Lactancia Materna Educación y Apoyo A Los padresUpToDate

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Lactancia materna: educación y apoyo para los padres

Autor: Ann Kellams, MD, IBCLC, FAAP, FABM
Editores de sección: Steven A. Abrams, MD, Teresa K Duryea, MD
Editor adjunto: Alison G Hoppin, MD
Todos los temas se actualizan a medida que se dispone de nueva evidencia y se completa nuestro proceso de
revisión por pares .
Revisión de literatura vigente hasta: enero de 2021. | Última actualización de este tema: 11 de
septiembre de 2020.
INTRODUCCIÓN
La leche materna es reconocida como la alimentación óptima para prácticamente todos los
bebés debido a sus beneficios para la salud de los bebés y sus madres. Existe un amplio
consenso en recomendar la lactancia materna exclusiva durante aproximadamente los
primeros seis meses y la lactancia materna continua, junto con la introducción de alimentos
sólidos, durante al menos un año después del nacimiento, siempre que la madre y el bebé lo
deseen mutuamente [ 1-5 ]. La Organización Mundial de la Salud recomienda continuar la
lactancia materna hasta al menos el segundo cumpleaños del niño.
Desafortunadamente, a pesar de las fuertes recomendaciones, la práctica real de la lactancia

materna no alcanza estos objetivos en muchos países y culturas. En los Estados Unidos, más
del 80 por ciento de las madres inician la lactancia, pero menos del 60 por ciento continúa
durante los seis meses posteriores al parto y menos del 40 por ciento lo hace a los 12 meses
[ 6 ]. La lactancia materna exclusiva es practicada por menos de la mitad de las madres a los
tres meses después del parto y sólo una cuarta parte de las madres a los seis meses. Estas
observaciones exigen la colaboración entre las madres, las familias, las comunidades, los
médicos, los centros de atención médica y los empleadores para apoyar activamente la
lactancia materna óptima [ 7 ].
La orientación anticipada y el asesoramiento y la educación continuos para las madres se

analizan a continuación. Se presentan por separado discusiones detalladas sobre los pasos
para iniciar la lactancia y abordar los problemas comunes de la lactancia. (Consulte "Inicio de
la lactancia materna" y "Problemas comunes de la lactancia materna y el destete" ).
https://www-uptodate-com.bibliotecavirtual.udla.edu.ec/contents/breastfeeding-parental-education-and-support/print?search=nutrición lactantes&topicRef=285… 1/34

FACTORES EN LAS DECISIONES DE ALIMENTACIÓN DE LOS PADRES

INFANTILES
Las madres a menudo toman decisiones sobre cómo alimentarán a su bebé al principio del
embarazo o antes de concebir [ 8 ]. Comprender qué factores afectan las decisiones de los
padres sobre la alimentación del lactante es esencial para brindar una educación y un apoyo
adecuados a las familias. Además, la comprensión de los conceptos erróneos comunes y las
barreras que enfrentan las nuevas madres y cómo superarlas facilitará el asesoramiento.
● Intención de amamantar - La intención de amamantar es un fuerte predictor del inicio

y la duración de la lactancia materna [ 9-11 ].
La intención materna de amamantar exclusivamente se asocia con las siguientes

características:
• Consciente de la recomendación de amamantar exclusivamente [ 12 ]

• No está de acuerdo con que "la fórmula infantil es tan buena como la leche
materna" [ 13 ]
• Se siente cómoda amamantando en público [ 13 ]
• No tiene un plan para regresar al trabajo [ 14 ]
• Es mayor y no tiene problemas de salud [ 15 ]
• Es atendido exclusivamente por parteras [ 15 ]
• Es primíparo [ 16 ]
• Tiene un mayor nivel de educación [ 8,16,17 ]
• No fuma [ 16 ]
• Tiene experiencia previa con la lactancia materna [ 16 ]
• Ella o su madre nació fuera de los Estados Unidos [ 17 ]
• Es de etnia / identidad hispana [ 9,17 ]
Las mujeres con las siguientes características tienen menos probabilidades de querer
amamantar:
• Está embarazada de gemelos [ 15 ]

• No asiste a clases prenatales [ 15 ]
• Tuvo nacimientos anteriores (a término o prematuros) [ 15 ]
• Tiene experiencia previa negativa o problemas con la lactancia materna [ 18 ]
● Clínico consejos - Recibir asesoramiento de un profesional de la salud para amamantar

se asocia con una mayor incidencia de la lactancia materna [ 19 ]. Sin embargo, los
consejos sobre lactancia materna no se brindan de manera universal y, cuando se
brindan, no siempre son consistentes con las recomendaciones de amamantar
exclusivamente [ 20 ].
● Mitos comunes sobre la lactancia materna : varios mitos comunes sobre la lactancia
materna podrían obstaculizar el éxito de la madre [ 21-23 ]. Estos incluyen la percepción
de que la lactancia materna es inherentemente dolorosa, que muchas madres no
pueden producir suficiente leche materna y que los bebés tienen poco aumento de peso
con la lactancia materna. Abordar cada una de estas preocupaciones es un componente
importante de la consejería mientras la madre toma su decisión sobre la lactancia y
durante las primeras fases después del parto. (Consulte 'Abordar preocupaciones
comunes' a continuación).
● Actitudes y normas sociales : las actitudes y las normas sociales desempeñan un papel
importante en la decisión de la madre sobre si amamantar y su éxito general en la
lactancia [ 24 ]. Esto incluye la percepción de la madre sobre si es aceptable o no
amamantar en público. Las madres pueden necesitar ayuda para sentirse cómodas y
empoderadas para alimentar a sus bebés en público y pueden beneficiarse de mensajes
positivos y estrategias de aprendizaje para mantener el nivel deseado de modestia
mientras lo hacen. La exposición a imágenes de los medios de comunicación, publicidad
y mensajes negativos sobre la lactancia también influye en el inicio y la continuación de
la lactancia materna [ 25 , 26 ].
• Generaciones perdidas : a fines de la década de 1970 y principios de la de 1980 en

los Estados Unidos, las tasas de iniciación a la lactancia materna eran tan bajas
como el 25% [ 27 ]. Esto significa que toda una generación de madres, abuelas,
personas de apoyo y médicos fue testigo de cómo la mayoría de las madres
alimentaban con fórmula a sus bebés y pocas madres intentaban amamantar. Ahora
que se reconoce ampliamente la importancia de la lactancia materna [ 6 ], las
madres y las familias necesitan más educación sobre por qué se recomienda la
lactancia materna y qué esperar, y los médicos que se capacitaron durante ese
tiempo deben desarrollar habilidades para apoyar a la madre que amamanta,
especialmente en la primera etapa. días y semanas posparto.
• Autoeficacia: la autoeficacia de la lactancia materna (la confianza de la madre en

su capacidad para amamantar) es uno de los predictores más sólidos del inicio y la
duración de la lactancia materna [ 28 ]. Se necesitan estrategias y técnicas de
asesoramiento que sirvan para aumentar la confianza de la madre tanto en el
período prenatal como en el posparto temprano para ayudarla a amamantar con
éxito desde el principio. La consejería puede ayudar a la madre a aprender a confiar
en su cuerpo, que acaba de crecer como un bebé precioso, y aprender formas de
confirmar que la lactancia materna va bien y que su bebé está recibiendo suficiente
nutrición.

ENFOQUES PROGRAMÁTICOS Y RECURSOS PROFESIONALES
● Hospital amigo del bebé: la Iniciativa de hospital amigo del bebé describe 10 pasos
que los hospitales y los médicos deben seguir para facilitar una lactancia materna
exitosa ( tabla 1) [ 29 ]. Estos incluyen asesoramiento a todas las mujeres embarazadas
a partir del primer trimestre sobre los beneficios de la lactancia materna, cómo abordar
cualquier inquietud y prácticas hospitalarias para fomentar el inicio de la lactancia
materna. (Consulte "Inicio de la lactancia materna", sección sobre "Entorno hospitalario"
).
● Entorno de oficina propicio para la lactancia materna : varias organizaciones tienen

recomendaciones sobre cómo hacer que las prácticas de oficina sean más favorables o
"amigables" para las madres que amamantan. Hay datos que indican que este tipo de
cambios a nivel de la práctica pueden mejorar las tasas de inicio y duración de la
lactancia materna [ 30-32 ].
● Apoyo profesional para madres que amamantan : el médico y la práctica deben

desarrollar relaciones de familiaridad y derivación con recursos profesionales para
apoyar la lactancia materna [ 2,33 ]. Las madres deben estar al tanto de todas las formas
en que pueden recibir ayuda profesional en el momento cuando y si encuentran un
problema con la lactancia. La ayuda oportuna es crucial antes de que ella o el bebé
desarrollen una afección médica y / o antes de que comience a tomar suplementos
cuando no sea médicamente necesario o deje de amamantar por completo.
Algunos ejemplos de apoyo profesional incluyen:
• Médicos de práctica avanzada: los médicos en una variedad de campos médicos

pueden desarrollar experiencia especial en la medicina de la lactancia materna, a
través de la afiliación, la educación y la capacitación con las siguientes
organizaciones:
- Sección de lactancia materna de la Academia Estadounidense de Pediatría

- Academia de Medicina de la Lactancia Materna
• Consultores de lactancia certificados por la Junta Internacional (IBCLC) : la

certificación como IBCLC requiere cursos de ciencias de la salud a nivel universitario,
más de 90 horas de educación específica en lactancia, registro de 300 a 1000 horas
de práctica clínica y la finalización exitosa de un examen de criterio de referencia
ofrecido por una junta de examinadores internacional independiente [ 34 ].
• Consejeros de lactancia materna: para las familias con inquietudes básicas sobre
lactancia materna, un consejero de lactancia certificado (CLC) o un educador de

lactancia certificado (CBE) puede proporcionar orientación sobre lactancia [ 34 ]. La

certificación requiere de 20 a 120 horas de capacitación especial y aprobar un
examen escrito ofrecido por la organización de capacitación.
• Profesionales de visitas domiciliarias: las visitas domiciliarias de una enfermera,

partera o doula posparto con experiencia en lactancia materna pueden ayudar a
superar algunos de los desafíos iniciales de la lactancia materna [ 35-37 ].
• Programas integrales de seguimiento posparto: estos programas están disponibles

en algunos sistemas de atención médica e incluyen enfermeras, especialistas en
pediatría, obstetras, consultoras en lactancia y, a veces, psicólogos. Esta atención
integral ha demostrado ser prometedora para ayudar a las nuevas madres y las
familias a tener un buen comienzo [ 38,39 ].
• Asistencia telefónica: la asistencia telefónica para la lactancia materna está

disponible en líneas directas como la Línea de ayuda de la Oficina Nacional de Salud
de la Mujer: 1- (800) -994-9662.
● Peer support – The clinician can facilitate peer support by providing a list of available
local resources and making referrals when appropriate. Peer support helps facilitate the
success of new and expectant mothers by promoting breastfeeding as a social norm,
enhancing self-efficacy, and encouraging them to reach out for social support and help
with breastfeeding problems [40]. Examples of peer counseling include:
• Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in
the United States offers breastfeeding peer counselors [41-46]
• La Leche League International groups
• Postpartum Support International
• Depending on locality, there are likely other breastfeeding or postpartum support
groups
INITIAL CLINICAL ASSESSMENT AND SUPPORT
All mothers should have an initial assessment and discussion by a clinician with experience in
breastfeeding. This could be an obstetrician or midwife, general practitioner or family
medicine clinician, pediatrician, or lactation consultant. Ideally, this assessment and
counseling should occur at several points during prenatal care and be reinforced in late
prenatal or early postnatal visits.
Initial assessment — The initial assessment involves assessing the mother's knowledge
about breastfeeding, identifying psychosocial and physiologic risk factors for breastfeeding
problems, and providing tailored education to reduce these risks.
● Assess the mother's knowledge and concerns – To initiate counseling, it is helpful to

start with an open-ended question such as "What have you heard about breastfeeding?"
or "What are your thoughts about breastfeeding?" rather than asking "How do you plan
to feed your baby?" The open-ended questions help to determine the mother's level of
knowledge, comfort, and self-efficacy with breastfeeding, so that education may more
resemble a conversation that is tailored to the mother's prior experiences and needs
[47].
Assessing the mother's understanding of breastfeeding and identifying common

concerns about breastfeeding, such as pain or concern for insufficient milk, ie,
"perceived insufficient milk supply" [48], can help the clinician focus counseling and
support. (See 'Address common concerns' below.)
● Identify mothers at risk for breastfeeding problems – Risk factors for breastfeeding
problems and/or low milk supply are outlined in the table ( table 2).
Women with risk factors for breastfeeding problems or low milk supply may benefit from
extra lactation support, including prenatal consultation with a lactation consultant, and
special education and attention during initiation of breastfeeding, as outlined below.
● Breast examination – The breast examination may identify anatomic features that
predict increased risk for breastfeeding problems. Women with these features and their
infants should be given extra support and monitoring during breastfeeding initiation.
• Insufficient glandular tissue – While it is rare, some mothers have insufficient

glandular tissue. The breasts tend to appear misshapen, somewhat triangular in
appearance, widely-spaced, and "less full" between the areolar complex and the
chest wall ( figure 1). These women are at risk of being unable to establish a full
milk supply, but the likelihood of successful breastfeeding cannot be fully predicted
from the physical examination.
For mothers with insufficient glandular tissue, the clinician should identify the
problem to manage her expectations and provide focused lactation counseling to
optimize her chance of successful breastfeeding. This includes guidance to establish
an effective latch from the very start and frequent expression of milk to maximize
breast milk production. Even if a mother is unable to produce the quantity of milk
needed for exclusive breastfeeding, it is likely that she can at least produce drops of
colostrum, which have important health benefits for the baby. She can also have a
breastfeeding relationship with her infant, offering suckling at the breast for
comfort and possibly even using a device that allows for supplementation at the
breast while the infant is suckling.

• Other anatomic risk factors – Prenatal breast assessments are helpful to identify
women with other anatomic conditions that may affect latching or milk supply, such
as scar tissue, previous surgeries, or flat or inverted nipples ( picture 1 and
figure 2). It is difficult to predict whether these findings will interfere with
breastfeeding. However, these mothers benefit from education and assistance
during breastfeeding initiation to help them effectively feed their infants, remove
milk frequently to help maximize their milk supply, achieve and sustain an effective
latch, and avoid nipple trauma. (See "Nipple inversion" and "Initiation of
breastfeeding", section on 'Inverted nipples'.)
Contraindications to breastfeeding — There are very few contraindications to

breastfeeding. Contraindications may be permanent or temporary. In some cases, the infant
may be fed expressed breast milk until it is safe to resume direct breastfeeding, as listed in
the table ( table 3).
Considerations for breastfeeding for a mother with Coronavirus disease 2019 (COVID-19) are
discussed separately. (See "Coronavirus disease 2019 (COVID-19): Labor, delivery, and
postpartum issues and care", section on 'Breastfeeding and formula feeding'.)
If one of these contraindications exist, the clinician should educate and support the mother
on how to feed her infant safely and effectively in another manner. If the suspension of
breastfeeding is temporary, she will need to drain her breasts frequently with either a breast
pump or hand expression in order to maintain her milk supply until she can return to
breastfeeding. A mother who is not able to breastfeed often experiences a sense of
disappointment and even guilt. The clinician can help by recognizing and validating those
feelings as well as helping her explore other ways to nurture and bond with her infant. (See
'Support for mothers who are not able to fully breastfeed' below.)
Support during breastfeeding initiation — Most mothers produce enough milk for their
infants if they have appropriate education and support. To optimize milk supply and promote
direct breastfeeding, key goals are:
● Avoid formula supplementation unless it is medically necessary

● Frequent feeding and emptying of the breast (including hand expression if needed)
● Avoid artificial nipples
To achieve these goals, recommended practices include immediate skin-to-skin contact after
birth, feeding in the first hour or two and with every cue, 24-hour rooming-in with the infant
to catch every feeding cue, working to achieve a comfortable position, and teaching an
effective latch each time. Mothers should be encouraged to ask for help and hands-on
assistance with positioning and troubleshooting problems such as nipple pain.

Details about how to support successful breastfeeding initiation are discussed in a separate
topic review. (See "Initiation of breastfeeding".)
Address common concerns
Pain — Pain during breastfeeding is a common concern but usually can be addressed by
making minor adjustments in the technique, particularly with regard to the angle that the
infant approaches the breast. Pain is usually a signal that the baby is compressing or rubbing
the nipple during suckling, which can impede milk flow. When a mother experiences pain
during suckling, she should use a finger to help break the latch and reposition the baby, so
that she and the baby are both comfortable. Pinching or rubbing the nipple during feeding
can lead to more soreness and does not provide optimal signaling to mother's body. If the
mother experiences pain while breastfeeding or latching the infant, even at the beginning of
a latch, the clinician should directly observe breastfeeding and teach the mother techniques
to achieve a good latch ( figure 3). (See "Initiation of breastfeeding", section on 'Latch-on'.)
Feeding a sleepy baby — Healthy babies wake easily and often to feed and ought to be
fed with every feeding cue (eg, stirring, lip smacking, rooting, opening the mouth, turning
the head, or sucking on fingers).
A newborn should eat at least eight times in 24 hours and more frequently if the baby is
giving feeding cues. The feedings are not usually spaced out evenly throughout the day and
night but rather may occur in "clusters" followed by "breaks" of up to four hours. It is
common for a newborn to fall asleep at the breast because this is where they are most
comfortable, but this can interfere with effective feeding and/or increase the mother's
burden by extending the length of each feeding session. To address this, the mother can try
to arouse the infant by taking "burp breaks"; changing the diaper; or rubbing his or her
head, back, arms, or feet. She can also encourage the infant to feed by using hand
expression and breast compression.
Concerns about milk supply — Most mothers make enough milk to feed their baby
without need for any supplementation. Understanding the normal progression of lactation
after delivery will help a mother to focus on steps to enhance lactation and shape her
expectations about milk volume. (See "Initiation of breastfeeding".)
In the first few days after birth, breasts will feel the same as before and mothers produce
colostrum, which is measured in drops rather than ounces. Colostrum is very concentrated
with antibodies and other nutrients and is all that the baby needs. Because the volumes are
small, babies will need to eat frequently. Mothers should not expect to produce significant
milk volume (ounces) until day 3 to 4 after delivery.
In the meantime, there are ways to tell if the baby is getting sufficient amounts of milk by
monitoring his or her weight, input and output, behavior, and other findings on the physical
examination:
● Healthy infants typically lose weight during the first three to five days of life, and then
their weight begins to increase by 15 to 30 g/day to regain their birth weight by 10 to 14
days. All healthy infants should regain their birth weight by three weeks of age [49].
● Infants should be evaluated more closely if they drop below the 75th percentile curve on
the newborn weight loss tool (NEWT) nomogram within the first 48 to 72 hours after
birth. (See "Initiation of breastfeeding", section on 'Assessment of intake'.)
● Other signs that warrant close monitoring include difficulty latching on or suckling,
maternal nipple pain or compression, or presence of urate crystals in the diaper or other
signs suggesting dehydration [50,51].
Maternal exhaustion — Caring for a newborn is exhausting work, with a 24-hour/7-days-

a-week schedule. Teaching mothers strategies for self-care may help them survive and thrive
during this challenging and often overwhelming time. Suggestions to attenuate maternal
exhaustion and facilitate self-care are summarized in the table ( table 4).
In addition, all mothers should be screened for perinatal mood and anxiety disorders at each
health maintenance visit for at least the first six months after birth. This can be done with a
validated screening tool, such as the Edinburgh Postpartum Depression Scale. (See 'Perinatal
mood and anxiety disorders' below.)
POSTNATAL MEDICAL SUPERVISION
Frequency of follow-up — Breastfeeding mother-infant dyads should have frequent follow-

up with a clinician until breastfeeding is well established. For those who appear to have
effectively initiated breastfeeding in the hospital and have no risk factors for breastfeeding
problems ( table 2), routine follow-up in the primary care office may be sufficient. The
initial visit depends on the length of the birth hospitalization but usually should be within 48
hours after discharge. The timing of subsequent follow-up visits depends upon the infant's
feeding and risk factors, such as prematurity or any other medical problems. Some infants
may need to be seen one or more times again prior to the routine two-week visit. (See
"Overview of the routine management of the healthy newborn infant".)
Patients with any problems with breastfeeding and/or poor infant weight gain should be
seen more often and may benefit from professional breastfeeding assistance, such as a
breastfeeding medicine clinician or a lactation consultant. (See 'Programmatic approaches
and professional resources' above and "Initiation of breastfeeding", section on 'Assessment
of intake'.)

Maternal diet — Maternal nutritional needs during lactation and frequently asked questions
about diet and weight management are discussed in a separate topic review. (See "Maternal
nutrition during lactation".)
Maternal alcohol use — A small percentage of alcohol is transferred into breast milk. The
amount of alcohol considered to be "safe" while breastfeeding is controversial. We suggest
that a breastfeeding woman avoid exposing the infant to alcohol by waiting to nurse for two
hours after a single serving of alcohol (12 ounces of beer, 5 ounces of wine, or 1.5 ounces of
80-proof liquor). If a woman drinks more than this amount, she should refrain from
breastfeeding for an additional two hours for each serving of alcohol [52]. It is not necessary
to express and discard milk after consuming alcohol, unless the breasts become
uncomfortably engorged before enough time has elapsed for the alcohol to leave her
system. Heavy alcohol intake can impair judgement and child care abilities and should be
avoided, regardless of how the infant is fed. Further details about the pharmacokinetics and
effects of alcohol use during lactation are available in the LactMed database.
Maternal cannabis use — Cannabis metabolites are secreted into breast milk; effects on the
infant's neurodevelopment have been suggested but not established [53-55]. (See "Infants of
mothers with substance use disorder", section on 'Breastfeeding'.)
Maternal medications — Most medications are compatible with breastfeeding. Even though
most medications diffuse into and out of breast milk via their concentration gradient with the
maternal serum, the amount transferred is usually quite small and unlikely to adversely
affect the infant [56,57]. The following general considerations help to guide decisions:
● Medications that can be prescribed directly to an infant are usually safe because the
doses transferred via breast milk are much lower than the therapeutic doses [58].
● The risk of medication toxicity is higher in preterm and ill infants and is rare in infants
over six months of age [56].
● If the medication could otherwise be prescribed to the infant for a medical condition, it is
generally considered safe for the mother to take while breastfeeding.
● Infant medication exposure can be minimized by dosing medications after nursing and
before prolonged infant sleep.
● Medications that are highly protein-bound, have low lipid solubility, or have large
molecular weights do not appreciably enter breast milk.
● Breastfed infants are generally not affected by medications with poor oral bioavailability,
such as insulin or heparin.

● Breastfeeding does not need to be interrupted when iodinated or gadolinium contrast is

administered for radiologic imaging. However, radiopharmaceuticals or radioactive
medications should generally be avoided ( table 3) [56].
● Some medications decrease breast milk volume, including dopamine agonists (eg,
bromocriptine), decongestants, and estrogens (eg, in hormonal contraceptives). If a
mother is taking these medications and has compromised breast milk supply, consider
alternative medications if possible. (See "Common problems of breastfeeding and
weaning", section on 'Assess and address contributing factors'.)
The LactMed database, produced by the National Library of Medicine, is a free, authoritative
reference for lactation compatibility for prescription and over-the-counter drugs. This
resource provides data on potential adverse effects on breastfeeding infants and lactation,
case reports of infant exposures, and recommendations for alternative medications. It
incorporates data on maternal plasma concentration and protein binding of each drug, size
of the molecule, degree of ionization, lipid solubility, and maternal pharmacogenomics.
Detailed discussions about specific classes of drugs can be found in the following UpToDate
topics:
● (See "Postpartum contraception: Counseling and methods", section on 'Impact of

contraception on breastfeeding'.)
● (See "Safety of infant exposure to antidepressants and benzodiazepines through
breastfeeding".)
● (See "Breastfeeding infants: Safety of exposure to antipsychotics, lithium, stimulants, and
medications for substance use disorders".)
● (See "Infants of mothers with substance use disorder", section on 'Breastfeeding'.)
● (See "Hyperthyroidism during pregnancy: Treatment", section on 'Breastfeeding'.)
Safe sleep and breastfeeding — To facilitate breastfeeding while maintaining safe sleep
practices, we suggest that the infant sleep in the mother's bedroom but not in the adult bed
for at least the first six months of life. The infant should sleep in a separate sleep surface
designed for infants, such as a crib or bassinet. Infants should never sleep in the adult bed or
on a sofa, recliner, armchair, or other type of cushioned chair. Infants should always be
placed supine for sleep. Due to exhaustion, it is not uncommon for mothers to fall asleep
while feeding their infants. For this reason, the American Academy of Pediatrics recommends
that if there is a risk of the mother falling asleep, feedings should occur in an adult bed (not a
couch, sofa, or chair) without any pillows, blankets, or soft bedding and that the infant be
returned to a nearby crib or bassinet when the mother awakens after the feeding [59,60].
(See "Sudden infant death syndrome: Risk factors and risk reduction strategies".)

Perinatal mood and anxiety disorders — It is important for mothers to be aware of the
difference between postpartum blues and other more serious disorders such as depression,
anxiety, and even postpartum psychosis since all of these are very treatable if recognized and
diagnosed and can impact a mother's breastfeeding journey. Many of the risk factors for
perinatal mood and anxiety disorders can also lead to breastfeeding problems such as
extreme maternal exhaustion, history of infertility, and traumatic birth experience. (See
"Postpartum blues" and "Postpartum unipolar major depression: Epidemiology, clinical
features, assessment, and diagnosis".)
Breastfeeding during a subsequent pregnancy — It is generally safe to breastfeed during

a subsequent pregnancy, as well as to "tandem" breastfeed an older infant along with a
newborn [61-64]. In fact, these practices are common in many cultures. Mothers with risk
factors for pregnancy loss or preterm labor who would like to continue to breastfeed their
older child during the pregnancy should discuss the potential risks and benefits with their
obstetrical clinician [65]. Once the newborn arrives, it is recommended that the mother feed
the newborn first for each feeding before offering the breast to the older child to ensure that
the newborn has adequate intake until a good weight gain pattern is established [62,66].
Special situations
Late preterm or early term infants — Mothers of late preterm infants (gestational age
34 to <37 weeks) and some early term infants may need additional support to establish
effective breastfeeding and an adequate milk supply. These infants, despite appearing
"normal" and not needing intensive care, are immature and should not be expected to be
"good breastfeeders" until they reach approximately 40 weeks gestational age. Their
mothers often require assistance with strategies to empty the breasts frequently and
effectively to ensure adequate intake and signaling by the mother's body to promote
sufficient milk production. Details are discussed in a separate topic review. (See
"Breastfeeding the preterm infant", section on 'Late preterm infants'.)
Twins — Multiples pose a challenge for new mothers as they both/all require frequent
feedings and often are born early. Mothers may need extra help with positioning the infants
at the breast and with general infant care. Tandem nursing (breastfeeding two infants
simultaneously) may be awkward and difficult for mothers to achieve without assistance at
first but can help with synching the feedings for the infants, so that the mother may rest
between feedings. As long as both/all of the infants are going to the breast with every
feeding cue, the mother's body will adapt and produce the amount of milk that it is signaled
to do so.
Infant jaundice — All newborns develop jaundice to some extent, which is considered
physiologic and may even be protective because bilirubin is a powerful antioxidant. The
baseline levels of bilirubin in breastfed infants are higher than in those who are formula
feeding; however, unless there is inadequate intake, breastfeeding alone does not cause the
bilirubin to rise to pathologic levels.
Early-onset pathologic jaundice has multiple potential causes, including hemolysis, infection,
and underlying genetic disorders, and requires evaluation and management. Cessation of
breastfeeding should only be considered in cases of extreme jaundice, in which the bilirubin
levels come close to the threshold for an exchange transfusion. To reduce the risk of
pathologic jaundice due to insufficient milk intake, all infants should receive optimal support
of breastfeeding from birth to help ensure an adequate milk supply. Infants with jaundice
should have focused feeding evaluations to ensure a comfortable, effective latch and milk
transfer to ensure adequate intake. Unless there are signs of insufficient intake, infants who
are breastfeeding should not require supplementation with anything other than mother's
own milk [50,67]. (See "Unconjugated hyperbilirubinemia in the newborn: Pathogenesis and
etiology" and "Unconjugated hyperbilirubinemia in term and late preterm infants:
Management".)
Infant hypoglycemia — Similar to jaundice, most infants do not develop pathologic

hypoglycemia. Measurement of infant blood glucose is recommended only for infants with
risk factors for hypoglycemia, such as a diabetic mother, prematurity, or small for gestational
age [68]. Strategies to prevent neonatal hypoglycemia include early breastfeeding within the
first hour after birth and teaching the mother to hand express drops of colostrum in the first
few days with each feeding. Evaluation and management of neonatal hypoglycemia are
discussed separately. (See "Pathogenesis, screening, and diagnosis of neonatal
hypoglycemia" and "Management and outcome of neonatal hypoglycemia".)
Relactation or induction of lactation — It is possible for a mother who has lactated

before to reestablish and maintain a milk supply. It is also possible, although more
challenging, to induce lactation in people who have never lactated. Protocols for inducing
lactation are not well studied but typically include both hormonal preparation and breast
signaling (nipple stimulation) with pumping [69-72]. The resulting milk production varies but
is often sufficient to support at least partial breastfeeding.
Induced lactation may be particularly valuable for adopting families [73] or other non-
gestational parents who wish to breastfeed/chestfeed [74,75]. This may include members of
same-sex couples or transgender and non-binary people, including transgender women [76-
78]. Because the possibility of induced lactation is not widely recognized, particularly in the
medical community, the clinician should specifically raise this question and offer assistance
to parents with nontraditional family structures.
Support for mothers who are not able to fully breastfeed — Some mothers encounter
problems with establishing breastfeeding that are beyond their control. The clinician's role is
to provide accurate information in a culturally sensitive manner, so that the mother is able to
make a truly informed choice about breastfeeding and to identify and remove barriers to
breastfeeding if possible [79]. Mothers and other family members deserve the clinician's
presence, listening skills, expertise, and guidance, so that they can participate in shared
decision-making about breastfeeding.
If the mother cannot or chooses not to breastfeed, the clinician should guide her toward a
plan for feeding, bonding, and interacting with her infant that will be as close as possible to
meeting her personal breastfeeding goals. This process will help to minimize her experience
of guilt or shame and ensure that she and her infant are safe, healthy, and have every
opportunity to bond and thrive.
SUPPORT FOR MAINTENANCE OF BREASTFEEDING
Support to maintain milk supply — All lactating mothers need a technique to express milk,
either by hand or with a manual or electric breast pump, in case they are ever separated
from their infant. In general, maintenance of supply requires frequent signaling of the
breasts, either with frequent feedings or with milk expression. Mothers should be instructed
to pump at least once every time the infant feeds anything other than her breast milk or in
her absence. If her supply is diminishing, increasing the frequency and amount of
breastfeeding and/or milk expression for a day or two will usually increase the milk
production within 24 to 48 hours, similar to when an infant feeds more frequently during a
growth spurt. Further information on equipment and technique is discussed separately. (See
"Breastfeeding the preterm infant".)
General support for ongoing breastfeeding — Infant feeding recommendations are for
exclusive breastfeeding for the first six months, followed by continued breastfeeding with
the introduction of complementary foods for at least one year (or two years according to the
World Health Organization). However, many mothers are unable to meet these targets [6]. In
the Infant Feeding Practices Study II, only 32.4 percent of mothers were able to meet their
own personal feeding goals and most of those personal goals were shorter than the
recommendations [80].
To help mothers come as close as possible to these goals for optimal infant feeding,
clinicians can take the following steps:
● Remind mothers of the recommendations
● Encourage mothers to set a personal goal for breastfeeding duration
● Provide anticipatory guidance for the common obstacles to breastfeeding, such as pain,
concern about supply, and return to work or school (see 'Address common concerns'
above)
● Become skilled at evaluation for an effective latch and milk transfer (see "Initiation of
breastfeeding", section on 'Mechanics of feeding')
● Troubleshoot common problems such as latch difficulties or nipple pain and provide
assistance if the mother encounters obstacles (see "Common problems of breastfeeding
and weaning")
● Adhere to the recommendations for a breastfeeding-friendly office (see 'Programmatic

approaches and professional resources' above)
● Collaborate and communicate with local obstetrical providers and maternity care centers
to ensure that evidence-based best practices are in place
● Become a role model in the community and advocate for lactation support in the
workplace, support mothers breastfeeding in public, and elicit community support
This guidance should ideally be part of each routine visit while the mother is breastfeeding.
To maintain a positive therapeutic relationship and avoid instilling guilt, the discussions
should be nonjudgmental, focused on problem-solving, and acknowledge that many women
are not able to meet the recommendations.
Return to work — Returning to work is a known barrier for both initiation of breastfeeding
and duration of continued breastfeeding [7]. Mothers should be given anticipatory guidance
about strategies to continue breastfeeding while working, pumping and expressing milk,
navigate workplace laws and accommodations, and understand solutions for pumping and
expressing in various different types of workplace environments [81].
Suggested guidance for mothers who plan to return to work includes:
● Suggest a gradual return to work, such as starting at the end of the week and then
having the weekend to recover and troubleshoot any concerns, or working part-time for
a period of time.
● Make sure she has an effective and efficient way to express her breast milk. A high-
quality, dual-electric breast pump is ideal but not required. Some women may not have
access to electrical outlets in the workplace or an expensive breast pump and can have
success with manual pumps and/or hand expression; the mother will need to check with
her insurance company to see what is available and what is covered.
● Encourage her to reach out to her supervisor to discuss plans about where and how
often she will need to express her milk.
● Guide her to express her milk at least once every time the baby feeds when she is away.

● Suggest that she keep a blanket that smells like her baby nearby and a picture or video
of her baby to view when pumping to help trigger the let-down reflex.
● Make sure she knows the current guidelines for milk storage. Recommend that she
begin in advance to build a few days' supply of expressed breast milk to store in the
freezer for emergencies. When possible, fresh refrigerated breast milk (pumped the day
before) should be used over frozen breast milk because this helps to preserve some of
the beneficial properties of breast milk, including some of the live cellular components
that help to prevent infection. The composition of breast milk changes over the infant's
different developmental stages, and using fresh refrigerated milk ensures that the infant
receives the milk that the mother is making specifically for that time period.
● Refer her to other local resources and working mother support groups [82].
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Breastfeeding and
infant nutrition".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles on
a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Weaning from breastfeeding (The Basics)" and
"Patient education: Deciding to breastfeed (The Basics)" and "Patient education:
Common breastfeeding problems (The Basics)" and "Patient education: Health and
nutrition for women who breastfeed (The Basics)" and "Patient education: Pumping
breast milk (The Basics)")

● Beyond the Basics topics (see "Patient education: Deciding to breastfeed (Beyond the
Basics)" and "Patient education: Common breastfeeding problems (Beyond the Basics)"
and "Patient education: Pumping breast milk (Beyond the Basics)" and "Patient
education: Maternal health and nutrition during breastfeeding (Beyond the Basics)" and
"Patient education: Weaning from breastfeeding (The Basics)")
SUMMARY AND RECOMMENDATIONS
● During prenatal care or early postnatal visits, all mothers should have an initial
assessment by a clinician with expertise in breastfeeding. This involves assessing the
mother's knowledge about breastfeeding, identifying psychosocial and physiologic risk
factors for breastfeeding problems ( table 2), and providing tailored education to
reduce these risks. The evaluation should include a breast examination to identify
anatomic differences in the breasts that may complicate breastfeeding, including flat or
inverted nipples ( picture 1 and figure 2) or hypoplastic breasts, which are rare (
figure 1). Women with these features can often breastfeed but will likely need extra
support and guidance. (See 'Initial clinical assessment and support' above.)
● There are very few contraindications to breastfeeding ( table 3). In some cases, the
contraindication is temporary and the infant may be fed expressed breast milk until it is
safe to resume direct breastfeeding. (See 'Contraindications to breastfeeding' above.)
● A common concern is that breastfeeding is inherently painful, which is not the case.
"Tugging," "pressure," and an unfamiliar sensation are common. Nipple pain or
compression are not normal and require immediate attention because they usually
indicate that the latch is ineffective and that milk flow is impaired. The clinician should
address this concern by observing a feeding and providing guidance during
breastfeeding initiation to ensure proper technique, including an effective latch (
figure 3). Counseling during breastfeeding initiation can also help with other common
concerns, including feeding a sleepy baby, ensuring sufficient milk supply, and
addressing maternal exhaustion ( table 4). (See 'Address common concerns' above.)
● Postnatal medical supervision for breastfeeding includes advice on maternal nutrition,

safe infant sleep, monitoring for perinatal mood and anxiety disorders, and addressing
any breastfeeding problems as they arise. (See 'Postnatal medical supervision' above and
"Common problems of breastfeeding and weaning".)
● Most, but not all, therapeutic drugs are compatible with breastfeeding. The safest
medications are those that are safe to administer directly to an infant and those that are
not orally bioavailable. The LactMed database is a free online database with reliable
information about medication compatibility. (See 'Maternal medications' above.)

● Early and focused guidance to optimize breastfeeding is particularly important for

certain infants, including those born late, preterm, or early term; twins; or those with
jaundice or hypoglycemia, as well as for mothers with risk factors for breastfeeding
problems. The clinician should also be aware of the possibility of inducing lactation for a
non-gestational parent, including adoptive parents, members of same-sex couples, or
transgender and non-binary people. (See 'Special situations' above.)
● A majority of mothers do not meet targets for sustained breastfeeding, which are
exclusive breastfeeding for the first six months followed by continued breastfeeding with
complementary foods for at least one year. To help mothers come as close as possible to
these goals, the clinician should ensure that the mother has an effective technique for
breast milk expression in order to maintain her milk supply when she is unable to
breastfeed directly and provide anticipatory guidance about strategies to continue
breastfeeding while returning to work or other activities. (See 'Support for maintenance
of breastfeeding' above.)
ACKNOWLEDGMENTS
The editorial staff at UpToDate would like to acknowledge Richard J Schanler, MD, and Debra
C Potak, MD, who contributed to an earlier version of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012;
129:e827.
2. ACOG Committee Opinion No. 756: Optimizing Support for Breastfeeding as Part of
Obstetric Practice. Obstet Gynecol 2018; 132:e187.
3. World Health Organization. 2020. Infant and young child feeding. Available at: https://w
ww-who-int.bibliotecavirtual.udla.edu.ec/news-room/fact-sheets/detail/infant-and-youn
g-child-feeding (Accessed on July 03, 2020).
4. American Academy of Family Physicians. Breastfeeding, Family Physicians Supporting (P
osition Paper). 2014. Available at: https://www.aafp.org/about/policies/all/breastfeeding-
support.html (Accessed on July 03, 2020).
5. United States Preventive Services Task Force. Breastfeeding: Primary Care Interventions.
2016. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/final-
recommendation-statement154/breastfeeding-primary-care-interventions (Accessed on
July 03, 2020).

6. Centers for Disease Control and Prevention. Breastfeeding Report Card. 2018. Available
at: https://www.cdc.gov/breastfeeding/data/reportcard.htm (Accessed on July 03, 2020).
7. United States Surgeon General. The Surgeon General’s Call to Action to Support Breastfe
eding. 2011. Available at: https://www.hhs.gov/sites/default/files/breastfeeding-call-to-a
ction-executive-summary.pdf (Accessed on July 03, 2020).
8. Gurka KK, Hornsby PP, Drake E, et al. Exploring intended infant feeding decisions among
low-income women. Breastfeed Med 2014; 9:377.
9. Colaizy TT, Saftlas AF, Morriss FH Jr. Maternal intention to breast-feed and breast-feeding
outcomes in term and preterm infants: Pregnancy Risk Assessment Monitoring System
(PRAMS), 2000-2003. Public Health Nutr 2012; 15:702.
10. Donath SM, Amir LH, ALSPAC Study Team. Relationship between prenatal infant feeding
intention and initiation and duration of breastfeeding: a cohort study. Acta Paediatr
2003; 92:352.
11. Marks EJ, Grant CC, de Castro TG, et al. Agreement between Future Parents on Infant
Feeding Intentions and Its Association with Breastfeeding Duration: Results from the
Growing Up in New Zealand Cohort Study. Int J Environ Res Public Health 2018; 15.
12. Wen LM, Baur LA, Rissel C, et al. Intention to breastfeed and awareness of health
recommendations: findings from first-time mothers in southwest Sydney, Australia. Int
Breastfeed J 2009; 4:9.
13. Stuebe AM, Bonuck K. What predicts intent to breastfeed exclusively? Breastfeeding
knowledge, attitudes, and beliefs in a diverse urban population. Breastfeed Med 2011;
6:413.
14. Thomas-Jackson SC, Bentley GE, Keyton K, et al. In-hospital Breastfeeding and Intention
to Return to Work Influence Mothers' Breastfeeding Intentions. J Hum Lact 2016;
32:NP76.
15. Lutsiv O, Pullenayegum E, Foster G, et al. Women's intentions to breastfeed: a
population-based cohort study. BJOG 2013; 120:1490.
16. Vieira TO, Martins CD, Santana GS, et al. [Maternal intention to breastfeed: a systematic
review]. Cien Saude Colet 2016; 21:3845.
17. McKee MD, Zayas LH, Jankowski KB. Breastfeeding intention and practice in an urban
minority population: relationship to maternal depressive symptoms and mother–infant
closeness. J Reprod Infant Psychol 2004; 22:167.
18. Burns W, Rovnyak V, Friedman C, et al. BAP: Testing of a Breastfeeding History
Questionnaire to Identify Mothers at Risk for Postpartum Formula Supplementation.
Clinical Lactaction 2018; 9.
19. Smith LA, Geller NL, Kellams AL, et al. Infant Sleep Location and Breastfeeding Practices
in the United States, 2011-2014. Acad Pediatr 2016; 16:540.
20. Eisenberg SR, Bair-Merritt MH, Colson ER, et al. Maternal Report of Advice Received for
Infant Care. Pediatrics 2015; 136:e315.
21. Odom EC, Li R, Scanlon KS, et al. Reasons for earlier than desired cessation of
breastfeeding. Pediatrics 2013; 131:e726.
22. McClellan HL, Kent JC, Hepworth AR, et al. Persistent Nipple Pain in Breastfeeding
Mothers Associated with Abnormal Infant Tongue Movement. Int J Environ Res Public
Health 2015; 12:10833.
23. Kent JC, Ashton E, Hardwick CM, et al. Nipple Pain in Breastfeeding Mothers: Incidence,
Causes and Treatments. Int J Environ Res Public Health 2015; 12:12247.
24. Moon RY, LoCasale-Crouch J, Turnbull KLP, et al. Investigating Mechanisms for Maternal
Education Disparities in Enacting Health-Promoting Infant Care Practices. Acad Pediatr
2020; 20:926.
25. Gellerson D, Hornsby PP, Lowenhaupt SA, et al. Prevalence of baby bottle versus
breastfeeding graphics on products in national chain stores. Breastfeed Med 2012;
7:469.
26. United States Surgeon General. The Surgeon General's Call to Action to Support Breastfe
eding. 2011. Available at: https://www.ncbi.nlm.nih.gov/books/NBK52688/ (Accessed on J
uly 03, 2020).
27. United States Surgeon General. The Surgeon General's Call to Action to Support Breastfe
eding. 2011. Available at: https://www.ncbi.nlm.nih.gov/books/NBK52681/ (Accessed on J
uly 03, 2020).
28. Labbok MH. Breastfeeding: population-based perspectives. Pediatr Clin North Am 2013;
60:11.
29. Baby-Friendly USA. The Baby-Friendly Hospital Initiative. 2019. Available at: https://www.
babyfriendlyusa.org/wp-content/uploads/2019/12/US-Interim-GEC_191107_CLEAN.pdf
(Accessed on July 03, 2020).
30. Meek JY, Hatcher AJ, SECTION ON BREASTFEEDING. The Breastfeeding-Friendly Pediatric
Office Practice. Pediatrics 2017; 139.
31. Grawey AE, Marinelli KA, Holmes AV, Academy of Breastfeeding Medicine. ABM Clinical
Protocol #14: Breastfeeding-friendly physician's office: optimizing care for infants and
children, revised 2013. Breastfeed Med 2013; 8:237.
32. Corriveau SK, Drake EE, Kellams AL, Rovnyak VG. Evaluation of an office protocol to
increase exclusivity of breastfeeding. Pediatrics 2013; 131:942.
33. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Primary Care
Interventions to Support Breastfeeding: US Preventive Services Task Force
Recommendation Statement. JAMA 2016; 316:1688.

34. United States Breastfeeding Committee. Lactation Support Provider Pathways Informati
on. 2020. Available at: http://www.usbreastfeeding.org/page/lsppathways (Accessed on J
uly 29, 2020).
35. Johnson TS, Brennan RA, Flynn-Tymkow CD. A home visit program for breastfeeding
education and support. J Obstet Gynecol Neonatal Nurs 1999; 28:480.
36. McKeever P, Stevens B, Miller KL, et al. Home versus hospital breastfeeding support for
newborns: a randomized controlled trial. Birth 2002; 29:258.
37. National Association of County & City Health Officials. Integrating Breastfeeding Services
into Home Visiting Programs. 2018. Available at: https://www.naccho.org/uploads/downl
oadable-resources/Home-Visiting-Breastfeeding.pdf (Accessed on July 29, 2020).
38. Olson T, Bowen A, Smith-Fehr J, Ghosh S. Going home with baby: innovative and
comprehensive support for new mothers. Prim Health Care Res Dev 2018; :1.
39. Keppler AB, Roudebush JL. Postpartum follow-up care in a hospital-based clinic: an
update on an expanded program. J Perinat Neonatal Nurs 1999; 13:1.
40. McFadden A, Siebelt L, Marshall JL, et al. Counselling interventions to enable women to
initiate and continue breastfeeding: a systematic review and meta-analysis. Int
Breastfeed J 2019; 14:42.
41. Grummer-Strawn LM, Rice SP, Dugas K, et al. An evaluation of breastfeeding promotion
through peer counseling in Mississippi WIC clinics. Matern Child Health J 1997; 1:35.
42. Ahluwalia IB, Tessaro I, Grummer-Strawn LM, et al. Georgia's breastfeeding promotion
program for low-income women. Pediatrics 2000; 105:E85.
43. Mitra AK, Khoury AJ, Carothers C, Foretich C. Evaluation of a comprehensive loving
support program among state Women, Infants, and Children (WIC) program breast-
feeding coordinators. South Med J 2003; 96:168.
44. Olson BH, Haider SJ, Vangjel L, et al. A quasi-experimental evaluation of a breastfeeding
support program for low income women in Michigan. Matern Child Health J 2010; 14:86.
45. Meier ER, Olson BH, Benton P, et al. A qualitative evaluation of a breastfeeding peer
counselor program. J Hum Lact 2007; 23:262.
46. Yun S, Liu Q, Mertzlufft K, et al. Evaluation of the Missouri WIC (Special Supplemental
Nutrition Program for Women, Infants, and Children) breast-feeding peer counselling
programme. Public Health Nutr 2010; 13:229.
47. Rollnick S, Miller WR. What is Motivational Interviewing? Behav Cogn Psychother 1995;
23:325.
48. Galipeau R, Dumas L, Lepage M. Perception of Not Having Enough Milk and Actual Milk
Production of First-Time Breastfeeding Mothers: Is There a Difference? Breastfeed Med
2017; 12:210.

49. Paul IM, Schaefer EW, Miller JR, et al. Weight Change Nomograms for the First Month
After Birth. Pediatrics 2016; 138.
50. Feldman-Winter L, Kellams A, Peter-Wohl S, et al. Evidence-Based Updates on the First
Week of Exclusive Breastfeeding Among Infants ≥35 Weeks. Pediatrics 2020; 145.
51. Flaherman VJ, Schaefer EW, Kuzniewicz MW, et al. Early weight loss nomograms for
exclusively breastfed newborns. Pediatrics 2015; 135:e16.
52. Ho E, Collantes A, Kapur BM, et al. Alcohol and breast feeding: calculation of time to zero
level in milk. Biol Neonate 2001; 80:219.
53. Baker T, Datta P, Rewers-Felkins K, et al. Transfer of Inhaled Cannabis Into Human Breast
Milk. Obstet Gynecol 2018; 131:783.
54. Reece-Stremtan S, Marinelli KA. ABM clinical protocol #21: guidelines for breastfeeding
and substance use or substance use disorder, revised 2015. Breastfeed Med 2015;
10:135.
55. Ryan SA, Ammerman SD, O'Connor ME, et al. Marijuana Use During Pregnancy and
Breastfeeding: Implications for Neonatal and Childhood Outcomes. Pediatrics 2018; 142.
56. Sachs HC, Committee On Drugs. The transfer of drugs and therapeutics into human
breast milk: An update on selected topics. Pediatrics 2013; 132:e796.
57. Hotham N, Hotham E. Drugs in breastfeeding. Aust Prescr 2015; 38:156.
58. Spencer JP, Gonzalez LS 3rd, Barnhart DJ. Medications in the breast-feeding mother. Am
Fam Physician 2001; 64:119.
59. TASK FORCE ON SUDDEN INFANT DEATH SYNDROME. SIDS and Other Sleep-Related
Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment.
Pediatrics 2016; 138.
60. Kellams, A. Breastfeeding without bed-sharing. In: Infant Safe Sleep: A Pocket Guide for
Clinicians, Moon, RY (Eds), Springer, 2020. p.131.
61. López-Fernández G, Barrios M, Goberna-Tricas J, Gómez-Benito J. Breastfeeding during
pregnancy: A systematic review. Women Birth 2017; 30:e292.
62. Madarshahian F, Hassanabadi M. A comparative study of breastfeeding during
pregnancy: impact on maternal and newborn outcomes. J Nurs Res 2012; 20:74.
63. Moscone SR, Moore MJ. Breastfeeding during pregnancy. J Hum Lact 1993; 9:83.
64. Pareja RG, Marquis GS, Penny ME, Dixon PM. A case-control study to examine the
association between breastfeeding during late pregnancy and risk of a small-for-
gestational-age birth in Lima, Peru. Matern Child Nutr 2015; 11:190.
65. Molitoris J. Breast-feeding During Pregnancy and the Risk of Miscarriage. Perspect Sex
Reprod Health 2019; 51:153.

66. Marquis GS, Penny ME, Diaz JM, Marín RM. Postpartum consequences of an overlap of
breastfeeding and pregnancy: reduced breast milk intake and growth during early
infancy. Pediatrics 2002; 109:e56.
67. Flaherman VJ, Maisels MJ, Academy of Breastfeeding Medicine. ABM Clinical Protocol
#22: Guidelines for Management of Jaundice in the Breastfeeding Infant 35 Weeks or
More of Gestation-Revised 2017. Breastfeed Med 2017; 12:250.
68. Wight N, Marinelli KA, Academy of Breastfeeding Medicine. ABM clinical protocol #1:
guidelines for blood glucose monitoring and treatment of hypoglycemia in term and
late-preterm neonates, revised 2014. Breastfeed Med 2014; 9:173.
69. Academy of Breastfeeding Medicine (ABM) Clinical Protocol #9: Use of galactogogues in i
nitiating or augmenting maternal milk production (2018): Available at: https://abm.mem
berclicks.net/assets/DOCUMENTS/PROTOCOLS/9-galactogogues-protocol-english.pdf (A
ccessed on August 26, 2020).
70. Wittig SL, Spatz DL. Induced lactation: gaining a better understanding. MCN Am J Matern
Child Nurs 2008; 33:76.
71. Bryant CA. Nursing the adopted infant. J Am Board Fam Med 2006; 19:374.
72. La Leche League GB, Relactation and Induced Lactation. Available at: https://www.lalech
e.org.uk/relactation-induced-lactation/ (Accessed on August 21, 2020).
73. Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding and the use of human milk.
Pediatrics 2005; 115:496.
74. Juntereal NA, Spatz DL. Breastfeeding experiences of same-sex mothers. Birth 2020;
47:21.
75. Juntereal NA, Spatz DL. Same-Sex Mothers and Lactation. MCN Am J Matern Child Nurs
2019; 44:164.
76. Reisman T, Goldstein Z. Case Report: Induced Lactation in a Transgender Woman.
Transgend Health 2018; 3:24.
77. Trautner E, McCool-Myers M, Joyner AB. Knowledge and practice of induction of lactation
in trans women among professionals working in trans health. Int Breastfeed J 2020;
15:63.
78. La Leche League International, Support for Transgender and Non-binary Parents. Availa
ble at: https://www.llli.org/breastfeeding-info/transgender-non-binary-parents/ (Accesse
d on August 21, 2020).
79. Sriraman NK, Kellams A. Breastfeeding: What are the Barriers? Why Women Struggle to
Achieve Their Goals. J Womens Health (Larchmt) 2016; 25:714.
80. Perrine CG, Scanlon KS, Li R, et al. Baby-Friendly hospital practices and meeting exclusive
breastfeeding intention. Pediatrics 2012; 130:54.

81. Office on Women's Health. Business Case for Breastfeeding. 2018. Available at: https://w
ww.womenshealth.gov/breastfeeding/breastfeeding-home-work-and-public/breastfeedi
ng-and-going-back-work/business-case (Accessed on July 03, 2020).
82. United States Department of Health and Human Services. The Business Case for Breastf
eeding: Steps for Creating a Breastfeeding Friendly Worksite. 2008. Available at: https://
www.womenshealth.gov/files/documents/bcfb_employees-guide-to-breastfeeding-and-
working.pdf (Accessed on July 29, 2020).
Topic 4978 Version 68.0

GRAPHICS
Ten steps to successful breastfeeding
Critical management procedures
1. Hospital policies:
Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health
Assembly resolutions
Have a written infant feeding policy that is routinely communicated to staff and parents
Establish ongoing monitoring and data-management systems
2. Ensure that staff have sufficient knowledge, competence, and skills to support breastfeeding
Key clinical practices
3. Discuss the importance and management of breastfeeding with pregnant women and their families
4. Facilitate immediate and uninterrupted skin-to-skin contact, and support mothers to initiate breastfeeding as soon
as possible after birth
5. Support mothers to initiate and maintain breastfeeding and manage common difficulties
6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated
7. Enable mothers and their infants to remain together and to practice rooming-in 24 hours a day
8. Support mothers to recognize and respond to their infants' cues for feeding
9. Counsel mothers on the use and risks of feeding bottles, teats, and pacifiers
10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care
Reprinted from: Ten steps to successful breastfeeding (revised 2018), World Health Organization, Copyright © 2019. Available at:
https://www.who.int/nutrition/bfhi/ten-steps/en/ (accessed on January 28, 2019).
Graphic 105476 Version 3.0

Factors that may cause or contribute to inadequate milk intake in young infants
Condition Comments/explanation/examples Management
Maternal
Breast surgery Likely to affect milk production: Optimize breastfeeding technique and any
Breast reduction using a technique that other contributing factors, while monitoring
has a high risk of insufficient milk infant's weight gain. Use pumping to increase
production. As an example, if the "free milk supply. If infant's weight gain is
nipple" technique was used for breast inadequate, consider supplementation.
reduction, breastfeeding is typically not
feasible.
Possibly may affect milk production:
Breast augmentation.
Unlikely to affect milk production:
Breast biopsy.
Nipple conditions Sore nipples may decrease milk supply Assess cause and optimize nipple care and
because of infrequent feeds or inadequate breastfeeding technique. Continue
breast emptying. breastfeeding to stimulate milk production.
Refer to UpToDate content on nipple pain
during breastfeeding.
Medications Combination oral contraceptive pills with Optimize breastfeeding technique; consider
associated with high estrogen content. alternative medication if possible. Refer to
decreased milk Pseudoephedrine. UpToDate content on postpartum contraception
production* Nicotine. and to the LactMed database*.
Diuretics.
Ethanol – Excessive use may decrease milk
supply. Conversely, a small amount of beer
may raise prolactin levels.
Antihistamines in high doses.
Hormonal Maternal stress, obesity, hypertension, Optimize breastfeeding technique while

diabetes, and elevated androgen levels can monitoring infant's weight gain closely. Assess
delay full milk production (lactogenesis II). for the cause and treat if possible. The degree to
Insufficient breast tissue due to congenital which these factors affect milk production and
decreased glandular development. ability to breastfeed varies with the cause and
Pituitary insufficiency due to postpartum severity.
pituitary infarction (Sheehan syndrome).
Retained placenta.
Infant Prematurity. Optimize breastfeeding technique; refer to a

Ankyloglossia. lactation consultant or other expert in
Neuromotor delay. swallowing disorders. For ankyloglossia,
frenulotomy should be performed only after
Sucking and swallowing disorders.
assessment by a lactation specialist.
Malformations of the lip and palate,
including cleft lip and/or palate.
Mother and infant Delayed breastfeeding initiation. Room-sharing (including in the postpartum
dyad Separation of mother and infant. period). Optimize breastfeeding technique; refer
Poor latch. to a lactation consultant if needed.
* Refer to the LactMed database for information on specific medications. LactMed, produced by the National Library of Medicine, is a
free, authoritative reference for lactation compatibility for prescription and over-the-counter drugs. It provides data on drug levels in
human milk and infant serum, potential adverse effects on breastfeeding infants and lactation, and recommendations for
alternative drugs.
References:
1. Reilly S, Reid J, Skeat J, Academy of Breastfeeding Medicine Clinical Protocol Committee. ABM clinical protocol #17: Guidelines for
breastfeeding infants with cleft lip, cleft palate, or cleft lip and palate. Breastfeed Med 2007; 2:243.
2. Thomas J, Marinelli KA, Hennessy M, Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #16:
Breastfeeding the hypotonic infant. Breastfeed Med 2007; 2:112.

3. Academy of Breastfeeding Medicine. ABM clinical protocol #10: Breastfeeding the late preterm infant (34(0/7) to 36(6/7) weeks
gestation) (ﬁrst revision June 2011). Breastfeed Med 2011; 6:151.

Examples of hypoplastic breasts
Examples of hypoplastic breasts.

(A) Poorly developed upper portion, scant lower tissue
(B) Poorly developed medial portion, so that nipple turns in
(C) Tubular breast, with bulbous areola
(D) Long tubular breast, bowed to outside, with large areola
(E) Wide-spaced and uneven breasts
(F) Wide-spaced breasts with scant tissue

Grade I nipple inversion
In grade I nipple inversion, the nipple is easily pulled out with gentle retraction or
squeezing of the areolar skin. Nipple projection is well maintained for several minutes,
but then the nipple reverts to an inverted state.

Flat or inverted nipples
The presence of flat or inverted nipples sometimes interferes with effective breastfeeding. Women with
these findings may benefit from assistance during breastfeeding initiation to help the infant achieve
and sustain an effective latch, remove milk effectively to maximize the milk supply, and avoid nipple
trauma. For techniques, refer to UpToDate content on initiation of breastfeeding.

Contraindications to breastfeeding or feeding expressed breast milk to infants
Do not breastfeed and do not feed expressed breast milk

Infant has classic galactosemia (ie, not Duarte variant) These conditions preclude breastfeeding.
Mother has HIV infection*
Mother is infected with HTLV I or II
Mother is using illicit drugs (eg, phencyclidine or

cocaine) ¶
Mother has suspected or confirmed Ebola virus disease
Temporarily do not breastfeed and do not feed expressed breast milk

Mother has untreated brucellosis Mothers may be able to resume breastfeeding after
consulting with a clinician to determine when their breast
Mother is taking certain medications Δ ◊ milk is safe for their infant. These mothers should be
provided with lactation support to learn how to maintain milk
Mother has an active HSV infection, with lesions present
production and feed their infants with pasteurized donor
on the breast §
human milk or formula while temporarily not breastfeeding.
Temporarily do not breastfeed, but may feed expressed breast milk to infant
Mother has untreated active tuberculosis ¥ Airborne and contact precautions may require temporary
separation of the mother and infant, during which time
expressed breast milk should be given to the infant by
another care provider. Mothers should be able to resume
Mother has active varicella that developed between 5 days
breastfeeding after consulting with a clinician to determine
prior to delivery and 2 days following delivery
when there is no longer a risk of spreading infection. These
mothers should be provided with lactation support to learn
how to maintain milk production while not breastfeeding
and/or while expressing their milk.
While human milk provides the most complete form of nutrition for infants, including premature and sick newborns, there
are rare exceptions when human milk/breastfeeding is not recommended, as outlined in this table.
HTLV: human T-lymphotropic virus; HSV: herpes simplex virus.

* This recommendation is for women in the United States and other resource-rich countries. Breastfeeding by HIV-infected women
may be appropriate in resource-limited settings if breast milk replacement is not feasible, affordable, or safe [1].
¶ Narcotic-dependent women who are in a supervised methadone program or buprenorphine program with negative screening for
HIV and other illicit drugs may breastfeed [1].
Δ Most, but not all, therapeutic drugs are compatible with breastfeeding [1]. Medications should be reviewed on a case-by-case basis
for potential contraindications. The LactMed database, produced by the National Library of Medicine, is a free authoritative
reference for lactation compatibility for prescription and over-the-counter drugs. This resource provides data on drug levels in
human milk and infant serum, potential adverse effects on breastfeeding infants and lactation, and recommendations for
alternative drugs.
◊ Breastfeeding should be suspended during and after administration of certain radiopharmaceutical drugs. The recommended
suspension of breastfeeding varies depending on the radioactive compound. Compounds used for tumor and cardiac imaging
usually require prolonged cessation of breastfeeding [2].
§ Mothers breastfeed directly from the unaffected breast if lesions on the affected breast are covered completely and with good
handwashing to avoid transmission.
¥ The mother may resume breastfeeding once she has been treated appropriately for 2 weeks and is documented to be no longer
contagious [1].
References:
1. Johnston M, Landers S, Noble L, et al. Breastfeeding and the use of human milk. Pediatrics 2012; 129:e827.
2. Sachs HC, Committee On Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics.
Pediatrics 2013; 132:e796.
Modiﬁed from: Centers for Disease Control and Prevention. Breastfeeding: Contraindications to Breastfeeding or Feeding Expressed Breast
Milk to Infants. Available at: https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/contraindications-to-
breastfeeding.html (Accessed on July 31, 2020).

Achieving a comfortable and effective latch for breastfeeding
During latch-on, the infant's lips form a seal, with the lower lip covering most of the areola under
the nipple. Signs of an effective latch and milk transfer are:
The infant's mouth is open as wide as if yawning.
More areola is seen near the infant's nose than jaw. In other words, the latch is asymmetric
with regard to the nipple, with the nipple high in the infant's mouth and much closer to the
infant's nose.
The infant's chin is buried in the breast, and the nose is near but not touching the breast.
The mother and infant are both completely comfortable. Mother feels tugging and pressure
but no nipple rubbing, compression, "tickling," or pain.
Swallows are audible.
The breast is lighter/softer after the feeding than before the start of the feeding.
The infant is content after the feeding: Arms are relaxed, and the infant is no longer rooting.

Advice to address maternal exhaustion related to breastfeeding
Planning and self-care

Plan to nap and rest during the day whenever possible to make up for lost sleep at night.
Set up "feeding stations" with water, snacks, and diaper-changing materials so that infant care can be bundled.
Prioritize activities that make you feel good, such as talking with family or friends, going outside, or taking an
uninterrupted shower or bath.
Feeding techniques
Allow baby to feed "on cue" or "cluster feed" (ie, responsive feeding). Frequent feeding will often be followed by a longer
sleep period.
Before or during each feed, provide some stimulation, such as changing the diaper or burping or massaging the infant.
This will encourage the baby to fully drain at least one breast.
At each feeding, encourage the baby to feed until he or she appears content, with relaxed arms or appearing "milk drunk,"
rather than feeding a smaller amount ("snacking").
Use techniques to maximize milk expression, including gentle breast compression during feeds to stimulate milk let-down
and hand expression after feedings.
Support from partner and others

Line up support from family and friends to help with infant care and household duties.
Consider home nursing or postpartum doula services.
Emotional support
Feelings of difficulty, exhaustion, and being overwhelmed are very common and normal. This is part of caring for a
newborn, and you will get through it.
If you are not feeling more and more like yourself after the first few weeks of being a new mother, discuss this with your
clinician.
As a mother, you have been "born" into a new role, and it is normal to go through a period of adjustment.
Additional resources
Useful websites:
American Academy of Pediatrics Healthy Children
Texas Tech Health Sciences Infant Risk Center
Reliable lactation advice and peer support:
KellyMom
New Mom Health
United States government websites:
Office on Women's Health
WIC Breastfeeding Support
Join a breastfeeding or postpartum support group either online or in-person:

La Leche League International
Postpartum Support International

Contributor Disclosures
Ann Kellams, MD, IBCLC, FAAP, FABM Nada que revelar Steven A Abrams, MD Subvención /
Investigación / Apoyo a ensayos clínicos: Fresenius Kabi [Enfermedad hepática asociada a la nutrición
parenteral]. Consultores / Consejos Asesores: MilkPep [Nutrición infantil]. Teresa K Duryea, MD Nada
que revelar Alison G Hoppin, MD Nada que revelar
El grupo editorial revisa las divulgaciones de los colaboradores para detectar conflictos de intereses.
Cuando se encuentran, estos se abordan mediante un proceso de revisión de varios niveles y mediante
requisitos para que se proporcionen referencias para respaldar el contenido. Se requiere que todos los
autores cuenten con contenido debidamente referenciado y éste debe cumplir con los estándares de
evidencia de UpToDate.
Política de conflicto de intereses

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17/2/2021 Breastfeeding: Parental education and support - UpToDate

Reimpresión oficial de UpToDate ®

Lactancia materna: educación y apoyo para los padres

Desafortunadamente, a pesar de las fuertes recomendaciones, la práctica real de la lactancia

La orientación anticipada y el asesoramiento y la educación continuos para las madres se

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FACTORES EN LAS DECISIONES DE ALIMENTACIÓN DE LOS PADRES

● Intención de amamantar - La intención de amamantar es un fuerte predictor del inicio

La intención materna de amamantar exclusivamente se asocia con las siguientes

• Consciente de la recomendación de amamantar exclusivamente [ 12 ]

• Está embarazada de gemelos [ 15 ]

● Clínico consejos - Recibir asesoramiento de un profesional de la salud para amamantar

• Generaciones perdidas : a fines de la década de 1970 y principios de la de 1980 en

• Autoeficacia: la autoeficacia de la lactancia materna (la confianza de la madre en

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ENFOQUES PROGRAMÁTICOS Y RECURSOS PROFESIONALES

● Entorno de oficina propicio para la lactancia materna : varias organizaciones tienen

● Apoyo profesional para madres que amamantan : el médico y la práctica deben

Algunos ejemplos de apoyo profesional incluyen:

• Médicos de práctica avanzada: los médicos en una variedad de campos médicos

- Sección de lactancia materna de la Academia Estadounidense de Pediatría

• Consultores de lactancia certificados por la Junta Internacional (IBCLC) : la

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lactancia certificado (CBE) puede proporcionar orientación sobre lactancia [ 34 ]. La

• Profesionales de visitas domiciliarias: las visitas domiciliarias de una enfermera,

• Programas integrales de seguimiento posparto: estos programas están disponibles

• Asistencia telefónica: la asistencia telefónica para la lactancia materna está

INITIAL CLINICAL ASSESSMENT AND SUPPORT

● Assess the mother's knowledge and concerns – To initiate counseling, it is helpful to

Assessing the mother's understanding of breastfeeding and identifying common

• Insufficient glandular tissue – While it is rare, some mothers have insufficient

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Contraindications to breastfeeding — There are very few contraindications to

● Avoid formula supplementation unless it is medically necessary

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Address common concerns

Maternal exhaustion — Caring for a newborn is exhausting work, with a 24-hour/7-days-

POSTNATAL MEDICAL SUPERVISION

Frequency of follow-up — Breastfeeding mother-infant dyads should have frequent follow-

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● Breastfeeding does not need to be interrupted when iodinated or gadolinium contrast is

● (See "Postpartum contraception: Counseling and methods", section on 'Impact of

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Breastfeeding during a subsequent pregnancy — It is generally safe to breastfeed during

Infant hypoglycemia — Similar to jaundice, most infants do not develop pathologic

Relactation or induction of lactation — It is possible for a mother who has lactated

SUPPORT FOR MAINTENANCE OF BREASTFEEDING

● Remind mothers of the recommendations

● Encourage mothers to set a personal goal for breastfeeding duration

● Adhere to the recommendations for a breastfeeding-friendly office (see 'Programmatic

Suggested guidance for mothers who plan to return to work includes:

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SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

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SUMMARY AND RECOMMENDATIONS

● Postnatal medical supervision for breastfeeding includes advice on maternal nutrition,

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● Early and focused guidance to optimize breastfeeding is particularly important for

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