Paeds · gastroenterology-hepatology-and-nutrition
Breastfeeding medicine and lactation support
Also known as Breastfeeding · Lactation · Breastfeeding difficulties · Lactation support · Mastitis · Low milk supply · Breast engorgement · Human milk · Relactation · Donor breast milk
Fellowship guide to breastfeeding medicine and lactation support: the care of the breastfeeding mother-infant dyad from the physiology of prolactin-driven milk synthesis and the oxytocin let-down reflex to the WHO recommendation of exclusive breastfeeding for about six months and continued breastfeeding to two years and beyond. The page covers the infant and maternal benefits, the few true contraindications, the disciplined assessment of latch and milk transfer with WHO growth standards, and the layered management of the common problems of engorgement, the mastitis spectrum, nipple trauma and perceived low supply. It addresses the safe use of medications in the lactating mother, the support of the late-preterm and preterm infant with pasteurised donor human milk, relactation, the Baby-Friendly Hospital Initiative and the equity gap for Indigenous, migrant and disadvantaged families.
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- A breastfed infant who is lethargic, has fewer than expected wet nappies, dry mucosa or continues to lose weight beyond two weeks is dehydrated or failing to thrive and needs urgent assessment of intake, electrolytes and glucose, not reassurance
- A fluctuant, exquisitely tender breast mass, persistent fever or a mastitis that fails to improve after 48 hours of antibiotics points to a breast abscess needing ultrasound and drainage
- Severely cracked, bleeding nipples risk infant blood exposure and maternal infection; pause direct feeding on the damaged side, express to maintain supply and feed expressed milk while healing
- Classic galactosaemia in the infant is an absolute contraindication to breastfeeding; maternal HIV is a regional decision and active untreated tuberculosis requires separation until non-infectious
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- Normal infant feeding and the WHO breastfeeding recommendations
- Assessment of effective breastfeeding and infant growth
- Common breastfeeding problems in the community
- Physiology of lactation and the management of breastfeeding problems
- Medications in the lactating mother and true contraindications
- Lactation support for the preterm and late-preterm infant
- The newborn feeding assessment and early breastfeeding support
- Maternal mastitis and the failing-to-thrive breastfed infant
- Long case: the mother with breastfeeding difficulty and low supply
- Short case: assessment of latch, transfer and infant growth
- Nutrition: breastfeeding and the use of human milk
- Common neonatal and infant feeding problems
- Breastfeeding physiology, benefits and recommendations
- Mastitis, low supply and contraindications to breastfeeding
- Communication: supporting a mother with breastfeeding difficulty
- Breastfeeding and infant nutrition
- Common breastfeeding problems and lactation support
- Patient Care: breastfeeding support and management of feeding problems
- Medical Expert: breastfeeding medicine and lactation support
Breastfeeding medicine is the clinical care of the mother-infant dyad. As a paediatric clinician your job is to protect, promote and support breastfeeding, to recognise and treat the common problems, and to know the few situations in which breastfeeding is contraindicated or needs modification. The evidence base is unusually strong and consistent across the World Health Organization, the Australian National Health and Medical Research Council, the American Academy of Pediatrics and the Academy of Breastfeeding Medicine. [1] [3]
Overview & Definition
Breastfeeding is far more than nutrition. Human milk provides immunoglobulins, antimicrobial proteins, growth factors and stem cells that shape the infant gut and immune system, and it lowers the risk of infant infections, sudden infant death syndrome, necrotising enterocolitis, leukaemia, obesity and diabetes. The mother benefits too, with reduced breast and ovarian cancer, longer inter-pregnancy intervals and a lower risk of type 2 diabetes. [1] [4]
The global recommendation, affirmed by the 2016 Lancet Breastfeeding Series and adopted in Australia, is exclusive breastfeeding for about the first six months of life, introduction of nutritionally adequate and safe complementary foods from around six months, and continued breastfeeding to two years and beyond. [1] [2] The 2022 American Academy of Pediatrics policy supports continued breastfeeding to two years and beyond, depending on the mutual desires of mother and infant. [3]
The heart of the matter is the dyad. A problem on one side is usually a problem on both: a poor latch causes maternal nipple trauma and infant poor transfer, which causes low supply, which causes more supplementation, which lowers supply further. Your task is to find the break in the loop and close it early. [3]
References12ShowHide
- [1]Victora CG; Bahl R; Barros AJ; et al Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet, 2016.PMID 26869575
- [2]Rollins NC; Bhandari N; Hajeebhoy N; et al Why invest, and what it will take to improve breastfeeding practices? Lancet, 2016.PMID 26869576
- [3]Meek JY; Noble L; Section on Breastfeeding Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics, 2022.PMID 35921640
- [4]Ip S; Chung M; Raman G; et al Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep), 2007.PMID 17764214
- [5]Mitchell KB; Johnson HM; Rodriguez JM; et al Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022. Breastfeed Med, 2022.PMID 35576513
- [6]Pérez-Escamilla R, Martinez JL, Segura-Pérez S Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr, 2016.PMID 26924775
- [7]Quigley M; Embleton ND; McGuire W Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev, 2019.PMID 31322731
- [8]Paul C; Zenut M; Dorut A; et al Use of domperidone as a galactagogue drug: a systematic review of the benefit-risk ratio. J Hum Lact, 2015.PMID 25475074
- [9]Moore ER; Bergman N; Anderson GC; et al Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev, 2016.PMID 27885658
- [10]O'Shea JE; Foster JP; O'Donnell CP; et al Frenotomy for tongue-tie in newborn infants. Cochrane Database Syst Rev, 2017.PMID 28284020
- [11]Jaafar SH; Ho JJ; Jahanfar S; et al Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev, 2016.PMID 27572944
- [12]Busch DW; Silbert-Flagg J Breastfeeding Plan of Care for the Late Preterm Infant From Birth Through Discharge. J Perinat Neonatal Nurs, 2021.PMID 33900247