Practical Management of the Nursing “Dyad”

Key Points

Breastfeeding units are best conceived of as physiologically interrelated, or “dyads,” although each family may include multiple interdependent dyads (e.g., those with multiples or more than one lactating parent).
Supporting lactation and breastfeeding requires understanding a rich tapestry, including the physiology of milk production, the mechanics of milk transfer, normal infant behavior and growth, and the multiple social forces that enable or prevent achieving parental goals.
Solving problems in lactation depends on addressing three components for each dyad: milk production (the mother), milk transfer, and infant oral function and growth.

Management of lactation begins with understanding the dyadic process of milk production, latching on, suckling, and milk transfer (see Chapter 3 ). For millennia, women have fed their young at the breast. Support for these women was, and is, culturally mediated. In some areas of the world, women support each other; in other areas, this cultural practice has been erased. Especially in areas lacking strong cultural support for breastfeeding, the medical provider plays a critical role in enabling human lactation.

Successful nursing depends on the interaction of mother and infant (the “dyad”), with appropriate support from other parents, the family, available health care resources, and the community. Because mothers and infants vary, there is not a simple set of rules that will guarantee success. In fact, lactation may not be limited to a mother and infant: gender nonconforming families may include several parents who desire to lactate, induce lactation, or feed donor milk to their children. Twins and triplets with differing health status may add complications in terms of milk production, timing, and transfer. Therefore lactation should be evaluated just like any other physiologic process—providers must understand the anatomy and physiology of lactation, assess and manage problems, and use complex decision-making procedures to enable the best outcomes. ¹ Different from other processes is the analysis of the dyadic interplay of two physiologies involved in milk transfer. Unfortunately, many physicians have not received formal education about breastfeeding; thus they gain information from a variety of sources, including personal experiences, and may generalize from these sources without complete knowledge. ², ³, ⁴

This chapter addresses the basic management of breastfeeding, including common and less common issues that may arise. Because it is not written for a lay audience, other books may be used for patient education, including K. Huggins’s The Nursing Mother’s Companion , now in its 8th edition after more than 30 years of inspiring mothers to breastfeed. ⁵ The Womanly Art of Breastfeeding from La Leche League International is also available. ⁶ The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) have a variety of country-specific resources and publications in multiple languages to support breastfeeding around the world. The references for this chapter are not an exhaustive list of all material written on the topic; rather, they are intended to assist a reader in locating research that supports the evidence-based concepts described here. This chapter is divided into two major parts. The first part describes routine management of lactation perinatally: (1) prenatal period; (2) immediate postpartum, or hospital, period; and (3) postnatal, or posthospital, period. The second part provides a structure for the diagnosis and management of breastfeeding problems.

Basic Practical Management of Lactation

Current Practices in the United States and Internationally

Although recommendations on infant feeding are clear, infant feeding practices continue to depart substantially from these guidelines. Infant feeding and care practices in the United States were assessed by the US Department of Health and Human Services and published as a supplement to Pediatrics in 2008. ⁷ This publication documents various aspects of infant feeding, as reported by more than 2000 women nationally for 1 year postpartum in 2004, and compares results with a similar study in 1993. In this cohort, approximately half of breastfed infants had received infant formula in the birth hospitalization, and nearly half were being fed solid foods before the age of 4 months. ⁶ The most frequently reported reason for weaning at any age was the maternal perception that the child was not satisfied by breast milk alone. ⁸, ⁹ In addition, a new trend emerged: approximately 6% of women fed their children expressed breast milk without ever putting their child to the breast, a trend that continues and is arguably increasing in the United States. ¹⁰ The Lancet 2016 series on breastfeeding included a more global perspective and reported that high-income countries had shorter breastfeeding duration than low- or middle-income countries, but that only 37% of infants younger than 6 months were exclusively breastfed even in these latter categories. ¹¹ In addition, people with lower incomes tended to breastfeed longer than their wealthier counterparts in all country groupings, although in the United States, this social gradient reversed in the 1960s.

It is therefore important to note that practices surrounding infant feeding vary widely. Although we have learned much about appropriate management, there remain large gaps in the literature. Therefore medical providers should be transparent with families about what is anecdotal about advice as opposed to what is evidence based. In addition, when formulating support plans, it is critical to acknowledge the variety of cultural influences on the management of breastfeeding, including geography, religion, and other social pressures from family or employers. Given that about 1 in 3 women worldwide has experienced physical and/or sexual violence, concerns for privacy, safety, and touch (both by the infant and by the provider) should be kept in mind. ¹² Women who have experienced intimate partner violence may be less likely to initiate breastfeeding and will need their providers to be carefully attuned to their medical and psychosocial needs. ¹³ (See also Breastfeeding Among Trauma Survivors, Chapter 15 .)

The key to counseling the nursing couple lies in supporting parental decision-making, enabling a sense of confidence, and providing rapid access to support when required. Then, when a problem arises, a mechanism is already in place for a mother to receive help from her provider’s office before the problem creates a serious medical complication.

Prenatal Breastfeeding Education and Management

Decision to Breastfeed and Informed Consent

Most decisions regarding breastfeeding initiation are made in the preconception or prenatal period; few women who intend to formula-feed change their minds at birth. ¹⁴, ¹⁵, ¹⁶ Therefore, ideally, education regarding breastfeeding should occur early in life or in the preconception period. Family planning counseling may provide obstetric providers with a brief moment to discuss breastfeeding in relation to a normal breast exam.

Support

Along with the medical provider, a breastfeeding family is likely to need and use support from other places, including family, friends, lactation consultants, employers, support groups, and online/technology-mediated support (see Chapter 16 ). In general, such supports should be encouraged and online resources fact-checked. Bringing a support person along for a visit is likely to be helpful when counseling about breastfeeding or managing breastfeeding problems. ¹⁷

Prenatal Period

It is most effective to prepare for breastfeeding well in advance of delivery, if possible, in preconception or at the first prenatal visit. The Academy of Breastfeeding Medicine (ABM) provides a helpful protocol titled “Breastfeeding Promotion in the Prenatal Setting.” ³ Particularly with first children, it is appropriate to suggest to the parents that they select a pediatric care provider early. Some pediatric providers offer a prenatal visit to discuss infant feeding, care concerns, and child-rearing questions. In some places, the medical profession has been hesitant to take anything but a neutral position in discussions of breastfeeding for fear of pressuring mothers or creating guilt. Manufacturers of infant formula have capitalized on this and created advertising campaigns designed to further polarize parents toward victimization. ³ Despite this, the ethical principle of autonomy makes clear a provider’s duty with respect to parents: evidence is clear that breast-milk substitutes (infant formula) carry risk; breastfeeding is an important health care decision with implications for lifelong health, and parents have the right to be advised and make informed choices. Finally, as support for breastfeeding has increased, so, too, have negative emotions experienced by mothers who are using infant formula. ¹⁸ Studies from around the world show that parents use informal information sources to learn best formula-feeding practices and that many practices are therefore unsafe. ¹⁹ The prenatal discussion should therefore include discussions of benefits and risks of infant feeding options, answers to any questions the parents may have about the lactation process and a mother’s ability to make milk, and medically approved resources to support further learning.

Breast and Nipple Exam

An examination of the breasts is part of good prenatal care and an excellent opportunity to discuss breastfeeding. For detailed information on breast and nipple examination, see Chapter 25 .

Resources Versus Discussion

Although a provider may give literature on breastfeeding or suggest reading sources for the patient, decision-making will be enhanced by open discussion with a knowledgeable provider. Childbirth preparation programs in the community and breastfeeding classes offered by lactation consultants or peer counselors may help prepare families for breastfeeding. However, the role of the care provider in promoting and supporting breastfeeding remains important, both by making a clear recommendation to breastfeed, where appropriate, and in ensuring best practices are followed after birth to support the family’s choice. ²⁰, ²¹ A 2017 Cochrane review found that support improved exclusivity and duration at 6 weeks and 6 months postpartum. ¹⁷

Although decisions to breastfeed include consideration of the health of the infant and mother, concerns about breastfeeding reported prenatally include medical as well as social concerns and are reported similarly around the world. ²², ²³, ²⁴, ²⁵ Authors have suggested prenatal counseling toolkits, including the “Ready, Set, BABY” counseling approach, and have found increases in breastfeeding intention. ²⁶ The American College of Obstetrics and Gynecology has a toolkit with patient handouts and resources, and the WHO/UNICEF offers online access to handouts in different languages. ²⁷ Table 7.1 reviews the most commonly expressed concerns in the prenatal period, along with counseling points for providers. (See Chapter 6 for making an informed decision, and see Chapter 16 for managing common concerns about the nipples and breasts.)

Table 7.1

Mothers’ Expressed Concerns About Breastfeeding When Interviewed Prenatally, Along With Counseling Points

Prenatal Concern	Evidence	Prenatal Counseling Points
Will I make enough milk?/Will baby latch and grow?	Because of the difficulty with measurement and diagnosis of low milk supply, studies vary on the prevalence of this issue. Estimates vary, but between 8% and 30% of mothers experience low milk supply in the first 2 weeks postpartum. ²⁰¹ Risk factors for low milk supply include (1) anatomic/medical concerns, such as mammary hypoplasia or no breast changes in pregnancy; (2) early disruption of milk removal through separation and supplementation with infant formula; and (3) conditions related to delayed lactogenesis 2 (after 72 hours) and milk supply (including hypertension, gestational diabetes, maternal age >30, primiparity, maternal body mass index >25, excess maternal gestational weight gain, infant birth weight >3600 g, preterm birth [and possible timing of antenatal steroids], and infrequent feeding or latch difficulties after birth. ²⁰² , ²⁰³ , ²⁰⁴ , ²⁰⁵ In addition, environmental and medical exposures, such as medications, tobacco smoking, smoke exposure, and alcohol use, may affect milk supply (see Chapter 11 ).	Most women make enough breast milk, and most babies will learn to latch. There are effective interventions to support milk production, such as skin to skin, rooming-in, and frequent feeding on cue. Identify postpartum supports for families so that they may access them when a concern arises. If a mother is at risk for low milk supply, she should be counseled to limit her risk factors when possible (e.g., tobacco, unnecessary medications); may consider antenatal colostrum expression to improve confidence, time to lactogenesis 2, and milk supply (see section on antenatal hand expression later in the chapter) ^a ; and should have close postpartum follow-up with trained lactation consultants.
Will it hurt?	Although many women are told that breastfeeding is a joyful experience and shouldn’t hurt, estimates suggest that from 10% to 96% of mothers report pain while breastfeeding. ^b As lactation consultants and experienced breastfeeding women know, seemingly small changes in positioning and offering the breast can make large impacts on maternal pain. In addition, because support for breastfeeding varies and the natural history of ankyloglossia without frenotomy is poorly understood, it is unclear how many women who stop breastfeeding as a result of nipple pain have had remediable causes.	The goal of breastfeeding is to establish an effective, pain-free latch. Nipple pain while breastfeeding may occur, but there are interventions that may help, such as latch support, diagnosis and management of infant ankyloglossia, and treatment of infections, should they arise. If your baby is latched and it hurts, you are not “doing it wrong”—your body is trying to tell you something. If you’re walking down the street and there’s a pebble in your shoe, you’re not walking wrong—your foot is telling you to remove the pebble. Similarly, if your baby’s latch is not comfortable, your breast is telling you to adjust your baby’s position.
What is the effect on the mother’s lifestyle, work, and sleep?	Breastfeeding requires a significant investment of time and effort. Reallocation of other maternal duties toward the home, other children, finances, food, and society may be an effective way of ensuring that breastfeeding mothers do not become overwhelmed. However, this varies significantly between cultures and families. In addition, paid parental leave policies vary substantially around the world; thus the financial landscape of making the decision to breastfeed differs. ²⁰⁶ Data support that it is possible to maintain lactation while separated from an infant (e.g., for work, to share infant feeding, etc.). Pumping or expression of milk in any location must be safe, clean, private, and available when mothers need to express milk. Some countries have labor laws supporting a mother’s right to express milk at work, but these are usually incompletely enforced, and mothers may continue to struggle against unfair labor practices. In these situations, health care providers may be allies to help families reach their breastfeeding goals. In unsupportive environments, employment may be a reason for both not initiating breastfeeding and for limiting the duration of breastfeeding (see Chapter 18 ). Breastfeeding has not been shown to cause infants to be “needy” or overly dependent on their mothers but, rather, to create a secure attachment that leads to independence later in life. ^c Most studies examining the role of breastfeeding on sleep have found either no effect of breastfeeding on the quantity of sleep or that breastfeeding mothers have qualitatively deeper sleep in the immediate postpartum period and overall longer duration of sleep than families who feed formula. ^d ^, ²⁰⁷	Help families to understand the importance of breastfeeding initiation, even if they are concerned about their ability to continue because of work or other concerns. The family may plan to share other maternal duties regarding the home, other children, finances, food, and society while breastfeeding. Teaching a mother to maintain lactation while separated from her infant is best practice and one of the tenets of the 10 steps. The health care provider can help to advocate for mothers who need support from their employers, notifying them of the benefits of having a breastfeeding employee (see Chapter 18 ) and any existing laws supporting mothers’ rights to express milk at work. Breastfeeding has not been shown to make babies temperamentally dependent. Breastfeeding has not been shown to worsen maternal sleep; some small studies suggest that it may improve sleep.
What is the effect on the mother’s breast shape and size?	Data indicate that breasts are affected by heredity, age, pregnancy, higher body mass index, significant weight loss (>50 lb), larger bra cup size, and smoking history. Weight gain during pregnancy and lack of regular upper body exercise were not found to be related to breast shape. ²⁰⁸ Pregnancy enlarges the breasts temporarily, as does early lactation, but the effect is temporary.	Pregnancy and other causes are more likely to change the ongoing shape of maternal breasts than lactation. Changes resulting from lactation are temporary. Breastfeeding decreases the risk of breast cancer, which also contributes to the risk of long-term breast changes.
Safety/breast exposure	Some women may have safety concerns about breastfeeding in public, whereas others may face social stigma, embarrassment, or abuse. These experiences vary geographically and culturally. Publicity campaigns, “latch-ins,” and increased reporting have changed the culture in some areas but not others. Medical providers must be attuned to community practices, prejudices, and consequences associated with breastfeeding in public in their area.	Discuss with pregnant women openly about their concerns about breastfeeding in public, and reassure, citing legislation protecting the right to breastfeed in public, when able. When breastfeeding in public may not be safe, considering breastfeeding covers, wearing loose/accessible clothing, or predetermining safe locations to breastfeed may help a mother to plan how to feed her baby outside of the house.

a Demirci J, Schmella M, Glasser M, et al. Delayed lactogenesis II and potential utility of antenatal milk expression in women developing late-onset preeclampsia: a case series. BMC Pregnancy Childbirth. 2018;18(1):68. http://doi:10.1186/s12884-018-1693-5 ; Demirci JR, Glasser M, Fichner J, et al. "It gave me so much confidence": first-time U.S. mothers' experiences with antenatal milk expression. Matern Child Nutr. 2019;15(4):e12824. http://doi:10.1111/mcn.12824 . Epub 2019 May 23.

b Dennis CL, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database Syst Rev. 2014;12:CD007366. http://doi:10.1002/14651858.CD007366.pub2 ; Puapornpong P, Paritakul P, Suksamarnwong M, et al. Nipple pain incidence, the predisposing factors, the recovery period after care management, and the exclusive breastfeeding outcome. Breastfeed Med . 2017;12:169–173. http://doi:10.1089/bfm.2016.0194 . Epub 2017 Apr 1.

c Gibbs BG, Forste R, Lybbert E. Breastfeeding, parenting, and infant attachment behaviors. Matern Child Health J. 2018;22(4):579–588. http://doi:10.1007/s10995-018-2427-z .

d Brown A, Harries V. Infant sleep and night feeding patterns during later infancy: association with breastfeeding frequency, daytime complementary food intake, and infant weight. Breastfeed Med. 2015;10(5):246–252. http://doi:10.1089/bfm.2014.0153 .

Hand Expression Prenatally

Prenatal hand expression has been discouraged because of the concern for the stimulation of uterine contraction, early labor, and prepartum mastitis. However, no significant harms were found in the Diabetes and Antenatal Milk Expressing (DAME) trial by Forster et al. ²⁸ In this multicenter randomized controlled trial (RCT), 635 women with diabetes in pregnancy were randomized to hand expression twice daily starting at 36 weeks’ gestation or standard care. There were no between-group differences in birth characteristics or infant admission to the neonatal intensive care unit (NICU), and there was a beneficial effect on exclusive breast-milk feeding in the first 24 hours of hospitalization after birth; however, there was no difference in exclusive breastfeeding across the birth hospitalization or in any or exclusive breastfeeding at 3 months. Given the concerns raised in studies on breast and nipple preparation, maternal experience is important to consider. In a qualitative study among 19 primiparous women recruited from a US midwifery practice, Demirci et al. found that twice-daily prenatal hand expression was considered easy to fit into their lives and increased their confidence in breastfeeding. ²⁹

Nipple Stimulation and Labor Management

Breast stimulation triggers the release of oxytocin from the posterior pituitary and has been used to augment or induce labor. In a Cochrane meta-analysis comparing breast stimulation with usual care, women allocated to breast stimulation were more likely to labor within 72 hours and less likely to have a postpartum hemorrhage; of note, in subgroup analyses, breast stimulation was effective for women with a favorable cervix but not for women with an unfavorable cervix. ³⁰

In an RCT in India ( n= 199), primiparous women were allocated to breast massage for 15 to 20 minutes three times a day or usual care. ³¹ Women allocated to breast massage were less likely to birth by cesarean (8% vs. 20.4%). In a study in Turkey of women with a Bishop’s score of 6 or higher ( n =390), nipple stimulation was performed for 4 to 5 minutes every 30 minutes; there were no C-sections in the nipple-stimulation group, and only 9.2% of primiparas and 4.6% of multiparas required synthetic oxytocin. In the control group, 8.5% of women underwent C-section, and oxytocin was required in 92.3% of primiparas and 86.2% of multiparas. ³² Tachysystole and bradycardia have been described secondary to nipple stimulation in a case report; terbutaline was administered, with recovery of the fetal heart tracing and subsequent uncomplicated vaginal birth. ³³

In a small feasibility study ( n =16) of 1 hour of nipple stimulation on 3 consecutive days, salivary oxytocin levels were highest on day 3; a subsequent study comparing women performing nipple stimulation with controls found that oxytocin increased from day 1 to day 3 in the nipple-stimulation group but not in the control group; however, there was no difference in onset of labor between the two groups. ³⁴, ³⁵

Nipple stimulation or infant suckling has also been studied for the management of the third stage of labor and reduction of postpartum hemorrhage. A Cochrane review found insufficient evidence on the effect of nipple stimulation for reducing maternal morbidity or postpartum blood loss. ³⁶ A subsequently published randomized clinical trial compared intermittent breast stimulation to an infusion of 30 IU oxytocin per 1000 mL infusate (maximum rate of 10 mL (0.3 IU) per minute) after delivery. ³⁷ There were no differences in the duration of the third stage, estimated blood loss, or change in hemoglobin from before delivery to 24 hours after delivery; however, maternal satisfaction was higher and pain was lower in the nipple-stimulation group. Of note, none of the women in the study held their infant skin to skin or breastfed during the third stage, which limits the generalizability of the results.

Summary of Appropriate Prenatal Management

1.
During preconception or at the first prenatal visit, begin to explore patient knowledge and attitudes about breastfeeding. During the first trimester, perform a breast examination and address any concerns. Continue (or begin) the discussion about how the infant is to be fed and the benefits of breastfeeding.
2.
Inquire about other influences on breastfeeding. Encourage the participation of fathers, other parents, or support people at visits. Consider referring families to a prenatal pediatric visit, childbirth classes, or breastfeeding classes. Knowledge of community resources is vital. At each prenatal visit, offer information about breastfeeding and address any concerns.
3.
In the second trimester, discuss the importance of skin-to-skin contact after birth, rooming-in, and feeding on cue, and address any concerns.
4.
If a patient has risk factors for delayed lactogenesis 2 or low milk supply, consider encouraging antenatal milk expression, and support the patient to make plans for early follow-up after discharge with a pediatric provider.
5.
To address prenatal anticipatory guidance, hand expression, and postpartum care, consider adding a board-certified lactation consultant to your staff.

Immediate Postpartum/Hospital Management

Birth practices, doulas, and medications in labor are addressed in Chapter 15 .

Immediate Postpartum Period/The First Hour

Immediately after the placenta has separated, the establishment of lactation begins. Breastfeeding is thus considered the completion of the reproductive cycle. This is a critical period because mothers who receive the proper support after birth are more likely to successfully establish an effective latch and milk supply.

Every birthing center, certified as part of the “Baby-Friendly Hospital Initiative” or not, should provide the basic management recommended by the 10 evidence-based steps to support breastfeeding (see Chapter 1 ). ³⁸, ³⁹ After birth, the infant should immediately be placed on the mother’s chest or abdomen, to root for and seek the breast (i.e., the “breast crawl,” see later discussion). The normal infant behaviors of latching will generally begin within 30 to 60 minutes of birth. Even if the mother does not ask, the obstetrician and delivery room staff should suggest and facilitate it. Data confirm the view that delivery room or birthing center protocols that interrupt interaction and suckling between mother and infant increase the stress of patients and have a negative impact on long-term lactation success. ⁴⁰, ⁴¹

In the mother, oxytocin levels at 15, 30, and 45 minutes after delivery are significantly elevated, coinciding both with breastfeeding and with the expulsion of the placenta. Oxytocin has been associated with positive maternal feelings and with maternal bonding; thus it is appropriate to optimize mother–infant interaction at this point of high oxytocin levels by facilitating suckling. ⁴¹, ⁴² Skin-to-skin contact after birth has been associated with other important maternal factors, including moderating the effect of birth trauma; functional magnetic resonance imaging (fMRI) demonstrated stimulation of bonding centers in the brain, improved confidence, reduced postpartum bleeding, and decreased depression. ⁴³, ⁴⁴, ⁴⁵

In the infant, skin-to-skin contact after birth performs an organizing function, which has been well documented in research on kangaroo care. A Cochrane review that included 38 trials with 3472 mother–infant pairs across 21 countries concluded that early skin-to-skin contact for healthy newborns resulted in lower infant crying time, improved thermoregulation, lower heart rate, and lower rates of hypoglycemia, in addition to improved breastfeeding duration and exclusivity. ⁴⁵

For preterm, low-birth-weight, or sick infants, this effect may be even more pronounced. Skin-to-skin holding during the time of critical care (NICU) has demonstrated improved physiologic stability and neurosensory integration, lowered morbidities, and improved parental attachment. Ten- and 20-year follow-up studies have shown lasting effects on cognition, social behaviors, and motor skills. ⁴⁶

The Breast Crawl

As noted earlier, healthy newborns placed on the mother’s abdomen will find their way to the breast and latch on if unimpeded. This “breast crawl” is based in mammalian neurophysiology and will be demonstrated as an innate behavior of healthy newborns if not interrupted. It is a fundamental component of establishing the confidence and learning associated with latching on and also positively affects the maternal milk supply. A video and textual description are available online at http://breastcrawl.org .

For this first breastfeeding, the infant should be placed prone on the mother, who is supine (“tummy to tummy”). The head, body, and back of the baby should be dried during skin-to-skin time, and dry blankets should replace wet ones to cover the baby (and mother, if desired). At this time, the infant is alert, opening its eyes, and adjusting to the world. The odor of the breast, maternal heat and heartbeat, and infant vernix all combine to help the infant orient to the breast. In this position, the infant’s legs are able to massage the uterus while pushing the infant up toward the breast. After crawling, a few rest breaks, massaging the breasts, and licking the nipple ( Fig. 7.1 ), the infant will generally gape and extend the tongue under the nipple to draw the breast into the mouth. If an infant is not able to or has not been allowed to crawl up to the breast, then the mother should be assisted to try different positions. The infant should be presented squarely to the breast and should not have to turn its head toward the breast. The mother may need assistance in holding her breast so as to present the nipple squarely into the infant’s mouth, which is stimulated to open by stroking the center of the lower lip with the nipple. When the nipple touches the lower lip, the infant will open widely and extend the tongue under the nipple. The breast will be drawn into the mouth, the nipple and areola elongated into a teat, and the suckling reflex initiated.

Fig. 7.1, Hand massage and licking: innate infant responses to skin-to-skin care immediately after birth.

Potential Obstacles to First Latch

A few possible obstacles exist to immediate nursing: (1) a heavily medicated mother or unanticipated cesarean with general anesthesia, (2) a sick infant (e.g., respiratory distress, low Apgar scores, prematurity), and (3) a stable premature or late preterm infant (i.e., hypotonic or at high risk of decompensation). In these cases, the following recommendations may be helpful:

If the mother and infant are stable , skin-to-skin and latching should be attempted with continuous assistance, and hand expression should follow, with the colostrum being given to the infant by syringe, cup, or swab.
If the dyad is separated , hand expression should proceed as soon as the mother is awake and alert, and the colostrum should be brought to the infant; this both stimulates the physiology of lactation and protects the infant with the metabolic and immune stability afforded by colostrum. (See Appendix E on the manual expression of breast milk.)
If the mother is unconscious and separated from her infant , and she plans to breastfeed or her plans are unknown, hand expression should begin as soon as is feasible, ideally within 1 hour of delivery. The mother should then be regularly expressed (pump or hand) every 3 hours until she is awake and able to express milk or transition to breastfeeding independently. Maternal medications should be reviewed for safety with breastfeeding (see Chapter 11 on medications and Chapter 15 on medical complications of mothers).
If the mother is unconscious, the infant is stable and not fully separated from her , and the mother’s medications do not preclude breastfeeding, the infant may feed directly from the breast, with assistance, until the mother is awake and able to breastfeed independently.

Other, more rare concerns include a tracheoesophageal fistula or choanal atresia. The concern for an infant with a tracheoesophageal fistula is important, but nonacidified breast milk has not been shown to cause injury to lung tissue. ⁴⁷ If polyhydramnios or excess secretions are present at birth, a tube may be passed to the stomach to make sure the esophagus is patent. Choanal atresia is another anomaly that would be of concern, wherein infants will be unable to sustain a suck on the breast or bottle, which will prompt investigation.

Environment

In hospitals, both mother and infant will do better if there is an atmosphere of tranquility in the room, although this is significantly culturally mediated. ⁴⁸ Another risk to the infant is thermal stress. If the room is cool, warmed dry blankets may be used, and a hat could cover the infant’s head. Alternatively, it may be necessary to provide a radiant warmer over the infant and mother, given that both should be naked for skin-to-skin contact. Some mothers have shaking chills following the strenuous event of labor and cannot provide adequate warmth for the infant without some external source of heat or a blanket. It is well described that inadequately drying or warming an infant may lead to a cascade of events, from hypothermia to hypoglycemia, tachypnea, mild acidosis, and even sepsis evaluation and separation from the parents. Hypothermia is therefore more easily prevented than treated.

Supervision and Sudden Unexpected Postnatal Collapse

Supervision of the mother–infant dyad after birth is important to the health of the newborn, if not of the mother. Sudden unexpected postnatal collapse (SUPC) refers to a life-threatening incident during hospitalization following birth that may or may not result in death. Infants appear to be at the highest risk for SUPC during the first 2 hours of life, while in a prone position and unsupervised (such as during skin-to-skin care or unsupervised breastfeeding. ⁴⁹ Paul et al. report on a quality improvement bundle designed to prevent SUPC while encouraging appropriate breastfeeding care, including skin-to-skin care. ⁵⁰ They reported no SUPC events after implementing a standardized assessment tool and measurement of oxygen saturation levels with prescribed responses during skin-to-skin care. The center’s rate of SUPC fell from 0.54/1000 to 0/13,964 after intervention. Routine oxygen monitoring is both expensive and impractical for many centers around the world, and no RCTs have proven benefit. In addition, reviews of implementation of the 10 steps show an overall decrease in sudden unexpected infant death in the first 6 days after birth. ⁵¹ Based on the current evidence, we therefore suggest that mother–infant dyads be observed continuously during skin to skin and breastfeeding in the first 2 hours after birth and that risk assessment tools be incorporated into care to identify which mothers may need longer periods of observation.

Family Bonding

If possible, the mother, other parent or support person, and infant should remain together for at least the next hour. The first hour for the infant is usually one of quiet alertness, a state that will usually recur only briefly again in the next few days.

Early Term/Postnatal Distress

Infants who are early term (37 to 38 weeks) or have had a difficult delivery (e.g., failure to progress, vacuum delivery, unanticipated cesarean, maternal infection) may demonstrate feeding difficulties. ⁵² In particular, perinatal hypoxia, as noted by low Apgar scores, may be associated with subtle difficulties in suck. One analysis showed that the rhythms of nonnutritive sucking in infants with a history of perinatal distress were significantly different from the rhythms of normal control subjects even when no gross neurologic signs were present. ⁵³ See Chapter 13, Chapter 14 for information on assisting infants with complications.

Ocular Gonorrhea Prophylaxis

Ocular gonorrhea prophylaxis remains an important intervention to reduce gonococcal ophthalmia neonatorum. ⁵⁴ However, providers should consider delaying the instillation of prophylactic eyedrops or ointment until after the first 1 to 2 hours after birth. If the drops are put into the eyes, blepharospasm may prevent the infant from opening the eyes and will mar eye-to-eye contact and further adaptation of the neonate. Only if there is a known risk for gonorrhea should the treatment be immediately applied. Protocols in delivery rooms for nursing procedures and even some legislation has included the prompt administration of treatment within 1 hour of birth or before leaving the delivery area, which is not based on medical necessity but, rather, hospital management and nursing control.

Baths

The impact of the timing of an infant’s first bath on breastfeeding has been researched. Initial findings showed increased breastfeeding initiation with delaying the first bath, although later studies have not replicated this finding. ⁵⁵, ⁵⁶, ⁵⁷ This may be a result of significant study heterogeneity in baseline timing of the bath between study populations. For example, one recent study showed improved breastfeeding exclusivity with delaying the bath to 13 hours of life, but the starting bath time was between 1 and 3 hours after birth. ⁵⁸ It is well known that interrupting breastfeeding in this earlier timeframe can interrupt first latch and therefore reduce breastfeeding success. Studies that did not show an improvement in breastfeeding exclusivity had baseline bath starting times later than 6 hours.

Infants have shown less hypothermia with delayed baths and immersion-style bathing rather than nearly immediate sponge-bathing. In some areas, parents prefer to participate in giving the first bath in the room, and this may function as a learning opportunity for discharge education. ⁵⁹ This, coupled with the improved breastfeeding outcomes, suggests that the standard of care is moving toward later, immersion-style baths in the parent’s room, if bathing is done at all. There is are significant cultural variations and traditions surrounding infant bathing after birth and skin care. Because of high infant mortality rates worldwide and the need for a focus on thermoregulation, the WHO recommends drying and rubbing the newborn after birth but delaying the bath for 24 hours. ⁶⁰

Assisting With Latch

Although healthy newborns can latch themselves after birth and skin-to-skin time, some infants may need more assistance, especially in the days following. There are many positions that are used for breastfeeding, and over the course of the first week, mothers should be instructed in several so that they may find what is most comfortable for them and their infants. The elements described herein are most important for newborns and young infants and are progressively less important over time: infants and toddlers may empty the breast comfortably in many positions. All positions should follow the same basic principles to ensure effectiveness (milk transfer) and comfort (lack of maternal pain or infant fussing). Table 7.2 describes the elements of an effective latch. In teaching families, it can help to remind them that these are the same as are required for an adult drinking a glass of water: lining up straight (body positioned straight toward the water), head straight (no head turning to allow for swallowing), arms wide (to ensure closeness with the glass), and head tilted back (when the head is brought straight again, this simulates nipple to nose). Ultrasound studies have been done to observe the oral mechanics involved in milk expression while nursing, helping to confirm the rationale for these positions. ⁶¹ Fig. 7.2 shows an ultrasound image of an infant at the breast, and Fig. 7.3 depicts latching at the breast. Images of various positions for the infant and mother to facilitate latching on are shown in Fig. 7.4A to E .

Table 7.2

Elements of Effective Latch in Any Position

Positioning	Rationale	Assistance
Body: Infant abdomen touching maternal abdomen (“tummy to tummy”)	Ensures infant and maternal proximity, encourages skin to skin while learning to latch, aids in aligning the infant to the breast so that the head may approach the breast properly	Unwrap baby. Laid-back: Place baby facedown on mother. Cross-cradle: place baby with abdomen touching mother’s horizontally.
Arms: Infant arms around breast	To manage infants’ sometimes active arms, many mothers are encouraged to “tuck in” the arms between the mother and infant. Pinning down the arms in this manner creates distance between the mother and infant, which may result in a shallower latch. Also, it can require the infant to turn their head to latch, limiting milk transfer.	Avoid tucking or “pinning” arms between mother and infant. Respond to earlier feeding cues so that arms are less active. If arm holding is necessary, the father/other parent or helper may assist.
Head: Aligned straight to mother’s breast/not turned	Having a turned head while latching creates a side-looking rooting, shallower gape, less nipple stretch, and poor milk transfer. This may be uncomfortable for both mother and infant.	Turning the infant’s body to face the mother is often all that is required to correct a turned head. In the “football” position/under the arm, pillows under the mother’s arm and behind her back will assist the head alignment.
Head: Nipple to infant’s nose (see Fig. 7.3 )	This allows the infant to create a natural head tilt, which enables maternal nipple stretching and effective infant swallowing. In this position, the infant’s lips should be flanged open (rolled outward) so that more of the mucus membrane of the mouth is touching the nipple rather than the lip itself.	If the mother positions with the nipple at the infant mouth, demonstrate moving the infant slightly so that the nipple starts pointing at the infant’s nose. Infants who push back from the breast are often responding to being placed directly in front of the nipple or with the nipple below the mouth.

Fig. 7.2, Ultrasound of an infant at the breast. Still picture of ultrasound scan frame from video recording. The scanner head is at the bottom, with a sector view of 90 degrees. Below is an artist’s impression of the image showing key features. The image is seen best when tilted through 45 degrees so that the infant’s head is vertical. The picture corresponds to the point in the sucking cycle when the maximum point of compression of the nipple by the tongue has almost reached the tip of the nipple. Once the nipple has become fully expanded, a fresh cycle of compression will be initiated at the base of the nipple and will then move back.

Fig. 7.3, (A) As the infant grasps the breast, the tongue moves forward to draw in the nipple. (B) The nipple and areola move toward the palate as the glottis still permits breathing. (C) The tongue moves along the nipple, pressing it against the hard palate and creating pressure. Ductules under the areola are milked, and flow begins as a result of peristaltic movement of the tongue. The glottis closes. Swallow follows.

Fig. 7.4, Different positions used for breastfeeding. (A) Laid-back breastfeeding position. (B) Side-lying position. (C) Cradle position for breastfeeding. (D) Cross-cradle position. (E) Football-hold position.

Shortly after birth, lying down may be preferable for the mother. The mother may lie back (fully or partially) ( laid back position) and latch with the infant lying on top of her or lie on her side, with the infant placed on its side, facing the breast. Breast support may be provided with the hands or bedding (small towel, blanket, or pillow). In any position, pillows help sustain the mother’s position, especially on her back, arms, and between her knees (if side-lying). The pillow between the knees while lying down may prevent her from rolling over should she drift asleep.

When a mother is sitting up, the cradle position , with the mother bringing the infant to the breast while cradling the infant in her bent elbow, is the most common and natural position, especially once a mother is home.

The cross-cradle or cross-over hold works best with the mother sitting erect with one to two pillows in her lap so that the baby is just at the level of the breast and not above the breast. The infant is held with the opposite arm so that the infant’s head and shoulders are held. The thumb is below one ear, and the fingers are below the other ear. With the head tipped back slightly and the infant brought to the breast, the nipple can stroke the infant’s lower lip.

The football hold refers to the infant being tucked under the arm so that the mother supports the infant’s head with her hand and the infant is supported by the mother’s arm or pillows under the arm. The infant must be squarely facing the breast. The side-lying position is where both mother and infant are lying on their sides on the same horizontal surface, with the infant directly facing the breast. The breast may be supported by a towel or pillow, and the mother’s hand supports the infant’s upper back, neck, and head as needed.

Traditional cradle and football positions were called into question by Colson et al., who observed less effective breastfeeding and declining duration with these positions, despite maternal training. ⁶² They studied 40 mothers and infants in England and France by watching videotaped feeds during the first month postpartum. Primitive neonatal reflexes were described and compared, along with their impact on latching (stimulating or inhibiting latch). They found that more stimulating reflexes were expressed by infants who were fed in a semireclined posture rather than an upright or side-lying position. When mothers chose their own body positions, they selected semiinclined positions, in which the infant displayed antigravity reflexes that helped them to latch. Gravity pulled the infant’s chin and tongue forward, triggering mouth opening to achieve attachment. This is also the basis for Pamela Douglas’s “Gestalt Breastfeeding” method, which attempts to return mothers from a “checklist” version of latching to a more natural, infant-led approach. ⁶³ These training methods are available online, at a cost. At the very least, these suggest that alternatives to side-lying and sitting upright are viable positions to initiate lactation. ⁶²

Introducing all the possible positions is overwhelming at first and should be avoided. With a little practice, mothers will find what works best. Visual demonstration of the latch is available online. “Fifteen-Minute Helper” is a physician-produced video for the physician audience created by Jane Morten, MD, from Stanford University. ⁶⁴

Hand Positions

Two natural hand positions for the mother to introduce the breast are used most often. With attention to a few details, either position works (one is not right and the other wrong). The mother should be encouraged to use the hand position that is most natural and comfortable for her. The scissor grasp involves placement of the thumb and index finger above the areola and the other three fingers below the breast for support, thus allowing some compression of the areola. Care should be taken that the hand is not in the infant’s way of getting sufficient areola into the mouth ( Fig. 7.5 ). This grip has been used for centuries and was shown in sketches and paintings of ancient times. It may work better than the palmar grasp if the hand is large or the breast small.

Fig. 7.5, Scissor grasp, presenting breast while supporting infant.

The palmar grasp is the placement of all the fingers under the breast and only the thumb above ( Fig. 7.6 ). This has been called the C-hold or V-hold , depending on the size of the breast and the size of the hand. This gives firm support to the breast. It permits directing the breast squarely into the infant’s mouth and avoids the need to press the breast away from the infant’s nose. The palmar grasp is similar to the prehensile grasp of apes when they nurse their young.

Fig. 7.6, Palmar grasp for initiating breastfeeding.

Apes, however, are unable to assume another hand posture neurologically or anatomically. If too much pressure is exerted by the human thumb, the nipple will be tipped upward ( Fig. 7.7B ), causing abrasion of the underside of the nipple. It is preferable that the nipple be directed horizontally as it is placed in the mouth (see Fig. 7.7A ), with the infant’s head tilted up (some describe this as “aiming the nipple at the baby’s palate”).

Fig. 7.7, Palmar grasp (C-hold). (A) When the palm and fingers cup the breast with support and the thumb rests lightly above the areola, the nipple projects straight ahead or slightly downward (correct). (B) When the fingers come forward and the thumb presses firmly above, the nipple tips up and causes improper positioning. Improper positioning is a common cause of nipple abrasion (lower half) and pain with suckling.

Days in the Hospital

All hospitals should incorporate the WHO/UNICEF 10 steps, which are the best current evidence for in-hospital breastfeeding support. Ideally, hospitals should become Baby-Friendly because it provides routine oversight and review of practices, enabling a hospital to be continuously self-reflective. If a birth takes place at home or in a birthing center, staff with a rich understanding of breastfeeding should be made available. The value of a well-trained, knowledgeable, and empathetic nursing staff should not be underestimated. The knowledge and attitude of the staff have been two of the most important variables in successful breastfeeding. This style of postpartum care better prepares parents for discharge because they will gain the confidence to know and respond to their infants’ cues.

Providers should ensure safe rooming-in: that patients are encouraged to have their infants with them at all times, except as required for medical complications, necessary procedures that cannot be done in the room, or parental exhaustion risking the well-being of the infant or parents. An experienced nursing staff is critical to the management of the nursing family in the first few days postpartum. Advice should be reasonable and consistent, following evidence and best practices. Care teams should be educated in these practices yearly and should be aware of the potential to cause parental confusion by providing different advice than other staff assisting with breastfeeding. When too many individuals are involved in postpartum care, mothers are easily overwhelmed with information, especially if each person says something different. The hospital should provide at least one staff member who is also a board-certified licensed lactation consultant for every 15 postpartum patients.

Key points in management should include the following ⁶⁵ :

1.
Rooming-in: A mother and infant should be housed together unless there is a medical contraindication. Delay the bath and perform it in the room when possible. The policy of the nursery should be to have all breastfed infants taken to their mothers when they awaken during the night, if they are not already rooming-in.
2.
Feeding on cue: Feed whenever the infant shows signs of hunger ( Box 7.1 ). In keeping with the Baby-Friendly Hospital Initiative (see Chapter 1 ), infants should be nursed on cue around the clock and receive no other food or drink unless medically indicated.
Box 7.1

Signs of Hunger in an Infant
- 1.
  Begins to stir
- 2.
  Brings hand(s) to mouth
- 3.
  Shows increasing efforts to root
- 4.
  Increasing activity, arms and legs flexed, hands in fists
- 5.
  If not picked up, progresses to frantic movements, whimpering
- 6.
  Cries (a late sign of hunger)
3.
Assist with latching:
- a.
  Help the mother find a comfortable position. No rules should exist about sitting up or lying down on her side or on her back. Use pillows to support maternal position. If needed, help the mother find a comfortable hold for her breast.
- b.
  Help the mother position the infant so that she may bring her baby to the breast. Avoid pushing the infant’s head toward the breast because the infant will push back, often arching away from the breast. Holding or pushing the infant’s head has been associated with persistent arching by the infant (arching reflex).
- c.
  When waking an infant to initiate feeding, unwrap the blanket if wrapped, place the infant skin to skin, and use a gentle stimulus.
- d.
  Help the mother reposition the infant on the second breast if the infant is still interested after releasing the first side. Moving may be difficult for the mother immediately postpartum.
- e.
  It is common for the infant to fall asleep at the breast. Nonnutritive suckling while asleep may result in a shallow latch, which can cause nipple discomfort and trauma. The mother should be shown how to un-latch the infant by breaking suction with her finger.
- f.
  Signs of satiety: Sounds of swallowing dwindle and stop, nonnutritive suckling occurs in brief bursts, the arms and legs relax, and the infant falls asleep and usually releases the nipple.
4.
Timing of feeds: Stopwatch timing is not appropriate. It takes 2 to 3 minutes for the let-down reflex to produce milk in the early days, so the feeding must allow for the let-down. It is helpful for some mothers to have guidelines or estimates from which to work. Usually, infants nurse for about 10 to 15 minutes per breast in the first days, 8 to 12 times per day. Nursing continually hour after hour without a stretch of sleep should prompt evaluation for poor milk transfer or low milk supply.
5.
Caring for the mother/visiting hours/naps: With hospital or home, liberal visiting hours may limit parental sleep and recovery from the labor of birth. Adequate rest is essential to successful lactation. In the early days of the Rooming-In Unit at the Yale–New Haven Hospital, Barnes et al. insisted that all postpartum mothers have a nap after lunch. ⁶⁶ Every day, the shades were drawn, and traffic was decreased on the unit for an hour. This has been reinstituted in some hospitals and birthing centers as an afternoon “quiet time” and is part of mothering the mother. Many traditional cultures continue practices of mothering the mother after a birth: mothers are supported to rest, fed, groomed, and protected after delivery, sometimes for weeks.
6.
Rooming-in is the standard of care for all infants, regardless of feeding method. As noted in the Baby-Friendly USA interim guidelines (Step 7, Guideline 7.1), “When a mother requests that her infant be cared for in the nursery, the health care staff should sensitively engage her in a conversation to learn more about her understanding of the importance of rooming-in and the reasons for the request. Staff should work to resolve any medical reasons, safety-related reasons, or maternal concerns. If the mother still requests or if it is determined that the infant is best cared for in the nursery, the process and informed decision should be documented.” ³⁹

Infant in the Hospital

Feeding characteristics: Can infants be said to have a feeding “type”?

In 1953 Dr. Edith Jackson, with Barnes and other colleagues from the Yale Rooming-In Unit, prepared a classic description of the management of breastfeeding that remains an insightful look at the behaviors and needs associated with establishing lactation in a hospital setting. ⁶⁶ Infants were described as barracudas, excited ineffectives, procrastinators, gourmets or mouthers, and resters. This construct was found to correlate with breastfeeding duration in a study done in 2004 by Mizuno et al. with 1474 Japanese mothers. ⁶⁷ Although it seems clear that infants have different feeding styles, and families should be educated to be attuned to their infant’s eating patterns and cues, these types of descriptors also likely correspond to different feeding problems that we understand better today. Teaching a family that their feeding problem is a result of their child’s personality may undermine both the diagnosis and management of that problem, as well as the bonding relationship. For instance, infants who have severe tongue restriction and who are causing maternal nipple damage and are said to be “barracudas,” who always want to nurse and have no regard for the mother’s pain. Mothers dread feedings and their infants as a result. Or a child with frank failure to thrive as a result of inadequate maternal milk supply is called lazy , thus delaying appropriate diagnosis and management of both the mother and infant. A procrastinator or rester may have had a difficult birth, an excited ineffective may be overly hungry, and so forth. In fact, a qualitative analysis of postpartum audio recordings of interactions between health professionals and mothers while discussing breastfeeding found that many negative interpretations of infant behavior took place, and these influenced how mothers perceived their infants. ⁶⁸ Also concerning were the findings in a descriptive study of 87 low-risk mothers and infants >34 weeks’ gestation in New South Wales. ⁶⁹ Lucas et al. found that mothers with a body mass index (BMI) over 25 who described their infants as “vigorous nursers” (i.e., barracudas) were less likely to exclusively directly breastfeed at 1 month postpartum. They hypothesized that this was a result of the perception of inadequate milk supply and continuing discomfort with latch, both of which raise the concern for ongoing medical or educational issues with breastfeeding rather than the infant’s behavior.

It is therefore preferable to emphasize actionable observational findings over personality characteristics or “types.” For example:

Instead of calling a baby a “procrastinator,” say: “I see your infant is falling asleep at the breast; this may happen when an infant is full or when they are tired out from trying to get milk. Let’s figure out which one.”
Instead of calling a baby a “barracuda” or “piranha,” say: “I see your baby is working very hard to nurse and causing you pain; let’s see if we can make this better for you both.”

Fixing a medical problem associated with difficult nursing situations often changes infant behaviors at the breast. Alternatively, the baby’s nursing method may match well with maternal supply and anatomy, and a mother may be reassured when it goes well.

Timing of Feeds

The role of the clock

In heavily industrialized cultures, living with close attention to schedules (i.e., “living by the clock”) has become necessary. Therefore families who are more familiar with schedules than they are with newborns may have trouble when advised to feed a newborn by their cues. Anthropologist Millard examined pediatric advice on breastfeeding from textbooks written from 1897 to 1987 and noted a focus on timing, coupled with a heavy distrust of maternal and infant knowing. ⁷⁰ It has taken some time for the medical community to move from this undermining approach toward a more biophysical and supportive one. In breastfeeding, providers can help families break their bonds to timing and move to the central issues of successful breastfeeding, responding to the mother’s body and the infant’s cues.

Feeding frequency

A comparison of mammalian care patterns and composition of milk shows an inverse relationship between protein concentration and frequency of feedings. From this, it might be deduced that a human infant might need to be fed more frequently than every 4 hours ( Table 7.3 ).

Table 7.3

Mammalian Care Patterns and Composition of Species Milk

	Pinnipedia: Seal, Sea Lion	Tree Shrew	Rabbit	Rat	Black Rhinoceros ^a	Chimpanzee	Human
Infant care pattern	Return to ocean after birth	—	Cache	Carry, hibernate	—	Carry	?
Feeding interval	Once a week	48 h	24 h	Continuous	—	Continuous	?
Composition of Milk
Total solids (%)	62–65	20	33–40	21	8.1	11.9	12.4
Protein (%)	8–14	11	14–23	10	0.0	3.7	3.8
Fat (%)	53	6.5	18	8	1.4	1.2	1.2
Carbohydrate (%)	0–0.90	3.2	2.0	2.6	6.1	7.0	7.0

a The rhinoceros has an anatomic variation in the stomach that provides four pouches that fill during a feeding and provide a constant trickle of milk to the central groove leading to the small intestine, thus creating a constant feed.

New mothers may be insecure and concerned about the lack of scheduling, especially when an ad lib program of feeding has been suggested. Other mothers may thrive on random scheduling. When rigid feeding schedules are proposed, this undermines the appropriate establishment of lactation. ⁷¹ A Cochrane review notes that feeding on cue is currently the standard of care, and there is no sufficient evidence to recommend scheduled feedings instead. ⁷² Three- to 4-hour feeding programs were originally based on the feedings of bottle-fed infants, whose slow emptying time of the stomach with formulas requires up to 4 hours. The emptying time for breast milk is about 1½ hours; thus frequent feedings are not unusual. Pediatric textbooks at the beginning of the 20th century described 10 to 12 feedings per day as normal. ⁷¹ In one study of 71 mother–infant pairs, feeding frequency was independent of timed fat content and, rather, varied by time of day, which breast was used, which breast had been used last, whether both breasts were offered, and whether the infant fed at night. ⁷³

Infants who sleep 5 to 6 hours at a stretch at night may make up for skipped feedings during the day. When milk intake and feeding patterns of 45 thriving, ad-lib-feeding, exclusively breastfed infants were documented from birth for the first 4 months of life by Butte et al., two feeding patterns emerged. ⁷⁴ In one, the authors describe the feedings as distributed throughout the 24-hour day. In the other, feedings were excluded from midnight to 6 am . Total intake was the same in 24 hours. Milk volume per feeding decreased over the day. Frequency and duration declined over the 4-month period. Weight gain was similar in the two groups. This suggests that there is not a perfect pattern for all infants, and milk intake can self-regulate when exclusive breastfeeding is going well, regardless of the pattern.

Patterns of intake

The pattern of intake during a feeding is different between breastfed and bottle-fed infants. A bottle-feeding infant sucks steadily in a linear pattern, receiving 81% of the feed in 10 minutes. Howie et al. showed that a breastfed infant has a biphasic pattern, which includes the first 4 minutes on the first breast and the first 4 minutes on the second breast (this latter between 15 and 19 minutes into the feed). ⁷⁵, ⁷⁶ The infant receives 84% of the total volume in those 8 minutes. In another study, 50% of the feed on each breast was consumed in 2 minutes and 80% to 90% by 5 minutes. Milk flow was minimal during the last 5 minutes. All these observations were made on the fifth to seventh day of life ( Fig. 7.8 ). Donna Geddes and Peter Hartmann confirmed this using submental ultrasound and intraoral vacuum measurement during nursing and found that infants become more efficient at milk transfer over time, having a total feed duration of 14 minutes at less than 1 month and 10 minutes at 4 months of age. ⁷⁷

Fig. 7.8, Mother–infant pattern of milk flow.

Providers and lactation consultants have recommended different patterns of nursing to promote milk supply and transfer; some of these recommendations may disrupt physiologic feeding. For example, “switch nursing” refers to removing the infant from the first side offered before they have emptied the breast—for example, feeding 5 minutes on the right side, then switching to the left for 5 minutes, then back to the right, then back to the left (see Fig. 7.8 ). When mothers fed 10 minutes on each breast (10 + 10), they produced the same amount of milk as they did when nursing for 5 minutes on a side and switching back (5+5+5+5). The suckling-induced prolactin was similar with both patterns as well. A major concern of switch nursing is not feeding long enough on either breast to obtain the full calories of hindmilk. Even if this improves volume, total calories may be decreased. The infants do not nurse for a full 20 minutes in some cases, and the nutritive feeding time is less than 15 minutes. The duration of feeding should be determined by the infant’s response and not by time. Enough time must be spent on a single breast to ensure that the infant gets the fat-rich, calorie-rich hindmilk. Another suggestion offered to parents is to offer the “third side,” which means after the infant has transferred what they can from the two breasts, putting them back to the first side again. This is done when the infant is still showing signs of hunger after what should be a “full feeding.” Howie et al.’s study (discussed previously) may help to explain why this rarely results in significant milk transfer. In our experience, test weights after this “third side” reveal little to no milk transfer. ⁷⁶ Rather, infants fall asleep, tired and unable to get a full feed.

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