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The following course content

Introduction   

Breastfeeding is a natural way of feeding an infant. Breastfeeding is a personal choice made by the mother of the infant and has been the source of debates throughout the years. This course is designed to provide an in-depth look at breastfeeding so nurses in turn can educate new mothers in an unbiased, professional manner.  

According to the CDC, in 2019, 83.2% of infants started out receiving some amount of breastmilk and 78.6% were still receiving any breastmilk at 1 month. At 6 months of age, 55.65% of infants were receiving any amount of breastmilk and 24.9% of infants were only receiving breast milk (1).  

These statistics reveal that most infants start out receiving breastmilk and then the number of infants that receive breastmilk declines as they age. Many families report that they do not breastfeed for as long as they set out too (1). For families to stay consistent in their breastfeeding choice, support is needed by friends, family members, and health care professionals (1). 

What are the benefits of breastfeeding? 

For Baby  

The choice to breastfeed their infant is made by many mothers due to the benefits for their infant. Breastmilk provides antibodies from the mother to the infant, which can help the infant develop a stronger immune system (2). This can help protect the infant from illnesses and diseases later in life.  

Breastfeeding has been shown to decrease the risk of respiratory tract infections, otitis media, asthma, sudden infant death syndrome, gastrointestinal infections, and childhood obesity, among other conditions (3). Infants that are breastfed have better dental health and increased neurodevelopment (3). 

For Mom 

While many focus on the benefits of breastfeeding for the child, there are proven benefits for the mother as well. Breastfeeding has been shown to decrease the risk of certain cancers such as thyroid cancer, endometrial cancer, ovarian cancer, and breast cancer (3). Breastfeeding has also been proven to decrease the potential of the mother developing hypertension, type 2 diabetes, and rheumatoid arthritis (3). It also promotes bonding between the infant and the mother.  

(2) 

Components of Breastmilk 

Even with extensive research over the years, it is still difficult to determine the composition of breastmilk. Breastmilk is individualized to the person and the needs of the infant. The makeup of breastmilk can vary based on the geographical location of the mother, the culture, and maternal nutritional status (5).  

When produced by a nourished individual, human milk contains micronutrients and macronutrients, probiotic bacteria, and biological components (4).  

Micronutrients are important minerals and vitamins for our health as adults and are used the same in infants (5). Some examples of these micronutrients are folate, thiamine, calcium, zinc, iron, vitamin c, vitamin d, and vitamin b12 (5). Some of these micronutrients are dependent on the mother’s nutrition whereas others are independent of the mother’s diet (5). Heat during pasteurization has been found to destroy some of the micronutrients found in breastmilk (5). Pasteurization is used when breastmilk is donated. Water is the most prevalent macronutrient found in breastmilk (5).  

The milk that is first expressed while nursing is known as the foremilk that is usually thinner and has more lactose in it to help with the infant’s thirst (27). The milk that follows the foremilk is known as the hindmilk, which is thicker and higher in fat (27). The ratios can vary over time and as the infants’ needs and age changes. 

What are the components of colostrum? 

Colostrum is a thick, yellow-colored liquid that is produced in the third trimester. Colostrum is consumed usually between 1-5 days after birth until lactogenesis starts at around day two or three postpartum, which is transitional milk (7).  

Colostrum has about 14-16g/L of protein which is more than mature milk (6). The fat content is less than mature milk at 15-20g/L (6). There are less carbohydrates in colostrum than breastmilk at about 50-62g/L (6). Colostrum is full of immunoglobulin A that helps infants fight infections (7). Colostrum also helps provide the infant’s intestinal tract with healthy bacteria (7). 

What are the components of mature milk? 

Mature milk is breastmilk that is produced 14 days after birth of an infant (6). The content of mature milk differs slightly from colostrum as the needs of the infant change over time. Water totals about 87%-91% of the breastmilk’s make up depending on the stage of lactation (5).  

Carbohydrates comprise about 60-70 g/L in mature milk. Adults consume carbohydrates in the form of glucose; however, an infant’s gastrointestinal tract is not fully developed yet so lactose is the largest carbohydrate in breastmilk (6). Lactose is the next ingredient in the make-up of breastmilk with about 70g/L (4). Lactose helps with providing the infant with energy and managing the water level (5).  

Total protein in mature milk is around 8-10g/L at 3 months and lowers to 7-8g/L around 6 months (6). Protein in breastmilk comes in two forms: whey and casein (6). The ratio is dependent on the stage of lactation (6). Fat is the second largest macronutrient (6). Mature milk consists of about 35-40g/L of fats (6).  

Hormones such as cortisol, insulin, melatonin, leptin, and adiponectin are also found in breastmilk (5). Growth factors, immunoglobulins, cytokines, antimicrobials, oligosaccharides, and stem cells are part of the biological components of breast milk (3). The make-up of breastmilk is still somewhat dependent on the mother’s nutrition and is not the same in all breastmilk. 

Common Myths of Breastfeeding 

There are many misconceptions about breastfeeding that can impede the success of breastfeeding. New moms or expecting mothers are given a lot of advice that might not always be true.  

Here are a few common myths of breastfeeding: 

• Size of breasts matter. Some women have been told they cannot breastfeed if they have small breasts. The size of the breast is dependent on the fat and breast tissue, not the alveoli that produces milk (8). Women that have a smaller breast size can produce and feed their infant with understanding infant cues the same as women with larger breast size (8).  

At the other end of the spectrum, some women are told that they are not able to breastfeed if they have a larger breast size. With larger breast size it may take some time and practice with different holds to find the right latch, but it is possible (9). 

• Breast milk will dry up. Breast milk is based on supply and demand. Breast milk will not dry up if the mother continues to effectively feed the infant based on their demand. If feedings are missed or if the mother supplements with formula, breastmilk production may decrease (9). 

• If the infant is crying a lot, they are not receiving enough breastmilk. Another misconception is that a crying infant is always hungry. While this may be true some of the time, infants can cry for other reasons. A breastfed infant that is irritable does not just signify they are not receiving enough breastmilk and need to be supplemented with formula (9). Infants can be fed on demand; the mother should look for hunger cues like lip smacking or turning of the head. It is important for routine well visits to the infant’s healthcare provider to assess for adequate growth (9).  

Latching on 

What are signs of a good latch? 

A good latch is an important part of the breastfeeding process. A good latch helps the infant receive the amount of breastmilk they need. The infant’s mouth should be open over the areola, and their lips should be turned out (11). The infant’s stomach and chest should be turned towards the mother’s body and their head should be in line with their body, not turned to the side (11). The infants swallow should be audible (11). 

What are signs of a poor latch? 

A poor latch can cause the infant to not receive enough breastmilk and be problematic in the breastfeeding process. A poor latch can be painful for the breastfeeding mother. The mother’s nipples can be cracked or bleeding and may look flat or misshaped (11). If the infant’s lips are turned inward this may be a sign of a poor latch (11). Also, if the baby keeps unlatching while breastfeeding, the infant may not have a secure latch (11). 

Case Study 

 A first-time mom on a labor and delivery unit requests to initiate breastfeeding. The infant was born 30 minutes ago with an Apgar score of 8. The infant was born at 40 weeks and 2 days via a spontaneous vaginal delivery. The mom places the infant on her right breast. The mom cradles the infants head in her right arm. The infant has the nipple in their mouth with the entire areola exposed. The infant’s lips are turned in. The infant takes their mouth off the breasts several times. The mom asks if the infant is feeding correctly. 

• Does the infant have a good or poor latch? 

• What hold does the mother have the infant positioned in? 

• How can the mom fix the infant’s latch? 

Breastfeeding Holds 

There are different positions that mothers can try when breastfeeding their infants. Breastfeeding moms can try different holds to find one that works best for them and their infant. 

• Side lying position – In this position the mom lies on their side placing a pillow behind their back and supporting their head with a pillow or arm (12). Then position the infant on their side with their mouth facing toward the mom (12). The mom can lift the breast to help the infant latch at the beginning of the breastfeeding session (10).  

This position can be beneficial for a mom post c-section, as this position does not put pressure on the mom’s abdomen (12). 

• Football hold – In this position the mom holds the infant at the mom’s side under their arm, so the infant is facing the mom (10). The infant’s head and back should be supported (12). The infant’s legs will stretch out behind the mom (12). A pillow can be placed under the mom’s elbow for support (12). 

This position could also be helpful for a mom post c-section because the pressure is not on the mom’s abdomen.  

• Cradle hold– In this hold the mom sits up straight and cradles the infant with their elbow. Th infant should be turned so their abdomen touches the mom’s (10). The infant’s head should be supported by the mom’s elbow (10). 

• Cross-cradle hold– In this position the mom is sitting up straight, as with the cradle hold but the mom is holding the infant in the opposite arm of the breast in use (10). This position can help with infants that are having difficulty latching because the mom can have more control of the infant’s head (12). The mom supports the back of the head and neck with their hand (12).  

Challenges and complications of breastfeeding 

While there are numerous benefits of breastfeeding, there can be challenges and complications as well. Here are some examples of possible challenges and complications that may arise while breastfeeding. 

Engorgement 

Engorgement is breast fullness that is usually experienced early in the postpartum period (13). Essentially, the alveolar ducts become distended with milk (13). There are preventative measures that can be taken. Studies have shown that early expression of colostrum can help prevent engorgement (13). Overly expressing milk can increase the milk production and increase the engorgement (13). Regular and complete expression of milk is important. Heat and cold packs can help.  

Mastitis 

Mastitis is a common complication that women may experience while breastfeeding. Risk factors of mastitis can be poor latching by the infant, oversupply, injury to the nipple, or missed feedings (13). The buildup of breastmilk in the breasts that can lead to a blockage of a milk duck is known as milk stasis (14). Milk stasis is one of the causes of mastitis.  

Treatment should be started early to prevent maternal sepsis, weaning early, or a breast abscess (13). Removal of milk is important for the management of mastitis; the mother should breastfeed or express the milk (13). Lymphatic massage can also promote drainage, where the mother massages from the areola to the axilla (14).  

Healthy infants can still breastfeed from a mother with mastitis. Infants may detect the milk may have a different taste and may not want to breastfeed from the affected breast (13). In these cases, the mother should attempt to pump, or hand express the breast milk (14).  

Hot compresses can help release milk and cold compresses can help reduce pain (14). Pain management is important during mastitis. The use of analgesics such as ibuprofen can be beneficial (14). Antibiotic treatment may be needed if symptoms persist after 24- 48 hours (14). If mastitis develops into an abscess, drainage and antibiotic therapy are needed.  

Low Milk Supply 

Confirmed low milk supply or the concern of low milk supply can be a source of anxiety for the mom. The average amount of feedings should be 8-12 per day. The infant should produce 6-8 wet diapers per day beginning around day five (13). Signs of low milk supply can be exhibited in the infant by decreased number of wet diapers, jaundice, irritability, and poor weight gain (13). Women returning to work after having a child can inhibit the breastfeeding. Work demands and the inability to pump at work can decrease the milk supply and can cause early unintentional weaning.  

Are there contraindications for breastfeeding? 

There are some contraindications for breastfeeding, where it can be harmful for the infant. There are only a few instances where breastfeeding is contraindicated. Infants that have been diagnosed with classic galactosemia should not breastfeed (15). Classic galactosemia or galactose-1 phosphate Uridylyltranserase deficiency is a genetic disorder where the infant cannot metabolize galactose, which is found in breastmilk (16). Ingesting breastmilk can cause hepatic damage, bleeding, sepsis, and failure to thrive. The severe risks of galactosemia can be prevented by starting the infant on lactose-free formula in the first days of life, and the symptoms can resolve. If left untreated older children may experience speech problems, cognitive delays, cataracts, and liver failure (16).  

A mother who has human immunodeficiency virus (HIV) should not breastfeed (15). HIV can be transmitted through breastmilk to the infant (17).  

A mother who has suspected or confirmed Ebola virus should not breastfeed, as the virus is spread through bodily fluids such as breastmilk and this could infect the infant with the virus (18).  

Women with untreated brucellosis should also not breastfeed, as this bacterium could be transmitted through breastmilk (19). Brucellosis is commonly transmitted by drinking or eating unpasteurized milk from an animal that is infected by the bacteria, however it can spread through breastmilk (19).  

Mothers that are using cocaine, opioids, and PCP (phencyclidine) should not breastfeed due to the increased risk of problems with neurobehavioral development (15). Breastfeeding is appropriate for mothers that are in a substance abuse program and taking buprenorphine or methadone (20).  

When the provider prescribes medications to breastfeeding women, it is vital for them to weigh the risk verses benefit, and risks of the medication for the infant (21). 

Pumping and Storing Milk 

Pumping breastmilk can be a choice by the mother or may be necessary if the infant is in the NICU. Mother may also choose to pump after returning to work. Milk can be expressed by hand or by using a manual or electric pump. If returning to work, pumping should be started prior to work to practice pumping and the infant can get adjusted to using a bottle (22).  

Some mothers exclusively pump to provide human milk for their infant. Pumping should be done as often as the infant would feed to keep up with supply (22). If the milk supply is less than the infant requires, then the mom may need to add in extra pumping sessions. 

Properly storing the breast milk is important for the quality of the milk and safety for the infant. Below are examples of guidelines for breast milk. 

• Breastmilk should be stored in a food safe container that is designed for breast milk (23).  

• Freshy pumped milk can be stored at room temperature for 4 hours, in the refrigerator for 4 days, and 6 months in the freezer for quality and up to 12 months in the freezer safely (23). 

• Thawed breastmilk can be kept at room temperature for up to one to two hours safely and up to 24 hours in the refrigerator (23). Thawed breastmilk should not be placed back in the freezer (23). 

• Milk that is left in the bottle after the infant feeds should not be kept for more than two hours (23).  

Weaning  

Weaning from breastfeeding is a personal decision that may be different for every mom. Weaning is the process of the infant tapering from breastmilk and transitioning to formula if the infant is younger than 12 months, or cow’s milk or soy beverage if the infant is older than 12 months (23). Weaning may take longer or shorter depending on the infant (23). 

Parent Education Tips 

As nurses we find ourselves in the role of educator in our careers. Educating new moms on breastfeeding may be necessary in the specialty we work in. We must provide unbiased information for parents. Breastfeeding begins in the hospital or birthing center and is critical in breastfeeding practices. Early skin to skin after birth and rooming-in with the infant have both been shown to improve the rates of breastfeeding (20).  

If breastfeeding is requested by the new mom, initiating breastfeeding in the first hour of life is important (20). Education is essential for the ongoing practice of breastfeeding. Moms should be informed about good techniques such as proper latching and properly adjusting the latch during a feed (24).  

The parents should also be taught about when to feed the newborn. The parents should be educated on feeding cues such as turning of the head (rooting), moving of the head when close the chest, the infant smacking their lips opened and closed, and the infant sucking on their hands (24).  

The milk supply is based on the demand. It is important to switch breasts at the start of each feed and have the infant emptying at least one breast. Some new parents have questions regarding pacifiers and breastfeeding. Generally, pacifiers are usually not recommended at the initiation of breastfeeding, so the infant can get used to breastfeeding and the milk supply is sufficient for the infant’s needs (24).  

Diet can be a concern for a new mother while breastfeeding. A balanced nutritious diet and an additional 500 calories are needed for breastfeeding, but guidelines may vary among mothers depending on their health status (25). 

Breastfeeding Resources and Support Groups 

While the education for breastfeeding can seem standard, many women have specific questions related to their lifestyle and their infant. There are numerous resources and support groups that have been established to promote breastfeeding and support moms in their breastfeeding journeys.  

These are some examples of support groups and resources that can provide help for breastfeeding mothers or healthcare professionals who work with breastfeeding mothers (26). 

• The breastfeeding hotline was started by the Office on Women’s Health. The helpline offers advice during business hours Monday through Friday. This hotline gives information on breastfeeding (26). 

• The American Academy of Pediatrics has a parenting website that promotes articles on breastfeeding. Healthychildren.org can provide answers for common breastfeeding questions (26). 

• The La Leche League International is an organization that educates and supports breastfeeding mothers. Local la leche groups can be found and can be a resource for mothers (26).  

• The United Breastfeeding Committee is a nonprofit organization that creates policies and support for breastfeeding mothers in the United States (26).  

• The Academy of Breastfeeding Medicine is an organization for healthcare providers to promote evidence-based practices for breastfeeding and provides education for providers to better manage their breastfeeding patients (26).  

Conclusion

Breastfeeding is a personal decision made by the mother of the infant and often takes support by family, friends, and health care professionals to be successful. Breastfeeding has numerous benefits for the infant and the mother and can provide the infant with optimal nutrition. With support, breastfeeding mothers can meet their individual breastfeeding goals. As healthcare professionals we must provide unbiased, fact-based information so our patients can make informed decisions about their choice to breastfeed.  

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