TABLE 1. Positive Factors Regarding Breast-Feeding

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1 Ruth A. Lawrence, MD* The questions below should help focus the reading of this article. 1. What should women do during the prenatal period to prepare for lactation? 2. Does physical examination of the breasts of women with insufficient mammary tissue typically demonstrate any abnormalities? 3. What clinical features help to differentiate between infants who are failing to thrive and healthy infants who are gaining weight slowly? 4. How do fore milk and hind milk differ? 5. When should supplemental bottle feedings be used for breast-fed infants? 6. What is the difference between early and late forms of breast-feeding related jaundice, and how are they treated? Lactation is the physiologic completion of the reproductive cycle. All mammalian species produce a milk specific to their own offspring and optimal for the ideal growth and development of those offspring. Only the human species has challenged or replaced this stage. Technologic advancement in nutrition has enabled us to manufacture a biochemically acceptable substitute using bovine milk as a base that sustains life and allows growth when the infant s own * Professor of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York. mother does not provide her own milk. This same technology has recently been applied to the study of human milk to reveal in even more biochemical, immunologic, and physiologic detail the species specificity of human milk. It is not simply a matter of providing macro- and micronutrients but the provision to the infant of a living dynamic fluid with nutrients, enzymes, epidermal growth modulators, infection protection, and allergy prophylaxis. At the same time, the process involves a hormonal milieu for the mother that promotes maternal feelings and facilitates the mother s physiologic return to the prepregnancy state while suppressing ovulation and delaying immediate return to fertility. Biochemists, enzymologists, anthropologists, and behavioral scientists all support the superior value of human milk and breast-feeding (Table 1). The pediatrician needs to be able to provide adequate information to expectant parents who need to make an informed choice. In 1970, only 20% of women left the hospital nursing their infants. Less than 10% were still nursing when the baby was 5 to 6 months of TABLE 1. Positive Factors Regarding Breast-Feeding Species specificity Nutrition advantages Host resistance factors Immunologic protection Allergy prophylaxis Psychologic bonding EDUCATIONAL OBJECTIVE 15. The pediatrician should have an appropriate understanding of the possibility that insufficient glandular tissue may be responsible for failure of lactation, and ability to distinguish this possibility from other causes for breast-feeding difficulties (Recent Advances, 89/90). This Educational Objective is a limited one but stimulated the Editor to request a general review of breast-feeding for our readers. Few topics in pediatrics are more important. R.J.H. Self-Evaluation CME Credit age. The efforts of a few physicians and many well-educated women who discovered for themselves the great benefits of breast-feeding and reversed that trend. A bipartisan government committee published health goals for the United States in 1978, stating that, by 1990, 75% of women should leave the hospital breast-feeding, and at least 35% should still be breast-feeding when the babies are 6 months of age. The Surgeon General has initiated an aggressive campaign to reach this goal. The pediatrician, however, as the coordinator of health planning and nutritional guidelines for the child, is crucial to its success. To date, this campaign is falling short of the goal. Having reached a high level of 62.4% in 1984, the incidence has decreased to 52.8% in Casual analysts have used increas- Quiz- As an organization accredited for continuing medical education, the American Academy of Pediatrics certifies that completion of the self-evaluation quiz in this issue of Pediatrics in Review meets the criteria for two hours of credit in category I of the Physician s Recognition Award of the American Medical Association and two hours of PREP credit. The questions for the self-evaluation quiz are located at the end of each article in this issue. Each question has a SINGLE BEST ANSWER. To obtain credit, record your answers on your quiz reply cards (which you received under separate cover), and return the cards to the Academy. On each card is space to answer the questions in five issues of the journal: CARD 1 for the July through November issues and CARD 2 for the December through April issues. To receive credit you must currently be enrolled in PREP or a subscriber to Pediatrics in Review-and we must receive both cards by June 30, Send your cards to: Pediatrics in Review, American Academy of Pediatrics, 141 Northwest Point Blvd, P0 Box 927, Elk Grove Village, IL The correct answers to the questions in this issue appear on the inside front cover. pediatrics in review #{149} vol. 11 no. 6 december 1989 PIR 163

2 ing maternal employment to account for the decrease but, in fact, stay-athome mothers are bottle feeding in equal or greater numbers. Many working women breast-feed and design a mechanism to continue to provide their milk and breast-feed even when returning to the job. Therefore, it is safe to conclude that the option is one of personal choice, as opposed to simple, practical necessity. The pediatrician is in a position to counsel mothers to make a more informed choice about breast-feeding. Many pediatricians cite inducing guilt as the primary reservation against counseling about breastfeeding. The assumption is that providing sound medical information about the value of breast-feeding will cause undue stress in the mother who chooses not to do so. That assumption seems at odds with the standard medical tenet of the value of informed choice. The real guilt that has become apparent is in the women who bore children in the 1960s and 1970s and did not breastfeed because they were never clearly informed of the pros and cons of both options. Fig 1. Female breast from infancy to lactation with corresponding cross section and duct structure. A to C, Gradual development of well-differentiated ductular and peripheral lobularalveolar system. D, Ductular sprouting and intensified peripheral lobular-alveolar development in pregnancy. Glandular luminal cells begin actively synthesizing milk fat and proteins near term; only small amounts are released into lumen. E. With postpartum withdrawal of luteal and placental sex steroids and placental lactogen, prolactin is able to induce full secretory activity of alveolar cells and release of milk into alveoli and smaller ducts. Photograph used with permission: Lawrence RA. Breastfeeding: A Guide for the Medical Profession. 3rd ed. St Louis, MO: CV Mosby Co; PREPARATION FOR LACTATION Women become aware early in pregnancy of the enlargement in their breasts. From the onset of pregnancy, the hormones generated by the pituitary, the corpus luteum in the ovary, and the placenta provide an environment conducive to the proliferation of the ductal system and the arborization of the alveolar structure. By the 16th week of gestation, the lacteal cells differentiate such that the breast will be capable of producing and releasing milk when the pregnancy ends and the placenta is delivered (Fig 1). The breast also prepares for the process of suckling. The areola becomes darker and more prominent, purportedly to make it more conspicuous to the infant, and the skin over the nipple and the areola becomes hardier to endure frequent sucking. The glands of Montgomery, sebaceous glands generously distributed over the areola, become visible as they hypertrophy and produce a secretion designed to lubricate the areola and nipple (Fig 2). The nipple Nipple - Subcutaneous Nipple subareolar and fat musculature Mammary fat,am.ui atferous sinus) / / Ldctterus ducts,arn (nterlcbu)ar connective tissue th rirnr,vei1 alveoli) parenchyma - Cooper s Lobules (suspensory) ligaments Fig 2. Morphologic features of mature breast with dissection to reveal mammary fat and duct system. Photograph used with permission: Lawrence RA. Breastfeeding: A Guide for the Medical Profession. 3rd ed. St Louis, MO: CV Mosby Co; PIR 164 pediatrics in review #{149}vol. 11 no. 6 december 1989

3 HEALTH SUPERVISION becomes more erect and its elastic tissue proliferates, creating an erect, pliable, stretchable protrusion that conducts the product of 15 to 20 milk ducts to the outside. (Any multiparous woman can attest to the tremendous elasticity of the nipple as an older infant turns his or her head while continuing to suckle.) In most cases, the mother need do nothing to prepare her breasts. At scheduled prenatal examinations, her obstetrician should discuss infant feeding. If there are anatomic vanations such as flat or inverted nipples when the mother plans to breastfeed, the problem can be identified, discussed, and treated before delivery. Ideally, a new mother also visits her pediatrician before delivery to discuss infant feeding, infant care, and other issues of parenting. The pediatrician should inquire about the breast examination and seek permission to discuss it with the obstetrician or offer to provide the examination if there is any question. The pregnant woman may not be ready to handle her breasts frequently until the infant is born. Ordinarily, no ointments, salves, lotions, or abrasive manipulation of the breasts is indicated. The latter, in fact, can be irritating, damaging the Montgomery glands or the proliferating elastic fibers. Even buffing with a turkish towel can destroy the glands, and pulling, stretching, and twisting the nipples can cause pain and infections or an aversion to breast-feeding. Vigorous nipple exercising has been associated with uterine contractions. In fact, nipple manipulation is used clinically by obstetricians as stimulus for an oxytocin challenge test or to stimulate labor. The average woman need only purchase some brassieres that are adjustable to her changing shape and are usable for both pregnancy and lactation. This will provide support for the heavy breasts and avoid undue stretching of the ligaments of Cooper. Opening the flaps in the front of the brassiere exposing the nipple and the areola under her clothing provides gentle, soft abrasion of the surface for days and weeks in preparation for breast-feeding. Swedish women, most of whom breast-feed, attribute the absence of sore nipples to the fact that they expose their breasts to sunshine and loose clothing routinely throughout young adult life. PROBLEM BREASTS Adequate Breast Tissue The size of the breasts should not be an obstacle to breast-feeding. There is little correlation between size and capacity to produce milk. Only when the breasts appear grossly abnormal does there exist overt evidence of a lack of breast tissue. (Neiffert reported cases of several dozen women unable to produce enough milk, which was attributed to madequate glandular tissue as evidenced by ultrasound.) Breasts that have been subjected to reduction mammoplasty may have had the nipple moved and reattached more centrally. The ducts are severed during this reattachment surgery. Augmentation mammoplasty, on the other hand, does not usually sever ducts or nerves, and lactation can be successful in most cases. Women who have had benign cysts removed can also usually breast-feed without a problem; however, women who have had breast cancer are advised to avoid pregnancy and lactation for 5 years. Advice, in this case, should be based on knowledge of the individual case and the pathologic findings of the lesion. If the breasts were grossly abnormal, however, there may be too little breast tissue and prenatal evaluation of glandular tissue, by special imagery techniques, is in order. It has been shown that, whenever surgery is done on the breast, sensory response is diminished for 6 months to 1 year following the manipulation. The sensory arc to letting down milk will be muted during that time. Inverted Nipples Inverted or flat nipples deserve prenatal attention, and treatment is most successful if initiated before delivery. There has been no controlled study demonstrating the value of vigorous pulling and stretching of the nipple manually. The most effective treatment is a passive method using breast shells (Fig 3) over the nipple and areola inside of the brassiere for 6 to 8 weeks (or longer) before delivery. This provides even, gentle, sus- Fig 3. Nipple shell in place inside brassiere to evert nipple. Photograph used with permission: Lawrence RA. Breastfeeding: A Guide for the Medical Profession. 3rd ed. St Louis, MO: CV Mosby Co; tamed pressure equally over the areola causing the nipple to evert through the central aperture. A domeshaped cover is worn over the plastic ring to protect the nipple while increasing the pressure within the brassiere against the ring. The shells should be worn between feedings immediately postpartum until lactation is well-established. An electric breast pump can be used postpartum in the hospital to further draw the nipple out, if necessary. LEARNING TO BREAST-FEED Breast-feeding is neither a reflex nor a signal behavior. A woman is not born knowing how, and she may give birth without knowing how, if she has had no role models or personal instruction. Lay groups such as La Leche League International and International Childbirth Education Association provide prenatal classes in birth and breast-feeding preparation. There are often women at these meetings who are actually breastfeeding. In addition, group practices of obstetrics, pediatrics, or family medicine often provide their own classes, guaranteeing that the information provided is in concert with their practice protocols. A woman, however, can manage to learn on the job after the baby is born, if the hospital nursery nursing staff is experienced, knowledgeable, and supportive. Learning from one of several how-to books available in book- pediatrics in review #{149}vol. 11 no. 6 december 1989 PIR 165

4 stores is also possible. The New York State Health Code has required, since 1 984, that every hospital where babies are delivered in New York State provide knowledgeable nursing staff and formal patient training about breast-feeding. The code also forbids bottle feeding or going-home packs of formula for breast-fed infants without a doctor s order. FEEDING THE INFANT There are only a few key factors necessary to initiating successful breast-feeding for most mothers and infants. It has been portrayed as far too complex by some counselors and much of their elaborate advice overlooks basic physiologic principles. The infant is born with a few primary reflexes. Sucking and swallowing have occurred in utero, and the infant seems to know what to do. Except in infants with neurologic disorders or premature infants less than 34 weeks gestation, sucking and swallowing are coordinated. Newborn infants also have a brisk rooting reflex at birth. Sucking at the breast is the physiologic process by which the nipple and areola are drawn into the mouth to make an elongated teat. The lips and gums form a seal to hold the breast in place, with negative pressure generated by the infant s suckling (Fig 4). The normal motion of the tongue is peristaltic in nature similar to the motion of the intestinal Fig 4. Suckling at breast is process by which nipple and areola are drawn into mouth to make elongated teat. Lips and gums form seal and hold breast in place. Undulation of tongue moves milk from ampullae along ducts to be ejected. Photograph used with permission: Lawrence RA. Breastfeeding: A Guide for the Medical Profession. 3rd ed. St Louis, MO: CV Mosby Co; tract. The tongue does not continually stroke the nipple, which would abrade it, but undulates, moving the milk along the ducts from the collecting ampulla. If one watches an infant who sucks his or her own tongue or continues to suck slowly when asleep at the breast, the peristaltic motion is evident. Bottle feeding requires a different motion, involving compressing and releasing the artificial rubber nippie against the palate. A rubber nipple is not conducive to peristaltic action. The position of the infant in relationship to the breast is a fundamental element in successful lactation. The infant faces the breast and should be held with the ventral surface facing the mother so the infant s head need not be turned. Snugly swaddled infants, the pride of some nurseries, are presented to the mother facing the ceiling, a position necessary for bottle feeding. To breast-feed, the infant should be rotated 900 to face the breast. The infant s head should rest in the crook of the mother s arm, and the forearm should support the back. The hand is then free to support the buttocks. The mother can draw the baby toward her body securely. A pillow in the mother s lap will give added support to the infant. The mother uses her other hand to present the breast. A scissors grip of the breast (two fingers above and three below and behind the areola) allowing areola and nipple to protrude is the traditional grasp (Fig 5). An alternative technique, the palmar grasp, works well when the breast is big and the hand small or there is excessive engorgement or a sore nipple. The breast is supported with all fingers below and the thumb above the breast, compressing the areola for the infant (Fig 6). This grasp assures placing the breast squarely in the mouth with adequate airway space. It also avoids the necessity of pressing the breast away from the nose which tips the nipple upward in the mouth causing abrasion of the underside of nipple and areola. Attention to proper positioning can avoid sore nipples and is mandatory when trying to correct sore nipples. The pediatrician needs to be familiar with alternative techniques and positions for breast-feeding that facilitate nursing while sitting or lying down. The remedial care of sore nipples or breasts or nursing after cesarian section are all responsibilities of the pediatrician. Effective remediation for mothers having difficulty initiating breast-feeding can only be prescribed after first observing the feeding process. Treatment depends on the proper mechanics of breast-feeding, not medications or substitute bottles. WHEN TO BREAST-FEED The ideal initial breast-feeding takes place shortly after birth. An infant placed on the mother s abdomen after the cord is clamped will often inch up the abdomen in search of the breast. An unmedicated infant with good Apgar scores is alert and vigorous and ready to suckle. No intervening water feedings are necessary for the healthy infant. The mother can be assisted to turn on her side and the infant placed ventral surface to ventral surface while the breast is held by the mother. If the corner of the mouth or lower lip is stroked with the nipple, the infant will turn toward the nipple and open his or her mouth. The breast can be inserted, and the infant will reflexively suck. There are conflicting opinions regarding the optimal duration and interval of feedings. Ideally, while supply is being established in the first few weeks, the infant will nurse at both breasts for 10 minutes or more. This will provide bilateral stimulation every few hours. If the infant nurses too long on the first breast, he or she will fall asleep before taking the second. Excessive sucking, especially in primiparous women, may lead to irritation of the nipple and areola. On the other hand, a stop watch approach to feeding interferes with letdown, and in the first few days of lactation it takes at least 2 minutes of sucking stimulus to complete the ejection reflex arc (Fig 7). The ejection of milk is a reflex that is triggered when suckling initiates a nerve message to the brain signaling the hypothalamus to release two hormones: prolactin, which stimulates the target organ (the breast) to produce milk, and oxytocin, which stimulates the myoepithelial cells of the breast duct system to contract and eject the milk. PIR 166 pediatrics in review #{149}vol. 11 no. 6 december 1989

5 HEALTH SUPERVISION t..1 Fig 5. Presenting breast while supporting infant. Scissors grasp of breast has thumb and forefinger on top and three fingers under breast (but well behind areola) to compress breast so that infant can latch on. Photograph used with permission: Lawrence RA. Breastfeeding: A Guide for the Medical Profession. 3rd ed. St Louis, MO: CV Mosby Co; Fig 6. Infant suckling with breast held in palmar grasp with fingers under breast and thumb on top; all well behind areola for good grasp of nipple and areola. Photograph used with permission: Lawrence RA. Breastfeeding: A Guide for the Medical Profession. 3rd ed. St Louis, MO: CV Mosby Co; Ejection of milk already in the duct system may be weakly stimulated by the smell, sound, or sight of the infant, but only sucking (or pumping) stimulates prolactin release and milk production. I I Duration of feedings is gradually increased as the infant s needs increase during the next few days. Usually, nursing is initiated on the alternate sides and timing is divided between the two breasts, approximately equal throughout a day s time. Attention to timing should not be rigid nor should it be totally neglected; each mother gradually adapts to her infant s signals. Many formula-oriented practitioners tend to apply bottle regimens to breast-fed infants, making frequency an issue of discussion. The emptying time of mother s milk from the infant s stomach is 1 1/2 hours, the emptying time of formula made from cow milk base is 3 hours, evaporated milk takes 4 hours, and unmodified pasteurized cow milk takes 6 hours. In general, in other species, the lower the fat and protein content of the milk, the shorter the interval between feedings. The goat, for example, feeds continuously. Human milk has less protein than goat s milk and is quickly digested by the human infant. The breast-fed infant is usually ready to feed again in 2 hours. In the early weeks of breast-feeding, a healthy, well-nourished infant may need to feed every 2 hours or sooner and will gradually space out feedings so that there is at least one sleeping period of 4 hours in a 24-hour period. Frequent feeding is important in establishing a good milk supply, but rigid schedules that mandate 4-hour intervals are often disastrous. Successful management of this approach is rare. More often, practitioners who hold to this advice have many women weaning in 1 or 2 months because of poor milk supply. Well-informed mothers who learn the physiology of lactation from other sources ignore such poor advice. Frequent feedings using both breasts for a total of approximately 20 minutes is preferable. Most infants have at least one lengthy (1 hour) feeding per day or a period of 3 or 4 hours, often in the evening, when they nurse frequently, seemingly continually. After a good supply is established, usually within 4 to 6 weeks, some mothers will find that their infants sleep longer and gain more weight if they nurse the entire feeding on one breast to get the fat-rich higher calorie hind milk. This may improve the weight of a slow gainer. SUPPLEMENTATION Introducing bottle feedings into the management of the nursing couple pediatrics in review #{149}vol. 11 no. 6 december 1989 PIR 167

6 Hypothalamus ProlactI1, Lacteal xytocin Uterus Myoepithellal Cell Gland I a result, the infant quickly weans to I bottles exclusively. A faltering milk supply should be evaluated for cause and appropriate treatment initiated. Treatment may include increased rest for the mother, added nutrition while breast-feeding, and stress reduction. Pumping with an electric pump between feedings will also facilitate increased milk production. MANAGEMENT AFTER HOSPITAL DISCHARGE The current practice of early discharge from the hospital occurs before the milk comes in in primiparous women (about 72 hours) and certainly before lactation is well-established. All infants discharged before the 4th day should be seen by 2 weeks of age. Primiparous women and their infants who are breast-feeding should be seen by 7 to 10 days of age. Phone contact between hospital discharge and the initial office visit should be encouraged. Fig 7. Diagram of ejection reflex arc. When infant suckles breast, he or she stimulates mechanoreceptors in nipple and areola that send stimulus along nerve pathways to hypothalamus, which stimulates posterior pituitary to release oxytocin. It is carried via bloodstream to breast and uterus. Oxytocin stimulates myoepithelial cell in breast to contract and eject milk from alveolus. Prolactin is responsible for milk production in alveolus. It is secreted by anterior pituitary gland in response to suckling. Stress such as pain and anxiety can inhibit let-down refelx. Sight or cry of infant can stimulate it, too. Photograph used with permission: Lawrence RA. Breastfeeding: A Guide for the Medical Profession. 3rd ed. St Louis, MO: CV Mosby Co; impacts on both the infant s adaptation to sucking and the mother s ability to produce milk. Some infants are undaunted by bottle feedings and unphysiologic schedules, and some women produce generous milk supplies despite obstacles. But, in general, mother-infant pairs falter under such stresses. These pairs can only be identified when lactation fails and retraining and reestablishing milk supply is abandoned. The breast-fed infant does not need water or glucose water after breast-feeding. Such supplements tend to mute the appetite for breastfeeding, depriving the mother of the much needed stimulus and the baby of the rich colostrum. Even 5% dextrose in water provides virtually no calories. Infants who receive water supplements lose more weight and regain more slowly than those who are unsupplemented. Some neonates do not tolerate being switched back and forth from breast to rubber nipple and fail to suck effectively on either. Substituting formula for breastfeeding may be necessary for medical indications of the mother, but the gap between breast-feeding should not exceed 8 hours unless the medical problem is serious. Two bottle feedings in succession at night, creating a 12-hour breech between breastfeedings, is a recipe for lactation failure. When this must occur for medical reasons, pumping the breasts with an electric pump for additional stimulus and special attention to the success of the lactation process will be required. After discharge from the hospital, it is advisable not to introduce a bottle at least until lactation is well-established (approximately 4 weeks). Topping off each feeding at the breast with a bottle of formula should the milk supply falter further aggravates the problem by depriving the breasts of adequate stimulus. As VOIDING AND STOOLING Mothers should keep track of their infants stooling and voiding as an indicator of adequate intake (Table 2). In the first few weeks, supraabsorbent diapers should be discouraged so that voiding can be adequately monitored. The well-fed infant uses at least six diapers per day, several of which should be drenched. In the first month of life, there should be a minimum of two stools a day, although breast-fed infants have a strong gastrocolic reflex and usually stool with every feeding. Failure to stool in the first few weeks of life may be an early sign of starvation and should not be ignored. An infant who TABLE 2. Assessment of Breast-Feeding Weight pattern-consistent weight gain Voiding-6 wet diapers/d; several soaked Stooling-minimum of 2 stools/d Feeding pattern-at least 6 feedings/d Duration of feedings-long enough to ensure hind milk Activity and vigor of infant PIR 168 pediatrics in review #{149}vol. 11 no. 6 december 1989

7 HEALTH SUPERVISION voids but does not stool may not be getting enough calories. After 1 month of life, stools may be less frequent, decreasing even to every few days. If everything else is normal, this can be normal also. The infant may get enough volume and more than enough lactose but not enough fat. Management requires the necessary efforts to enhance production of fatrich hind milk, such as feeding on one breast at least 20 minutes before switching to the second. COMMON CAUSES OF POOR MILK PRODUCTION Early identification of problems with lactation can usually help avoid lactation failure, inadequate milk production, and early termination of breast-feeding. When evaluating poor infant weight gain, it is important to distinguish between slow gaining and failure to thrive (Table 3). Infants who are alert and active, have good tone and turgor, and are gaining slowly but consistently are slow TABLE 3. Evaluation of Breast- Fed Infants* Infant Who is Slow to Gain Weight Alert healthy appearance Good muscle tone Good skin turgor At least 6 wet diapers/d Pale dilute urine Stools frequent, seedy (or if infrequent, large and soft) 8 or more nursings/d, lasting mm Well-established let-down reflex Weight gain consistent but slow Infant With Failure to Thrive Apathetic or crying Poor tone Poor turgor Few wet diapers Strong urine Stools infrequent, scanty Fewer than 8 feedings/d, often brief No signs of functioning let-down reflex Weight erratic or weight loss * From Lawrence RA. Breastfeeding: A Guide for the MedicalProfession, 3rd ed. St Louis, MO: CV Mosby Co; 1989 (used with permission). gainers. This deserves attention but is not an emergency, and it is most likely that breast-feeding needs adjustment, not supplementation. The reason for slow weight gain could be that, although there is plenty of lactose-rich milk to cause frequent loose stools, there is not enough fat in the diet. A review of feeding patterns may be helpful. Switch nursing (switching from one breast to the other every few minutes) may interfere with both volume and fat content. If the mother is switching to the second breast in the middle of feeding, the breast may have enough time to produce only low-fat fore milk before the infant is switched. The infant should be tried on one breast for feeding until satiated. The mother may use a pump on the other breast if she needs to stimulate volume. Slow gaining may also occur in an infant who has an underlying structural problem or systemic disease such as congenital heart disease. In contrast, true failure to thrive commands immediate intervention. It is characterized by apathy, a weak cry, poor tone and turgor, few wet diapers (none soaked), and infrequent scanty stools. Early recognition is essential to avoid hypernatrernia from involutional milk and preserve both the integrity of the infant brain and the breast-feeding. A guide for the evaluation of failure to thrive is given in Fig 8. The infant may have POOR SUCK POOR INTAKE INFREQUENT FEEDS // STRUCTURAL ABNORMALITY VOMITING & DIARRHEA INFANT LOW NET INTAKE MALABSORPTION CAUSES INFECTION / N CNS HIGH ENERGY CONG HEART REQUIREMENT DISEASE FAILURE TO THRIVE WHILE BREAST-FED SGA MATERNAL CAUSES high energy needs or additional losses or may be a poor feeder because of structural, neurologic, or metabolic reasons. The pediatrician should investigate failure to thrive due to infant causes in a manner similar to failure to thrive while bottle feeding. Poor maternal production and poor let-down should also be investigated. While the investigation of causes is underway, the infant must be nourished. Providing additional milk by dropper, small cup, or lactation supplernenter, instead of introducing a rubber nipple and bottle, will preserve the infant s skill in nursing at the breast and continue to provide stimulus to the breast for milk production. If intravenous fluids are necessary, additional breast stimulus can be provided by an efficient breast pump. (Breast pumps can be rented from medical supply stores. A cycling pump with adjustable pressure capabilities and sylastin breast flange, such as the White River, works best.) Assessment of breast-feeding itself can take place while fluids and calories are provided. The breast-feeding may require modifications in positioning, timing, and duration of feedings. When the milk is analyzed, the sample should include both fore and hind milk and milk from each breast. High levels of sodium will be seen in involutional milk, ie, if lactation is failing and the breast is involuting. If the DIET POOR PRODUCTION FATIGUE ILLNESS POOR LET-DOWN PSYCHOLOGIC DRUGS SMOKING Fig 8. Diagnostic flow chart for failure to thrive. Photograph used with permission: Lawrence RA. Breastfeeding: A Guide for the Medical Profession. 3rd ed. St LoUis, MO: CV Mosby Co; pediatrics in review #{149} vol. 11 no. 6 december 1989 PIR 169

8 mother returns to full lactation, sodium levels will become physiologic. Common causes of poor milk production include fatigue in the mother or domestic stress. Although malnourished women can produce good milk, attention to diet may be effective in increasing milk supply. Brewers yeast may provide a feeling of well-being. The mother should drink to satisfy thirst and feed herself when she feeds the baby, but she should not force fluids. Smoking may interfere with let-down. Diuretics and some xanthine medications may interfere with volume of milk. JAUNDICE IN THE BREAST-FED INFANT Bilirubin levels greater than 12 mg/ dl have been noted more frequently in breast-fed than bottle-fed infants, but the causes of this are often related to our newborn nursery management rather than to innate properties of human milk. All infants who are jaundiced in the newborn period deserve the same careful assessment to rule out blood type incompatibilities and hematolgic, metabolic, and infectious disorders. There are two types of jaundice in breast-fed infants, crudely divided into early and late jaundice. A rare type that occurs late (5th day) tends to peak about the 10th day and may linger for months, occurring in all infants in the same family who are breast-fed. This is breast milk jaundice and is related to some as-yetunidentified factor in the milk. Its incidence is less than 1 in Treatment includes phototherapy and dilution of breast milk with other milk to maintain the bilirubin concentration less than 10 mg/dl. The disease is self-limited and disappears when the baby is approximately 3 months of age. To test the association between delayed jaundice and breast milk, breast-feeding should be interrupted for 24 hours and bilirubin levels monitored every 6 hours. A decrease of more than 2 mg/dl of bilirubin indicates probable breast milk jaundice. Phototherapy cannot be used during this evaluation. If the bilirubin levels increase more than 1 mg/dl again with reinstatement of full breast-feeding, the diagnosis is confirmed. Usually, all siblings will experience the same problem. Early idiopathic jaundice, appearing in the less than 5-day-old breastfed infant, is considered starvation jaundice and is associated with slow establishment of milk supply but is closely related to stool pattern. Similarly, idiopathic jaundice in the bottlefed infant may also be caused by failure to stool and poor feeding or starvation jaundice. Early attention to passage of the first meconium stool and early stool frequency of the breast-fed infant will alert the physician to the potential for jaundice. When the infant nurses poorly or is fed in the nursery at night, there is not enough stimulus to the breast to initiate adequate milk supply. This provides too little substance to the gut and thus too little stimulus to empty the intestinal tract. There are 450 mg of bilirubin in meconium in the intestinal tract at birth. If this is not passed in the first 2 days, much of it can be converted to indirect bilirubin again by the newly introduced bacteria and reabsorbed. Treatment of early jaundice should be preventive by assuring early and adequate stooling in the neonate and facilitating the establishment of a good milk supply in the mother through knowledgeable supportive care. Frequent feeding and adequate rest and nourishment for the mother, as well as positive support from experienced staff, are the cornerstones of lactation success. The pediatrician needs to be sure the milk supply is well-established and be sure the infant is not receiving water between feedings. Indirect bilirubin is not water soluble and is not excreted in the kidneys; it is conjugated and excreted in the bile and, thus, into the intestinal tract to be excreted via the stool. When phototherapy is necessary, the breast-fed infant should be nursed more frequently. If the mother has been discharged and cannot feed the infant around the clock, the infant should receive formula (calories and nourishment) when not breast-fed to facilitate excretion of bilirubin via the stools. The breakdown product of indirect bilirubin by photoenergy is water soluble and is partially excreted in the urine as a colorless double pyrrole ring. If mother and infant must be separated during phototherapy, not only should the infant be fed but the mother must pump her breasts at least every 4 hours to maintain her milk supply. Hand pumps are available, but the bicycle horn pump should not be used. A Kenneson model ($20 to $40; cylinder shaped) is satisfactory. Electric pumps can be rented and are far more efficient and well worth the rental price. RETURNING TO WORK WHILE BREAST-FEEDING Ideally, the mother will be able to postpone returning to work for 6 to 8 weeks postpartum, giving sufficient time for the milk supply to be established and to get the infant settled into a routine that includes a period at night of at least 4 hours when the infant sleeps. Every mother will have to develop some organizational skills, but some may need help in setting priorities, because it will no longer be possible to do everything. The advantages of continuing to breast-feed are considerable. It is a task only a mother can do, and it provides an intimacy that will be important to maintain because they will be separated during work time. In addition, mother s milk provides infection protection that will be advantageous if the infant is placed in day care with dozens of other children. Data are accumulating to demonstrate that breast-fed infants do better than bottie-fed infants in the day-care setting, experiencing fewer and less severe infections. Exactly how feedings are scheduled and how many, if any, bottles are given to the infant will depend on the hours and flexibility of the mother s job and the child care arrangements. Being able to leave work and breast-feed at every feeding is highly unlikely. Being able to pump in place of feedings, saving the milk for the next day s bottle feeding, may be difficult but possible. The mother should learn to pump before she goes back to work and establish a routine compatible with work hours, even trying a dry run a few days before. The same schedule of feedings should be maintained on weekends as well to preserve the milk supply PIR 170 pediatrics in review #{149}vol. 11 no. 6 december 1989

9 HEALTH SUPERVISION and not confuse the infant. Substituting breast-feedings for pumping times is reasonable on weekends. Milk that is pumped and refrigerated should be used within 24 to 36 hours. If there is no refrigeration available, the breast milk can be placed in a thermos bottle until the mother returns home. If the mother pumps and stores her milk ahead of time, in anticipation of returning to work, the milk can be frozen in glass containers to preserve the cells and antibodies. Milk can be frozen for 1 month if stored in the freezer of the refrigerator and 6 months or more if placed in a deep freezer. It should be thawed by placing in warm water and shaken thoroughly to resuspend the fat that has separated out. It should not need to be sterilized or boiled for use in a healthy infant. SUMMARY The pediatrician plays a crucial role in the success of breast-feeding by providing well-researched, practical advice and support to the lactating woman, beginning in the prenatal period and continuing until total weaning. The pediatrician can provide much needed support and affirmation when the mother is sabotaged by well-meaning friends and relatives who are misinformed about the value or techniques of breast-feeding. Mothers state that their pediatrician is the most important member of the support team but also the one most apt to obstruct success with inappropriate advice. An understanding of lactation as a physiologic process will provide a sound basis for anticipatory guidance. SUGGESTED READING American Academy of Pediatrics. The Promotion of breast-feeding. Pediatrics 1982, 69: DeCarvaiho M, Robertson S, Friedman A, Klaus, M. Frequency of Breast-feeding and Serum Bilirubin Concentration. Am J Dis Child 1 982, 136: Lawrence RA. Breastfeeding: A Guide for the Medical Profession. 3rd ed. St Louis, MO: CV Mosby Co, 1989 Lawrence RA. Practices and attitudes toward breast-feeding among medical professionals. Pediatrics ;70: Neifert MR, Seacat JM. A guide to successful breastfeeding. Contemp Pediatr ;3:26-45 Reiff MS, Essock-Vitale SM. Hospital influences on early infant-feeding practices. Pediatrics. 1985;76: Report of the Surgeon General s Workshop. Breasifeeding and Human Lactation. Washington, DC: US Dept of Health and Human Services, publication HRS-D-MC 84-2 Woolndge MW, Fisher C. Colic overfeeding and Symptoms of lactose malabsorption in the breastfed baby: a possible artifact of feed management? Lancet ;2: Self-Evaluation Quiz 1. Prenatally, women who plan to breastfeed should prepare their breasts by: A. Applying bland ointment or salves. B. Buffing the areolae regularly with a turkish towel. C. Pulling and stretching the nipples twice daily. D. Exercising nipples vigorously three or four times per week. E. Doing nothing or just exposing nipples to soft clothing. 2. Each of the following is a true statement, except: A. There is little correlation between breast size and the capacity to produce milk. B. Inadequate glandular tissue is almost always associated with normal-appearing breasts. C. Lactation can be successful in most cases following augmentation mammoplasty. 0. Inverted nipples should be treated prenatally with breast shells. E. Breast milk can be safely stored in the refrigerator for 24 to 36 hours, in the freezer for 1 month, and in a deep freezer for 6 months. 3. Which of the following would suggest failure to thrive in a breast-fed infant? A. Six or more wet diapers per day. B. Frequent seedy stools. C. No signs of functional let-down reflex. 0. Eight or more nursings per day. E. Feedings lasting 1 5 to 20 minutes. 4. Each of the following is a true statement, except: A. A rubber nipple is not conducive to the peristaltic tongue actions of breast-feeding. B. In the first few days of lactation, it takes at least 2 minutes of sucking stimulus to complete the ejection reflex arc. C. The emptying time of mother s milk from the infant s stomach is 1 1/2 hours; cow milk-based formula is emptied in 3 hours. 0. The hind milk is fat-poor and low in cabries. E. Frequentfeeding is important in establishing a good milk supply. 5. Which of the following is least likely to be a true statement? A. Should the milk supply falter, topping off each breast feeding with a bottle of formula will resolve the problem. B. Breast-fed infants who receive water supplements lose more weight. C. If switched back and forth from breast to rubber nipple, some neonates fail to suck effectively on either. 0. Using an electric pump between feedings will facilitate increased milk production. E. It is advisable to not introduce a bottle until lactation is well established. 6. Each of the following is a true statement about jaundice related to breast-feeding, except: A. The causes are often related to newborn nursery management rather than to innate properties of human milk. B. Water between feedings significantly reduces serum bilirubin levels. C. The late type is rare and often occurs in siblings. 0. The early type is considered starvation jaundice. E. Preventive treatment includes assuring adequate stooling in the infant and facilitating a good milk supply in the mother. pediatrics in review #{149}vol. 11 no. 6 december 1989 PIR 171