Substances in breast milk, such as bifidus factor, leukocytes, lysozymes, and lactoferrin, help prevent infection in the infant. Immunoglobulins are present in highest amounts in colostrum but are present throughout lactation. Secretory IgA produced in the breasts helps prevent viral and bacterial invasion of the intestinal mucosa, resulting in fewer intestinal infections. Infants who are breastfed have an decreased incidence of respiratory, gastrointestinal, and urinary tract infections, otitis media, asthma, diabetes, necrotizing enterocolitis, some cancers, obesity, sudden infant death syndrome, and infant mortality (Lawrence & Lawrence, 2011).

Although the fatty acid content of breast milk is influenced by the mother’s diet, malnourished mothers’ milk has about the same amounts of total fat, protein, carbohydrates, and most minerals as milk from those who are well nourished. Levels of water-soluble vitamins in breast milk, however, are affected by the mother’s intake and stores (Lawrence & Lawrence, 2011). It is important that breastfeeding women eat a well-balanced diet to maintain their own health and energy levels (see Nutrition for the Lactating Mother in Chapter 14 p. 293.)

Unmodified cow’s milk (whole milk, lowfat milk, or fat-free milk) is not recommended for infants younger than 12 months. It contains too much protein, potassium, chloride, and sodium; lacks enough fatty acids, iron, and vitamin E; and may cause gastrointestinal bleeding and anemia. It also causes the renal solute load to be too high (Kleinman, 2009).

Modified cow’s milk is the source of most commercial formulas. Manufacturers specifically formulate it for infants by making changes in the protein and fat and adding vitamins and other nutrients to simulate the contents of breast milk. Formula with added iron should be used for all infants receiving formula.

Infants with galactosemia, lactase deficiency, or those whose families are vegetarians may receive soy formula. As many as half of infants allergic to cow’s milk are also allergic to soy protein (Nguyen & Kerner, 2009). Protein hydrolysate formulas are better tolerated by infants with allergies. The protein in these formulas is treated to make it less allergenic. The formulas are also used for infants with malabsorption disorders. Amino acid formulas are used for allergic infants who do not thrive on extensively hydrolyzed protein formulas.

Lactose-free formula uses primarily glucose instead of lactose for infants who do not tolerate lactose. Low-phenylalanine formulas are needed for infants with phenylketonuria, a deficiency in the enzyme to digest phenylalanine found in standard formulas. The preterm infant may require a more concentrated formula with more calories in less liquid. Modifications of other nutrients are also made. Human milk fortifiers can be added to breast milk to adapt it for preterm infants.

The decision to breastfeed is strongly influenced by the woman’s family and friends. She is likely to ask for advice from her partner first, followed by advice from her mother, family, and friends (USDHHS, 2011). The woman with little support or with active discouragement from her family will probably have a more difficult time nursing. Advice from friends who have breastfed may also influence the mother’s decision.

Involvement of the father in infant care is important for some families, and some may feel it is only possible with feedings. Nurses can suggest other infant care measures, such as holding, rocking, and bathing, which fathers can enjoy. Educating family members about the advantages of breastfeeding and how to deal with problems may lead to their encouragement and support.

Prenatal classes that include breastfeeding information may help a woman decide to breastfeed and may help her develop confidence that she will be successful. Educating fathers about the benefits of breastfeeding, as well as techniques for coping with any difficulties that might occur, is important. Fathers should also attend the classes so they can provide increased support based on their knowledge. Both prenatal classes and new mother support groups led by lactation consultants are associated with higher breastfeeding rates at 6 months postpartum (Rosen, Krueger, Carney, et al., 2008).

Encouragement from the woman’s health care provider may be a powerful influence in the woman choosing to breastfeed (Newton, 2007). The support the mother receives from the nursing staff plays a significant part in whether she feels comfortable with her chosen feeding method. Mothers who do not feel confident in their ability to breastfeed before they leave the birth facility are less likely to continue breastfeeding if they encounter difficulties at home.

Other support also may be important. Doulas, trained lay-women who make home visits to assist women with breastfeeding after discharge, have been shown to increase the rate of breastfeeding at 6 weeks postpartum (Nommsen-Rivers, Mastergeorge, Hansen, et al., 2009). One study of African-American women found that breastfeeding self-efficacy, a woman’s belief that she will be able to breastfeed successfully, was associated with a longer period of breastfeeding and more exclusive breastfeeding at 1 and 6 months postpartum (McCarter-Spaulding & Gore, 2009).

Cultural influences may dictate decisions about how a mother feeds her infant. For example, many Mormon women believe that breastfeeding is an important part of motherhood. Muslim women often breastfeed for the first 2 years. Women who are most likely to breastfeed are Asian, Pacific Islander, or Hispanic. Those with the lowest breastfeeding rates include women who are non-Hispanic Black (USDHHS, 2011).

Immigrants to the United States often would breastfeed infants if they were still in their own countries. For example, in Russia, women are expected to breastfeed, and formula is not available in birth houses (Callister, Getmanenko, Garvrish, et al., 2007). Hispanic women who are new immigrants are more likely to begin breastfeeding and continue for a longer period than more acculturated immigrants (Gill, 2009). Some of these women may think that formula is the preferred method of feeding in the United States because it is available in the hospital. Nurses must emphasize the superiority of breastfeeding and encourage these women to continue their cultural tradition of breastfeeding.

Nurses should be particularly watchful for ways to help mothers from other cultures who might wish to breastfeed but fail to do so because of lack of support. Some Asian and Latina mothers give their infants formula while in the birth facility and do not begin to breastfeed until at home. This practice may be caused by modesty about nursing in front of others in the birth facility, as well as lack of understanding about the value of colostrum. Women in some cultures believe that colostrum may be “spoiled” because it has been in the breasts for a long time. They may express colostrum and discard it before they begin to breastfeed the infant. Education from nurses can help mothers understand the importance of giving colostrum and that much of the milk is produced as the infant is suckling (feeding at the breast).

Rituals may be important in some cultures. In the Philippines, the ritual of lihi, stroking the mother’s breasts with papaya leaves and sugar cane stalks ensures a good supply of rich milk (Riordan, 2010). Hispanic women may believe that they can transmit negative emotions to their breastfeeding infants. Navajo women believe they pass maternal attributes and model good behavior by breastfeeding (Kleinman, 2009).

It is important that all birth facility staff members have education about how to help women breastfeed and do not provide inaccurate or conflicting information to new mothers. Educational programs are effective in helping to ensure that all staff have the same basic knowledge and skills to help breastfeeding mothers. Programs may involve formal classes, protocols, and self-paced learning modules (Bernaix, Beaman, Schmidt, et al., 2010; Mellin, Poplawski, & Gole, 2011).

Other factors may also influence a woman’s decision. Her knowledge and past experience with infant feeding are important. Women who receive assistance from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), those without some college education, and those who live in the southeastern United States have lower breastfeeding rates than other women (USDHHS, 2011). One study found that women were more likely to breastfeed exclusively in the hospital if they began prenatal care in the first trimester and had expressed an intention during pregnancy to breastfeed exclusively. Women who were overweight or obese were half as likely to breastfeed exclusively during the hospital stay (Tenfelde, Finnegan, & Hill, 2011).

At birth, loss of placental hormones results in increasing levels and effectiveness of prolactin to stimulate milk production. Suckling and the removal of colostrum or milk cause continued increased levels of prolactin. Prolactin is secreted at highest levels with suckling and during the night (Lawrence & Lawrence, 2011). Levels are high during the early months and then gradually decrease until weaning.

When mothers see, hear, or think about their infants, they often have an increase in oxytocin, bringing about a let-down of milk. Pain or lack of relaxation can decrease oxytocin release. Oxytocin also causes the uterine contractions mothers may feel at the beginning of nursing sessions. These contractions are beneficial because they hasten involution of the uterus (Figure 23-1).

Women with and without experience often need information to have a successful breastfeeding experience. A woman’s confidence in her ability to breastfeed may be an important determinant of her success. Therefore nurses should help women increase their confidence and help prevent early weaning by using the nursing diagnosis: