Each female breast is composed of approximately 15 to 20 segments (lobes) embedded in fat and connective tissues and well supplied with blood vessels, lymphatic vessels, and nerves. Within each lobe is glandular tissue consisting of alveoli, the milk-producing cells, surrounded by myoepithelial cells that contract to send the milk forward to the nipple during milk ejection. Each nipple has multiple pores that transfer milk to the suckling infant. A ratio of glandular to adipose tissue in the lactating breast is approximately 2:1 compared with a 1:1 ratio in the nonlactating breast.

Within each breast is a complex, intertwining network of milk ducts that transport milk from the alveoli to the nipple. Milk ducts dilate and expand with milk ejection. The size and shape of the breast are not accurate indicators of its ability to produce milk. While nearly every woman can lactate, a small number have insufficient mammary gland development to breastfeed their infants exclusively.

Human milk is the ideal food for human infants. Human milk is a dynamic substance with a composition that changes to meet the changing nutritional and immunologic needs of the growing infant. Breast milk is specific to the needs of each infant; for example, the milk produced by mothers of preterm infants differs in composition from that of mothers who give birth at term. Human milk contains immunologically active components that provide some protection against a broad spectrum of bacterial, viral, and protozoal infections. Breast milk promotes colonization and maturation of the infant's intestinal microbiome, which is essential to the development of the immune system. Human milk composition and volumes vary according to the stage of lactation.

Composition of human milk changes over time as the infant grows and develops. Fat is the most variable component of human milk with changes in concentration over a feeding. Over a 24-hour period, and across time, variations in fat content exist between breasts and among individuals. During each feeding, the concentration of fat gradually increases from the lower fat foremilk to the richer hindmilk. Hindmilk contains denser calories from fat necessary for ensuring optimal growth and contentment between feedings. Because of the changing composition of human milk during each feeding, breastfeeding the infant long enough to supply a balanced feeding is important. Production gradually increases as the baby grows. Infants have fairly predictable growth spurts (at approximately 10 days, 3 weeks, 6 weeks, 3 months, and 6 months) when more frequent feedings stimulate increased milk production. Growth spurts usually last 24–48 hours, after which the infants resume their usual feeding pattern as the mother's milk supply increases.

The ideal time to begin breastfeeding is within the first hour after birth. Infants exhibit feeding-readiness cues or early signs of hunger, such as sucking or mouthing motions, hand-to-mouth or hand-to-hand movements, and the rooting reflex. The rooting reflex is when the infant moves toward whatever touches the area around the mouth and attempts to suck.

Knowledge Deficit:  Latch/Transfer Difficulties

Problem or need: Knowledge deficit about breastfeeding as evidenced by primiparity and no prenatal education related to breastfeeding

• • Expected outcome: Mother will verbalize understanding and demonstrate correct positioning and latch technique.

    • Intervention: Assess knowledge about breastfeeding.

      • Rationale: To provide starting point for teaching.

    • Intervention: Observe feeding session at least once every shift and assist as needed with positioning and latch.

      • Rationale: To provide baseline assessment and monitoring of progress.

• Expected outcome: Mother will report no nipple pain with infant suckling.

  • Intervention: Instruct mother about signs of effective feeding and other aspects of breastfeeding; give her a list of available resources (local and web-based).

    • Rationale: To prepare her for what to expect in the days ahead and to be able to seek help as needed.

Problem or need: Difficulty with latch and milk transfer related to sleepy infant as evidenced by infant’s lack of output

• Expected outcome: Infant will latch and suck effectively with evidence of milk transfer.

  • Intervention: Teach mother to observe for feeding-readiness cues.

    • Rationale: To identify signs that the infant may be ready to feed.

• Expected outcome: Infant will awaken and breastfeed every 2–3 hrs for least 15–20 min.

  • Intervention: Assist mother with techniques to awaken infant, including skin-to-skin contact, massage, changing diaper; and assist her with latch and keeping the infant awake during feeding.

    • Rationale: To gently awaken infant in readiness for feeding and to keep the infant awake and sucking to allow milk transfer.

• Expected outcome: Infant will void at least 2–3 times in the next 24 hrs and will have at least one bowel movement.

  • Intervention: Closely monitor and document infant’s output; assess daily weight.

    • Rationale: To assess for signs of dehydration.

Anxiety

Problem or need: Anxiety about ability to produce adequate milk supply as evidenced by stated concerns

• Expected outcome: Mother will state signs that infant is receiving adequate breast milk.

  • Intervention: Teach mother signs of effective breastfeeding (e.g., infant urine and stool output, weight gain, behavior, breasts softening with feeding). 

    • Rationale: To enable mother to recognize if milk supply may be insufficient.

• Expected outcome: Mother will verbalize understanding of factors influencing milk production.

  • Intervention: Assess for factors that may impact milk production; teach mother about supply-meets-demand principle of milk production and importance of regular feeding and/or pumping; teach her how to hand-express her milk.

    • Rationale: To address any risk factors and to reduce her anxiety by empowering her with knowledge.

• Expected outcome: Mother will identify resources for help with concerns related to milk supply post-discharge.

  • Intervention: Refer her to a lactation consultant and provide list of available resources in the community and through the internet.

    • Rationale: To decrease her anxiety and provide needed information and support.

Frequency of Feedings

Feeding patterns vary because every mother-infant dyad is unique. Breastfeeding frequency can be influenced by a variety of factors:

• Infant's age

• Weight

• Maturity level

• Stomach capacity

• Gastric emptying time

• Storage capacity of the breast (i.e., the milk is available when the breast is full)

Newborns need to breastfeed at least 8 to 12 times in a 24-hour period. Some infants breastfeed every 2 to 3 hours throughout a 24-hour period, while others cluster-feed. Cluster-feeding is when infants breastfeed every hour or so for three to five feedings and then sleep for 3 to 4 hours between clusters.  During the first 24 to 48 hours after birth, most babies do not awaken enough to feed. Parents need to understand that they need to awaken the baby to feed at least every 3 hours during the day and at least every 4 hours at night.  Once the infant is feeding well and gaining weight adequately, going to demand feeding is appropriate, in which case the infant determines the frequency of feedings. Infants should be fed whenever they exhibit feeding cues. This is known as "cue-based feeding." Keeping the baby close is the best way to observe and respond to these cues.

Duration of Feedings

The duration of breastfeeding sessions varies greatly because the timing of milk transfer differs for each mother-baby pair. The average time for early feedings is 30 to 40 minutes or approximately 15 to 20 minutes per breast. As infants grow, they become more efficient at breastfeeding, and consequently the length of feedings decreases. The amount of time an infant spends breastfeeding is not a reliable indicator of the amount of milk the infant consumes because some of the time at the breast is spent nonnutritive sucking. If a baby seems to be feeding effectively and urine output and bowel movements are adequate but the weight gain is not satisfactory, the mother may be switching to the second breast too soon. Feeding on the first breast until it softens ensures that the baby receives the higher-fat hindmilk, which usually results in increased weight gain.

Unless a medical indication exists, no supplements should be given to breastfeeding infants. With sound breastfeeding knowledge and practice, supplements are rarely needed. However, when supplementation is deemed necessary, giving the baby expressed breast milk is best. If the mother is not able to provide milk, the recommended alternative is pasteurized donor milk from a milk bank.

Infant

• Hypoglycemia

• Dehydration

• Weight loss of more than 8% by day 5 or weight loss exceeding 75th percentile for age associated with delayed lactogenesis

• Delayed passage of bowel movements or meconium stool continued to day 5

• Hyperbilirubinemia

Mother

• Delayed lactogenesis

• Intolerable pain during feedings

• Temporary cessation of breastfeeding because of maternal medications

• Insufficient glandular tissue

• Previous breast surgery such as augmentation or reduction

Slow weight gain

• • Keep in mind newborn infants typically lose 5% to 10% of body weight after birth before they begin to gain weight. Therefore, weight loss of more than 7% in a breastfeeding infant during the first 3 days of life needs to be investigated. Once the early milk has transitioned to mature milk, infants should gain approximately 110 to 200 g (3.9 to 7 oz) per week or 20 to 28 g (0.7 to 1 oz) per day for the first 3 months. In most instances, the solution to slow weight gain is to increase feeding frequency and to improve the feeding technique.

Jaundice

• • To prevent early-onset, breastfeeding-associated jaundice, newborns should breastfeed frequently (at least 8 to 12 times in 24 hours) during the first several days of life. To treat early-onset jaundice, breastfeeding is evaluated in terms of frequency and length of feedings, positioning, latch, and milk transfer.

  • Late-onset jaundice or breast milk jaundice affects a small number of breastfed infants and develops between 5 and 10 days of age. Any breastfeeding infant who develops jaundice should be evaluated carefully for weight loss greater than 7% decreased milk intake, infrequent stooling (fewer than three stools per day), and decreased urine output (fewer than four to six wet diapers per day).

Preterm infants

• • Human milk is the ideal food for preterm infants, with benefits that are unique and in addition to those received by term, healthy infants. Breast milk enhances retinal maturation in the preterm infant and improves neurocognitive outcomes. Human milk also decreases the risk for sepsis and necrotizing enterocolitis. Greater physiologic stability occurs with breastfeeding compared to bottle-feeding as well. Depending on gestational age and physical condition, many preterm infants are capable of breastfeeding for at least some feedings each day. Mothers of preterm infants who are not able to breastfeed their infants should begin pumping their breasts as soon as possible after birth with a hospital-grade electric pump.

Early-term infants

• • Neonates born at 34 0/7 to 36 6/7 weeks of gestation are categorized as late preterm infants. Infants born at 37 0/7 to 38 6/7 weeks are considered early term. Both categories of newborns are at risk for breastfeeding difficulties because of their low energy stores and high energy demands.

  • A number of factors can contribute to inadequate milk intake resulting in dehydration and poor weight gain among neonates, which in turn predisposes mothers to delayed onset of lactogenesis II and inadequate milk supply.

Late preterm and early term neonates are prone to:

• • Hypothermia

  • Hypoglycemia

  • Respiratory problems

  • Hyperbilirubinemia

  • Sleepiness

  • Minimal and short wakeful periods

  • Tiring easily while feeding

  • Having a weak suck and low tone

Breastfeeding multiple infants: Mothers are capable of producing an adequate milk supply for multiple infants.

Weaning may be defined as the process of transferring the infant's dependence on the mother's milk for nutrition to other sources of nutrition. The process of weaning is initiated when babies are introduced to foods other than breast milk and concludes with the last breastfeeding, which ideally continues until the infant is 1 year of age and beyond. Gradual weaning over weeks or months is easier for mothers and infants than abrupt weaning. Abrupt weaning is likely to be distressing for mother and baby and physically uncomfortable for the mother because it can cause engorgement and mastitis. Weaning will be initiated by either the infant or the mother, however, with infant-led warning the infant moves at his or her own pace in omitting feedings, which usually facilitates a gradual decrease in the mother's milk supply.

Nutrition

A breastfeeding mother should eat a healthy, well-balanced diet. Caloric intake for mothers during lactation should be sufficient to achieve the goal of balancing energy intake and expenditure. Most women can achieve balanced intake and expenditure by adding 450 to 500 calories per day.

Rest

A breastfeeding mother should rest as much as possible, especially in the first 1 or 2 weeks after birth.

Breast Care

A breastfeeding mother's normal routine bathing is all that is necessary to keep her breasts clean. Soap can have a drying effect on nipples; therefore, the mother should avoid washing the nipples with soap. Additionally, breast creams should not be used routinely because they can block the natural oil secreted by the Montgomery glands on the areola.

Breastfeeding and Contraception

Although breastfeeding confers a period of infertility, it is not considered an effective method of contraception unless the mother is strictly following the guidelines for the lactational amenorrhea method of contraception. Breastfeeding delays the return of ovulation and menstruation; however, ovulation can occur before the first menstrual period after birth. Hormonal contraceptives containing estrogen, including combined estrogen-progesterone pills or injectables, are not recommended for breastfeeding mothers because of the potential for reducing milk supply. Progestin-only contraceptives (pill, injection, or implant) are better options for breastfeeding mothers, although their use is not recommended during the first 6 weeks after birth.

Breastfeeding during Pregnancy

Breastfeeding women who become pregnant can continue to breastfeed if there are no medical contraindications (e.g., risk for preterm labor). For pregnant women who are breastfeeding, adequate nutrition is especially important to promote normal fetal growth.

Breastfeeding after Breast Surgery

Any type of previous breast or chest surgery (biopsy, augmentation, reduction, reconstructive surgery) can affect the ability to produce breast milk and transfer it. It is possible for some women with a history of breast cancer to breastfeed. However, treatment for breast cancer (surgery, radiation, chemotherapy) can result in reduced milk supply or absence of lactation in the affected breast.

Breastfeeding and Nipple Piercing

Women who have nipple piercings can safely breastfeed.

Breastfeeding and Obesity

Women who are overweight or obese are less likely to breastfeed, and the duration of breastfeeding tends to be shortened. These women are more likely to experience delayed onset of lactogenesis stage II and to experience problems with insufficient milk production compared with women of average weight. For women who have had bariatric surgery and plan to breastfeed, nutritional deficiencies are a primary concern.

Medications, Alcohol, Smoking, and Caffeine

Although much concern exists about the compatibility of drugs and breastfeeding, few drugs are absolutely contraindicated during lactation. In general, any medication that is given to an infant routinely is safe for a mother who is breastfeeding. Benefits of breastfeeding should be weighed against any risks of the medication to the infant. Information about the safety of medications and breastfeeding can be accessed through the Drugs and Lactation Database (LactMed), a website provided by the National Library of Medicine 

Links to an external site.

.

Drugs that are associated with adverse effects on the breastfeeding infant include:

• Antimetabolite and cytotoxic medications

• Cocaine

• Heroin

• Amphetamines

• Phencyclidine

Methadone and buprenorphine are considered safe during breastfeeding. Psychotropic medications are prescribed for breastfeeding mothers based on risk/benefit considerations. Commonly used antidepressant medications that are considered safe during lactation include nortriptyline, sertraline, and paroxetine. No standard recommendation about avoiding alcohol use when breastfeeding, it is important for mothers to be aware of potential risks. Alcohol intake by breastfeeding women should be minimal, and smoking by breastfeeding mothers should be strongly discouraged. Moderate intake of caffeine by breastfeeding mothers appears to pose no risk to normal, full-term infants.

Herbs and Herbal Preparations

There is a lack of evidence related to the prevalence, effectiveness, and safety of herbs during breastfeeding.

In the first 24 to 48 hours of life, a newborn typically consumes 15 to 30 ml of formula at a feeding. An infant's intake gradually increases during the first week of life. Most newborns drink 90 to 150 ml at a feeding by the end of the second week or sooner.

A newborn infant should be fed on demand, not going longer than 4 hours between feeds, even if it is necessary to wake him or her for the feedings. An infant showing an adequate weight gain may be allowed to sleep at night and be fed only upon awakening. Most newborns need six to eight feedings in 24 hours; however, the number of feedings decreases as the infant matures and consumes more at each feeding.

By 3 to 4 weeks after birth, a fairly predictable feeding pattern has usually developed. Mothers usually notice increases in the infant's appetite at the age of approximately 10 days, 3 weeks, 6 weeks, 3 months, and 6 months. Appetite spurts correspond to growth spurts; mothers should increase the amount of formula per feeding by approximately 30 ml to meet the baby's needs at this time.

• Videos and printed material, as well as warm lines, should be made available to new parents. Specific suggestions as to how much formula to feed initially and as the infant grows and how voiding and stool patterns and weight gain reflect adequate nutrition can provide education guidelines.

• Clients need to be aware that infant feeding cues are diverse and vary across factors such as age, sex, genotype, developmental level, and method of feeding. Both infant and maternal characteristics affect how feeding cues are perceived. Hunger cues are easier to perceive than cues that the baby is satisfied.

• Education regarding the various newborn cries and their possible reasons can reassure parents and their extended families that feeding should not be the first and only option. Overfeeding during the first week of life increases the risk of becoming overweight by age 2. Babies who are exclusively breastfed are least likely to gain extra weight during the first weeks of life. Parents can be taught about how overfeeding affects the infant's health. Parents need information about the risks of overfeeding and the health implications of childhood obesity. The education of parents should include that complementary foods are introduced no earlier than 6 months of age.

Formula Preparation 

Various brands and styles of bottles and nipples are available. However, the following list outlines the basic steps for formulat preparation and feeding.

1. Using warm soapy water, wash your hands and arms and clean under your nails; rinse well. Clean and sanitize the surface where you will be preparing the bottles.

2. In a basin that is only used for cleaning equipment used in formula preparation and feeding, thoroughly wash bottles, nipples, rings, caps, can opener, and other preparation utensils in hot, soapy water and rinse thoroughly. Squeeze water through nipples to make sure that the holes are open.

3. Place bottles, nipples, rings, and caps in a pot, and cover with water; boil for 5 minutes; remove items from the pot with sanitized tongs and allow them to air dry. (Do this before using items the first time; thereafter you can continue to do this or place items in the dishwasher.)

4. Note the expiration date on the formula container. It should be used before the expiration date. Any unopened expired formula should be returned to the place of purchase.

5. Read the label on the container of formula, and mix it exactly according to the directions.

6. Mix formula with tap water deemed safe by the local health department. Allow cold water to run for 1 minute before collecting it. If water is unsafe or the safety is uncertain, it should be boiled for 1 minute and allowed to cool, but not for longer than 30 minutes, before mixing with formula. If using bottled water, make sure that it is labeled as "sterile;" unsterile bottled water must be boiled.

7. If using a can of ready-to-feed or concentrated formula, wash the top of the can with hot soapy water and rinse well. Shake the can before opening it.

8. Mixing formula

   • Ready-to-feed: No mixing is needed; do not add water. Pour the desired amount of formula into a clean bottle; add nipple and ring.

   • Concentrate: Pour the desired amount of formula into a clean bottle and add an equal amount of cooled boiled water. Add nipple and ring and shake well.

   • Powder: When first opening the container of powder, write the date on the lid. Using the scoop from the container, add 1 scoop of powdered formula for each 2 oz. of boiled, cooled water in a clean bottle. For example, if 6 oz. of water is in the bottle, add three scoops of powder. Add nipple and ring, and shake well.

9. If preparing multiple bottles at the same time, place the nipple right side up on each bottle and cover with a clean nipple cap. Use bottles within 48 hours.

10. Opened cans of ready-to-feed or concentrated formula can be stored at room temperature.

11. If the formula is refrigerated, warm it by placing the bottle in a pan of hot water. Never use a microwave to warm any food to be given to a baby. Test the temperature of the formula by letting a few drops fall on the inside of your wrist. If the formula feels comfortably warm to you, the temperature is correct. Milk at room temperature can be fed to the infant.

12. A bottle of formula should be discarded within 1 hour after being fed to an infant; do not save the "leftovers" for another feeding.

Feeding Techniques and Tips

• Wash your hands with soap and water before feeding.

• Newborns should be fed at least every 3 to 4 hours and should never go longer than 4 hours without feeding until a satisfactory pattern of weight gain is established. This period can be as long as 2 weeks. If a baby cries or fusses between feedings, check to see if the diaper should be changed and if the baby needs to be picked up and cuddled. If the baby continues to cry and acts hungry, feed him or her. Babies do not get hungry on a regular schedule.

• Infants gradually increase the amount of milk they drink with each feeding. On the first day or so, most newborns consume 15 to 30 ml (0.5 to 1 oz.) with each feeding. This amount increases as the infant grows. If any formula remains in the bottle as the feeding ends, it must be thrown away because saliva from the baby's mouth can cause the formula to spoil.

• Keep a feeding diary, writing down the amount of formula the infant drinks with each feeding for the first week or so. Also record the number of the baby's wet diapers and bowel movements. Take this diary with you to the baby's first follow-up visit with the primary health care provider.

• For feeding, hold the infant close in a semi-reclining position. Talk to him or her during the feeding. This time is ideal for social interaction and cuddling.

• Place the nipple in the infant's mouth on the tongue. It should touch the roof of the mouth to stimulate the baby's sucking reflex. Hold the bottle like a pencil. Keep it tipped so the nipple stays filled with milk and the baby does not suck in air.

• Taking a few sucks and then pausing briefly before continuing to suck again is normal for infants. Some infants take longer to feed than others. Be patient. Keep the baby awake; encouraging sucking may be necessary. Moving the nipple gently in the infant's mouth may stimulate sucking.

• Another technique that can be used for bottle-feeding is paced bottle-feeding. The infant is placed in a more upright position, and the bottle is held at a more horizontal angle. When the baby pauses between bursts of sucking, withdraw the nipple and allow it to rest on the baby's lip until he or she is ready to resume sucking. This slows the flow of milk from the bottle so the infant is more in control. Paced bottle-feeding works well for infants who are primarily breastfeeding but are occasionally fed from a bottle.

• Newborns are apt to swallow air when sucking. Give the infant opportunities to burp several times during a feeding. As he or she gets older, you will know better when to stop for burping.

• Watch for signs that the infant is getting full: spitting out the nipple, sealing the lips together, slower sucking, or turning away from the nipple.

• After the first 2 or 3 days, the stools of a formula-fed infant are yellow and soft but formed. The infant may have a stool with each feeding in the first 2 weeks, although this amount can decrease to one or two stools each day. It is not abnormal for formula-fed infants to have a stool every other day.

Safety Tips

Infants should be held and never left alone while feeding. Never prop the bottle. The infant could inhale formula or choke on any that was spit up. Infants who fall asleep with a propped bottle of milk can be prone to cavities when the first teeth come in. Make sure the mother knows how to use the bulb syringe and help an infant who is choking.

Vitamin and Mineral Supplementation

Commercial iron-fortified formula has all of the nutrients that infants need for the first 6 months of life. After 6 months of age, fluoride supplementation is recommended based on levels in the water supply.

Regardless of feeding method, babies should be burped to express air bubbles taken in while nursing.  A breastfed infant should be burped after each breast.  A bottle fed baby should be burped about every 1/2 ounce in the newborn stage.  There are different ways to burp a baby; regardless of feeding type, the head of the baby needs to be supported.  Most people begin burping by laying the child over the parent's shoulder, but infants can also be laid over the parent's lap or sat on a parent's lap with the chin cradled in the parent's hand.