breastfeeding education and support during prenatal care, the birth hospitalization, and beyond [8]. These recommended policies and procedures are endorsed by the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and American Academy of Family Physicians as evidence-based best practices [2,5,9]. Exposure to these Ten Steps is correlated with successful breastfeeding [6,10-12].

Components include:

●Hospital policies – Step 1 outlines several critical hospital policies [8]. These include:

•A requirement to adhere to the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions, which stipulate that any infant formula must be purchased at fair market price and not accepted as a donation from industry and that sales representatives are not permitted to visit the maternity unit or provide promotional materials (pens and notepads with corporate names) or materials for patient care and education [13,14]. These practices were previously common and served to promote formula feeding during a period that is critical for establishing breastfeeding. Similarly, any images used for decoration or patient education should not contain bottles or artificial nipples; images of breastfeeding mothers and infants are encouraged to help contribute to a culture of normalizing and supporting breastfeeding.

•Hospitals should have a written infant feeding policy that covers all aspects of maternity and infant nutrition care. Sample hospital breastfeeding policies have been published by the Academy of Breastfeeding Medicine and the American Academy of Pediatrics [15,16].

•The hospital is required to track the rates of breastfeeding and use of any supplements other than mother's milk in order to monitor its progress in the support of breastfeeding.

●Staff education and support – Step 2 outlines a requirement for training for all maternity and newborn care staff. Staff training and competence in the initiation of breastfeeding and managing common concerns ensures that mothers receive optimal support, which all mothers are entitled to as part of routine care during their maternity stay and not as an added luxury if and when there is funding or time [7]. Although clinicians generally recognize the importance of breastfeeding for the health of mothers and infants, they often lack clinical skills in basic assessment and management of breastfeeding [17,18].

Hospitals must also promote breastfeeding and provide lactation support in the workplace for employees and patients, which includes providing break rooms and time for expressing breast milk for employees [19]. Health care providers are less likely to champion breastfeeding if they have had negative personal experiences [18,20-22].

●Key clinical practices – The remaining steps outline key clinical practices, which include [8]:

•Prenatal education on the importance and management of breastfeeding for all expectant mothers

•In-hospital procedures to support breastfeeding (skin-to-skin contact, rooming in, avoiding food or fluids other than breast milk, avoiding in-hospital use of artificial nipples and pacifiers if possible)

•Guidance to optimize the establishment of breastfeeding and troubleshoot problems

•Coordinated care and breastfeeding support post-discharge

The rationale and detailed implementation of these key clinical practices will be discussed in the remainder of this topic.

Baby-friendly hospital and other metrics — A hospital that demonstrates implementation of all Ten Steps may be designated as a Baby-Friendly Hospital. Giving birth in this environment is associated with breastfeeding success, as measured by increased breastfeeding initiation and longer duration of exclusive breastfeeding and any breastfeeding [23,24]. The increasing adoption of Baby-Friendly policies and practices may also help reduce socioeconomic disparities in breastfeeding [25,26]. Over 20,000 hospitals and maternity care centers in over 150 countries have the Baby-Friendly designation, and numbers in the United States have dramatically increased since 2000 [27].

In the United States, progress towards implementing the Ten Steps is also captured by a periodic national survey on Maternity Practices in Infant Nutrition and Care, which assesses maternity care practices related to breastfeeding support. The 2018 survey gave the hospitals in the United States a 79 out of 100, with the lowest scores in areas of institutional management, rooming-in, and discharge support and considerable variability between states [28].

PARENTAL EDUCATION AND SUPPORT — Breastfeeding support and education should begin during prenatal care, be reinforced during the birth hospitalization, and continue into postnatal outpatient care:

●Prenatal care – During prenatal care, clinicians should discuss the importance and management of breastfeeding with pregnant women and their families. Relevant information, such as the mother's breastfeeding history and previous experience as well as any identified risk factors for breastfeeding problems, should be communicated to the clinicians involved in labor and delivery and postpartum care [29]. Details of the initial evaluation and counseling are discussed separately. (See "Breastfeeding: Parental education and support", section on 'Initial clinical assessment and support'.)

●Birth hospitalization – Support for the establishment of breastfeeding should be initiated at birth and continue during the postpartum hospital stay. An experienced clinician should assess a mother's knowledge of breastfeeding, inquire about her preferred feeding plan, provide tailored education, and help her to have realistic expectations about caring for a newborn during and after the hospital stay. New mothers can feel overwhelmed, exhausted, and emotional in the first few days and weeks. Helping them know what to expect helps to ease their transition into parenthood. Giving new mothers information so they can make an informed choice about breastfeeding promotes their self-efficacy, empowers them to advocate for themselves and their newborns, encourages participation in shared decision-making, and sets the stage for successful initiation and continuation of breastfeeding [30-34].

Key practices in the hospital include skin-to-skin contact, rooming-in, feeding on cue, and avoiding unnecessary supplementation with infant formula. Explaining the reasoning behind these practices to the parent(s) and support persons is an important step in effective implementation. (See 'Overview of postpartum care' below.)

New mother-infant dyads require frequent assessments to gauge the effectiveness of breastfeeding [5,29]. An experienced clinician should directly observe or inquire about early attempts at breastfeeding to ensure that the latch is comfortable from the beginning and that milk transfer is present and to offer advice to troubleshoot and manage common concerns [35-39]. Clinical expertise in the assessment and management of common breastfeeding concerns is essential and should be considered a part of routine care for the dyad [7]. (See 'Optimize mechanics of feeding' below.)

●Post-discharge – Coordinate discharge so that parents and their infants will have timely follow-up with reassessment and support for breastfeeding. This includes ready access to a clinician and/or lactation consultant for advice about any breastfeeding problems or concerns. (See "Breastfeeding: Parental education and support", section on 'Postnatal medical supervision'.)

OVERVIEW OF POSTPARTUM CARE

Skin-to-skin contact — All infants should be placed skin-to-skin with the mother immediately after either vaginal or cesarian birth, unless medically contraindicated (eg, if the mother or infant is medically unstable, requiring further evaluation or care). During this period of skin-to-skin contact, a first attempt at breastfeeding should be encouraged [8,40]. Weighing, measuring, and routine care for the infant should be delayed until the first feeding is completed [5].

The practice of skin-to-skin contact offers several benefits to the infant, including more stable vital signs and increased mean blood glucose during the first few days of life, and is associated with increased breastfeeding duration at one to four months postpartum [41].

Skin-to-skin care is part of a neurobehavioral approach that recognizes and facilitates the infant's innate breastfeeding behaviors, sometimes termed "biologic nursing." When skin-to-skin, healthy newborn infants go through a series of reflexes and innate behaviors often referred to as the "breast crawl" that enable them to find and self-attach to the breast (table 2) [42,43]. Encouraging the mother to breastfeed in a comfortable laid-back position facilitates this innate infant behavior (figure 1). Self-attachment by the infant through these behaviors may decrease complications such as nipple pain for mothers. In a study that compared biologic nursing with routine hospital practices, women in the biologic nursing group had reduced risk for breast problems such as cracked or sore nipples [44].

Professional staff should be available to instruct and observe closely during this period of skin-to-skin contact and breastfeeding, ensuring safe positioning of the infant and that their face is clear and the airway not obstructed. Mother-infant dyads with risk factors for possible collapse or falls in the immediate postpartum period should be identified and monitored closely by staff during early breastfeeding. Risk factors include low Apgar scores, difficult delivery, and excessively sleepy or medicated mothers or newborns [45,46].

Consideration should also be given to providing only medically necessary interventions during childbirth because some interventions such as epidural anesthesia and opioid pain medications can have implications for breastfeeding. Maternal epidurals and opioid pain medications have been associated with decreased adaptive breastfeeding behaviors in the newborn and early breastfeeding cessation [47-50]. Labor pain medications have also been associated with delayed onset of lactation (defined as lactogenesis stage II occurring >72 hours after birth), regardless of method of delivery [51]. For women who require these pain medications, special attention may be needed to assist with frequency and effectiveness of breastfeeding and to monitor the infant's hydration status if there is a risk of delayed onset of lactation. Minimizing medical interventions during labor and birth may help set the stage for uncomplicated breastfeeding [52,53].

24-hour rooming-in — The infant should stay with the mother through recovery and room-in with the mother to enhance infant-maternal bonding and to facilitate subsequent feedings, which should be offered in response to infant cues ("on demand") rather than scheduled. (See 'Feed with every cue' below.)

●Rationale – Keeping the mother and infant together during the hospital stay has been shown to facilitate the establishment of breastfeeding and the transition to motherhood [54]. The close contact allows the mother to bond with and get to know her infant, respond to her infant's needs, and learn the basics of normal infant care in addition to establishing breastfeeding [55,56]. Mothers and newborns share a dynamic, interconnected physiology, especially in the first hours and days after birth. As an example, the mother's skin temperature helps regulate and stabilize the infant's temperature when skin-to-skin [40,41]. In addition, the infant's frequent suckling at the breast helps trigger the onset of lactogenesis stage II (or production of ounces of milk) [43]. Lactogenesis II typically occurs between 50 and 72 hours after birth, although minor delays are common [57]. While some mothers may need respite care in certain situations (eg, a mother who has had a cesarean delivery and does not have a care partner with her in the room to help care for the infant), the separation of newborns from their mothers should not be a part of routine postpartum management of the dyad [8].

Emotional and physical support for the mother is an important component of 24-hour rooming-in. Giving birth to and subsequently caring for a newborn is a life-changing, novel experience for the mother that often requires time, experience, and a steep learning curve in order to completely adjust. At the same time, the mother is physically recovering from the pregnancy and childbirth. Mothers may feel ecstatic or elated one minute, hyperalert and hypervigilant the next, and exhausted and overwhelmed the next. Ideally, having the combination of skilled postpartum nursing assistance and/or lactation or doula assistance and a supportive care partner at the bedside provides needed assistance with routine care of the newborn and emotional support for the mother and helps foster the successful initiation of breastfeeding [58-61]. Volunteer peer support also shows promise in helping women adjust to new motherhood and feel empowered and less stressed, particularly for women who are unfamiliar with breastfeeding [62].

With adequate support, most mothers feel positive about keeping their newborns with them during the hospital stay [63,64]. As of 2015, more than one-half of hospitals in the United States had implemented rooming-in for newborns during the birth hospital stay [65].

●Infant care practices to ensure safety while rooming-in – Birth hospitals must have policies and procedures in place to help prevent two important causes of neonatal morbidity and mortality:

•Sudden unexpected postnatal collapse (SUPC) is defined as a sudden unexpected collapse within the first week of life of an otherwise healthy-appearing newborn greater than 35 weeks gestation with a normal five-minute Apgar score. Approximately one-third of these events occur within the first two hours after birth, and another one-third occur within the first 2 to 24 hours. Therefore, prevention of SUPC is an important part of postpartum care. Nearly one-half of these events are idiopathic, and another one-quarter are caused by undetected congenital anomalies. Risk factors for SUPC include the first breastfeeding attempt, unsafe infant sleep practices (especially prone infant sleeping and bedsharing), primiparous mothers, parents left alone with the newborn, and cell phone use. Though the etiology of SUPC is often not determined, some of these risk factors are similar to those for sudden infant death syndrome (SIDS), suggesting that there may be some shared pathophysiology. (See "Sudden infant death syndrome: Risk factors and risk reduction strategies", section on 'Hospital setting'.)

•Infant falls are another preventable hazard during the birth hospitalization. Annually in the United States, an estimated 600 to 1600 newborns fall during the birth hospitalization and this is likely an underestimation [66]. The highest risk is in newborns born to mothers who have had epidural anesthesia or whose parent falls asleep while holding the infant [46,67-72].

To ensure safety, whoever is holding or feeding the infant should be awake, alert, and able to respond to the infant. If the infant needs to breastfeed and the mother is at risk of falling asleep, a care partner or health care worker should ideally observe the feeding to ensure that the infant's nose and mouth are clear and that the skin color remains normal. However, continuous observation may not be a realistic possibility on the postpartum hospital ward. Therefore, for mothers who are alone and at risk of falling asleep while feeding their infant, the safest environment for infant feeding is in an adult bed on a flat, firm, non-inclined surface with no loose bedding, pillows, blankets, or other soft objects, as outlined in American Academy of Pediatrics guidelines (figure 2) [73]. The mother should be advised to place the infant in a nearby bassinet after the feed or call out for assistance, consistent with recommended practices for safe infant sleep. Modeling safe sleep and feeding practices in the hospital may help augment other education provided to parents and help set the stage for adherence to safe infant care practices at home [74,75]. (See "Sudden infant death syndrome: Risk factors and risk reduction strategies", section on 'Prevention'.)

Maternal medications — Decisions about medications for maternal pain management and other needs should take into account the compatibility and dosing safety with breastfeeding. Although most medications are compatible with breastfeeding, it is important to consult an evidence-based source such as the National Institutes of Health Drugs and Lactation Database (LactMed) that considers lactation pharmacology as well as the routine pharmacokinetic considerations for the adult patient [76]. (See "Breastfeeding: Parental education and support", section on 'Maternal medications'.)

PRINCIPLES OF BREASTFEEDING

Feed with every cue — New parents should be guided to:

●Expect the newborn to wake easily and often to feed

●Recognize what feeding cues in their infant look like

●Feed every time the infant displays these feeding cues

Upon birth, newborns switch from having a continuous source of nutrition through the placenta to requiring enteral nutrition, initially from the rich, golden drops of colostrum. Colostrum provides a concentrated early source of nutrition and immune protection. Immediate and frequent expression of colostrum from the breasts via the infant sucking or other forms of milk expression is also an important trigger for lactogenesis stage II (or the production of ounces of milk around three to four days postpartum) [43].

The typical healthy newborn wakes to feed at least 8 to 12 times per 24 hours, with some variation depending on maternal and infant factors and the effectiveness of milk transfer [5,8,77]. Some infants may cue to feed as often as every hour but may then sleep for a little longer in between feedings.

The parent should watch for signs of feeding cues and offer the breast in response. Important infant cues include rooting or turning of the head, opening and closing the mouth or smacking the lips, and sucking on fingers or hands [78,79]. The best feeding attempts will be when the infant has begun to stir and shows these cues. Crying is a late sign of hunger, so parents should be encouraged to feed the infant when they start showing feeding cues rather than wait for crying. A crying infant needs to be settled and consoled prior to the start of a feeding. Frequent feeding of the newborn, prompted by the infant's cues rather than a feeding schedule, has been associated with increased breastfeeding duration, increased breast milk intake, and faster regain of birth weight [80-83].

For infants who are sleepy at the breast, the mother can try to arouse them by taking "burp breaks"; changing the diaper; or rubbing their head, back, arms, or feet. The mother can also encourage the infant to feed by using breast compression during the feed and hand expression of colostrum or milk. The colostrum or milk can be expressed either directly into the infant's mouth or into a spoon or cup and then fed to the infant.

Milk expression is important for any infant who is not successfully transferring milk because it provides an important signal to the mother's body to produce more milk [84-87]. (See 'Milk expression' below.)

Recognize signs of satiety — The goal of each feeding session should be to feed the infant until they show signs of satiety and is content. An infant that is adequately fed and "settled" relaxes their hands and facial muscles, stops giving feeding cues while awake, and generally seems more contented for a time after feeding. New parents should be advised that frequent feeding is normal and is not a sign of inadequate feeding as long as the infant appears content or satiated after feeds.

Cluster feeding (feeding frequently over a period of hours) is a common newborn behavior, and the infant may not fully settle after every feed. However, the infant should generally calm or rest comfortably in between feedings. An infant that does not settle or appear content between feedings may not be effectively transferring milk and requires a feeding observation and further investigation and management to optimize feeding. (See 'Optimize mechanics of feeding' below and 'Assessment of intake' below.)

Optimize mechanics of feeding — For every new birth, a breastfeeding session should be observed during the hospital stay by a clinician knowledgeable in breastfeeding, latch, swallowing, and infant satiety and successful performance of these tasks should be documented [5].

The importance of comfort — The comfort of a breastfeeding position is the foundation for effective infant attachment to the breast. When choosing a position, the emphasis should be on the mother's comfort and how the breastfeeding feels at the nipple when the baby is suckling, rather than how she is holding the infant, on which side, or with which hand. What all of the different breastfeeding positions have in common is that both mother and infant are comfortable (figure 3). The mother is not straining or "curled up" into a tense or cramped posture; her nipple is free from pain, compression, or rubbing by the baby's tongue or gums; and the infant is relaxed and supported.

Positioning and effective (asymmetric) latch

●Infant position – In general, the infant's head, navel, and pelvis are aligned for comfort and so that the neck and esophagus are relatively straight to facilitate swallowing. The infant's abdomen should be hugged in flat against the mother's body such that they have to "look up" to approach the breast with head tilted back (a "chugging" position). The infant's mouth should be open as wide as a yawn, in contrast with the smaller gape of the mouth when an infant suckles on an artificial nipple or pacifier.

●Effective (asymmetric) latch – When the infant is attached to the breast, the border of the nipple-areolar complex and part of the areola is visible outside of the infant's upper lip and the nose is free, while the infant's chin is buried in the breast, with no areola showing outside of the infant's lower lip (figure 4). By positioning the nipple high in the mouth, the infant's tongue contacts the base of the nipple rather than its tip and the nipple is not compressed or rubbed during suckling, allowing free flow of milk through the ducts in the nipple and avoiding nipple injury (figure 5).

Evaluating a latch for effectiveness — The clinical evaluation for an effective latch includes:

●Sucking and swallowing pattern – Observe the sucking pattern of the infant and listen for audible swallows [88]. Infants typically start a feed with rapid, shallow-amplitude suckling without swallows, which triggers the milk let-down reflex in the mother. Once milk flow is triggered, the sucks are deeper and longer, with three to five long sucks in a row, followed by a swallow (indicated by a small "kuh" sound) [89]. Once lactogenesis stage II occurs, the infant swallows more frequently so that each long suck is followed by a swallow, with bursts of several suck-swallows in a row. Lactogenesis II typically occurs between 50 and 72 hours after birth, although minor delays are common. Infants with a sleepy, erratic, or disorganized suckling pattern tend to have fewer swallows and less transfer of milk [90,91].

●Maternal nipple pain – Nipple pain during feeding is an important sign of an ineffective latch. An ineffective latch can interfere with milk transfer if the milk ducts in the nipple are compressed, lead to nipple trauma, contribute to low milk supply due to inadequate signaling, and is associated with early cessation of breastfeeding [92,93]. These problems can be avoided by adjusting the latch every time that it is painful. (See 'Adjusting a painful latch' below.)

●Shape of the mother's nipple after feeding – Observing the appearance of the mother's nipple when the infant unlatches can be informative. A nipple that appears compressed or "sloped" after the feed suggests that the infant's tongue has been compressing or rubbing the nipple (figure 6). Very slight adjustments in the asymmetry of the latch and/or widening the gape of the infant's mouth when at the breast can usually easily correct the problem.

●Satiety cues – Signs of satiety after the feed suggest that the latch and milk transfer were effective. (See 'Recognize signs of satiety' above.)

Some clinicians or institutions document these observations using a standardized measure such as the LATCH score [94].

Adjusting a painful latch — The most common reason for a painful attachment to the breast is that the infant's tongue is rubbing or compressing the tip of the nipple rather than contacting the nipple at its base. It is normal for a mother to have to unlatch and relatch the newborn infant multiple times during a feeding as they both learn.

To adjust a painful latch, the mother should use a finger to gently unlatch the infant by breaking the seal between the infant's mouth and breast. Then, she should help the infant reattach in a more effective position by bringing the infant toward the breast from below and with their head tilted back, so that the nipple is pointed up toward the infant's forehead and the nipple is high in the mouth (figure 4). When the nipple is properly positioned in the infant's mouth, the mother will feel "tugging" or "pressure" when the infant is suckling and will not feel pain, pinching, or rubbing on the sensitive tissue of the nipple. (See 'Positioning and effective (asymmetric) latch' above.)

Any pain with the latch is an indication of tissue damage, which can ultimately lead to fissuring, bleeding, and increased discomfort for the mother. Adjusting the latch will also ensure adequate signaling to trigger the let-down reflex and adequate milk transfer by avoiding compression of the milk ducts and also to promote further milk production. In a study of more than 1600 women with newborns, approximately 10 percent had nipple pain persisting beyond the first week, almost three-quarters of which was attributed to the way in which the infant was latching. The women who had pain were given assistance with positioning, which resolved the pain within two weeks and resulted in similar rates of breastfeeding compared with women without pain [95]. Only assistance with positioning and latching can affect the underlying problem that is causing nipple pain and/or fissuring; topical medications may soothe damaged tissue but do not fix the underlying problem [96,97].

Milk expression — New mothers should be taught how to express their milk using hand expression and/or a breast pump. Initially, this allows the mother to express milk if the infant is not feeding effectively and to stimulate her milk supply. Later, milk expression may be needed to relieve breast engorgement after milk production increases (lactogenesis II) or for times when the mother is separated from the infant, including returning to work. This education can begin during the birth hospitalization but may require reinforcement after discharge as the mother's milk supply and needs change. (See "Common problems of breastfeeding and weaning", section on 'Engorgement' and "Breastfeeding: Parental education and support", section on 'Support for maintenance of breastfeeding'.)

SPECIAL SITUATIONS

Ankyloglossia — Infants should be assessed for ankyloglossia (tight frenulum, also termed tongue-tie), which is sometimes a cause of poor latch or ineffective milk extraction. During breastfeeding, the infant's tongue extends beyond the lower alveolar ridge and should also elevate toward the palate in the infant's mouth near the base of the nipple. Infants with a tight frenulum may have restricted movement of their tongue (picture 1). Depending on the mother's anatomy and degree of elasticity of the tissue as well as the infant's anatomy and degree of tongue mobility, some infants are able to successfully breastfeed without intervention.

If the infant has ankyloglossia and the dyad has persistent breastfeeding difficulties (poor milk transfer and/or painful latch), we suggest consultation with a lactation specialist as the first step in management. If the problems persist, consideration can be given to perform a lingual frenotomy, which can be done without general anesthesia. Results from clinical trials are mixed but generally suggest that frenotomy helps relieve maternal pain with breastfeeding in appropriately selected dyads [98,99]. (See "Ankyloglossia (tongue-tie) in infants and children", section on 'Breastfeeding problems'.)

Flat or inverted nipples — Flat or inverted nipples are considered normal variants (figure 7 and picture 2); however, in some cases, this anatomy may increase the risk for breastfeeding problems, for two reasons:

●First, infants' sucking reflex is triggered by palatal stimulation. If the mother's nipple does not protrude far enough to stimulate the palate, the infant may not begin to suckle when attached and thus fail to trigger the let-down reflex. To address this problem, mothers can try "rolling" the nipple with their fingers to induce the nipple to protrude before breastfeeding. Alternatively, they can use a special suction device, hand pump, or electric breast pump [100,101]. Another approach is to use a silicon nipple shield placed over the nipple to add some "stiffness" and palatal stimulation to trigger suckling until the infant learns to associate suckling with being at the breast [102]. The nipple shield can later be slipped out during feedings and/or the mother and infant can practice starting the feedings without the shield once breastfeeding is well established.

●Second, flat or inverted nipples may interfere with the infant's ability to attach without "catching" or rubbing the nipple and causing nipple pain and/or ineffective milk transfer. For these infants, achieving an asymmetric latch is particularly important and the angle at which the infant approaches the breast may need to be exaggerated in order to achieve a comfortable, effective latch [95]. (See 'Adjusting a painful latch' above.)

Mothers with flat or inverted nipples would benefit from early recognition and special assistance from lactation experts during the first stages of breastfeeding [103]. In addition, their infants should be monitored closely for adequate intake [104].

ASSESSMENT OF INTAKE — Most women can make enough milk. Establishing and maintaining a breast milk supply depends on frequency and effectiveness of milk removal (ie, the milk supply responds to the demand). For most women, having at least eight feeding or milk expression sessions in 24 hours is sufficient, provided that each session completely empties the breast. To ensure complete breast emptying, steps should be taken to rouse a sleepy infant, adjust a painful latch, and/or hand express or pump after the feed. If improvements are made in the feeding frequency and effectiveness, milk production increases within 24 to 48 hours. (See 'Principles of breastfeeding' above.)

Risk factors for suboptimal milk production — Both maternal and infant factors are associated with risk for suboptimal milk production, as listed in the table (table 3). Dyads with these risk factors may benefit from additional support from the time of birth to ensure frequent feeding, an effective latch, and breast emptying to maximize milk production. Important modifiable risk factors are breastfeeding frequency and technique and avoiding supplemental feeds with formula. (See "Breastfeeding: Parental education and support", section on 'Initial assessment'.)

One marker of milk production is the timing of lactogenesis II, which is the transition from making concentrated drops of colostrum to ounces of more mature breast milk and typically occurs by 72 hours postpartum. In clinical practice, we describe this as a "transition" rather than as "milk coming in" to emphasize that the low volume produced by the breasts during the first few days after birth is normal and provides all that the infant needs. Lactogenesis II is delayed if has not occurred within three to four days postpartum. Delayed lactogenesis II can occur in up to 20 to 30 percent of women and is more common in primiparous women [105].

Warning signs of insufficient intake — Warning signs of insufficient intake include any of the following [29]:

●Weight curve – Infant's weight is below the 75^th percentile curve on the newborn weight loss tool (NEWT) nomogram. Note that higher percentiles on this nomogram indicate greater weight loss compared with other infants at the same age (unlike standard weight-for-age growth charts, in which higher percentiles indicate greater weight gain).

●During the first three to four days after birth, signs of insufficient intake that warrant a feeding evaluation are:

•Less than one void per day of age (ie, goal is at least one void on day 1, at least two voids on day 2, etc.)

•Less than one stool daily

•Urate crystals in diaper

•Dry mucus membranes

•Decreased skin turgor

•Severe signs of insufficient intake:

-Sunken eyes and/or sunken anterior fontanelle

-Thready radial pulse or cold extremities

Indications of effective breastfeeding and adequate intake — Routine monitoring during the neonatal period includes review of infant feeding behavior, review of signs of an effective latch and effective breastfeeding, and assessment for the infant warning signs listed above. A clinical checklist is shown in the table (table 4). Early identification of a problem with breastfeeding or milk transfer followed by focused breastfeeding guidance often resolves the issue before the infant shows signs of insufficient intake.

OTHER CONSIDERATIONS

When and how to supplement with formula

●When to supplement – For most breastfeeding infants, nutritional needs can be met by feeding mother's milk alone. Starting formula supplementation in the hospital should ideally be avoided because it is a strong predictor of early cessation of breastfeeding [29,106,107].

Formula supplements should be given to a breastfed infant only when there is a medical indication such as clinical evidence of insufficient intake (especially excessive weight loss, as measured by the newborn weight loss tool [NEWT] nomogram (see 'Warning signs of insufficient intake' above)) combined with the mother being unable to express as much milk as the infant requires. If the infant's intake is inadequate but the mother's milk supply is sufficient, the infant should be fed mother's expressed breast milk in addition to ongoing breastfeeding, rather than supplementing with formula.

Whenever formula supplements are considered, the first step is an expert breastfeeding evaluation to identify and address the root cause of the insufficient intake. Possible causes include not feeding frequently enough, ineffective suckling with poor milk transfer, or insufficient maternal milk production. When supplements are medically necessary, they can often be given for a brief period while addressing the breastfeeding technique and ensuring signaling to improve the mother's milk supply (ie, increased frequency and complete emptying of the breast [108]).

●Volume and type of supplement – If supplementation is required, one option is pasteurized donor milk (if available). Although health benefits of donor milk over formula have not been established for term infants, donor milk may help maintain the gastrointestinal flora seen in breast milk-fed infants. It also reduces the exposure to cow's milk protein and thus may reduce the risk of cow's milk protein intolerance [109].

If supplemental feeds are given, they should be given after the breastfeeding attempt and only in a limited volume. This approach encourages the infant to continue cueing frequently to practice feeding at the breast [5,29,106]. The Academy of Breastfeeding Medicine suggests the following volumes for healthy term infants based on age of the infant [106]:

•First 24 hours – 2 to 10 mLs/feed

•24 to 48 hours – 5 to 15 mLs/feed

•48 to 72 hours – 15 to 30 mLs/feed

•72 to 96 hours – 30 to 60 mLs/feed

●How to feed the supplement – Every time the infant is supplemented with anything other than the mother's freshly expressed milk, the mother should hand express or pump her breasts in order to signal her body to produce more milk. Missed opportunities to signal may lead to further problems with low milk production.

When possible, the supplemental formula should be given via one or more alternative techniques, including use of a syringe, cup, spoon, or a supplemental nursing system at the breast, rather than using a bottle and artificial nipple. Use of these alternative techniques helps reduce or avoid exposure to artificial bottle nipples [106,110-112]. When fed with an artificial nipple, some infants develop a strong preference for bottle feeding, which can cause difficulties in returning to exclusive breastfeeding in some cases.

●How to get back to breastfeeding – Whenever possible, the infant should continue direct breastfeeding while receiving formula supplements. Maximizing the proportion of feeds taken through direct breastfeeding facilitates the return to full breastfeeding and also tends to support a healthier rate of weight gain compared with bottle feeding [113,114]. In many cases, the mother's milk supply will increase with close attention to breast signaling (frequent feeds and complete emptying of the breasts). As the mother's milk supply increases, and as the infant matures and becomes more effective at draining the breast, the amount of supplementation can be gradually tapered down.

Vitamin D — Vitamin D supplementation is required for all breastfeeding infants and all formula feeding infants who are consuming <27 oz of infant formula daily. The recommended dose of vitamin D is 10 micrograms (400 international units) daily, beginning within a few days after birth. (See "Vitamin D insufficiency and deficiency in children and adolescents", section on 'Prevention in the perinatal period and in infants'.)

Pacifier use — During the first two to four weeks of life, use of a pacifier may interfere with the establishment of breastfeeding. Suckling on the breast is preferable because it helps to signal the mother's body to make more milk. During this period, if the infant desires suckling, we advise the mother to offer the breast for sucking to ensure adequate frequency of feeding and to maximize intake and signaling of milk production. Once breastfeeding is well established (ie, the infant is back above birth weight, mother has an established full supply, and the infant is effectively draining the breast each feeding), then the infant can be offered a pacifier for sleeping. Use of a pacifier during sleep appears to reduce the risk of sudden infant death syndrome (SIDS) and is suggested by the American Academy of Pediatrics [73]. (See "Sudden infant death syndrome: Risk factors and risk reduction strategies", section on 'Protective factors'.)

DISCHARGE FOLLOW-UP — Breastfeeding mother-infant dyads should have frequent follow-up with a clinician until breastfeeding is well established. The visit should include a history focused on breastfeeding comfort and efficacy and assessment of the infant's weight gain and hydration, as outlined in the table (table 5). Observation of a feed should be included if any concerns are identified.

For dyads that appear to have effectively initiated breastfeeding in the hospital and have no risk factors for breastfeeding problems (table 3), routine follow-up in the primary care office may be sufficient [115]. The initial visit depends on the length of the birth hospitalization but usually should be within 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 prior to the routine two-week visit and/or until breastfeeding is well established [9,11,17,40,41]. (See "Overview of the routine management of the healthy newborn infant".)

If there are any problems with breastfeeding during the perinatal period, the infant should be discharged from the hospital only if a mechanism for appropriate and timely follow-up is ensured [115]. The follow-up visit can take place in a home, clinic, or hospital outpatient setting as long as the clinician who examines the infant is experienced in newborn assessment and the results of the follow-up visit are promptly reported to the infant's primary care provider or their designee.

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 5^th to 6^th 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 10^th to 12^th 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: Breastfeeding (The Basics)" and "Patient education: Deciding to breastfeed (The Basics)")

●Beyond the Basics topics (see "Patient education: Breastfeeding guide (Beyond the Basics)" and "Patient education: Deciding to breastfeed (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Hospital policies and environment – Key strategies to support initiation and maintenance of breastfeeding are captured in the World Health Organization's Ten Steps to Successful Breastfeeding (table 1), which includes hospital policies and key clinical practices for breastfeeding education and support during the prenatal care, the birth hospitalization, and beyond. (See 'Ten steps to successful breastfeeding' above.)

●Postpartum care – Infants should be placed skin-to-skin with the mother immediately after either vaginal or cesarian birth, unless medically contraindicated. During this period of skin-to-skin contact, a first attempt at breastfeeding should be encouraged (figure 1). The infant should remain with the mother throughout the hospital stay to facilitate bonding and the establishment of breastfeeding (figure 2). (See 'Overview of postpartum care' above.)

●Basic guidance  

•Frequency – To help establish breastfeeding, new parents should be guided to feed with every cue (on-demand feeding) and to encourage the infant to feed until they show signs of satiety. (See 'Feed with every cue' above.)

•Effective latch – The mother should also learn how to initiate a feed to achieve an effective latch, in which the nipple is high and deep in the infant's mouth (figure 4 and figure 5). Pain during breastfeeding is a key symptom of an ineffective latch and should be addressed immediately by unlatching the infant and reattaching in a more effective position. (See 'Optimize mechanics of feeding' above and 'Adjusting a painful latch' above.)

●Monitoring

•Both maternal and infant factors are associated with risk for suboptimal milk production (table 3). Dyads with these risk factors may benefit from additional support from the time of birth to ensure frequent feeding, an effective latch, and breast emptying to maximize milk production. Warning signs of inadequate intake include an infant's weight below the 75^th percentile curve on the newborn weight loss tool (NEWT) nomogram and any signs of dehydration (table 4). (See 'Assessment of intake' above.)

•The mother-infant dyad should be evaluated soon after hospital discharge and followed closely until breastfeeding is well established. Key elements of this follow-up are outlined in the table (table 5). (See 'Discharge follow-up' above.)

ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Richard J Schanler, MD, and Debra C Potak, RN, BSN, IBCLC, who contributed to earlier versions of this topic review.