ACOGClinicalClinical ReviewReview Volume 12 • Issue 1 (Supplement) January–February 2007

SPECIAL REPORT FROM ACOG Breastfeeding: Maternal and Infant Aspects Committee on Health Care for Underserved Women Committee on Obstetric Practice

he promotion of breastfeeding has Obstetricians and Gynecologists strongly The increase in the proportion of Tbeen an ongoing priority of the supports breastfeeding and calls on its women initiating breastfeeding reflects College. Working with national and Fellows, other health care professionals car- a growing awareness of the advantages international groups dedicated to pro- ing for women and their infants, hospitals, of milk over formula. Improve- moting the health of infants worldwide, and employers to support women in choos- ment in breastfeeding initiation rates, ACOG has participated in an interdisci- ing to breastfeed their infants. Specifically, however, has been uneven, as women plinary group effort to formulate guide- obstetrician–gynecologists and other health attempt to overcome practical obsta- lines for breastfeeding. These guidelines care professionals caring for pregnant cles. Breastfeeding initiation rates are were developed by the ACOG Com- women should regularly impart accurate lowest among non-Hispanic black mittee on Health Care for Underserved information about breastfeeding to expec- women, women younger than 20 years, Women and the ACOG Committee on tant mothers and be prepared to support women enrolled in WIC (Special Obstetric Practice and are presented in them should any problems arise while Supplemental Nutrition Program for this special report in an effort to give breastfeeding. Women, Infants, and Children), and them the widest possible exposure and those who completed high school or eventually reach those who would bene- BACKGROUND less. Breastfeeding initiation rates vary fit most—mothers and their babies. With the development of iron-fortified considerably by state with the lowest These guidelines, as well as additional formula, breastfeeding rates began to rates (less than 55%) occurring in information, can be found at www.acog.org. decrease in the late 1950s as formula Arkansas, Kentucky, Louisiana, Mis- feeding gained popularity. In 1971, sissippi, and West Virginia (2). Ralph W. Hale, MD only 24.7% of mothers left the hospital In 2005, the rate of any breastfeed- ACOG Executive Vice President breastfeeding. Since that time, breast- ing at 6 months reached 39.1%, the feeding initiation rates have been highest rate in the nearly 35 years such ABSTRACT: Evidence continues to mount increasing fairly consistently, but they data have been collected. The lowest 6- regarding the value of breastfeeding for have not yet reached the goal set by month rates are among mothers with both women and their infants. Human the U.S. Public Health Service for the same demographic and socioeco- milk provides developmental, nutritional, Healthy People 2010 (1). In 2005, nomic characteristics as those who and immunologic benefits to the infant 72.9% of all U.S. mothers initiated have the lowest breastfeeding initiation that cannot be duplicated by formula feed- breastfeeding (2). Although this is rates (2). ing. Breastfeeding also provides significant close to the target rate of 75% in the The sharpest decrease in breastfeed- benefits to women. It is critical that early postpartum period, there is still a ing (approximately 20%) occurs within women make an informed choice in decid- long way to go to achieve breastfeed- the first month after discharge. Ac- ing what is best for them, their families, ing rates of 50% at 6 months, and 25% counting for this precipitous decrease, and their babies. The American College of at 12 months (1). the most common reasons given for

ISSN 1085-6862 JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW • 1S premature discontinuation are insuffi- recognized to be enhanced by exclusivity cient milk production, difficulty with and duration (9). Early studies, which attachment (-on and infant suck- failed to account for these factors, led to ling), and lack of maternal confidence inconsistent conclusions. Obstetrician– (3–6). Some concentrated educational gynecologists who review these sources efforts have had a statistical impact in of evidence for infant benefit will be bet- specific populations (7). Compared ter prepared to care for the women in with other demographic groups, the their practices. breastfeeding initiation rates increased ACOG most rapidly among black women Infants Clinical Review between 1993 and 2003. However, The benefits of breastfeeding for the infant have been established in the fol- Morton A. Stenchever, MD despite this welcome trend, the breast- Editor feeding rates at hospital discharge in lowing areas. Human milk provides species-specific and age-specific nutri- Ralph W. Hale, MD 2003 remained lowest among black Associate Editor women at 48.3% compared with nation- ents for the infant (10). Colostrum, the Nancy Rowe al rates of 66.0%. Additionally, women fluid secreted from the breast immedi- Managing Editor enrolled in WIC are among those with ately after the infant’s birth, conveys a ❧ the most rapid increases in rates of high level of immune protection, partic- ularly secretory immunoglobulin A (IgA). The ACOG Committee on Health Care breastfeeding, although their rates for Underserved Women and the ACOG remain well below national averages During the first 4–7 days after birth, Committee on Obstetric Practice would (8). protein and mineral concentrations like to thank Sharon Mass, MD, for her contributions to the development of This document addresses primarily decrease, and water, fat, and lactose this document. breastfeeding by healthy mothers with increase. Milk composition continues to ❧ healthy infants born at term. Human change to match infant nutritional Copyright © January 2007 by the American College of milk and breastfeeding are recom- needs. In addition to the right balance of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights mended for premature newborns and nutrients and immunologic factors, reserved. Published bi-monthly by the American College of Obstetricians and Gynecologists. Subscription prices mother–infant pairs with other special human milk contains factors that act as per year: Annual rate: $119, Institutional rate: $235, and biologic signals for promoting cellular ACOG Junior Fellow in residency and subspecialty fel- needs; however, specific information in lowship rate: $31. For subscriptions and back issues growth and differentiation. Human milk please call 1-800-762-2264. Periodicals postage paid at this regard is beyond the scope of this Washington, DC and at additional mailing offices. document. also contains multiple substances with Postmaster: Send address changes to ACOG Clinical Review, the American College of Obstetricians and antimicrobial properties, which protect Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. No part of this publica- against infection (10, 11). However, tion may be reproduced, stored in a retrieval system, post- BENEFITS OF BREASTFEEDING ed on the Internet, or transmitted, in any form or by any human milk alone may not provide means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the Research in the United States and adequate iron for infants older than 6 publisher. No responsibility is assumed by the American months, infants whose mothers have low College of Obstetricians and Gynecologists for any injury throughout the world indicates that and/or damage to persons or property as a matter of prod- breastfeeding and human milk provide iron stores, and premature infants at all ucts liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas benefits to infants, women, families, and ages (11). contained in material herein. Because of rapid advances in the medical sciences, independent verification of diag- society. This research has been conduct- noses and drug dosages should be made. Discussions, views, and recommendations as to medical procedures, ed in a variety of settings, resulting in Women choice of drugs, and drug dosages are the responsibility of the authors. The appearance of advertising in publica- information derived from culturally and The benefits of breastfeeding for women tions of the American College of Obstetricians and Gynecologists (and/or in exhibits at meetings of the economically diverse populations. are well documented. Benefits start in College) does not constitute a guarantee or endorsement In 2005, the American Academy of the immediate postpartum period with of the quality or value of such product or of the claims made for it by its manufacturer. The fact that a product, Pediatrics (AAP) published a revised pol- the release of oxytocin during milk let- service, or company is advertised in a publication or exhibited at a meeting of the College shall not be referred icy statement, “Breastfeeding and the down. This results in increased uterine to by the manufacturer in advertising. Requests for authorization to make photocopies should be directed to Use of Human Milk” (9). The statement contractions aiding with uterine involu- Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400. was developed by the AAP Section on tion and a decrease in maternal blood Breastfeeding, which evaluated the con- loss (12). Additionally, evidence exists siderable amount of research literature on that oxytocin and prolactin contribute relationships between breastfeeding and to the mother’s feelings of relaxation infant health and development. The and of her attachment to her baby. statement summarizes established infant Breastfeeding also is associated with a protective effects, as well as positive asso- decreased risk of developing ovarian and ciations that require further study (see (13–15). Moreover, breast- box). Many of the benefits of breastfeed- feeding delays postpartum ovulation, ing for both the mother and infant are supporting birth spacing (16–18).

2S • JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW ISSN 1085-6862 support women in initiating and contin- Research on Established and Potential Protective Effects of uing breastfeeding. Studies support the Human Milk and Breastfeeding on Infants influence of the physician’s recommen- dation to breastfeed exclusively, even According to the American Academy of Pediatrics’ policy statement,“Breast- when mothers have not made a clear feeding and the Use of Human Milk,” the findings of extensive research suggest various benefits of breastfeeding as indicated in the following excerpt. choice to do so. For example, physicians who express support for exclusive breast- Infectious Diseases feeding have a higher percentage of Research in developed and developing countries of the world, including middle- class populations in developed countries, provides strong evidence that human mothers who breastfeed for an extended milk feeding decreases the incidence and/or severity of a wide range of infec- period (4, 23). tious diseases including bacterial meningitis, bacteremia, diarrhea, respiratory Modern society has created obstacles tract infection, necrotizing enterocolitis, otitis media, urinary tract infection, and to breastfeeding that may contribute to late-onset sepsis in preterm infants. In addition, postneonatal infant mortality the low percentage of mothers (13.9% rates in the United States are reduced by 21% in breastfed infants. in 2005) breastfeeding exclusively at 6 Other Health Outcomes months postpartum (2). Short hospital Some studies suggest decreased rates of sudden infant death syndrome in the stays make the teaching of breastfeeding first year of life and reduction in incidence of insulin-dependent (type 1) and non-insulin-dependent (type 2) diabetes mellitus, lymphoma, leukemia, and a challenge. Lack of spousal or partner Hodgkin disease, overweight and obesity, hypercholesterolemia, and asthma in support and family customs may dis- older children and adults who were breastfed, compared with individuals who courage breastfeeding. Although some were not breasted. Additional research in this area is warranted. employers recognize that encouraging Neurodevelopment breastfeeding as a policy improves Breastfeeding has been associated with slightly enhanced performance on tests employee morale and decreases absen- of cognitive development. Breastfeeding during a painful procedure such as a teeism (24, 25), having to return to heel-stick for newborn screening provides analgesia to infants. work may still be an obstacle. An Breastfeeding and the use of human milk. AAP Policy Statement. American Academy of Pediatrics. unfriendly social environment may also Section on Breastfeeding. Pediatrics 2005;115:496–506. (To review the full-text AAP document online with complete references, go to http://pediatrics. make it difficult to breastfeed in public. aappublications.org/cgi/reprint/115/2/496.) Although the effect of these obstacles can be mitigated by educating the fami- lies, employers, and society, some Although breastfeeding causes some able money compared with formula women will decide that the challenges bone demineralization, studies indicate feeding (22). Society may benefit as well outweigh the benefits for themselves that “catch-up” remineralization occurs when the ecologic issues of disposal of and their babies. after weaning. Importantly, clinical formula cans, bottles, and bottle liners studies have demonstrated a protective are considered. WHO CAN BREASTFEED effect of breastfeeding, such as a lower Nearly every woman can breastfeed her incidence of osteoporosis and hip frac- OBSTACLES TO ture after menopause (19, 20). child. Mother and newborn can more BREASTFEEDING easily learn the basics and how to deal Families and Society Women need to know that breastfeed- with the challenges if they have skilled Studies indicate that the breastfed child ing, like other aspects of having a new and experienced support. The patient has fewer illnesses and, therefore, fewer baby, has its demands as well as its population for maternity services has visits to the doctor and hospital (21). rewards. Women who initiate breast- changed dramatically over the past This translates into lower medical feeding should be assured that they will decade with an increase in the percent- expenses and, for women who work out- have support and that there are options age of mother–infant dyads with risk side the home, less absenteeism from for problem solving and professionals factors for breastfeeding problems. work. Because women now constitute a available to help address the difficulties These include mothers who have cesare- large portion of the workforce, the they may encounter. Any doubts a an deliveries, have multiple births, have improvement in work productivity may woman has regarding her ability or will- near term infants, had breast surgery, or be significant for society as well. More ingness to continue or potential barriers have been separated from their infants than 60% of all women return to out- to breastfeeding should be discussed and (6, 26, 27). Women who have cesarean side employment during the first year she should be encouraged to try breast- deliveries should be reassured that they after birth of a child. feeding. Physicians and other health can breastfeed their newborns as well as Breastfeeding, while demanding professionals should recognize the women who have vaginal deliveries. maternal time and attention, can save potential effectiveness of applying their With early identification and proactive families and public programs consider- knowledge and skills to encourage and management, additional support can be

ISSN 1085-6862 JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW • 3S focused on promoting the three key fac- ficient milk and should seek specialized ACOG’s resource Special Issues in tors: the establishment of adequate milk advice; this condition is rare. Women’s Health (32). There is evidence production, attachment (latch-on and Some babies with cleft lips or palates that women who participate in a suc- infant suckling), and maternal confidence. may be able to breastfeed. The soft cessful methadone maintenance pro- With an increase in the percentage of breast tissue may fill the defect and gram may breastfeed (31). mothers with risk factors for breastfeeding enable the infant to develop a seal. Infants with galactosemia should nei- problems, physicians should recognize Sometimes a palatal obturator allows the ther breastfeed nor consume any formula opportunities in the early postpartum infant to breastfeed and not aspirate containing lactose (eg, cows’ milk) because period for preventive management. milk. Mothers with premature infants doing so will exacerbate the condition. Some women are incorrectly in- can breastfeed. However, a premature These infants should be fed special lactose- formed, or assume, they cannot breast- infant has special nutritional needs. In free formula. feed because of their anatomy or other all of these situations, evaluation by Some infections contraindicate breast- special circumstances, such as women experts may be beneficial. feeding; others require precautions. who have inverted or have had Approaches to breastfeeding vary accord- breast surgery. In reality, these circum- ing to the infection and the environ- WHO SHOULD NOT stances do not necessarily prevent breast- ment. Information about breastfeeding in feeding. True inverted nipples are rare. If BREASTFEED relation to common maternal infections milk production can be established by Although it is true that most women can is available for further reference (10). means of hand or electrical expression, breastfeed, there are exceptional circum- Highlights of this information follow. inverted nipples should not preclude stances. All clinicians should understand Women in the United States who breast-milk feeding or direct breastfeed- these exceptions so that a patient’s frustra- have human immunodeficiency virus ing with the use of a silicone tion and disappointment can be minimized. (HIV) or human T-cell lymphotropic shield. Most women with nipples that The contraindications to breastfeeding are virus infections should not breastfeed appear flat or inverted can breastfeed few (9, 30). Women who should not breast- because breast milk can transmit these given appropriate assistance in the early feed are those who: infections to the infant. In some coun- days of lactation. Pumping for a minute • Take street drugs or do not control tries with high infant mortality rates, or two before offering the breast to the alcohol use (9) however, the benefits of breastfeeding in newborn has been shown to facilitate • Have an infant with galactosemia (9) providing nutrition and preventing latch-on (10). Lactation is possible for • Have certain infections, such as human infections may still outweigh the risks of women who have had breast surgery immunodeficiency virus (HIV); hu- transmitting HIV or human T-cell lym- unless it involved the complete severing man T-cell lymphotropic virus type I photropic virus. of the lactiferous ducts. Women may or type II; active, untreated tubercu- If a woman has active pulmonary breastfeed after reduction mammoplasty, losis or varicella; or active herpes sim- , the repeated and prolonged depending on the degree of interruption plex with breast lesions (10) close contact involved in feeding exposes to the ductile system (28). Those who the infant to risk of airborne infection. • Are taking antineoplastic, thyrotoxic, have had augmentation mammoplasty Therefore, the woman should not be in and immunosuppressive agents (9, may facilitate breastfeeding through fre- contact with her baby until she has been 10, 31) quent emptying during the time of lac- adequately treated and is considered to togenesis. Breast biopsies involving an • Take certain medications or are under- be noncontagious. The infant can be areolar incision have the potential to be going treatment for breast cancer (10, given the mother’s expressed breast milk problematic, but women can compen- 31) because it does not contain Mycobac- sate by augmenting production on the Drugs ingested by a woman can be terium tuberculosis (10). uninvolved side. Women with periareo- transmitted to her newborn through A woman with active varicella (chick- lar incisions and women who have had breastfeeding. If the effect of the drug on enpox) lesions should neither breastfeed breast reductions should be counseled the newborn is detrimental, or question- nor bottle-feed her infant. She should be about monitoring infant growth because able, it should be avoided. This is espe- isolated from the infant while she is clin- they are at increased risk of producing an cially true of alcohol and illicit drugs. ically infectious. Once the infant has insufficient supply of milk. Pierced nip- Alcohol is a toxin. A woman who drinks received varicella-zoster immune globu- ples have not been associated with significant amounts of alcohol should lin (10), the woman can provide breastfeeding difficulties unless there is not breastfeed (11). Information on infant expressed breast milk for the infant if infection or scarring. Nipple devices exposure to street drugs in breast milk, there are no skin lesions on the . should be removed before feeding to such as cocaine, 3,4-methylenedioxy- She can resume breastfeeding when she avoid the risk of infant choking (29). methamphetamine (MDMA), lysergic is no longer clinically infectious. An Women with hypoplastic or tubular acid diethylamide (LSD), phencyclidine immunocompetent woman who devel- breasts may have difficulty producing suf- (PCP), and heroin, can be found in ops herpes zoster infection (shingles) can

4S • JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW ISSN 1085-6862 continue breastfeeding if lesions are cov- undergoing chemotherapy or radiation als, such as pediatricians, nurses, and ered and are not on the breast. Maternal therapy should not breastfeed (31, 33, certified lactation specialists, also play antibodies delivered through the placen- 35). Medications with relative con- an important role. Alternatively, hospi- ta and breast milk will prevent the dis- traindications may sometimes be used tals and other organizations, including ease or diminish its severity. An infant cautiously by timing doses to immedi- mother-to-mother groups and other lay may be given varicella-zoster immune ately follow a feeding (35). Diagnostic organizations, can provide education for globulin to reduce risk of transmission radioactive isotopes require temporary pregnant women and their partners. (10). Breastfeeding also is contraindicat- interruption of breastfeeding. For addi- Some women who choose to breastfeed ed in women who have active herpes tional information, refer to guidelines were breastfed themselves or had a sibling simplex infections on the breast until developed by the Nuclear Regulatory who was breastfed, which established it the lesions are cleared. Commission (36). as normal behavior in their household. Hepatitis infections do not preclude These women would probably benefit breastfeeding. With appropriate immu- from some education and reinforcement noprophylaxis, including hepatitis B PRECONCEPTION AND concerning breastfeeding. Women whose immune globulin and hepatitis vaccine, PRENATAL EDUCATION ON family and friends have not shared breast- breastfeeding of babies born to women BREASTFEEDING feeding experiences also approach preg- positive for hepatitis B surface antigen The health benefits of breastfeeding and nancy with a desire to do what is healthiest poses no additional risk for the transmis- the health risks of not breastfeeding war- for their babies. Guidance and consider- sion of hepatitis B virus (33). If a woman rant professional cooperation and coor- ation of life situations are important in has acute hepatitis A infection, her infant dination among all health care workers helping these women and their families can breastfeed after receiving immune to educate and encourage women and make a decision about feeding their serum globulin and vaccine (10). The their families to choose breastfeeding. infants. Information about the benefits average rate of hepatitis C virus (HCV) Patient education materials can reinforce and challenges of breastfeeding com- infection reported in infants born to the message (see “Resources”). The obste- pared with the use of formula will help HCV-positive women is 4% for both trician–gynecologist has many opportu- them make good decisions. breastfed and bottle-fed infants. There- nities during periodic gynecologic The initial prenatal visit is an optimal fore, maternal HCV is not considered a examinations and prenatal visits to pro- time to encourage or reinforce the deci- contraindication to breastfeeding (34). mote breastfeeding, allay a woman’s anx- sion to breastfeed. Most patients seek In women with cytomegalovirus ieties, and suggest solutions or resources information and guidance from their infection, both the virus and maternal to make breastfeeding a practical choice physicians, and the importance of the antibodies are present in breast milk. for the patient and her family. physician’s recommendation should nev- Because of this, otherwise healthy infants er be underestimated. A large percentage born at term with congenital or acquired Periodic Gynecologic of women make decisions about infant cytomegalovirus infections usually are not Examinations feeding before pregnancy or in the first affected by the virus if they are breastfed. Obstetrician–gynecologists can advocate trimester. The first visit is, therefore, an A study of infants who developed infec- breastfeeding to all reproductive-aged ideal time to emphasize the advantages tions during breastfeeding found that women by mentioning breastfeeding of breastfeeding compared with formula the infants also developed an immune during the breast examination portion feeding, as well as the advantages of response, did not develop the disease, and of routine gynecologic visits, if appropri- exclusive breastfeeding. Mothers who rarely manifested symptoms (30). ate. Women whose breast anatomy intend to combine breastfeeding and Many medications are compatible appears to be normal can be told that if bottle-feeding rather than exclusively with breastfeeding (31). Information they decide to have a baby, there are no breastfeeding are less likely to reach their about the current data on the transfer of structural impediments to breastfeeding. own breastfeeding goals (37). Some drugs and other chemicals in human experts suggest replacing the question, milk can be found in the AAP/ACOG Prenatal Visits “Are you planning to bottle-feed or resource Breastfeeding Handbook for Teaching the pregnant woman and her breastfeed?” with statements that do not Physicians (see “Resources”). There is partner about childbirth and breastfeed- equate the two feeding methods. Suggest- also a new online National Library of ing is an integral part of good prenatal ed statements that would promote discus- Medicine database on drugs and lacta- care. Other family members who could sion include, “Have you noticed your tion available at http://toxnet.nlm.nih. support breastfeeding may be included. breasts are changing in preparation for gov/. Generally, breastfeeding is contra- Education can occur in the physician’s feeding your baby?” or “What have you indicated for women taking antineoplas- office or clinic. The advice and encour- heard about breastfeeding?” Barriers tic, thyrotoxic, and immunosuppressive agement of the obstetrician–gynecolo- should be explored to determine if they agents. Similarly, women who are receiv- gist are critical in making the decision can be addressed in such a way as to ing therapeutic radioactive isotopes or to breastfeed. Other health profession- encourage breastfeeding. During the

ISSN 1085-6862 JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW • 5S breast examination, the physician can ation rates. To support a mother’s desire of supplementation. The initial feeding perform a breastfeeding-specific examina- to breastfeed, pain management should should occur as soon after birth as possi- tion and answer any questions about the be balanced to ensure pain relief for the ble, preferably in the first hour when the usual pattern of changes in the breasts mother while avoiding excessive amounts baby is awake, alert, and ready to suckle. during pregnancy and breastfeeding. If of medication, particularly narcotics that The longer the interval between birth there are no structural problems, the can adversely affect the infant’s ability to and the first feeding, the more likely the woman can be reassured about her ability breastfeed effectively. Although cesarean use of supplementation (41). Newborn to breastfeed. If her nipples appear to be delivery may make breastfeeding more eye prophylaxis, weighing, measuring, inverted, she should know that appear- challenging (29), patients who have a and other such examinations should be ance is not necessarily prognostic and she cesarean delivery should still be encour- deferred until after the first feeding or may be able to breastfeed. The techniques aged to breastfeed. Women undergoing until they can take place without sepa- to assist in nipple eversion, however, are cesarean deliveries using a regional anes- rating the infant from the mother (9). not recommended during pregnancy thetic or under nonemergent situations Such procedures usually can be per- because there is no evidence to support are more likely to initiate and continue formed later in the woman’s room. their effectiveness (10). Any abnormal breastfeeding than those who have under- breast masses noted on this examination gone an emergency cesarean delivery or POSTPARTUM SUPPORT FOR should be adequately explored with the received general anesthesia (40). use of technology such as ultrasonogra- BREASTFEEDING phy and, possibly, biopsy as indicated. All hospitals should have trained person- DELIVERY nel available to provide breastfeeding Prenatal Breastfeeding The immediate postpartum period support and should offer 24-hour room- Instruction should allow the woman and her new- ing-in to maximize the interaction Today, with shorter postpartum hospital born to experience optimal bonding between the woman and her newborn. stays, it is important for pregnant wom- with immediate physical contact, prefer- Rooming-in allows the mother to begin en to come to the hospital for delivery ably skin to skin. Separation may lead to recognizing her infant’s hunger cues. with a good foundation of knowledge complications such as hypothermia and Rooming-in and promoting skin-to-skin gained during the antepartum period. hypoglycemia, increasing the likelihood contact have numerous advantages for Prenatal education groups have been shown to be particularly effective in increasing duration of breastfeeding (38). Ten Hospital Practices to Encourage Education in the hospital can then focus and Support Breastfeeding* on operational aspects of breastfeeding such as latch-on and feeding techniques. 1. Maintain a [supportive] written breastfeeding policy that is communicated to A woman who is appropriately coun- all health care staff. seled on breastfeeding options and 2. Train all pertinent health care staff in skills necessary to implement this chooses not to breastfeed should be reas- policy. sured that her milk production will 3. Inform all pregnant women about the benefits of breastfeeding. abate during the first few days after 4. Offer all mothers the opportunity to initiate breastfeeding within 1 hour delivery. Hormone treatment to stop of birth. milk production is no longer recom- 5. Show breastfeeding mothers how to breastfeed and how to maintain lacta- tion even if they are separated from their infants. mended. Current recommendations 6. Give breastfeeding infants only breast milk unless medically indicated. include a well-fitted support bra, anal- 7. Facilitate rooming-in; encourage all mothers and infants to remain together gesics, and ice packs to relieve the pain. during their hospital stay. She also can be assured that if she 8. Encourage unrestricted breastfeeding when baby exhibits hunger cues or changes her mind, she may still be able signals or on request of mother. to initiate breastfeeding within the first 9. Encourage exclusive suckling at the breast by providing no pacifiers or artifi- few days postpartum. Several hospital cial nipples. protocols and practices have been shown 10. Refer mothers to established breastfeeding and/or mothers’ support groups to increase rates of successful breastfeed- and services, and foster the establishment of those services when they are ing (see the box) (39). not available. *The 1994 report of the Healthy Mothers, Healthy Babies National Coalition Expert Work Group recommended that the UNICEF-WHO Baby Friendly Hospital Initiative be adapted for use in the LABOR United States as the United States Breastfeeding Health Initiative, using the adapted 10 steps above. Healthy Mothers, Healthy Babies National Coalition. Baby friendly hospital initiative feasibility study: Certain pain management interventions final report.Alexandria (VA): HMHB; 1994. in labor may decrease breastfeeding initi-

6S • JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW ISSN 1085-6862 both the infant and mother. Infants cry Instructions should indicate that born during the first week after birth. At less, sleep more, and become adept at breastfeeding should not be painful, but least six urinations per day and three to breastfeeding sooner (41, 42). Mothers minor discomfort is common during the four bowel movements per day are to be also sleep better and have increased milk first 2 weeks. Discomfort may occur expected by 5–7 days of age. She can be production (43, 44). Separation of a temporarily as the woman’s milk is shown how to keep simple records for the breastfeeding woman and newborn beginning to be produced. A physician first few weeks, noting the frequency and should be avoided whenever possible. should assess any significant pain or length of feedings and the number of Most newborn care and procedures, tenderness promptly. Generally, painful bowel movements and wet diapers, for including bathing, blood drawing, phys- breastfeeding almost always results from discussion with her health care providers. ical examinations, and administration of poor positioning or latch-on, which Although new, more absorbent diapers medication and phototherapy, can be should be immediately corrected, rather make it difficult to assess frequency of performed in the mother’s room (9). In than from breastfeeding “too long.” urination, a simple gage of adequate this way, mother and baby can benefit ACOG’s “Breastfeeding Your Baby” breast-milk intake is loose, bright-yellow together from the nursing care available. pamphlet is a resource that can be used bowel movements by day 5. She should to help women with positioning and understand expected patterns of new- latch-on (see “Resources”). Latch-on is born weight loss and gain. Before gaining POSTPARTUM EDUCATION ON one of the most important steps to suc- weight, the breastfeeding newborn may BREASTFEEDING cessful breastfeeding (see the box). lose 5–7% of birth weight in the first Instruction During Several helpful approaches are reviewed week. When the loss is greater than 5–7% Hospital Stay in greater depth in the Breastfeeding or reaches that level in the first 3 days, a Handbook for Physicians (see “Resources”). clinician should evaluate the breastfeed- Hospital personnel should have adequate ing process to address any problems time allotted to each patient, no matter Instructions for the First Week before they become serious. A weight when the delivery occurs, and provide a of Breastfeeding loss of up to 10% is the maximum that is specific program on practical aspects of Before discharge the woman should be acceptable only if all else is going well breastfeeding that women master before educated about indicators of adequate and the physical examination findings are discharge. Trained staff should assess intake and informed that for most breast- negative for problems. Follow-up should breastfeeding behavior of the woman and feeding infants, no water is required. She confirm that the newborn is beginning to newborn during the first 24–48 hours also should be educated about age-appro- regain weight after the first week (10). after birth for correct nursing positions, priate elimination patterns of her new- Continued meconium elimination by latch-on, and adequacy of newborn milk transfer (9). They also should ensure that the woman is skilled in the technique of manual expression of milk. Milk ex- Positioning and Latch-On for Breastfeeding pressed by hand into a plastic spoon can When observing an infant being breastfed, take note of the following: be fed to the infant. This simple skill can • Position of mother, body language, and tension. Pillows may provide support help augment milk production and feed for the arms or the infant. the sleepy baby or one who latches poor- • Position of infant: Ventral surface should be to mother’s ventral surface, with ly. If the mother becomes engorged at lower arm, if not swaddled, around mother’s thorax. Infant cannot swallow if home, she will know from this instruc- head has to turn to breast, and grasp of areola will be poor. Infant’s head tion how to soften the breast, feed the should be in crook of arm and moved toward breast by the mother’s arm baby, and preserve production. During a movement if cradle hold is used. rooming-in experience, a woman can • Position of mother’s hand on breast not in way of proper grasp by infant 1 learn to observe and respond to her new- • Position of infant’s lips on areola about 1–1 ⁄2 inches (2.5–3.7 cm) from base born’s signs of hunger, such as increased of nipple alertness or activity, mouthing, or root- • Lips flanged and lower lip not folded in so that infant does not suck it ing. She should understand that crying is • Actual events around the presenting breast to assist infant in latching on a late sign of hunger. Personnel should • The infant’s response to lower lip stimulus by opening mouth wide teach mothers that newborns need to be • The motions of the masseter muscle during suckling and sounds of swallowing indicative of appropriate suckling breastfed on demand approximately 8–12 times every 24 hours until satiety • Ratio of sucks to swallows becomes 1:1 as feeding progresses (9); time at the breast varies and often is • Mother comfortable with no 10–15 minutes on each breast, and Modified from Lawrence RA, Lawrence RM. Breastfeeding: a guide for the medical profession. 6th ed. Philadelphia (PA): Elsevier Mosby; 2005, with permission from Elsevier. breastfeeding should not be limited unless a mother experiences soreness.

ISSN 1085-6862 JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW • 7S day 5 also should prompt further evalua- fied milk or formula is 500 mL (9, 46, tionship, including a desired resump- tion of the breastfeeding process. 47) or vitamin D supplemented foods tion of sexual intercourse. Health care are added. Vitamin D supplementation providers should address contraceptive Phone-In Resource for a woman will not significantly needs, and the emotional adjustments, The departure of a woman and her new- increase the content of vitamin D in her as well as physical problems of soreness, born from the hospital can be a joyous breast milk. In general, mothers can be fatigue, and vaginal dryness secondary to but daunting experience. The family is reassured that the quantitative and lactation. now responsible for the care and feeding caloric value of their breast milk will not of the newborn. Whether or not they be affected with dieting and exercise have a support system at home, a phone- (48). CONTRACEPTION in resource is needed for ongoing On average, it is estimated that Women should be encouraged to con- instruction and advice. The obstetri- women will need approximately 500 sider their future plans for contraception cian–gynecologist’s office, the place kcal per day more than recommended and childbearing during prenatal care where the woman has received most of levels for nonpregnant and nonlactating and be given information and services her care, should be that resource or at women. Additional maternal food that will help them meet their goals. least provide links to other resources in intake generally will provide additional Many women resume intercourse before the community, such as lactation spe- needed vitamins and minerals (with the they return for their postpartum check- cialists and support groups. Many times possible exceptions of calcium and zinc). up and may be at risk of becoming preg- these specialists and groups are available Women of childbearing age need to nant. Avoiding unintended pregnancy is through local hospitals. maintain a calcium intake of 1,000 mg important for a woman who is breast- per day at all times, including during feeding because there will be fewer vari- ables that can affect her milk production POSTPARTUM CARE pregnancy and lactation (1,300 mg for adolescents through 18 years of age). and nutrition status if the next pregnan- All breastfeeding women and their Dietary intake is the preferred source of cy is delayed until she has completed babies should be seen by a pediatrician all needed nutrients. However, many breastfeeding (10). Most women desire a or other knowledgeable health care prac- women breastfeed on a lower calorie birth interval of greater than 1 year, so a titioner when the baby is 3–5 days old intake level than suggested, consuming discussion of contraception with both (9). Timing depends in part on time of bodily stores instead. The resultant breastfeeding and nonbreastfeeding discharge from the hospital and other weight loss of the mother usually does women is important. For more informa- risk factors such as those for hyperbiliru- not affect breastfeeding but may result in tion on contraception and breastfeeding binemia (45). This early visit is impor- the woman having deficiencies of mag- refer to the Breastfeeding Handbook for tant in order to evaluate health status of nesium, vitamin B , folate, calcium, and Physicians (see “Resources”). the newborn (eg, weight, hydration, and 6 zinc (11, 47). Corrective measures can The average time to first ovulation is hyperbilirubinemia) at this critical age, be suggested by a nutritionist for 45 days postpartum (range, 25–72 days) as well as to observe the woman and for a woman who does not breastfeed improving nutrient intakes of women newborn during breastfeeding. Breast- (49). In contrast, ovulation in women with extreme or restrictive eating pat- feeding infants should have a second who breastfeed exclusively can be terns (11). Women should be encour- ambulatory care visit at 2–3 weeks of age delayed 6 months. When carefully aged to drink plenty of fluids to satisfy to further monitor weight gain and pro- defined criteria are met, this can be used their thirst and maintain adequate vide ongoing support to the mother (9). as a reliable natural form of family plan- hydration. However, fluid intake does Women can be reassured that eating a ning or birth spacing temporarily (see not affect milk volume. Breastfeeding well-balanced diet generally will provide section on “Lactational Amenorrhea”). the nutrients their infants need. One women need not avoid spicy or strong exception is that many individuals do flavored foods unless the infant seems to Nonhormonal Methods not synthesize adequate amounts of vita- react negatively to specific foods. Nonhormonal contraceptive options min D from the sunlight. Furthermore, The spouse or partner can play a vital neither affect breastfeeding nor pose a unprotected exposure to sunlight is not support role for the breastfeeding risk to the infant. Such methods include recommended. For this reason vitamin woman by doing such things as bringing intrauterine devices, condoms, dia- D is added to milk for general consump- the newborn to her for feeding, chang- phragms, or cervical caps. Intrauterine tion and to infant formula. Breastfed ing the newborn, holding the newborn, devices may be particularly well suited to babies should also receive vitamin D and offering encouragement. Couples breastfeeding women because they often supplementation (200 international units should be encouraged to discuss emo- desire highly effective long-term contra- of oral drops daily) beginning in the first tional adjustments to their new family ception, they are parous, and they desire 2 months of life and continuing until status. Couples may find that caring a method that has no impact on breast- daily consumption of vitamin D forti- for a baby can complicate their own rela- feeding. Diaphragms and cervical caps

8S • JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW ISSN 1085-6862 may need to be refitted postpartum. sidered, such as uncertainty about the extent and the woman has not experi- Prelubricated latex condoms have non- opportunities for follow-up. Given the enced her first postpartum menses, contraceptive advantages in helping to overall lack of data, health care providers breastfeeding provides greater than 98% prevent sexually transmitted diseases may consider earlier initiation of pro- protection from pregnancy in the first 6 and to relieve vaginal dryness. Female gestin-only methods (eg, before hospital months after delivery (49, 51, 52). Four sterilization or vasectomy may be con- discharge) and initiation of estrogen- prospective clinical trials of the contra- sidered by couples desiring permanent containing hormonal contraception ceptive effect of the lactational amenor- birth control (49). after the period of hypercoagulability rhea method demonstrated cumulative associated with pregnancy has resolved 6-month life-table, perfect-use preg- Hormonal Methods (eg, 2–4 weeks). nancy rates of 0.5%, 0.6%, 1.0%, and Limited data exist about the impact of 1.5% among women who relied solely hormonal contraception on breastfeed- Lactational Amenorrhea on it. To suspend fertility, women should ing. Although some studies suggest that Women who breastfeed can make use of be advised that intervals between feed- estrogen-containing hormonal contra- the natural contraceptive effect of lacta- ings should not exceed 4 hours during ceptives may decrease the amount of tion. The lactational amenorrhea meth- the day or 6 hours at night (Fig. 1). breastmilk produced, no well-designed od is most appropriate for women who Supplemental feedings should not randomized controlled trials have plan to breastfeed exclusively for 6 exceed 5–10% of the total (53–57). For proved this association. Evidence related months. If the baby is fed only breast example, more than one supplemental to the effect of progestin-only methods milk or is given supplemental non- feeding out of every 10 might increase is similarly lacking. Package inserts rec- breast-milk feedings only to a minor the likelihood of returning fertility. ommend delaying or avoiding hormon- al contraception. This reflects early concerns that have not been supported Ask the mother, or advise her to ask herself, these three questions: by subsequent research and experience. A recent Cochrane review concluded that evidence is insufficient to reach conclusions about the impact of hor- 1. YES monal contraception on breastfeeding Have your menses returned? (50). Based on clinical experience in the absence of conclusive data, ACOG makes the following practical recom- NO mendations for hormonal contraception 4. in breastfeeding women: 2. The mother’s chance of pregnancy increased. For continued Are you supplementing reg- YES • Progestin-only oral contraceptives can ularly or allowing long periods without protection, advise the be prescribed or dispensed at discharge breastfeeding, either day mother to begin using or night? a complementary family plan- from the hospital to be started 2–3 ning method and to continue weeks postpartum (eg, the first Sunday breastfeeding for the child’s health. after the newborn is 2 weeks old). NO • Depot medroxyprogesterone acetate 3. can be initiated at 6 weeks postpartum. YES Is your baby more than 6 months old? • Hormonal implants can be inserted at 6 weeks postpartum. • The levonorgestrel intrauterine sys- tem can be inserted at 6 weeks post- NO partum. There is only a 1% to 2% chance of * • Combined estrogen–progestin con- pregnancy at this time. traceptives, if prescribed, typically When the answer to any one of these should not be started before 6 weeks questions becomes YES… postpartum, and only when lactation *However, the mother may choose to use a complementary family planning method at any time. is well established and the infant’s nutritional status is appropriate. Figure 1. Algorithm for lactational amenorrhea method (LAM). (Labbok M, Cooney K, There are certain clinical situations in Coly S. Guidelines: breastfeeding, family panning, and the lactational amenorrhea method— which earlier initiation might be con- LAM.Washington, DC: Institute for Reproductive Health, Georgetown University; 1994.)

ISSN 1085-6862 JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW • 9S Feeding practices other than direct BOTTLE SUPPLEMENTS AND BREAST PAIN breastfeeding, insofar as they may reduce PACIFIERS Breast and nipple pain is a common the vigor and frequency of suckling and problem for the breastfeeding woman, the maternal neuroendocrine response, The use of pacifiers and supplemental and is the second most common factor increase the probability of returning ovu- bottle-feeding are considered by many to leading to cessation of breastfeeding lation (58). If there is uncertainty regard- be deterrents to sustained breastfeeding. (68). The cause should be diagnosed and ing the extent to which a woman is However, evidence is not clear that a treated promptly. Breast pain may result breastfeeding, it would be prudent to rec- direct effect on breastfeeding exists (6, from engorgement, nipple pain, or ommend additional methods of family 63–66). Poor breastfeeding outcomes . planning. and the use of bottles and pacifiers may be common results of behaviors such as extending intervals between feedings Engorgement VACCINATION and beginning weaning. Because intro- Engorgement results from ineffective or duction of a pacifier or bottle has the infrequent removal of milk from the Neither inactivated nor live vaccines potential to disrupt the development of breast and leads to full, hard, and tender administered to a lactating woman affect effective breastfeeding behavior, their breasts. This may result from mother and the safety of breastfeeding for mothers or use should be minimized until breast- infant separation, a sleepy baby, sore nip- infants. Breastfeeding does not adversely feeding is well established. It is impor- ples, or improper breastfeeding technique. affect immunization and is not a con- tant to help mothers understand that Prevention involves ensuring proper traindication for any vaccine. Although substituting for or delaying breastfeed- latch-on and milk removal and encourag- live vaccines multiply within the moth- ings may ultimately reduce milk supply ing on-demand feeding (10, 68). er’s body, most have not been demon- because of the reduction in stimulation strated to be excreted in human milk. derived from infant suckling. Encoura- Nipple Pain Inactivated, recombinant, subunit, poly- ging good breastfeeding practices should Sore nipples are the most common com- saccharide, conjugate vaccines, and tox- be the primary focus of counseling along plaint raised by mothers in the immedi- oids pose no risk for mothers who are with increasing the mother’s under- ate postpartum period. Soreness usually breastfeeding or for their infants (59). standing that the use of pacifiers and results from poor positioning or latch- For information on vaccines, refer to bottles often has been associated with on. Trauma, plugged ducts, candidiasis, Medications and Mother’s Milk (see reduced breastfeeding (6, 65, 66). harsh breast cleansing, or use of poten- “Resources”). tially irritating products, and skin disor- ders also may contribute to nipple pain. INTERRUPTION OF The first-line treatment should be coun- MAINTAINING MILK SUPPLY BREASTFEEDING seling about basic latch-on techniques Regular breastfeeding generally ensures Separation of mother and infant should (69). Purified lanolin cream and breast adequate milk supply. As the baby grows be avoided whenever possible, especially shells (to protect the nipples from fric- and requires more milk, the woman’s during the early establishment of lacta- tion between feedings) may be suggested supply increases to accommodate the tion (first 3 weeks). If it is known in to facilitate healing (68, 70). baby’s needs. This matching of supply advance that hospitalization or a trip, for with demand may extend even to situa- example, will require the mother to be Mastitis tions such as multiple births and contin- separated from the infant for more than Mastitis occurs in 2–9.5% of breastfeed- uing to breastfeed a child along with a a day, careful planning can ensure that ing women (71, 72). It most commonly subsequently delivered infant (tandem the ability to breastfeed will be preserved occurs between the second and third feeding). Avoiding unintended preg- and breast milk will be available for the weeks postpartum but may be seen any nancy is important for a woman who infant. During the separation, regular time throughout the first year (73). breastfeeds because variations in her pumping of the breasts should be suffi- Mastitis is manifested by a sore, red- milk production and nutrition status are cient to maintain the milk supply. The dened area on one breast and often is minimized if she is not simultaneously milk may be saved for feeding the infant. accompanied by chills, fever, and breastfeeding and pregnant (10). Galac- When the separation is because of hospi- malaise. The fever can be as high as tagogues, which are intended to enhance talization, the milk should be discarded 40˚C. A segment of the breast becomes milk supply, should be used only with if it is judged to contain drugs that are hard and erythematous. caution. Although some have been stud- contraindicated. Anesthetics are not The differential diagnosis includes ied (35, 60–62), they also are used pri- contraindicated (67). When the mother clogged milk duct, marked breast marily outside of FDA regulation and infant are reunited, the reestablish- engorgement, and a rare but lethal con- regarding content, safety, strength, and ment of normal breastfeeding generally dition, inflammatory breast carcinoma. effectiveness. progresses well. Clogged milk ducts present as localized

10S • JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW ISSN 1085-6862 tender masses. They respond to warm of antibiotics is associated with an She also should be assured that profes- wet compresses and manual massage of increased incidence of breast . sional support is available to help her the loculated milk toward the nipple. Many staphylococcal infections are continue breastfeeding. The physician is always bilateral caused by organisms sensitive to peni- should continue to support the woman, with generalized involvement. It occurs cillin or a cephalosporin. Empirical treat- ultimately helping her choose the best most commonly in the first 2 weeks post- ment with dicloxacillin may be started alternative possible for feeding her infant partum. The major feature that differen- (75, 80). Women who are allergic to if she chooses to stop breastfeeding. tiates mastitis from inflammatory breast penicillin may be given erythromycin. If cancer is the knowledge of previous neg- the infection is caused by resistant, peni- Expressing Milk ative breast examination results during cillinase-producing staphylococci, an Several methods are available to collect the pregnancy. If examination results antibiotic such as vancomycin or cefote- milk. Health care professionals should have been normal, breast engorgement is tan can be used. All antibiotics should be ensure that breastfeeding women can the more likely diagnosis (71). Inflam- continued until 2 days after the infection successfully express milk by hand. matory breast cancer presents as unilater- subsides, a minimum of 10–14 days. Because use of a breast pump is more efficient, rental or purchase of a pump al erythema, heat, and induration that is more diffuse and recurrent (74). can be considered. In general, electric An abscess is diagnosed by the presence The most common causative agent in pumps are more efficient than hand of a palpable mass or fever that fails to mastitis is Staphylococcus aureus, occur- pumps. Pumping both breasts simulta- abate within 48–72 hours of antibiotic neously is more effective and saves time. ring in 40% of cases (75). It also is the therapy. Generally, abscesses have been On occasion, women have to educate most common cause of abscess. Other treated with incision and drainage. employers about the necessity of time common organisms in mastitis include Multiple abscesses may require multiple and location to pump breasts during the Haemophilus influenzae and H parain- incisions, with a finger inserted to break workday. The influence of the physician fluenzae, Escherichia coli, Enterococcus down the locules. Breast milk should be in creating a better environment should faecalis, Klebsiella pneumoniae, Entero- discarded for the first 24 hours after sur- not be underestimated. A physician’s let- bacter cloacae, Serratia marcescens, group gery, with breastfeeding resuming there- ter or telephone call to the employer B streptococci, and Pseudomonas picket- after if there is no drainage into the explaining how simple but vital the tii (74, 76–78). breast milk (10). Recently, ultrasono- breastfeeding employee’s needs are can The condition usually can be treated graphically guided needle aspiration was be effective. Women who pump milk successfully with narrow-spectrum antibi- shown to be successful in treating should have clean pumping and washing otics (the first choice for women who are abscesses (81, 82). facilities available and, ideally, a refriger- not allergic is dicloxacillin, 500 mg, four ator to store milk. times daily for 10–14 days), hydration, bed rest, and analgesics such as acetamin- WORKING MOTHERS Storage of Milk ophen or ibuprofen. The mother should AND TIME AWAY Human milk should be stored in a cool, continue to breastfeed or express the milk Many mothers are employed outside the safe place to maximize its preservation from both breasts because it is important home. In some situations they can feed and minimize contamination. Breast to empty the affected breast. Discarding their infants at work, but this is not milk can be stored in the refrigerator or the milk from the affected breast is not common. Health care professionals can on ice in glass or plastic containers. The recommended when a mother with mas- help the mother consider the method by use of refrigerated milk within 2 days is titis is being treated, except in unusual which she plans to feed her infant when recommended, which is well before circumstances. It does not pose a risk for she returns to work. Employers are appreciable bacterial growth usually the healthy, term infant. Breast milk from increasingly supportive of accommodat- occurs. Breast milk intended for longer the unaffected breast may be used under ing the needs of their breastfeeding storage should be frozen as soon as pos- any circumstance. The antibiotics com- employees (24). If a woman wants to sible and kept at the lowest and most monly used to treat mastitis and anti- continue to breastfeed or breast-milk constant temperatures available; for inflammatory agents, such as ibuprofen, feed, she should plan to pump her example, a deep freezer is preferable to a are safe to use when breastfeeding (33, breasts to maintain her milk supply and refrigerator freezer with a self-defrost 79). to provide stored milk for the caregiver cycle. Frozen milk can be stored for 3–6 If mastitis is not treated aggressively, it to feed the infant in her absence. A months. Milk should be dated and used may become chronic or an abscess may mother can be reassured that breastfeed- in date order to avoid loss of beneficial develop. Treatment is successful in curing ing has already benefited her infant and properties over time. Frozen milk can be mastitis if started early; the most com- that continuing breastfeeding and the thawed quickly under running water or mon cause of recurrent mastitis is inade- use of breast milk to whatever degree she gradually in the refrigerator. It should quate treatment. Delayed administration finds possible will be of further benefit. not be left out at room temperature for

ISSN 1085-6862 JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW • 11S more than 4–8 hours, exposed to very value and importance of breastfeeding growth and development of the infant. hot water, or put in the microwave. Once and understand that their contacts with The American College of Obstetricians the milk has thawed, it should be used patients can help them decide to breast- and Gynecologists recommends that within 24 hours or discarded (10, 83). feed and encourage them to continue exclusive breastfeeding be continued until (see the box). the infant is approximately 6 months old. Health care providers should be BREASTFEEDING A longer breastfeeding experience is, of aware that the giving of gift packs with course, beneficial. The professional XPECTATIONS IN AILY IFE E D L formula to breastfeeding women is com- objectives are to encourage and enable as There is an increased level of acceptance monly a deterrent to continuation of many women as possible to breastfeed of breastfeeding nationally, but sporadic breastfeeding (84, 85). A professional and to help them continue as long as instances of authorities forbidding breast- recommendation of the care and feeding possible. Gradual introduction of iron- feeding in public remain. Supportive laws products in the gift pack is implied. It enriched solid foods in the second half and policies are becoming the norm. should be recognized and explained to of the first year should complement the Recently, breastfeeding mothers have had new mothers that formula companies breast-milk diet. The AAP recommends increasing success in leading active lives. try to attract the interest of pregnant that breastfeeding continue for at least 12 Couples commonly take their babies with women with these gift packs. Physicians months, and thereafter for as long as is them to meetings, outings, restaurants, may conclude that noncommercial edu- mutually desired (9). Although some and while traveling. Women who wish to cational alternatives or gift packs with- women continue breastfeeding during be unobtrusive while breastfeeding their out health-related items are preferable. and after a subsequent pregnancy, the babies in public can do so. mother may wish to wean when a subse- Physicians’ offices and other health HOW LONG TO BREASTFEED quent pregnancy occurs or the infant may care facilities should welcome and wean naturally. Weaning creates a hor- encourage breastfeeding by providing During the first 6 months of life, exclu- monal milieu conducive to remineraliza- educational material and an atmosphere sive breastfeeding is the preferred feed- tion of bone and maternal replenishment. receptive to breastfeeding women. All ing approach for the healthy infant born This may be a consideration favoring staff members should be aware of the at term. It provides optimal nutrients for delay of the next pregnancy until the mother has completed breastfeeding. There are no rules about when to Office Tips wean. Various situations and preferences may influence the timing. Whenever • Make ACOG Patient Education Pamphlets and other patient education mate- rials available in waiting and examination rooms. possible, the weaning process should be • Offer a call-in telephone number for advice—yours or another health care gradual. Eliminating a feeding every 2–3 resource available in the community or hospital of birth. days will achieve a comfortable transition • Provide information about and telephone numbers of lactation consultants for the infant and prevent engorgement and resources such as La Leche League in your community. in the mother. An infant weaned before • Show videos on breastfeeding; if women’s health videos normally play in the 12 months should receive iron-fortified waiting room, include those on breastfeeding so all patients see them, not just infant formula rather than cows’ milk pregnant or breastfeeding patients. (9). If an infant is younger than 6 • Provide seating, such as pillows and a rocking chair for women with infants, months, weaning can be accomplished that keeps breastfeeding in mind. by substituting a bottle or cup for a • Have pumps and an appropriate room for employees and patients. If in a med- ical office complex with other practices, make its availability known to other breastfeeding. If an infant is 6 months or employees (they may be your patients) or collaborate in setting up a room older, he or she may use a cup and sub- elsewhere in the building. stitute other foods for breastfeeding. It • Identify a staff member interested in being a special resource on breastfeed- should be recognized that the baby may ing in the office and facilitate further training for the individual in order to wean by itself abruptly or gradually. assist you, other staff, and patients. Abrupt weaning can be difficult for • Develop breastfeeding statistics for your practice and encourage staff by showing changes over time on displays in staff areas. the mother and the baby, but certain • Ask about hospital policies and practices and offer to help with staff training measures can be helpful. The mother and patient orientation materials. should wear a support bra. She does not • Find out about breastfeeding skills, interests, and services of family physician need to restrict fluids. She may manual- and pediatric colleagues in the community. Encourage women and parents to ly express just enough milk to relieve the choose a supportive caregiver for the infant and meet with him or her during engorgement. Cool compresses will pregnancy. reduce engorgement. Hormonal therapy is not recommended.

12S • JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW ISSN 1085-6862 BREAST CANCER DETECTION contaminants in human milk. These practices, through community efforts, or environmental sources include food, through supportive legislation. The Clinical breast examination and breast water, air, cleaning products, and other American College of Obstetricians and self-examination are recommended for daily exposures. Although additional Gynecologists’ Executive Board has indi- breastfeeding women, just as for all research is needed, to date, there is little women aged 19 years and older. Because cated that “The American College of or no evidence of morbidity in a nursing of normal changes in the breasts during Obstetricians and Gynecologists strong- infant from common chemical agents pregnancy and lactation, cancer detec- ly supports breastfeeding and calls upon tion by palpation becomes more diffi- even though most of these substances are its Fellows, other health professionals cult. Studies indicate there are delays in detectable in breast milk, including some caring for women and their infants, hos- the diagnosis of breast cancer during persistent organic pollutants (87, 88). pitals, and employers to support women in choosing to breastfeed their infants. pregnancy and lactation, including Milk Banks greater intervals between palpation of a All should work to facilitate the contin- lesion and diagnosis. These delays result Some women who cannot breastfeed uation of breastfeeding in the work place in an increased risk of metastatic disease look to donor breast milk rather than and public facilities. Breastfeeding is the at diagnosis and a reduced chance of formula to nourish their infants. Donor preferred method of feeding for new- diagnosis at stage I (86). If a mass or human milk is particularly beneficial for borns and infants. Health professionals other abnormality is detected during lac- infants in neonatal intensive care units, have a wide range of opportunities to tation, it should be fully evaluated, primarily very low birth weight infants serve as a primary resource to the public including biopsy, if indicated. Breast- and those with gastrointestinal pathology and their patients regarding the benefits feeding can continue during the evalua- (89). The Human Milk Bank Association of breastfeeding and the knowledge, tion. Although the milk is not affected of North America (HMBANA) is the skills, and support needed for successful by a mammogram, a woman may want only professional membership associa- breastfeeding” (90). to breastfeed her infant just before the tion for milk banks in Canada, Mexico, With the cooperation of many dedi- procedure to reduce discomfort. During and the United States, and sets the stan- cated health care providers, it appears that lactation, mammograms are less reliable dards and guidelines for donor screening, the Healthy People 2010 goals may be because of the associated increase in storage, sterilization of milk, and modern achievable. However, even if 75% of breast tissue density, which may make distribution methods. For more informa- women initiate breastfeeding, two thirds the test more difficult to interpret (74). tion, refer to the Human Milk Banking of them will need to continue breastfeed- Ultrasound examination can provide Association of North America at ing to reach the proposed target of 50% further assistance in evaluating palpable http://www.hmbana.org. In the United of all women breastfeeding at 6 months. breast masses (solid or fluid-filled) dur- States, these banks have been able to This will be a challenge given that in ing lactation (29). meet the needs of neonatal intensive care 2004, the rate of any breastfeeding at Clinical breast examinations of units throughout most of the country, 6 months was 36.2% (2). The greatest women who may become pregnant are although priority is given to the most benefits for mother and infant and the especially important. Increasing age is vulnerable infants. Locations of milk best continuation rates accrue with exclu- one of many risk factors for breast can- banks include Raleigh, North Carolina; sive breastfeeding in approximately the cer; this concern is especially important San Jose, California; Denver, Colorado; first 6 months. Obstetrician–gynecolo- for women who are having babies in Newark, Delaware; Iowa City, Iowa; and gists should ensure that women have the their late 30s and early 40s. Although Austin, Texas. Informal sources, includ- correct information to make an informed regular breast examinations should con- ing Internet sites, for matching donors decision and, together with pediatricians, tinue during the 1- or 2-year period of and families in need of human milk gen- they should ensure that each woman has pregnancy and lactation, detection of erally should not be recommended for the help and support necessary to contin- abnormalities may be more difficult dur- safety reasons, such as transmission of ue to breastfeed successfully (91, 92). The ing that time. Therefore, some women infection caused by improper screening, combined efforts of all health care and their health care providers may con- sterilization, and storage. providers will be necessary to meet these sider a screening mammogram before goals. age 40 years for women planning preg- CONCLUSION nancies in their late 30s. References In addition to supportive clinical care for 1. U.S. Department of Health and Human EMERGING ISSUES their own patients, obstetrician–gyne- Services. Increase in the proportion of cologists should be in the forefront of mothers who breastfeed their babies. In: Environmental Toxins fostering changes in the public environ- Healthy people 2010: objectives for improving health. 2nd ed. Washington, Numerous national organizations have ment that will support breastfeeding, DC: U.S. Government Printing Office; evaluated the issue of environmental whether through change in hospital 2000. p. 16-46–16-48.

ISSN 1085-6862 JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW • 13S 2. Centers for Disease Control and Preven- 16. Kennedy KI, Visness CM. Contraceptive for Education in Maternal and Child tion. Breastfeeding: data and statistics: efficacy of lactational amenorrhoea. Health; 1997. breastfeeding practices—results from the Lancet 1992;339:227–30. 31. The transfer of drugs and other chemicals 2005 National Immunization Survey. 17. Gray RH, Campbell OM, Apelo R, into human milk. American Academy of Atlanta (GA): CDC. Available at: http:// Eslami SS, Zacur H, Ramos RM, et al. Pediatrics Committee on Drugs. Pediatrics www.cdc.gov/breastfeeding/data/NIS_data/ Risk of ovulation during lactation. Lancet 2001;108:776–89. data_2005.htm. Retrieved November 14, 2006. 1990;335:25–9. 32. American College of Obstetricians and 3. Ertem IO, Votto N, Leventhal JM. The 18. Labbok MH, Colie C. Puerperium and Gynecologists. Special issues in women’s timing and predictors of early termination breast-feeding. Curr Opin Obstet Gynecol health. Washington, DC: ACOG; 2005. of breastfeeding. Pediatrics 2001;107: 1992;4:818–25. 33. American Academy of Pediatrics, Ameri- 543–8. 19. Melton LJ 3d, Bryant SC, Wahner HW, can College of Obstetricians and Gyne- 4. Taveras EM, Capra AM, Braveman PA, O’Fallon WM, Malkasian GD, Judd HL, cologists. Guidelines for perinatal care. Jensvold NG, Escobar GJ, Lieu TA. Clini- et al. Influence of breastfeeding and other 5th ed. Elk Grove Village (IL): AAP; cian support and psychosocial risk factors reproductive factors on bone mass later in Washington, DC: ACOG; 2002. associated with breastfeeding discontinu- life. Osteoporos Int 1993;3:76–83. 34. Recommendations for prevention and ation. Pediatrics 2003;112:108–15. 20. Cumming RG, Klineberg RJ. Breast- control of hepatitis C virus (HCV) infec- 5. Kuan LW, Britto M, Decolongon J, feeding and other reproductive factors tion and HCV-related chronic disease. Schoettker PJ, Atherton JD, Kotagal UR. and the risk of hip fractures in elderly Centers for Disease Control and Preven- Health system factors contributing to women [published erratum appears in tion. MMWR Recomm Rep 1998;47 breastfeeding success. Pediatrics 1999; Int J Epidemiol 1993;22:962]. Int J Epi- (RR-19):1–39. 104(3):e28. demiol 1993;22:684–91. 35. Hale TW. Maternal medications during 6. Dewey KG, Nommsen-Rivers LA, Heinig 21. Ball TM, Wright AL. Health care costs of breastfeeding. Clin Obstet Gynecol 2004; MJ, Cohen RJ. Risk factors for subopti- formula-feeding in the first year of life. 47:696–711. mal infant breastfeeding behavior, delayed Pediatrics 1999;103:870–6. 36. U.S. Nuclear Regulatory Commission. onset of lactation, and excess neonatal 22. Montgomery DL, Splett PL. Economic Table U.3. Activities of radiopharmaceuti- weight loss. Pediatrics 2003;112:607–19. benefit of breast-feeding infants enrolled cals that require instructions and records 7. Ryan AS. The resurgence of breastfeeding in WIC. J Am Diet Assoc 1997;97: when administered to patients who are in the United States. Pediatrics 1997;99: 379–85. breast-feeding an infant or child. In: E12. 23 Taveras EM, Li R, Grummer-Strawn L, Consolidated guidance about materials 8. Ross Products Division of Abbott Richardson M, Marshall R, Rego VH, et al. licenses. Program-specific guidance about Laboratories. Breastfeeding trends—2003. Opinions and practices of clinicians associ- medical use licenses. Final report. Vol. 9, Columbus (OH): Abbott Laboratories. Rev. 1. Washington, DC: NRC; 2005. p. ated with continuation of exclusive breast- Available at: http://www.ross.com/images/ U-9–U-10. Publication No. NUREG- feeding. Pediatrics 2004;113:e283–90. library/BF_Trends_2003.pdf. Retrieved 1556. Available at: http://www.nrc.gov/ 24. Washington Business Group on Health. August 17, 2006. reading-rm/doc-collections/nuregs/staff/ Business, babies and the bottom line: cor- 9. Breastfeeding and the use of human milk. sr1556/v9/r1/sr1556v9r1.pdf. Retrieved porate innovations and best practices in AAP Policy Statement. American Acad- September 19, 2006. maternal and child health. Washington, emy of Pediatrics. Section on Breastfeed- 37. Chezem J, Friesen C, Boettcher J. DC: WBGH; 1996. ing. Pediatrics 2005;115:496–506. Breastfeeding knowledge, breastfeeding 10. Lawrence RA, Lawrence RM. Breastfeed- 25. Cohen R, Mrtek MB, Mrtek RG. confidence, and infant feeding plans: ing: a guide for the medical profession. Comparison of maternal absenteeism and effects on actual feeding practices. J 6th ed. Philadelphia (PA): Elsevier infant illness rates among breast-feeding Obstet Gynecol Neonatal Nurs 2003;32: Mosby; 2005. and formula-feeding women in two cor- 40–7. 11. Institute of Medicine (US). Nutrition dur- porations. Am J Health Promot 1995;10: 38. Pugin E, Valdes V, Labbok MH, Perez A, ing lactation. Washington, DC: National 148–53. Aravena R. Does prenatal breastfeeding Academy Press; 1991. 26. Sarici SU, Serdar MA, Korkmaz A, Erdem skills group education increase the effec- 12. Chua S, Arulkumaran S, Lim I, Selamat G, Oran O, Tekinalp G, et al. Incidence, tiveness of a comprehensive breastfeeding N, Ratnam SS. Influence of breastfeeding course, and prediction of hyperbilirubine- promotion program? J Hum Lact 1996; and nipple stimulation on postpartum mia in near-term and term newborns. 12:15–9. uterine activity. Br J Obstet Gynaecol Pediatrics 2004;113:775–80. 39. Healthy Mothers, Healthy Babies National 1994;101:804–5. 27. Powers NG, Bloom B, Peabody J, Clark Coalition. Baby friendly hospital initiative 13. Rosenblatt KA, Thomas DB. Lactation R. Site of care influences breastmilk feed- feasibility study: final report. Alexandria and the risk of epithelial ovarian cancer. ings at NICU discharge. J Perinatol 2003; (VA): HMHB; 1994. The WHO Collaborative Study of 23:10–13. 40. Mathur GP, Pandey PK, Mathur S, Neoplasia and Steroid Contraceptives. Int 28. Souto GC, Giugliani ER, Giugliani C, Sharma S, Agnihotri M, Bhalla M, et al. J Epidemiol 1993;22:192–7. Schneider MA. The impact of breast Breastfeeding in babies delivered by 14. Newcomb PA, Storer BE, Longnecker reduction surgery on breastfeeding per- cesarean section. Indian Pediatr 1993;30: MP, Mittendorf R, Greenberg ER, Clapp formance. J Hum Lact 2003;19:43–9; 1285–90. RW, et al. Lactation and a reduced risk of quiz 66–9, 120. 41. Kurinij N, Shiono PH. Early formula sup- premenopausal breast cancer. N Engl J 29. American Academy of Pediatrics, Ameri- plementation of breast-feeding. Pediatrics Med 1994;330:81–7. can College of Obstetricians and Gyne- 1991;88:745–50. 15. Breast cancer and breastfeeding: collabo- cologists. Breastfeeding handbook for 42. Ferber SG, Makhoul IR. The effect of rative reanalysis of individual data from physicians. Elk Grove Village (IL): AAP; skin-to-skin contact (kangaroo care) 47 epidemiological studies in 30 coun- Washington, DC: ACOG; 2006. shortly after birth on the neurobehavioral tries, including 50302 women with breast 30. Lawrence RA. A review of the medical responses of the term newborn: a ran- cancer and 96973 women without the benefits and contraindications to breast- domized, controlled trial. Pediatrics 2004; disease. Collaborative Group on Hor- feeding in the United States. Maternal 113:858–65. monal Factors in Breast Cancer. Lancet and Child Health Technical Information 43. Quillan SI, Glenn LL. Interaction 2002;360:187–95. Bulletin. Arlington (VA): National Center between feeding method and co-sleeping

14S • JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW ISSN 1085-6862 on maternal-newborn sleep. J Obstet 58. Campbell OM, Gray RH. Characteristics 946 breastfeeding women in the United Gynecol Neonatal Nurs 2004;33:580–8. and determinants of postpartum ovarian States. Am J Epidemiol 2002;155:103–14. 44. Hurst N. Breastfeeding after breast aug- function in women in the United States. 73. Niebyl JR, Spence MR, Parmley TH. mentation. J Hum Lact 2003;19:70–1. Am J Obstet Gynecol 1993;169:55–60. Sporadic (nonepidemic) puerperal masti- 45. Management of hyperbilirubinemia in the 59. Atkinson WL, Pickering LK, Schwartz B, tis. J Reprod Med 1978;20:97–100. newborn infant 35 or more weeks of ges- Weniger BG, Iskander JK, Watson JC. 74. Snyder R, Zahn C. Breast disease during tation [published erratum appears in General recommendations on immuniza- pregnancy and lactation. In: Gilstrap LC Pediatrics 2004;114:1138]. Pediatrics tion. Recommendations of the Advisory 3rd, Cunningham FG, VanDorsten JP, 2004;114:297–316. Committee on Immunization Practices editors. Operative obstetrics. 2nd ed. New 46. Institute of Medicine (US). Dietary refer- (ACIP) and the American Academy of York (NY): McGraw-Hill; 2002. ence intakes for calcium, phosphorus, Family Physicians (AAFP). Centers for 75. Matheson I, Aursnes I, Horgen M, Aabo magnesium, vitamin D, and fluoride. Disease Control and Prevention. MMWR O, Melby K. Bacteriological findings and Washington, DC: National Academy Recomm Rep 2002;51(RR-2):1–35. clinical symptoms in relation to clinical Press; 1997. 60. Academy of Breastfeeding Medicine. outcome in puerperal mastitis. Acta 47. Gartner LM, Greer FR. Prevention of Protocol #9: use of galactogogues in initi- Obstet Gynecol Scand 1988;67:723–6. rickets and vitamin D deficiency: new ating or augmenting maternal milk supply. 76. Osterman KL, Rahm VA. Lactation mas- guidelines for vitamin D intake. Section Available at: http://www.bfmed.org/acefiles/ titis: bacterial cultivation of breast milk, on Breastfeeding and Committee on protocol/prot9galactogoguesEnglish.pdf. symptoms, treatment, and outcome. J Nutrition. American Academy of Retrieved August 18, 2006. Hum Lact 2000;16:297–302. Pediatrics. Pediatrics 2003;111:908–10. 61. Betzold CM. Galactogogues. J Midwifery 77. Kotiw M, Zhang GW, Daggard G, Reiss- 48. Dewey K. Effects of maternal caloric Womens Health 2004;49:151–4. Levy E, Tapsall JW, Numa A. Late-onset restriction and exercise during lactation. J 62. FDA warns against using unapproved and recurrent neonatal Group B strepto- Nutr 1998;128 (suppl):386S–389S. drug, domperidone, to increase milk pro- coccal disease associated with breast-milk 49. Hatcher RA, Trussell J, Stewart FH, duction. FDA talk paper. Rockville (MD): transmission. Pediatr Dev Pathol 2003;6: Nelson AL, Cates W Jr, Guest F, et al. U.S. Food and Drug Administration; 2004. 251–6. Contraceptive technology. 18th ed. New Available at: http://www.fda.gov/bbs/ 78. Dinger J, Muller D, Pargac N, Schwarze York (NY): Ardent Media, Inc; 2004. topics/ANSWERS/2004/ANS01292.html. R. Breast milk transmission of group B 50. Truitt ST, Fraser A, Gallo MF, Lopez LM, Retrieved August 29, 2006. streptococcal infection. Pediatr Infect Dis Grimes DA, Schulz KF. Combined hor- 63. Howard CR, Howard FM, Lanphear B, J 2002;21:567–8. deBlieck EA, Eberly S, Lawrence RA. The monal versus nonhormonal versus pro- 79. American Academy of Pediatrics. Red effects of early pacifier use on breastfeed- gestin-only contraception in lactation. book. Report of the Committee on ing duration. Pediatrics 1999;103:E33. Cochrane Database of Systematic Reviews Infectious Diseases. 27th ed. Elk Grove 64. Schubiger G, Schwarz U, Tonz O. 2003, Issue 2. Art. No.: CD003988. Village (IL): AAP; 2006. UNICEF/WHO baby-friendly hospital DOI: 10.1002/14651858.CD003988. 80. Hindle WH. Other benign breast prob- initiative: does the use of bottles and paci- 51. Kennedy KI, Rivera R, McNeilly AS. lems. Clin Obstet Gynecol 1994;37: fiers in the neonatal nursery prevent suc- Consensus statement on the use of breast- 916–24. cessful breastfeeding? Neonatal Study feeding as a family planning method. Group. Eur J Pediatr 1997;156:874–7. 81. Karstrup S, Solvig J, Nolsoe CP, Nilsson P, Contraception 1989;39:477–96. 65. Ekstrom A, Widstrom AM, Nissen E. Khattar S, Loren I, et al. Acute puerperal 52. The World Health Organization multina- Duration of breastfeeding in Swedish breast abscesses: US-guided drainage. tional study of breast-feeding and lacta- primiparous and multiparous women. J Radiology 1993;188:807–9. tional amenorrhea. III. Pregnancy during Hum Lact 2003;19:172–8. 82. Christensen AF, Al-Suliman N, Nielsen breast-feeding. World Health Organiza- 66. Howard CR, Howard FM, Lanphear B, KR, Vejborg I, Severinsen N, Christensen tion. Task Force on Methods for the Eberly S, deBlieck AW, Oakes D, et al. H, et al. Ultrasound-guided drainage of Natural Regulation of Fertility. Fertil Randomized clinical trial of pacifier use breast abscesses: results in 151 patients. Br Steril 1999;72;431–40. and bottle-feeding or cupfeeding and their J Radiol 2005:78;186–8. 53. Perez A, Labbok MH, Queenan JT. effect on breastfeeding. Pediatrics 2003; 83. Human Milk Banking Association of Clinical study of the lactational amenor- 111:511–8. North America. Recommendations for rhoea method for family planning. Lancet 67. Hale TW. Medications and mother’s milk. collection, storage, and handling of a 1992;339:968–70. 12th ed. Amarillo (TX): Hale Publishing; mother’s milk for her own infant in the 54. Ramos R, Kennedy KI, Visness CM. 2006. hospital setting. 3rd ed. Denver (CO): Effectiveness of lactational amenorrhoea 68. Mass S. Breast pain: engorgement, nipple HMBANA; 1999. in prevention of pregnancy in Manila, the pain and mastitis. Clin Obstet Gynecol 84. Howard C, Howard F, Lawrence R, Philippines: non-comparative prospective 2004;47:676–82. Andresen E, DeBlieck E, Weitzman M. trial. BMJ 1996;313:909–12. 69. American College of Obstetricians and Office prenatal formula advertising and its 55. Labbok MH, Hight-Laukaran V, Peterson Gynecologists. Breastfeeding your baby. effect on breast-feeding patterns. Obstet AE, Fletcher V, von Hertzen H, Van Look ACOG Patient Education Pamphlet Gynecol 2000;95:296–303. PF. Multicenter study of the Lactational AP029. Washington, DC: ACOG; 2001. 85. Perez-Escamilla R, Pollitt E, Lonnerdal B, Amenorrhea Method (LAM): I. Efficacy, 70. Brent N, Rudy SJ, Redd B, Rudy TE, Dewey KG. Infant feeding policies in duration, and implications for clinical Roth LA. Sore nipples in breast-feeding maternity wards and their effect on breast- application. Contraception 1997;55: 327–36. women: a clinical trial of wound dressings feeding success: an analytical overview. 56. Kazi A, Kennedy KI, Visness CM, Khan vs conventional care. Arch Pediatr Adolesc Am J Public Health 1994;84:89–97. T. Effectiveness of the lactational amenor- Med 1998;152:1077–82. 86. Zemlickis D, Lishner M, Degendorfer P, rhea method in Pakistan. Fertil Steril 71. Stehman FB. Infections and inflammations Panzarella T, Burke B, Sutcliffe SB, et al. 1995;64:717–23. of the breast. In: Hindle WH, editor. Maternal and fetal outcome after breast 57. Labbok M, Cooney K, Coly S. Guide- Breast disease for gynecologists. Norwalk cancer in pregnancy. Am J Obstet Gynecol lines: breastfeeding, family planning, and (CT): Appleton & Lange; 1990. p.151–4. 1992;166:781–7. the lactational amenorrhea method— 72. Foxman B, D’Arcy H, Gillespie B, Bobo 87. PCBs in breast milk. American Academy LAM. Washington, DC: Institute for JK, Schwartz K. Lactation mastitis: occur- of Pediatrics Committee on Environ- Reproductive Health; 1994. rence and medical management among mental Health. Pediatrics 1994;94:122–3.

ISSN 1085-6862 JANUARY–FEBRUARY 2007 • ACOG CLINICAL REVIEW • 15S 88. American Academy of Pediatrics. Pedi- American College of Obstetricians and Academy of Breastfeeding Medicine. Breast- atric environmental health. 2nd ed. Elk Gynecologist. Breastfeeding your baby. ACOG feeding Medicine. New Rochelle (NY): ABM. Grove Village (IL): AAP; 2003. Patient Education Pamphlet AP029. Washing- Subscribing information is available at http:// 89. Schanler RJ. The use of human milk for ton, DC: ACOG; 2001. Available for purchase www.bfmed.org. Retrieved August 30, 2006. at http://sales.acog.org. premature infants. Pediatr Clin North Am Breastfeeding and the use of human milk. 2001;48:207–19. Breastfeeding: loving support for a bright future. American Academy of Pediatrics Section on 90. American College of Obstetricians and Q & A. In: Physicians’ breastfeeding support kit. Breastfeeding. Pediatrics 2005;115:496–506. Gynecologists. Breastfeeding. ACOG Exec- Tampa (FL): Best Start Social Marketing; 1998. Hale TW. Medications and mother’s milk. 12th utive Board Statement. Washington, DC: Available for purchase at http://www.beststart- ed. Amarillo (TX): Hale Publishing; 2006. ACOG; 2003. Available at: http://www. inc.org/professional_education_materials.asp. acog.org/departments/underserved/breast Retrieved September 8, 2006. Lawrence RA, Lawrence RM. Breastfeeding: a feedingStatement.pdf. guide for the medical profession. 6th ed. National Healthy Mothers, Healthy Babies 91. Freed GL, Clark SJ, Cefalo RC, Sorenson Philadelphia (PA): Elsevier Mosby; 2005. JR. Breast-feeding education of obstetrics- Coalition. Working & breastfeeding. Can you Physicians’ breastfeeding support kit. Tampa gynecology residents and practitioners. Am do it? Yes, you can! Alexandria (VA): NHMHB; 1997. Available for sale at http://www.hmhb. (FL): Best Start Social Marketing; 1998. J Obstet Gynecol 1995;173:1607–13. org/pub_breast.html. Available for purchase at http://www.beststart- 92. Power ML, Locke E, Chapin J, Klein L, inc.org/professional_education_materials.asp. Schulkin J. The effort to increase breast- References for Health Care Professionals Retrieved September 8, 2006. feeding: do obstetricians, in the forefront, and Patients need help? J Reprod Med 2003;48:72–8. American Academy of Pediatrics, American Transfer of drugs and other chemicals into College of Obstetricians and Gynecologists. human milk. American Academy of Pediatrics Resources Breastfeeding handbook for physicians. Elk Committee on Drugs. Pediatrics 2001;108: Grove Village (IL): AAP; Washington, DC: 776–89. Patient Education Materials ACOG; 2006. American Academy of Pediatrics. Ten steps to American Academy of Pediatrics, American support parents’ choice to breastfeed their baby. College of Obstetricians and Gynecologists. Elk Grove Village (IL): AAP; 1999. Available at: Guidelines for perinatal care. 5th ed. Elk Grove http://www.aap.org/breastfeeding/tenSteps.pdf. Village (IL): AAP; Washington, DC: ACOG; Retrieved August 22, 2006. 2002.

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