Initial Management of Breastfeeding

Author: Keith Sinusas, Amy Gagliardi
Date: Sept 15, 2001

Breast milk is widely accepted as the ideal source of nutrition for infants. In order to ensure success in breastfeeding, it is important that it be initiated as early as possible during the neonatal period. This is facilitated by skin-to-skin contact between the mother and infant immediately following birth. When possible, the infant should be allowed to root and latch on spontaneously within the first hour of life. Many common nursery routines such as weighing the infant, administration of vitamin K and application of ocular antibiotics can be safely delayed until after the initial breastfeeding. Postpartum care practices that improve breastfeeding rates include rooming-in, anticipatory guidance about breastfeeding problems and the avoidance of formula supplementation and pacifiers. (Am Fam Physician 2001;64:981-8,991-2.)

One goal of the Healthy People 2010(1) initiative is to achieve a breastfeeding initiation rate of 75 percent. Breastfeeding is supported by the American Academy of Family Physicians(2) and the American Academy of Pediatrics (AAP).(3) The AAP recommends continuation of breastfeeding for at least the first full year of life. Clearly, an important goal of family physicians, whether or not they provide maternity care, is to ensure that all women receive support for breastfeeding and encouragement to provide this ideal form of nutrition to their infants (Table 1).(3)

TABLE 1Advantages of BreastfeedingAdvantages for the newbornLower incidence of following conditions: Allergies and asthma Bacteremia and meningitis Botulism Childhood lymphoma Chronic constipation Diabetes Gastrointestinal infections Infantile eczema Inflammatory bowel disease Iron deficiency anemia Lower respiratory tract infection Necrotizing enterocolitis Otitis media Sudden infant death syndrome Urinary tract infectionIncreased IQ scores later in childhoodEnhanced neurodevelopmental performanceAdvantages for the motherDelayed ovulation resulting in increased child spacingEarlier return to prepregnancy weightIncreased bone density resulting in lower postmenopausal fracture rateLess postpartum bleedingLower incidence of ovarian cancerLower incidence of premenopausal breast cancerAdvantages to society and familyEconomic savings from cost of purchasing infant formulaReduced employee absenteeism related to child illnessesReduced health care costs from fewer physician and hospital visitsInformation from American Academy of Pediatrics, Work groupon breastfeeding. Breastfeeding and the use of human milk.Pediatrics 1997;100:1035-9.

This article describes ways in which family physicians can facilitate the early initiation and long-term success of breastfeeding in their patients.

Patient Education

The first strategy in ensuring early initiation of breastfeeding should begin during prenatal care. Prenatal education can integrate written materials, support groups and one-to-one discussions between the patient and physician.(4) An excellent example of an effective breastfeeding education program is Best Start (Best Start Social Marketing, Tampa, Fla.), which was found to double breastfeeding initiation rates among an inner-city population.(5)

After admission of the expectant mother to the hospital, the family physician can reiterate the support of breastfeeding and review plans for early breastfeeding management while in the delivery room. Often, breastfeeding preferences are included in the patient's personal birth plan.

Effects of Early Contact

Immediately following delivery, the healthy infant should be placed on the mother's chest or upper abdomen. The infant can be dried by delivery room personnel at the bedside to help lessen evaporative heat loss but at this point, skin-to-skin contact between the mother and infant can facilitate breastfeeding. Results of studies have demonstrated that early skin-to-skin contact improves maternal-infant bonding.(6,7) Further, infants who have early maternal contact have been found to nurse more effectively at the first feeding and, in some cases, if the baby is left alone on the mother's chest, it has crawled spontaneously to the breast and suckled.(8)

Videotapes of infants at the first breastfeeding reveal that newborns who are allowed to go to the breast spontaneously showed better tongue positioning at latch-on, suggesting that "forcing the infant to the breast might abolish the rooting reflex and disturb placement of the tongue."(9) Therefore, it might be advisable to give newborns an opportunity to root and latch on without assistance for up to 60 minutes before intervening to effect the latch-on.

There is conflicting evidence about the long-term effects of early contact on continued, successful breastfeeding. While a 1994 Cochrane Library(10) systematic review found three randomized trials reporting no increase in the success of long-term breastfeeding in infants with early contact, results from another trial revealed that breastfeeding rates at weeks 6 and 12 were higher in infants who were allowed early contact with their mother.(7) In addition, suckling and skin-to-skin contact within the first hour following birth resulted in a mean duration of breastfeeding that was 2.5 months longer than the duration in maternal-infant pairs not afforded the same early contact.(11) Conversely, when infants were separated from their mothers during the early stage of the hospital stay, only 37 percent were breastfeeding at three months compared with 72 percent of infants not separated from their mothers during the early stage of the hospital stay.(12)

Because early maternal-infant contact is a pleasurable and low-risk intervention, it seems reasonable, based on available evidence, to promote early initiation of breastfeeding. If a mother is separated from her infant, and early contact is not possible, measures should be taken to ensure high quality contact as soon as possible. Support and encouragement by well-trained professionals--physicians, nurses or a lactation consultant--can be of great benefit.(13)

Positioning and Latch-On

It is unclear whether the use of a specific breastfeeding position in the delivery room is correlated with better outcomes; therefore, it would be prudent to allow the mother to breastfeed in any position that seems comfortable for her or her infant. Options include the cradle hold, cross-cradle hold, football hold, side-lying position and Australian hold (Figures 1 through 5). The latter position might be more difficult to accomplish if the physician needs to perform a perineal repair at this time.

To achieve a proper latch-on, the mother should support her breast using the C-hold (Figure 6). It is important not to have her fingers too close to the nipple because this can result in distortion of the natural shape of the nipple. The infant is then brought close to the breast, with the mother just touching the nipple gently on the baby's lips. This touch should initiate a reflex causing the infant to open its mouth widely. At this point, the infant should quickly be brought closer to allow a proper latch-on. If the latch-on is done correctly, the entire nipple and most of the areola should be in the baby's mouth. Newborns are often quite alert during the first hour of life. If a good latch-on is achieved, the infant should be sucking well at the breast and may continue to do so for about 10 minutes.

Effect of Intrapartum Analgesia and Anesthesia

Brazelton, a pioneer in infant behavior, provided evidence as early as 1961 that maternal analgesia led to disorganized behavior in the infant, which can result in a delay in effective breastfeeding and infant weight gain.(14) More recent data reveal that both butorphanol (Stadol) and nalbuphine (Nubain) cause a delay in the time to effective breastfeeding when administered to women during labor, particularly if administered more than one hour before delivery.(15)

Epidural anesthesia has become increasingly popular for pain control during labor. Unfortunately, its effect on breastfeeding when given intrapartum has not been directly studied. In a review of 13 trials evaluating the neurobehavioral effects of epidural anesthesia on infants, seven of these trials showed a negative effect on infant behavior, which the reviewer infers might affect lactation.(16) When epidural administration of anesthesia is used to control postoperative pain following cesarean delivery, breastfeeding is affected negatively, but only if a narcotic agent (e.g., buprenorphine [Buprenex]) is infused in the epidural space.(16) Postoperative epidural infusion of the anesthetic bupivacaine (Marcaine) alone does not affect the success of breastfeeding and may, in fact, have even less effect on successful breastfeeding than oral ibuprofen.(17,18)

Effect of Cesarean Delivery

(32.) Victora CG, Behague DP, Barros FC, Olinto MT, Weiderpass E. Pacifier use and short breastfeeding duration: cause, consequence, or coincidence? Pediatrics 1997;99:445-53.

(33.) Yamauchi Y, Yamanouchi I. The relationship between rooming-in/not rooming-in and breastfeeding variables. Acta Paediatr Scand 1990;79:1017-22.

(34.) Yamauchi Y, Yamanouchi I. Breastfeeding frequency during the first 24 hours after birth in full-term neonates. Pediatrics 1990;86:171-5.

(35.) Salariya EM, Easton PM, Cater JI. Duration of breastfeeding after early initiation and frequent feeding. Lancet 1978;2:1141-43.

(36.) Renfrew MJ, Lang S, Martin L, Woolridge MW. Feeding schedules in hospitals for newborn infants (Cochrane Review). In: The Cochrane Library, 1, 2001. Oxford: Update Software.

(37.) Keefe MR. The impact of infant rooming-in on maternal sleep at night. J Obstet Gynecol Neonatal Nurs 1988;17:122-6.

(38.) Hill PD, Humenick SS, Brennan ML, Woolley D. Does early supplementation affect long-term breastfeeding? Clin Pediatr 1997;36:345-50.

(39.) Wright A, Rice S, Wells S. Changing hospital practices to increase the duration of breastfeeding. Pediatrics 1996;97:669-75.

(40.) Neifert MR. The optimization of breastfeeding in the perinatal period. Clin Perinatol 1998;25:303-26.

(41.) Mohrbacher N, Stock J, eds. The breastfeeding answer book. Rev. ed. Schaumburg, Ill.: La Leche League International, 1997:363-5.

(42.) Dungy CI, Christensen-Szalanski J, Losch M, Russell D. Effect of discharge samples on duration of breastfeeding. Pediatrics 1992;90(2 pt 1):233-7.

(43.) Healthy stay for healthy term newborns. American Academy of Pediatrics Committee on Fetus and Newborn. Pediatrics 1995;96(4 pt 1):788-90.

(44.) Winikoff B, Myers D, Laukaran VH, Stone R. Overcoming obstacles to breastfeeding in a large municipal hospital: applications of lessons learned. Pediatrics 1987;80:423-33.

(45.) Evidence based guidelines for breastfeeding management during the first fourteen days. Raleigh, N.C.: International Lactation Consultant Association, 1999.

(46.) Protecting, promoting and supporting breastfeeding: the special role of maternity services. A joint WHO/UNICEF statement. Int J Gynaecol Obstet 1990; 31(suppl 1):171-83.

(47.) Bellamy C. The state of the world's children 1998. New York: Oxford University Press for UNICEF, 1998:50-1.

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