Newborn Nutrition

Jill Janke

This chapter offers information and guidelines for the perinatal nurse caring for new mothers and infants during the initiation and early days of infant feeding. This chapter emphasizes that breast milk is the ideal food for the newborn and provides helpful information for nurses working with families who choose to breastfeed. In addition, guidelines are given for helping families who choose to formula-feed their newborn.

INFANT FEEDING DECISION

The decision about what to feed a newborn is frequently made by the mother long before giving birth (American Academy of Family Physicians [AAFP], 2008; Labbock & Taylor, 2008; Swanson, Power, Kaur, Carter, & Shepherd, 2007). A woman’s selection of an infant feeding method is more than just a lifestyle choice; it should be based on current scientific evidence. Perinatal nurses have the responsibility to make sure a woman has the needed information to make an informed decision. However, once an informed decision is made, the mother’s choice should be respected by all healthcare professionals.

A mother’s infant feeding decision is influenced by many factors, including her education (Callen & Pinelli, 2004; Labbock & Taylor, 2008; Phares et al., 2004), age (Labbock & Taylor, 2008; Phares et al., 2004), previous breastfeeding experience (Bailey & Wright, 2011), prenatal breastfeeding education (Dyson, Green, Renfrew, McMillan, & Woolridge, 2010; Kervin, Kemp, & Pulver, 2010), and the attitudes and knowledge of healthcare professionals (Britton, McCormick, Renfrew, Wade, & King, 2007; Kervin et al., 2010; Ryan & Zhou, 2006). Sources of personal support also impact the infant feeding decision, including encouragement from the husband; significant others (AAFP, 2008; Bolling, Grant, Hamlyn, & Thornton, 2007; Kervin et al., 2010); extended family, including grandmothers (Anderson, Nicklas, Spence, & Kavanagh, 2009; Grassley & Eschiti, 2008; Ryan & Zhou, 2006); and peers (Anderson et al., 2009; Chapman, Morel, Anderson, Damio, & Perez-Escamilla, 2010).

BENEFITS OF BREASTFEEDING

Human milk is a dynamic food, meeting the infant’s needs to build an immune system, to grow and develop the brain, and to form attachments with other human beings. Research has produced compelling data about the short- and long-term health benefits of breastfeeding for the mother and newborn. Numerous economic advantages of breastfeeding have also been identified.

NEWBORN HEALTH BENEFITS

There is substantial scientific evidence that newborns who are breastfed, or who are given breast milk, are healthier than those who receive formula. An integrated review and meta-analysis (Ip et al., 2007) concluded that during the first year of life, breastfed infants have decreased their risk for severe respiratory illness by 72%, otitis media by 50%, gastrointestinal illness by 64%, necrotizing enterocolitis by 5%, and sudden infant death syndrome (SIDS) by 36%. The long-term neonatal health benefits of breastfeeding have also been identified. Table 20-1 lists long- and short-term medical problems that may be associated with not breastfeeding.

Table 20-1. RISK OF SPECIFIC MEDICAL CONDITIONS THAT MAY BE ASSOCIATED WITH NOT BREASTFEEDING

Disease or Condition	Study	Result
Asthma	Ip et al. (2007)	Meta-analysis found a significant association between breastfeeding and a 27% reduced risk of asthma in subjects without family history of asthma. Subjects under 10 yr of age who were breastfed and had positive family history of asthma also had reduced risk.
	Bener, Ehlayel, Alsowsidi, & Sabbah (2007)	Exclusive breastfeeding prevents development of asthma and allergic diseases in children.
	Ogbuanu, Karmaus, Arshad, Kurukulaaratchy, & Ewart (2009)	Using lung function as a measure of susceptibility to asthma, children breastfed for at least 4 mo had increased lung volume, suggesting a decreased susceptibility to asthma.
Otitis media	Ip et al. (2007)	Meta-analysis showed breastfeeding was associated with a significant reduction (50%) in the risk of otitis.
Respiratory conditions	Ip et al. (2007)	Meta-analysis found a 72% reduction in the risk of being hospitalized with a lower respiratory tract disease in infants who were exclusively breastfed for 4 mo or longer.
	Mihrshahi, Oddy, Peat, & Kabir (2008)	Exclusive or predominant breastfeeding can reduce rates of respiratory infection.
Gastrointestinal (GI) infection	Ip et al. (2007)	Evidence from three primary studies shows that breastfeeding was associated with 64% reduction in the risk for GI infection during first year of life.
	Mihrshahi et al. (2008)	Exclusive or predominant breastfeeding can reduce rates of diarrhea.
	Monterrosa et al. (2008)	Predominantly breastfed infants had lower risk for GI infection during the first 6 mo when compared to formula-fed and partially breastfed infants.
Cognitive development	Ip et al. (2007)	Meta-analysis included preterm and term infants. Results are inconclusive because no studies controlled for maternal IQ.
	Kramer et al. (2008)	Randomized controlled trial with 17,046 infants (81.5% were followed to age 6.5 yr). Reported strong evidence that prolonged and exclusive breastfeeding is associated with children’s cognitive development.
	Bartels, van Beijsterveldt, & Boomsma (2009)	Significant positive effect of breastfeeding found on cognitive abilities after controlling for differences in maternal education.
	Rees & Sabia (2009)	A study of siblings concluded breastfeeding is associated with cognitive ability.
	Sloan, Stewart, & Dunne (2010)	A study of 137 infants concluded breastfeeding over 1 mo may have a beneficial effect on cognitive development.
Obesity	Ip et al. (2007)	Meta-analysis concluded there is an association between breastfeeding and reduced risk of obesity later in life.
	Butte (2009)	Breastfeeding had small but consistent protective effect against childhood obesity. Author noted that genetic and environmental variables may pose greater risk, such as socioeconomic status, parental obesity, parental smoking, birth weight, and rapid weight gain during infancy.
	Griffiths, Smeeth, Hawkins, Cole, & Dezateux (2009)	Initiating and prolonging breastfeeding may reduce excessive weight gain during the preschool years.
Diabetes	Ip et al. (2007)	Evidence suggests that breastfeeding for >3 mo is associated with reduced risk of developing type 1 and type 2 diabetes (39%).
	Taylor, Kacmar, Nothnagle, & Lawrence (2005)	Systematic review concluded that being breastfed for at least 2 mo might lower the risk of diabetes in children.
Necrotizing enterocolitis (NEC)	Ip et al. (2007)	Evidence supports an association between breastfeeding and reduced risk of NEC in preterm infants.
	Henderson, Craig, Brocklehurst, & McGuire (2007)	Subjects who did not develop NEC were significantly more likely to have received human breast milk when compared to those who did develop NEC (91% vs. 75%).
	Chauhan, Henderson, & McGuire (2008)	Concluded that feeding preterm infants human milk vs. formula can reduce the risk of NEC threefold.
Allergies	Ip et al. (2007)	Results equivocal, more research needed.
Sudden infant death syndrome (SIDS)	Ip et al. (2007)	Meta-analysis showed a significant reduction in the incidence of SIDS (36%) when infant breastfed.
Cardiovascular disease	Ip et al. (2007)	Results inconclusive on the relationship between breastfeeding and adult cholesterol and between breastfeeding and mortality from cardiovascular disease. However, there was a significant association between breastfeeding and a small reduction in adult blood pressure.
Childhood leukemia and lymphomas	Ip et al. (2007)	Meta-analysis concluded there was a significant association between breastfeeding for at least 6 mo and a reduced risk for acute lymphocytic leukemia (ALL) and acute myelogenous leukemia (AML).

MATERNAL HEALTH BENEFITS

Maternal health benefits also are associated with breastfeeding. In the immediate postpartum period, breastfeeding enhances mother-infant attachment. It also stimulates uterine involution resulting in less blood loss, thus reducing the risk for anemia and infection. Long-term maternal health benefits are also related with breastfeeding. Typically, the more breastfeeding a woman does during her lifetime, the greater the health benefits. Known benefits include a 28% risk reduction for developing breast cancer, a 21% risk reduction for ovarian cancer, and a 2% to 12% risk reduction for type II diabetes (Ip et al., 2007; Stuebe & Schwarz, 2010). In addition, breastfeeding is associated with a reduced risk for developing metabolic syndrome (Gunderson et al., 2010), hypertension, hyperlipidemia, and cardiovascular disease (Schwarz et al., 2009).

ECONOMIC BENEFITS

Exclusive use of formula and its consequent increased neonatal morbidity is responsible for substantial expenditures of healthcare dollars. Bartick and Reinhold (2010) estimated that there would be an annual healthcare cost savings of $13 billion if 90% of new mothers in the United States breastfed exclusively for the first 6 months. Employers also benefit when a woman breastfeeds. The U.S. Department of Health and Human Services (USDHHS; 2008) has published a toolkit, The Business Case for Breastfeeding, which includes reports from various companies that have implemented breastfeeding support programs in the workplace. One organization reported increased breastfeeding rates at 6 months (72.5%) after implementation of their support program. They also reported an annual savings of $240,000 in healthcare expenses for breastfeeding mothers and children, a 72% reduction in lost work time due to infant illness that resulted in an annual savings of $60,000, and lower pharmacy costs due to a 62% reduction in prescriptions.

CONTRAINDICATIONS TO BREASTFEEDING

The American Academy of Pediatrics (AAP; 2012) and AAFP (2008) maintain that with few exceptions, human milk is preferred for all infants, including premature and sick newborns. Contraindications to breastfeeding are rare and include a mother who has human T-cell lymphotropic virus type I or II infection; needs cancer treatment with antimetabolites, chemotherapeutic agents, or radiation; has untreated active tuberculosis; uses illicit drugs; has herpes simplex lesions on the breast; or who is seropositive for the human immunodeficiency virus (HIV). Breastfeeding is also contraindicated when infants have certain types of inborn errors of metabolism, such as galactosemia (AAP, 2012).

INCIDENCE OF BREASTFEEDING

HEALTHY PEOPLE GOALS

Given the importance of breast milk and breastfeeding to mothers, newborns, and society as a whole, one of the Healthy People 2020 national goals is to increase initiation and duration rates of breastfeeding. The target initiation and duration rates have been altered over the last three decades as more information about infant feeding practices is available. The Healthy People 2020 target for any breastfeeding is that 81.9% of women will initiate breastfeeding, 60.6% will be breastfeeding at 6 months, and 34.1% will still be breastfeeding until the infant is 12 months of age. The Healthy People 2020 target for exclusive breastfeeding is that 44.3% of women who initiated breastfeeding will exclusively breastfeed through the first 3 months and 25.5% will exclusively breastfeed for 6 months (USDHHS, 2011).

The AAP (2012) and the AAFP (2008) recommend that women continue to breastfeed longer than 12 months if mutually desired. The World Health Organization (WHO; 2011) extends that recommendation to 2 years or longer. There is no evidence of psychological or developmental harm from continued breastfeeding into the third year of life or longer. Researchers have reported distinct benefits to extending breastfeeding past the first year. The AAFP (2008) noted that children weaned before 2 years have an increased risk of illness. This was supported by an older study (Gulick, 1986) that reported toddlers between the ages of 16 and 30 months who continued to breastfeed had fewer illnesses and, when they did get sick, their illness was of shorter duration when compared to nonnursing toddlers.

While breastfeeding rates have steadily increased since the 1990s, more work is needed to meet the Healthy People 2020 goals. According to a national survey conducted on 2007 data, 75% of mothers in the United States initiated breastfeeding; of those, 33% were exclusively breastfeeding at 3 months. At 6 months, 43% continued to do some breastfeeding, with 13.3% breastfeeding exclusively. At 1 year, 22.4% of women continued doing some breastfeeding, and at 18 months, 7.4% were still breastfeeding (Centers for Disease Control and Prevention [CDC], 2010a). Although no Healthy People 2020 goal has been set for breastfeeding beyond 1 year, the Breastfeeding Report Card published by the CDC (2010a) noted that breastfeeding at 18 months ranged from 5.5% to 7.4% between 2000 and 2007.

Despite research identifying the benefits of giving breast milk to preterm infants, no national goal has been set for this high-risk population. No national statistics were found on breastfeeding rates for preterm infants, but we do know they are much lower than for term infants. In one report, breastfeeding rates in the neonatal intensive care unit (NICU) ranged from 36.9% to 50% (Castrucci, Hoover, Lim, & Maus, 2007). It is important to note that the higher rate was associated with hospitals that used lactation consultants. Among late preterm infants (34 0/7 to 36 6/7 weeks’ gestation), breastfeeding initiation was reported between 59% and 70%, with a significant reduction in breastfeeding duration and exclusivity (Radtke, 2011).

Table 20-2 HEALTHY PEOPLE BREASTFEEDING GOALS

			National Immunization Study 2007 (CDC, 2010a )
Goal	2010 Target	2020 Target	Overall U.S. Average	Range (State Disparity)
Initiate any breastfeeding	75%	81.9%	75.0%	52.5%-89.8%^*
At 6 mo, any breastfeeding	50%	60.6%	43.0%	20.2%-62.2%^†
At 12 mo, any breastfeeding	25%	34.1%	22.4%	8.0%-39.7%^‡
At 3 mo, exclusive breastfeeding	40%	44.3%	33.0%	15.2%-50.8%^**
At 6 mo, exclusive breastfeeding	17%	25.5%	13.3%	6.5%-23.7%
^Thirteen states have exceeded Healthy People 2020 goal for initiating any breastfeeding.^†One state has exceeded Healthy People 2020 goal for any breastfeeding at 6 mo.^‡Four states have exceeded Healthy People 2020 goal for any breastfeeding at 12 mo.^*Nine states have exceeded Healthy People 2020 goal for exclusive breastfeeding at 3 mo.

Although the overall breastfeeding rates have improved, the CDC (2010a) reported great disparity in breastfeeding initiation and duration between geographic areas and various population groups, with some states reporting much higher rates than others. See Table 20-2 for a comparison of Healthy People 2010 and 2020 goals, the average U.S. breastfeeding rates, as well as the range disparities in rates between states.

PROFILE OF WOMEN WHO BREASTFEED

Knowing the characteristics of women who are less likely to initiate and continue breastfeeding can help the perinatal nurse target at-risk populations for more education and support. Researchers have reported consistently that breastfeeding is lowest among women who are African American, had less than or equal to a high school education, were single and younger than 20 years of age, lived in the southern United States, and were enrolled in the Women, Infants, and Children (WIC) program (CDC, 2010a; Labbock & Taylor, 2008; Ziol-Guest & Hernandez, 2010). In contrast, women who are more likely to initiate and continue breastfeeding tend to be Caucasian or Hispanic, at least 30 years of age, married, college educated, not enrolled in the WIC program, and not living in the southeastern part of the United States (CDC, 2010a; Labbock & Taylor, 2008). It is anticipated that rates of breastfeeding initiation, duration, and exclusivity in WIC women will improve in the future. In 2009, federal regulations were passed that offered incentives to WIC women who exclusively breastfed. Examples of incentives included receiving larger maternal food packages over a longer period of time (1 year). By comparison, mothers who used formula received free formula and a smaller maternal food package for a shorter period of time (6 months). These incentives, in addition to the breastfeeding education and support from WIC counselors, should positively impact breastfeeding rates in WIC women (USDHHS, 2011).

BARRIERS TO BREASTFEEDING

Researchers have identified barriers to breastfeeding that are responsive to interventions (Display 20-1). The Healthy People 2020 national plan addresses several of those interventions, including increased worksite support, reduced hospital supplementation rates, and improved hospital practices (USDHHS, 2011).

It is well documented that hospital policies can adversely impact breastfeeding. In 1991, the WHO and the United Nations International Children’s Emergency Fund (UNICEF) published the Baby-Friendly Hospital Initiative (WHO/UNICEF Joint Statement, 1989). This document included the Ten Steps to Successful Breastfeeding, which was designed to eliminate counterproductive hospital practices (Display 20-2). Researchers have reported that implementation of the Ten Steps facilitates successful breastfeeding by all women (Abrahams & Labbock, 2009; Bartick, Stuebe, Shealy, Walker, & Grummer-Strawn, 2009; DiGirolamo, Grummer-Strawn, & Fein, 2008; Forster & McLachlan, 2007; Murray, Rickets, & Dellaport, 2007; Rosenberg, Stull, Adler, Kasehagen, & Crivelli-Kovach, 2008). Some hospitals have sought official “Baby-Friendly Hospital” certification. In 2006, there were 52 Baby-Friendly hospitals and birthing centers in the United States. This increased to 108 in 2011. While not all hospitals have sought Baby-Friendly certification, many have modeled their policies and protocols after the Ten Steps with similar improvements in breastfeeding rates.

Perinatal nurses need to understand their role in promoting breastfeeding. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN; 2007a) identifies the professional responsibilities of perinatal nurses who care for breastfeeding women and newborns in the prenatal and postpartum periods (Display 20-3). Many of those responsibilities are aimed at reducing barriers to breastfeeding.

DISPLAY 20-1 Barriers to Breastfeeding that Are Responsive to Interventions

Healthcare Professionals

Apathy
Misinformation
Professional education that lacks information on breastfeeding
Outdated clinical practices

Hospital Practices

Failing to provide skilled support (i.e., lactation experts)
Routine separation of mother-infant dyad
Delay of first feeding
Routine formula or water supplementation
Use of pacifiers
Lack of staff training
Lack of a breastfeeding policy
Inappropriate interventions (i.e., supplemental feeding, pacifiers, overuse of nipple shields)
Disruptions of breastfeeding
Discharge packs that include formula samples and/or coupons for formula
Lack of discharge policy
Lack of follow-up after discharge

Lack of Support

From partner, peers, and family
From workplace
From healthcare professionals

Societal Attitudes

Media portrayal of bottle-feeding as normal
Commercial pressures on mothers to bottle-feed or supplement with formula
Formula club sign-up sheets in obstetric offices and clinics
Prenatal formula starter kits
Coupons for free formula
Formula ads in parent magazines
Formula ads on Internet sites of interest to parents
Discounted formula available through the Internet

BREASTFEEDING PROMOTION

Several systematic reviews were published on interventions designed to increase breastfeeding initiation, exclusivity, and duration in term infants (Chapman et al., 2010; Chung, Raman, Trikalinos, Lau, & Ip, 2008; Hannula, Kaunonen, & Tarkka, 2008). They concluded that multiple interventions, using a variety of educational methods and sources of professional and peer support, were more effective over any single intervention. In addition, programs that spanned the prenatal, intrapartal, and postpartal time periods were more successful than interventions that focused on a single time period. A systematic review on breastfeeding promotion in the NICU found the following interventions to be effective at promoting preterm breastfeeding: skin-to-skin contact, peer support, breast milk pumping on both breasts simultaneously, staff training across all disciplines, and Baby-Friendly accreditation (Renfrew et al., 2009). The authors concluded it was unlikely any single intervention made a difference; rather, it was the combination of multiple interventions.

DISPLAY 20-2 Ten Steps to Successful Breastfeeding

Have a written breastfeeding policy that is routinely communicated to all healthcare staff (see Model Breastfeeding Policy [Academy of Breastfeeding Medicine [ABM], 2010b]).
Educate healthcare providers in skills necessary to implement this policy.
Inform all pregnant women about the benefits and management of breastfeeding.
Help mothers initiate breastfeeding within 1 hour of birth.
Show mothers how to breastfeed and how to maintain lactation even when they are separated from their newborns.
Give newborns no food or drink other than breast milk, unless medically indicated.
Practice “rooming-in”; allow mothers and newborns to remain together 24 hours each day.
Encourage unrestricted breastfeeding.
Give no artificial nipples or pacifiers to breastfeeding newborns.
Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

From World Health Organization/United Nations International Children’s Emergency Fund Joint Statement. (1989). Protecting and supporting breastfeeding: The special role of maternity services. Geneva, Switzerland: World Health Organization. Retrieved from http://www.babyfriendlyusa.org/eng/index.html

PHYSIOLOGY OF MILK PRODUCTION

Perinatal nurses need to understand the science of milk production. This knowledge is essential to help women breastfeed successfully.

MAMMOGENESIS

Mammogenesis refers to growth of the mammary glands. It occurs in two stages as the gland responds to the hormones of puberty and later during the first half of pregnancy. During pregnancy, estrogen and progesterone prepare the breasts for lactation. Numerous external changes occur. The breasts enlarge; the skin stretches and appears thinner, making veins more visible. The nipples enlarge, and the Montgomery glands become prominent and start to secrete a substance that lubricates and protects the nipples and areola. The areola grows in diameter and darkens. Internal changes in the breast also occur and include growth and differentiation of the mammary ducts as well as development of the lobules and alveoli. Sometime in the second trimester, lactogenesis I begins (Lauwers & Swisher, 2011; Lawrence & Lawrence, 2011).

DISPLAY 20-3 Breastfeeding and the Role of the Nurse in the Promotion of Breastfeeding

Attain knowledge about the benefits of breastfeeding, including anatomy and physiology of lactation, initiation of lactation, and management of common concerns and problems.
Provide preconception and antenatal counseling on the benefits of breastfeeding.
Provide breastfeeding education to all women during prenatal period, including exploration of concerns, fears, and myths that may inhibit successful breastfeeding.
Work in collaboration with lactation specialists and other healthcare providers to optimize the breastfeeding experience for the mother and infant.
Integrate culturally appropriate and sensitive information into all breastfeeding education.
Ensure that breastfeeding is initiated in the immediate postpartum period whenever possible.
Promote nonseparation of mother and baby during the postpartum period.
Provide information about breastfeeding resources in the community at the time of hospital or birthing center discharge.
Use and conduct research related to breastfeeding.

From Association of Women’s Health, Obstetric and Neonatal Nurses. (2007a). Breastfeeding and the Role of the Nurse in the Promotion of Breastfeeding.

Washington, DC: Author.

LACTOGENESIS I

Lactogenesis I starts around midpregnancy and lasts until 1 to 2 days postpartum. During this time, further cell differentiation occurs, and the lactocytes that are capable of secreting milk components proliferate. Prolactin levels rise during pregnancy and stimulate production of colostrum, which is present from midpregnancy forward (Lauwers & Swisher, 2011; Lawrence & Lawrence, 2011).

LACTOGENESIS II

Lactogenesis II is defined as the onset of copious milk production that occurs 48 to 72 hours after the birth (Hurst, 2007). Prolactin levels rise higher in the postpartum period when levels of progesterone drop after the placenta is expelled. The higher prolactin levels, along with infant suckling, stimulate the breast to synthesize and secrete milk (Lauwers & Swisher, 2011; Lawrence & Lawrence, 2011).

Delayed onset of lactogenesis II can occur. In one study, 44% of the 431 subjects experienced delayed onset of lactation (Nommsen-Rivers, Chantry, Peerson, Cohen, & Dewey, 2010). It is important that perinatal nurses know the risk factors for delayed onset and monitor and intervene accordingly. Common risk factors for delayed onset of lactogenesis II are listed in Display 20-4.

LACTOGENESIS III

Lactogenesis III is the phase when a woman has established a mature milk supply. Production of milk changes from the hormonal endocrine control that exists in the first few days after birth to autocrine control when the milk supply is more established. With autocrine control, prolactin continues to be produced in response to infant suckling and emptying of the breasts. Oxytocin is also released in response to suckling. This occurs numerous times during a feeding. Oxytocin stimulates the cells around the alveoli to contract and eject milk down the ducts, making it accessible when the newborn suckles. The sensation that accompanies the release of oxytocin on breast tissue is referred to as the letdown reflex or the milk-ejection reflex. Some mothers feel this as a heaviness or tingling sensation in the breast. Other mothers never feel the milk let down but observe milk leaking from the other breast or hear the newborn swallowing milk (Riordan & Wambach, 2010; Walker, 2011).

DISPLAY 20-4 Common Risk Factors for Delayed Onset of Lactogenesis II

Primiparity

Maternal age ≥ 30 years

Cesarean birth

Prolonged labor

Obesity

High levels of stress during the birth

Premature delivery (including late preterm)

Insulin dependent diabetes mellitus

Birth weight > 3,600 g

Retained placenta

Surgical procedures on breast

Insufficient mammary tissue

Breast hypoplasia

Delay with first feeding

Hypothyroid

Hypertension

Data from Hurst, 2007; Nommsen-Rivers, L. A., Chantry, C. J., Peerson, J. M., Cohen, R. J., & Dewey, K. G. (2010). Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding. American Journal of Clinical Nutrition, 92 (3), 574-584; Scott, J. A., Binns, C. W., & Oddy, W. H. (2007). Predictors of delayed onset of lactation. Maternal & Child Nutrition, 3 (3), 186-193. doi:10.1111/j.1740-8709.2007.00096.x

Oxytocin also stimulates uterine contractions that control postpartum bleeding and promote involution. Mothers, especially multiparous women, feel these “after-birth pains” during feedings for several days after the birth. The discomfort can create a distraction that inhibits milk letdown. It is important to make the mother comfortable prior to and during the feeding. To minimize discomfort from afterpains, mothers should be encouraged to keep their bladder empty, since a full bladder contributes to cramping. An analgesic prior to feeding should be considered. Ibuprofen is often effective, but in some cases, a mother might need something stronger. Nurses should reassure the mother that afterpains are normal and help limit blood loss; they are also self-limiting, lasting a few days (Riordan & Wambach, 2010; Walker, 2011).

Oxytocin-producing neurons throughout the brain are thought to be associated with social behavior and attachment. In addition to being released in the maternal brain tissue, oxytocin is released into the newborn brain by means of milk transfer and is thought to modulate attachment behaviors between mother and newborn (Insel, 1997; Nelson & Panksepp, 1998). Oxytocin also is partially responsible for the calmness women exhibit while breastfeeding and has been linked to a decreased response to stressors and pain in the breastfeeding woman (Goer, Davis, & Hemphill, 2002).

Milk production is a supply-and-demand system; as milk is removed from the breast, prolactin triggers the breast to produce more milk. For most women, milk production closely matches the needs of the newborn. The more efficiently the newborn nurses, the faster the rate of milk synthesis (Lawrence & Lawrence, 2011).

Leaving milk in the breasts for long periods can contribute to slower and lower amounts of milk production. A whey protein, feedback inhibitor of lactation (FIL), inhibits milk secretion as alveoli become distended and milk is not removed. The longer the period of time milk is left in the breast, the greater the concentrations of FIL. This mechanism works independently, and each breast will synthesize milk at different rates depending on the frequency and degree of drainage (Lawrence & Lawrence, 2011).

BIOSPECIFICITY OF HUMAN MILK

Human milk is a species-specific fluid. The composition is not static or uniform. Breast milk is designed to meet the needs of newborns to grow and develop a brain, protect the immature gut, be a substitute for an immature immune system, and assist in developing attachment behavior. The composition of human milk changes over time. Colostrum (1 to 5 days postpartum) evolves to transitional milk (6 to 13 days postpartum) and then into mature milk (14 days and beyond). During any given feeding, foremilk changes to hindmilk the longer the infant breastfeeds. Milk composition also fluctuates over the course of the entire lactation. Milk of preterm mothers differs from that of term mothers in order to meet the nutritional needs based on gestational age. For example, during the first 3 to 5 days after birth, term milk contains 1.85 g/dL of protein, whereas preterm milk contains 3.00 g/dL (Walker, 2011).

Colostrum is present in the breast from about 12 to 16 weeks of pregnancy. This first milk is thick and has a yellowish color. Average energy value is about 18 kcal/oz, compared with mature milk, which contains 21 kcal/oz (AAP Committee on Nutrition, 2009). The volume of colostrum is low (measured in teaspoons), which ensures the infant will want to nurse frequently. This frequent nursing is what stimulates the transition to milk. Compared with mature milk, colostrum is higher in protein, sodium, chloride, potassium, and fat-soluble vitamins. It is rich in antioxidants, antibodies, interferon, fibronectin, and immunoglobulins, especially secretory immunoglobulin (Ig) A. Secretory IgA is antigen specific. When mothers come in contact with microbes, antibodies are synthesized in their milk, targeting pathogens in the newborn’s immediate environment. These antibodies are passed to the newborn. Separating the mother and newborn interferes with this defense mechanism. Colostrum begins the establishment of normal bacterial flora in the newborn’s gastrointestinal tract and exerts a laxative effect that begins elimination of meconium, decreasing the potential reabsorption of bilirubin (Riordan & Wambach, 2010; Walker, 2011).

Mature milk composition changes during the feeding. Foremilk is produced initially; it is more watery and has lower fat content. Later in the feeding on a given breast, cell membranes release fat globules and protein, which forms hindmilk (Lawrence & Lawrence, 2011). Hindmilk is high in calories and fat and is critical to growth and brain development. To make sure infants get adequate hindmilk, the baby should be allowed to completely finish on one side before offering the other breast. Babies are done feeding on a breast when the baby lets go of the nipple, falls asleep, or ceases to actively suck and swallow (Lawrence & Lawrence, 2011).

NUTRITIONAL COMPONENTS

WATER

Human milk is composed of 87.5% water, in which all other components are dissolved, dispersed, or in suspension (Riordan & Wambach, 2010; Walker, 2011). Infants receiving adequate amounts of breast milk do not need additional water, even in hot climates (Almroth, 1978; Ashraf, Jalil, Aperia, & Lindblad, 1993).

FAT (LIPIDS)

Fat content of human milk ranges from 3.5% to 4.5% and contributes 50% of the calories (Walker, 2011). It varies during a feeding; hindmilk has almost double the fat content when compared to levels in foremilk (Saarela, Kokkonen, & Koivisto, 2005). Fat content increases over the first days of lactation and shows diurnal rhythms. Total fat content is reduced in mothers who smoke (Agostoni et al., 2003; Vio, Salazar, & Infante, 1991) and increases when women breastfeed more frequently. The long-chain polyunsaturated fatty acids docosahexanoic acid and arachidonic acid contained in breast milk are found in the brain, retina, and central nervous system of newborns and are necessary for the growth of these structures during the first year of life (Riordan & Wambach, 2010). The absence of these fatty acids in formula may contribute to differences in cognitive development that has been reported in the literature (Anderson, Johnstone, & Remley, 1999; Ip et al., 2007; Walker, 2011).

PROTEIN

Protein concentration is high in colostrum and settles to 0.8% to 1.0% in mature milk. The whey-to-casein ratio in human milk changes from 90:10 in the early milk to 60:40 in mature milk and 50:50 in late lactation (AAP Committee on Nutrition, 2009; Walker, 2011). The whey protein that predominates in human milk forms soft curds that are easily digested and supply the infant with most of the nutrients in human milk. One of the components of the whey protein, lactoferrin, is important in the immunologic effects of human milk. The bacteriostatic effect of lactoferrin makes iron unavailable to pathogens that require the mineral to proliferate (Riordan & Wambach, 2010).

CARBOHYDRATE

The principal carbohydrate in human milk is lactose. Lactose supports colonization of the gut with microflora that increases the acidity of the intestine. The increased acidity decreases growth of pathogens and ensures a supply of galactose and glucose, which are necessary for brain development. Calcium absorption is also enhanced in the acidic environment (Riordan & Wambach, 2010; Walker, 2011).

VITAMINS AND MINERALS

Breast milk contains all of the vitamins and minerals needed by most infants for about the first 6 months of life. In the event that iron stores need additional support in the first 6 months, oral iron drops may be needed. After 6 months of exclusive breastfeeding, infants require supplementary food rich in iron and zinc (AAP, 2012). Vitamin D deficiency is a risk factor for some breastfed children, and due to scattered reports of rickets in the United States, the AAP now recommends all infants receive a vitamin D supplement of 400 IU/day beginning at hospital discharge (AAP, 2012; Wagner & Greer, 2008). It is important to note that human milk does have vitamin D, estimated to average 26 IU/mL. While adequate for some infants, this quantity is inadequate in cases where infants lack sun exposure (due to climate or use of sunscreen) or when the mother is deficient in vitamin D during pregnancy.

PRETERM MILK AND LACTATION

DIFFERENCES BETWEEN PRETERM AND TERM MILK

Like milk produced by mothers of term infants, milk produced by mothers of preterm infants changes to meet the infant’s growth needs. Composition differs from term milk with higher levels of immune factors, energy, lipids, protein, nitrogen, and fatty acids (Riordan & Wambach, 2010; Walker, 2011).

BENEFITS OF HUMAN MILK FOR PRETERM INFANTS

The preterm infant benefits from receiving human milk with lower rates of infection, necrotizing enterocolitis, and hospital readmissions. In addition, preterm infants who receive breast milk have improved feeding tolerance, enhanced neurodevelopment, increased scores on cognitive and developmental tests, and closer family attachment. Given the extensive benefits of human milk, the AAP (2012) indicated all preterm infants should receive human milk, ideally the mother’s own milk; if mother’s milk is not available, pasteurized donor milk can substitute. Mothers who breastfeed or provide breast milk for their preterm infants demonstrated increased self-esteem and maternal role attainment. Although these benefits are similar for term infants, they have far greater impact on the vulnerable preterm infant (British Columbia Reproductive Care Program, 2001; Merewood, Brooks, Bauchner, MacAuley, & Mehta, 2006).

PRETERM BREASTFEEDING BARRIERS

Mothers of preterm infants face the same barriers to breastfeeding as do mothers of term infants. They also have unique barriers, such as the need to use hand expression or a breast pump for a prolonged period of time and possible limited contact with their infant. Reduced mother-infant contact may be due to the infant’s condition or due to the mother being discharged from the hospital. In some large regional centers, mothers may live a distance from the facility. Stress is known to inhibit milk production (Walker, 2011). The NICU environment contributes to maternal stress with all its machines, monitoring devices, and alarms (AAFP, 2008). Other sources of stress for NICU mothers often include fear for their infant, separation from their infant, or concerns about the cost of intensive care.

DISPLAY 20-5 Resources and Guidelines for Preterm Breastfeeding

Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) (http://www.awhonn.org)

March of Dimes (http://www.modimes.org)

Oklahoma Infant Alliance (http://www.oklahomainfantalliance.org/lpi_guidelines.html)

Cochrane Database of Systematic Reviews (http://www.thecochranelibrary.com)

California Perinatal Quality Care Collaborative (http://www.cpqcc.org/quality_improvement/qi_toolkits/nutritional_support_of_the_vlbw_infant_rev_december_2008)

Academy of Breastfeeding Medicine (ABM) Protocols (http://www.bfmed.org/Resources/Protocols.aspx)

Breastfeeding Support: Prenatal Care Through the First Year Guideline, Second Edition. (AWHONN, 2007b)

Assessment & Care of the Late Preterm Infant Guideline (AWHONN, 2010)

Prematurity Awareness Campaign

Caring for the Late Preterm Infant: A Clinical Practice Guideline (Oklahoma Infant Alliance, 2010)

“Cup Feeding versus Other Forms of Supplemental Enteral Feeding for Newborn Infants Unable to Fully Breastfeed” (Flint, New & Davies, 2008)

Nutrition support of the VLBW infant (revised) (California Perinatal Quality Care Collaborative, 2008)

ABM Clinical Protocol #10: “Breastfeeding the Late Preterm Infant” (ABM, 2011)

ABM Clinical Protocol #16: “Breastfeeding the Hypotonic Infant” (ABM, 2007b)

ABM Clinical Protocol #22: “Guidelines for Management of Jaundice in Breastfeeding Infant Equal to or Greater than 35 Weeks’ Gestation” (ABM, 2010a)

PROMOTING PRETERM BREASTFEEDING

Nurses play a major role in promoting breastfeeding for preterm infants. Certain practices have been proven helpful: early discussion of breastfeeding; written materials; promotion of hand expression along with simultaneous pumping of both breasts with a hospital grade electric pump; breast massage; encouraging skin-to-skin contact (kangaroo care) to facilitate attachment, milk production, and subsequent establishment of breastfeeding; and use of an alternate feeding method, such as cup feeding, instead of an artificial nipple (AAFP, 2008). Mothers also need to learn about storage methods for expressed milk. Display 20-5 provides a list of guidelines and resources for preterm breastfeeding.

BREASTFEEDING PROCESS

PREPARATION FOR BREASTFEEDING

Physical Preparation

There is no research supporting physical preparation of the breasts during pregnancy. Prenatal nipple rolling, application of creams, and expression of colostrum have not been shown to decrease pain or nipple trauma during the postpartum period. Use of methods to improve nipple erectility, such as Hoffman exercises and breast shells, may actually decrease a woman’s desire and motivation to breastfeed by conveying the message that her nipples are inferior and need correcting (Centuori et al., 1999; Riordan & Wambach, 2010).

Prenatal Education

Women should be encouraged to attend prenatal breastfeeding classes. The short postpartum hospital stay puts pressure on the nurse, the mother, and the newborn to demonstrate effective breastfeeding before some mother-baby couples are ready. The fast learning pace in the inpatient setting and the mother’s cognitive sluggishness for verbal instructions during the first 24 hours postpartum suggest that there would be a benefit in providing breastfeeding information before birth. Prenatal breastfeeding education programs have been shown to increase the knowledge levels of pregnant women and their partners, increase the support women perceive from their partners around the decision to breastfeed, and increase breastfeeding initiation and duration rates (Guise et al., 2003; Lauwers & Swisher, 2011; Riordan & Wambach, 2010; Sikorski, Renfrew, Rindoria, & Wade, 2002; U.S. Preventive Services Task Force [USPSTF], 2008). The Academy of Breastfeeding Medicine (ABM; 2009) has a clinical protocol for breastfeeding promotion (see Display 20-5 for resources).

POSITIONING FOR BREASTFEEDING

A variety of positions are used for breastfeeding. It is important that the mother assume a relaxed, comfortable position with her back and arms well supported. If she is seated in a chair, placing a footstool beneath her feet decreases strain on her back and may discourage her from leaning forward over the baby. Some mothers benefit from a pillow on the lap or use of a commercially available nursing pillow. These can be especially helpful when nursing twins. If the mother is lying on her side, a pillow behind her back will help with support (Riordan & Wambach, 2010; Walker, 2011).

The newborn and the mother should face each other while breastfeeding. The mother should not lean forward over the newborn but instead concentrate on bringing the baby toward her. The newborn should be loosely wrapped or not wrapped at all so the nurse and the mother can clearly see the infant’s position on the breast. There is no need to be concerned about keeping the newborn warm because mother and baby generate body heat during breastfeeding. Skin-to-skin contact is useful for increasing a low temperature in a newborn during the transitional period. As the feeding progresses, if necessary, a light blanket may be placed over both for privacy (Riordan & Wambach, 2010; Walker, 2011).

Cradle Hold

With the mother comfortably seated, the newborn is held in a side-lying position with his or her entire body completely facing the mother. Held on a slight incline, the newborn’s lower arm is tucked around the outside of the breast. The newborn’s body is in complete contact with the mother; the newborn’s legs are wrapped around her waist. If the newborn is wrapped in a blanket, loosen it to permit the newborn to freely move its arms and legs. Avoid covering the infant’s hands with the undershirt cuffs. The newborn’s head rests on the mother’s forearm, which along with her wrist and hands, supports the baby’s back and bottom (Fig. 20-1). Specially designed L-shaped pillows fit around the mother’s waist and help to elevate and support her arm. Use of this pillow has been associated with increased length of breastfeeding at 2 and 8 weeks (Humenick, Hill, & Hart, 1998). Regular bed pillows may also be used.

Cross-Cradle Hold

The cradle position can be modified by having the woman alter the position of her arms, using what is called the cross-cradle hold. This is a good position to use for preterm infants and infants with fractured clavicles. The newborn is placed in the same position as in the cradle hold but held with the opposite arm such that the head is in the mother’s hand and her forearm is supporting the back. This gives the mother much more control over positioning and, along with the clutch hold, may be easier to learn (Fig. 20-2).

FIGURE 20-1. Cradle hold.

Clutch Hold

The clutch position (i.e., football hold) is useful for feeding preterm infants or twins and for mothers who have had a cesarean birth. The newborn is positioned to the mother’s side. Placing a pillow under the newborn raises the infant slightly and decreases the weight the mother needs to lift. The newborn’s head is in her hand, and its feet are positioned toward her back. Care should be taken to ensure that the full weight of the breast does not rest on the newborn’s chest (Fig. 20-3).

FIGURE 20-2. Cross-cradle hold.

FIGURE 20-3. Clutch hold.

Side Lying

The side-lying position works well after a cesarean birth or for a woman with a painful perineum. In this position, the newborn and the mother lay on their sides facing each other. A small rolled blanket can be placed behind the newborn’s back, or the mother can support the infant with her free arm (Fig. 20-4).

Laid-Back Breastfeeding

Laid-back breastfeeding is based on the concept of biologic nurturing (BN). Central to BN is the assumption that breastfeeding initiation is intrinsic for both mother and baby and not something they need to learn. BN stresses the fact that no one posture is right for everyone. Women are capable of finding a position of comfort, and positions can change and evolve over time (Colson, Meek, & Hawdon, 2008).

FIGURE 20-4. Side lying.

Many women choose a semireclined position. Once the mother is comfortable, the baby is placed prone on the mother’s front with the baby’s face near the breast. Skin-to-skin should be optional based on the mother’s preference. While the traditional positions (see previous) may work for some women, the BN approach allows women more options and is much less prescriptive. More information on BN can be found at http://www.biologicalnurturing.com (Colson et al., 2008).

SUPPORTING THE BREAST

Historically, mothers have been encouraged to support their breasts using a variety of techniques (scissor hold, C-hold, etc.). The current approach is to let the mother decide what works best for her. In some cases and in some positions, there is no need to hold the breast. In the event the breast is being held, a variety of techniques could be used as long as the mother’s fingers do not impede the infant from a correct latch or compress ducts (Colson et al., 2008).

Figure 20-1 shows the commonly used C-hold. With this technique, the mother supports her breast with her thumb on top and fingers below and against the chest wall. The thumb and fingers are away from the areola. This hold makes it easy for the mother to direct her nipple toward the center of the mouth during latch on. Mothers are encouraged to use whichever hand is more comfortable. Pressure should not be applied to the breast with the thumb. The newborn’s pug-shaped nose allows breathing through the grooves along the sides of the nares during breastfeeding, even when the nose is touching the breast. In all breastfeeding positions, pulling the newborn’s buttocks closer to the mother’s body or gently lifting the breast causes the newborn’s head to drop back slightly, providing room for breathing (Riordan & Wambach, 2010; Walker, 2011).

LATCH ON

Proper attachment of the newborn at the breast is necessary for pain-free and effective milk transfer. Once positioned comfortably, the mother moves the newborn’s lips to the nipple; when the newborn’s mouth is wide open, she draws the newborn forward toward her. The lower lip and chin contact the breast first. The newborn should grasp the nipple and areola, pulling it as a unit forward and deep into his mouth. The tongue is cupped and thrust forward over the lower gum. When the jaw lowers and creates negative pressure, milk moves into the trough of the tongue and is channeled to the back of the mouth, where the swallow reflex is triggered. Display 20-6 lists observations made when the newborn is latched on to the breast correctly.

For women with very large breasts, a rolled receiving blanket or small towel can be placed under the breast so the baby does not drag down on the nipple. Care should be taken to avoid pushing the newborn’s head into the breast. Pressure on the occipital region of the head causes extension of the neck. Tilting, squeezing, or distorting the nipple or areola should also be avoided because doing so can cause pain and skin damage. If the mother feels a pinching or biting sensation while nursing, she should be instructed to pull down gently on the newborn’s chin. This causes his mouth to open wider so that more of the areola is drawn into his mouth. If this does not work, have the mother insert her little finger into the side of the newborn’s mouth to release the suction (Riordan & Wambach, 2010; Walker, 2011). She should begin again to achieve a better latch on.

DISPLAY 20-6 Observations Indicating Correct Latch On

Lips are rolled outward (flared).
Clicking or smacking sounds are absent.
Dimpled cheeks are absent.
Muscles above and in front of the ear move.
Both cheeks are equally close to the breast.
Chin and nose are touching the breast.
All of the nipple and part of the areola is covered by the newborn’s mouth.
More of the areola is visible above the upper lip than below it.
Angle at the corner of the mouth is wide.
When the lower lip is gently pulled away from the breast, the tongue is visible over the lower gum line.

Data from Lauwers, J., & Swisher, A. (2011). Counseling the Nursing Mother: A Lactation Consultant’s Guide (5th ed.). Sudbury, MA: Jones & Bartlett; Lawrence, R. A., & Lawrence, R. M. (2011). Breastfeeding: A Guide for the Medical Profession (7th ed.). Philadelphia: Saunders; Riordan, J. M., & Wambach, K. (2010). Breastfeeding and Human Lactation (4th ed.). London, England: Jones & Bartlett.

MILK TRANSFER

When the newborn suckles effectively, the breast releases milk and milk transfer occurs. Even though a newborn may suck at the breast for 15 minutes with its jaw moving up and down, it does not mean that there has been a transfer of milk. Display 20-7

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