Breast Is Best for Babies Alexander K.C. Leung, MBBS. FRCPC. FRCP (UK & lrel), FRCPCH and Reginald S. Sauve, MD, FRCPC Calgary, Alberta, Canada Breastfeeding is tne optimal method of infont feeding. Breast mit provides almost ail the necessary nutients, ‘growth factors ond immunological components a heatthy term infont needs. Other advantages of breastteeding include reduction of incidences and severty of infections: ‘revention of alegies: posible enhancement of cognitive development: and prevention of obesty hypertension ond insuin-dependent dicbetes mits. Heath gains for breast feeding mothers include lactation amenonied, eaty iver lufion ofthe viens, enhanced banding between the moth- ‘erond the infant, and reduction incidence of evrion and ‘breast cancer. from the economic penpectve, reastiees- ing is less expensive thon formula feeding. In most cases, ‘maternal ingestion of medications and materne infections ‘are not contraindicatons to breastfeeding. Breostfeeding, however. is contrindicated in infonts with galactesemia, The management of common breastfeeding isves, such as ‘breast engorgement, sore nipples. mosis ond insufficient ilk, is dscussed. Brecstieeding should be initiated as soon after defvary 05 posse. fo promate, protect and support breasiteeding the World Heath Organization (WHO} ond ‘he United Nations Children's Fund (UNICEF| developed the Baby-Fiencly® Hospital intatve (BFA! 10 Steps fo Success reastfeeding. Heathcare professional have an imporiant role to play in promoting ond protecting breastfeeding Key words: breastleecing ll advantages Wl promote HE suppor (0205. For ne Deparment o! Sedat. he Aerio Chiten's spl ‘ond he Uva of Calgary. Cola. Abra Send conerponcence ond rapt reqet fer Nol Med assoc. 700597110131 oD Alerander EC Leung, #200288 dh ve. Calgary, Abra tC, Canta fx. 13230820 ermal seungeucugay.ce 1010 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION The advantages of breastfeeding are many and have ‘been well documented in the literature." Breastfeeding, is universally accepted as the optimal method of infant feeding forthe frst year of life and thereafter as long. as is beneficial to the mother-infant dyad.'* Studies have shown that benefits increase with the duration and exclusivity of breastfeeding up to six months. As such, the medical profession's obligation in the promotion of breastfeeding is clear and unequivocal. Healthcare pro- fessionals who deal with lactating mothers must fami iarize themselves with various aspects of breastfeeding, ‘and be well versed in the handling of potential prob- lems associated with breastfeeding. PHYSIOLOGY OF LACTATION ‘The first half of pregnancy is characterized. by ‘growth and proliferation of the ductal system, arboriza- tion of the alveolar structure and formation of lobules. Prolactin, which is secreted by the anterior pituitary land, stimulates the secretory cells in the alveoli to secrete milk, Lactation during pregnancy is inhibited by high levels of estrogen and progesterone, which inhibit the release of prolactin and interfere with the action of prolactin at the alveolar cell receptor level. As the estro- ‘gen and progesterone decline abruptly in the postpartum period, the anterior pituitary gland releases very large amounts of prolactin, which stimulates the alveoli to produce significant amounts of milk. The most impor tant factor in an ongoing release of prolactin is nipple stimulation from suckling.’ In response to suckling, oxy- tocin is released by the posterior pituitary gland. Oxy- tocin causes the myoepithelial cells surrounding the alveoli to contract and propel milk to the milk sinuses in the areolar area. This milk ejection (let-down reflex) is usually described as a tingling sensation. Endocrine contral is supplanted by autocrine control as the mother’s baseline levels of prolactin return to ‘more normal levels at about three months postpartum At this time, itis the removal of milk (in particular, & feedback inhibitor of lactation in the milk) from the breast that maintains the supply of milk." The more the ‘mother empties her breast, the more milk is produced * VOL.97.NO. 7, JULY 2005ADVANTAGES OF BREASTFEEDING Nutritional Considerations Human milk contains the appropriate proportions of protein, carbohydrates, fat, minerals and vitamins for optimal growth, with the exception of vitamins D and K.** All newborn infants should receive vitamin K at birth, and breastfed infants should receive vita- min-D supplementation until the diet provides an adequate source of vitamin D. The whey/casein ratio of human milk is approximately 72:28, whereas the whey/casein ratio of whole cow's milk is approxi- mately 18:82." The whey/casein ratio in infant for- mulas range through 18:82, 60:40 or 100% whey. ‘Whey proteins are acidified in the stomach, forming soft flocculent curds that are more easily digested than casein, which forms tough, hard-to-digest curds in the stomach. The amino acids taurine and cysteine are present in much higher concentrations in human milk than in whole cow’s milk. These amino acids may be essential for premature infants. On the other hand, the amounts of methionine and phenylalanine, which are poorly tolerated by some infants, are found in lower concentrations in human milk." ‘The renal solute load of human milk is epproxi- mately one-third that of whole cow's milk, The small renal solute load helps to protect the infant's kidneys from needing to excrete a large solute load, thereby leaving a wider margin of safety in situations that may lead to dehydration.’ Lactose accounts for most of the carbohydrates in human milk, Lactose enhances calcium and iron absorption and promotes the growth of lactobacilli, which in turn helps prevent the growth of pathogenic flora in the gut. Lactose metabolizes readily to glu- cose and galactose, important sources of energy for the growing infant. Glucose isan essential fuel for the brain. Human milk ensures a supply of galactocere- brosides, which are essential to brain development. Triglycerides, the main constituent of milk fats, are readily broken down into free fatty acids and glycerol by lipase. Human milk provides generous amounts of essential fatty acids (linoleic acid and linolenic acid), long-chain polyunsaturated fatty acids (docosahexaenoic acid and arachidonic acid) and cholesterol. Table 1. Drugs Usually Contraindicated during Breastfeeding 1. Cytotoxic 2. Radioactive agents 3. legal drugs of abuse 4. Phenindione 5. Chioramphenicel 6 Tetracycline BREASTS BEST Human milk also contains nucleotides, which are necessary for energy metabolism, growth and matu- ration of the gastrointestinal tract, enzymatic reac- tions and enhanced immune function. ‘Although human mitk has only a smell amount of iron (0.3 mg/l. to 1 mg/L), iron in human mitk is highly bioavailable, possibly because of the lower calcium and phosphorous content and the presence of lactoferrin. Approximately 50% of the iron in the human milk is absorbed, compared to about 10% of that in whole cow's milk. Milk from mothers of preterm infants contains higher concentrations of fat, protein and sodium but slightly lower concentrations of lactose, caleium and phosphorous, compared to milk form mothers of term infants." For the very premature infants, human milk alone does not meet the high demands of growth.” To correct the nutritional inadequacies in the very premature infants, fortification of human ilk may be fequired.*"*" Commercial human milk fortifiers are available in powdered or liquid form.” Immunological and Anti-Infective Advantages The protective properties of human milk can be divided into cellular or humoral factors. Cellular components, including T and B-lymphocytes, macrophages and neutrophils, are at especially high levels in colostrum, and they persist in milk in lower concentrations but in activated forms for as long as, breast milk is produced."* Humoral factors include ‘immungolobulins, lysozyme, nucleotides, lactoferrin, complements, bifidus factor, interferon, lactoperoxi- dase, oligosaccharides, vitamin Br2 binding protein and epidermal growth factor. Secretory IgA predomi- nates in human milk and plays a vital role in the pro- vision of local protection to the mucosal membrane. ‘Human milk contains glucosamines, which promote the growth of lactobacillus bifidus, which helps 0 prevent the growth of pathogenic flora in the gut. Breastfeeding decreases the incidence anor severity of gastrointestinal tract infection," lower respiratory tract infection," otitis media," urinary tract infec- tion,” meningitis,” septicemia and necrotizing ente- Table 2. Signs of Successful Breastfeeding In the Early Weeks 1. Satistactory weight gain 2 Audible swallowing 3. Al leost eight feedings per day 4, Al eost two bowel movements pes day 5. Atleast sx wet diopers per day & Urine pate and odorless 7. Infant olet and active JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOR. 97.NO. 7, JULY 2008 1011BREASTS BEST rocolitis.® There is also evidence that breasticeding actively stimulates the immune system of the infant.” Prevention of Allergies Breastfeeding does have a protective effect on the incidence of atopy in infants with a genetic predisposi tion to atopy. A meta-analysis of 12 prospective studies (18,183) suggcsts that exclusive breastfeeding during the first months of life is associated with lower asthma rates during childhood.” In high-risk infants, exclusive breastfeeding with delayed introduction of solid foods (until six months of age) may delay, or pos- sibly prevent, the onset of food allergy in some chil dren? Because small amounts of food antigens ingested by the mother are excreted in breast milk, avoidance of allergenic foods by lactating mothers is often recommended.” Infants with elevated cord serum IgE and a positive family history of atopy are at risk for the development of atopic disease, Breastfeeding pro- tects against the development of allergy by several ‘mechanisms. Colostrum is responsible for seating the gut, thereby preventing the entrance of large foreign proteins and thus preventing an allergic response. Colostrum also prevents the adherence of pathogens. Breastfeeding reduces the amount of foreign protein in an infants gastrointestinal tract and passively transfers maternal IgA to the infant, thereby protecting the infant's gastrointestinal tract from absorbing antigens Transfer of cell-mediated immunity from mother to infant stimulates IgA synthesis inthe infant.” In addi- tion, epidermal growth factor present in human milk hastens maturation of intestinal mucosa and epithe! ‘um, thereby strengthening the mucosal barrier to anti- gen.” Finally, several studies have shown that respirato- ty and gastrointestinal infections may lead to the development of allergic diseases. Thus, an allergy- preventive effect of breastfeeding may be secondary 10 a reduction in the number of infections in the infant. Enhanced Cognitive Development ‘Children who are breastfed have higher cognitive function than children who are formula-fed." Anderson etal. performed a meta-analysis on 11 stud- ies that reported unadjusted and covariate-adjusted findings comparing cognitive development of breast- fed and formula-fed infants." After adjusting for pos- sible confounding variables, such as socioeconomic. status and maternal education, the “cognitive devel- ‘opment score” was 3.16 points higher in breastfed infants (n=7,081) compared with formula-fed infants." The meta-analysis also found that the dura- tion of breastfeeding correlated with development and cognitive outcome. A recent study suggests that the effect may last well into adulthood.” Prevention of Obesity Breastfeeding reduces the risk of childhood obesi- ty toa moderate extent.” Of 11 studies that exam- ined prevalence of obesity in children >3 years of age that had a sample size of 2100 per feeding group, eight showed a lower risk of obesity in children who had been breastfed after controlling for potential con- founders.” The three “negative” studies lacked infor- mation on the exclusivity of breastfeeding.® Child- hood obesity may persist into adult obesity with associated morbidity, such as type-2 diabetes melli- tus, hypertension and hypercholesterolemia.* Prevention of Insulin-Dependent Diabetes Mellitus An association between carly exposure to cow's ‘milk protein and risk for insulin-dependent diabetes Table 3. Ten Stops to Successful Breastleeding Every facility or agency providing maternily sorvices ond care of newbom infants should: |. Have a written breastleeding policy that is routinely communicated to all health-care stoft 2. Tain all health-care staf in skills necessary to implement this policy. 3. Inform oll pregnant women about the benefits nd manogement of breastleeding. icte breasHtesding within a half-hour of bith, 5. Show mothers how to breastfeed and how to maintain lactation even i they should be separated 4. Help mothers i from their infants. 6. Give newborn infants no food or drink other than breast mik unless medically indicated, 7, Practise roomingyin (allow mothers and infants to remain together 24 hours a dayh, 8. Encourage breastfeeding on demand, 9. Give no aniificial teats or pacifiers (oko called dummies or soothers} 10 breastfeeding infants. 19, Foster the estabishment of breastteeding support groups and refer mothers fo them on discharge trom the hospital or clini. ‘Adapted tom: WHOJUNCEE Folecting, promoting and supporting breosfeecina, The seecil re ol mareriy seizes. jin! ‘WHO/UNICEF stotemen. nj Gynaecol Costes, 1790.3 50ppI THA TSS 1012 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION. VOL.97,NO. 7, JULY 2008mellitus has been reported in many studies.” Bovine serum albumin may provoke an immunolog- ical response in genetically susceptible individuals, ‘which then cross-reacts with a beta-cell surface pro= tein, p 692°" The expression of this protein on the surface of beta cells is believed to mediate their destruction by exposing them to immune attack.” Destruction of beta cells may lead to the develop- ‘ment of diabetes mellitus. The American Academy of Pediatrics recommends breastfeeding and avoid- ance of commercially available cow’s miik and prod- uts containing intact cow's milk protein during the first year of life in families with a strong history of insulin-dependent diabetes mellitus. Prevention of Hypertension There is evidence that breastfeeding may protect, against high blood pressure in later life."*! In a recent study, Martin et al. found that for every three months of breastfeeding, the children had a 0.2-mm Hg reduction in systotic blood pressure." The redue- tion in blood pressure, though small. is significant and may have important public health implications Prevention of Certain Gastrointestinal Diseases Several studies have suggested that breastfeeding may prevent or delay the onset of celiac disease, SREASTIS BEST Crohn’s discase and ulcerative colitis.“ Further studies are necessary before a definitive conclusion, can be made. Nevertheless, it is prudent to recom- mend that mothers with a family history of these conditions breastfeed exclusively for six months. Prevention of Sudden Infant Death Syndrome Several studies have suggested that breastfeeding may be protective against sudden infant death syn- drome.*" None of the studies, however, has controlled for the sleeping position and household smoke expo- sure? Thus, « casual relationship remains unproven. Maternal Health Benefits Health gains for breastfeeding mothers include lactation amenorrhea, decreased postpartum bleed- ing, early involution of the uterus, postpartum weight loss, and protection against ovarian cancer and breast cancer.**"* The Collaborative Group on Hormonal Factors in Breast Cancer combined data from 47 epidemiological studies (n=50,302) con- ducted in 30 countries to examine the relation between breastfeeding and breast cancer." The group found that the relative risk of breast cancer decreased by 4.3% (95% Cl 2.9-5.8; p=0.0001) for every 12 months of breastfeeding in addition to a decrease of 7% (5-9: p<0.0001) for each birth. The 2. No tree samples to mothers 3. No promotion of product suppies, 5. No gifs oF personal samples fo health workers. product. 4, No company representatives to advise mothers. Table 4. Summary of the WHO/UNICEF International Code of Marketing of Breast Milk Substitutes and ‘subsequent WHA Resolutions 1. No advertising of products under the scope of the Code fo the public. in health-care facilities, including the distribution of tree or lows cost 6. No words or pictures idealzing ortifcial feeding, Including the pictures of infants on the labels of the 7. Information to health workers should be scientific and factual 8. Allinformation on artificial feeding, including the labe's, should explain the benefits of breastfeeding ‘and all cosls and hazards associated with artificial feeding, 9. Unsuitable products, such as sweetened condensed milk, should not be promoted fer babies. 10, All products should be of a high qualily and lake into account the climatic and storage conditions of the country where they are used, 11, Foster oppropriate complementary feeding from the age of about six months, recognizing thet ny food or drink given before complementary feeding is nulitionally requied may interfere with initiation ‘or maintenance of breastfeeding. 12. Ensure that complementary foods are not marketed for or used in ways that undermine exclusive ond sustained breastfeeding, 13. Fnancial assistance from the infant feeding industry may interfere with professionals’ unequivocal support for breastfeeding and should be avoided. + Wo: Wes Heth Organization; UNICEF Lites Noone Chicken’ Fung: WHA: Word Heol Astemb: Adapted om Wer Heath Grgznizton niernatonal Gade of Marketing of ecr-nik SubsTuter WHO: Gonevo, Wl Or subsequent WIA rez JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION YOL.97,NO.7, JULY 2005 1018BREASTIS BEST longer women breastfeed, the more they are protect- ed against breast cancer. Breastfeeding also gives the mother a sense of fulfillment and enhances maternal-infant bonding. Economic Benefits From the economic perspective, breastfeeding is less expensive than formula feeding. Breastfeeding is environmentally friendly. The decteased rates of various illnesses in breastfed infants translate into savings for medical care. Exclusive breastfeeding also promotes child-spacing,” POTENTIAL CONTRAINDICATIONS TO BREASTFEEDING Drugs Generally, drugs given to nursing mothers appear in only small amounts in human milk, usually <1% of the maternal dosage. Most drugs are safe in the breastfed child. Several drugs, however, because of their high excretion into the breast milk and their toxi- city, should be avoided during lactation (Table 1). In addition, lithium, prozac, amiodarone, clofazimine, lamotrigine, ergotamine, mefloquine, ganciclovir, cyclosporine, anticonvulsants, anticoagu- lants, antidepressants, tetracycline, sulfa drugs, gold salts, metronidazole and salicylates may have effects ‘on some breastfed infants and may be of concern." For the limited number of drugs that are contraindi- cated during lactation, a safe alternative medication can usually be found. Bromocriptine should be avoid ccd during lactation as it may inhibit milk production.” Environmental Chemical Agents Maternal exposure to low-level environmental chemical agents, such as organochlorine compo- nents, is nota contraindication to breastfeeding."*” Maternal Infections In most cases, maternal infections are not con- traindications to breastfeeding. For most infections, infants have already been exposed to the infectious agents during the prodromal period, and to interrupt breastfeeding at a time when antibodies are being provided by breastfeeding is counterproduetive.* ‘Tuberculosis is rarely transmitted by breast milk but can be transmitted by exposure to the sputum from an infected mother” As such, mothers with untreated active tuberculosis should not be in con- tact with their infants, regardless of the mode of feeding.* Mothers with active tuberculosis may breastfeed their infants only after they have received adequate therapy and are considered noninfectious.” Neonatal herpes virus infection can be very 3014 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION severe, Nevertheless, a mother with active herpes virus infection can continue breastleeding, provided there is no active herpetic lesions on or near the nip- ple." If a herpetic lesion is present on or near the nipple, breastfeeding is contraindicated." Human immunodeficiency virus (HIV) can be transmitted from the mother to her infant during preg~ nancy or breastfeeding. The transmission rate of HIV. through breastfeeding 1s 5-20%.* In developed coun- tries, itis recommended that HIV-infected mothers not breastfeed their infants.” In developing countries, when children born to women living with HIV can be ensured uninterrupted access to nutritionally ade- ‘quate breast milk substitutes that are safely prepared and fed to them, they are at less risk of illness and death if they are not breastfed." When these condi- tions are not fulfilled—in particular, in an environ- ment where infectious diseases and malnutrition are the primary causes of death during infancy, artificial feeding substantially increases children’s tisk of ill- ness and death.* In most countries, policy must cover a range of socioeconomic conditions, and the aim. should be to promote and protect breastfeeding for the majority of women while offering as much choice as possible to women who are HIV-positive, enabling them to decide what is most appropriate for their cir- cumstances and supporting them in their choice. Certain Metabolic Disorders In infants with galactosemia, galactose must be excluded from the diet early in life to avoid cirrhosis of the liver, mental retardation, cataracts and hypo- glycemia. As such, breastfeeding is contraindicated in infants with galactosemia, Infants with phenylketonuria, because of the defi- ciency of phenylalanine hydroxylase, are unable to degrade phenylalanine via the tyrosine pathway. Because breast milk is low in phenylalanine, such infants may be partially breastfed provided they can be supplemented with an approximate amount of pheny- lalanine-free formula and are closely monitored." Breast Cancer ‘A mother with a newly diagnosed breast cancer probably stiould not breastfeed her infant since pro- Jactin levels remain high during lactation, and the role of prolactin in stimulating the growth of breast cancer is still in dispute-® On the other hand, the fear of cancer in the breastied female offspring of a women with breast cancer does not justify avoiding breastfeeding * MANAGEMENT OF COMMON BREASTFEEDING ISSUES Breast Engorgement Postpartum engorgement is a transitory condition VOL 97, NO. 7, JULY 2008due to lymphatic and vascular congestion, which prevents adequate milk flow. Engorgement can result in discomfort, difficulty in establishing milk flow and difficulty in latch-on.* Engorgement can bbe prevented by early, effective and frequent nurs- ing. Management includes rest and hand expression ‘or pumping before nursing, to soften the breast and to enhance maternal comfort.’ The use of alternating. warm and cold compresses and mild analgesics, such as ibuprofen, may sometimes be necessary.? Oversupply or Overactive Milk Ejection Reflex Hyperactive let-down may result in premature ‘weaning, gas and breast refusal when milk over- whelms the infant. Management includes removing the infant from the breast when let-down occurs and ‘waiting for the milk flow to slow down before put- ‘ing the infant to the breast. Plugged Ducts Plugged ducts may result from an overly copious milk supply, a tight bra or incomplete emptying of the breast. Clinically, a plugged duct may manifest as a “white spot on the nipple oras a breast lump. There nay bbe mild, local tenderness. Treatment consists of apphi- cation of heat and massage towards the nipple, together ‘with frequent nursing in 2 variety of postions.” Inverted Nipples Infants are breastfed and not nipple-fed. As tong as the degree of inversion does not affect the ability ofthe infant to grasp the areolar tissue and draw the nipple into the mouth, there is no reason why a ‘mother with inverted nipples should not be able (0 breastfeed." Treatment consists of gently rolling the nipples between the thumb and index finger before feeding to help the nipples stand up.” Some breastfeeding experts believe that proper latch-on of ‘the infant will overcome flat or inverted nipples. Sore Nipples Nipple soreness is often the result of trauma from poor positioning and Jatch-on of the infant during breastfeeding and, if uncorrected, may lead to cracked nipples and breast infection.” Sore nipples can be managed by proper positioning of the infant's mouth on the nipple, alternating nursing positions with each feeding and optimizing nipple care."** Engorgement and monilial infections of the nipple may also contribute to nipple soreness which, if present, should be treated appropriately. Mastitis Approximately 15% of nursing mothers experi- ence mastitis.” Predisposing factors include a JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION BREAST IS BEST decrease in nursing frequency leading to milk stasis, inadequate drainage in a mother with an abundant milk supply, cracked nipples and fatigue.? The usual ‘causative organism is Staphylococcus aureus." Less ‘commonly, it may be caused by Escherichia coli, Klebsiella pnewmoniae and Streptococcus species. Treatment consists of heat, massage, continued breastfeeding, rest and the judicious use of anal- gesics and antibiotics. Monilial Infection Monilial infection of the nipple has been associat- ‘ed with nipple damage, use of antibiotics, maternal ‘monilial vaginitis during pregnancy and thrush in the infant.” The condition usually presents as intense, burning pain in the nipples when nursing, The nipples and arcolae also may be red and itchy. Treatment con- sists of topical application of nystatin cream. In resist- ant cases, ketoconazole or fluconazole can be used. Both the mother and the infant should be treated if monilial infection is diagnosed on either the mother’s breast or in the infant's mouth.* Breast Abscess Breast abscess may result from untreated mastitis ‘or mastitis complicating a plugged duct.” Treatment consists of incision and drainage, antibiotic therapy and analgesics. The affected breast should be emp- tied by gentle mechanical pumping, and the infant should continue to feed from the opposite breast. Mammoplasty In general, breastfeeding is usually possible with ‘augmentation surgery or mastopexy The ability to breastfeed after reduction surgery depends on whether the nerve and blood supply to the nipple and areola are completely severed. Insufficient Milk Insufficient milk may be secondary to congenital mammary hypoplasia/aplasia, postmasteetomy or after reduction surgery, infrequent or incomplete breast emptying, anxiety, exhaustion, inadequate maternal diet, or heavy smoking.” The condition is ‘more comrhon in primiparovs women." The under- lying cause should be treated if possible. One shoutd always correct the latch first. Frequent nursing, ie ‘once every two hours, should be encouraged. Breast compression can be used to increase milk supply. With a continued problem of supply, mechanical pomping and the use of domperidone may increase milk production, and this may be worth a trial The recommended dose of domperidone is 20 mg QID. If there is no improvement within a few days, the dose may be increased to 30 mg QID. Once the ‘mother’s milk production is sufficient for the baby to VOL.97,NO.7, JULY 2008 1018‘BREAST 1s BEST Table 5. Role of Physicians in Promoting and Protecting Breastfeeding . Promote. support and protect breastfeeding enthusiastically. n consideration of the extensively published evidence for improved health and developmental outcomes in breastfed infants and their mothers, a strong position on behalf of breastfeeding is warranted. 2. Promote breastfeeding as a cultural norm and encourage family and societal support for breastfeeding. 3. Recognize the effect of cutural diversity on breastieeding attitudes and practices and encourege varicons, I eppropricte, that effectively promote and suppot breastfeeding in diferent cultures. 4, Become knowledgeable and skilled in the physiology and the current clinical management of breastfeeding. 5. Encouroge development of formal training in breastfeeding and lactation in medical schoo, in residency and felowship fairing progroms, and for practicing pediaticions. 6. Use every opportunity to provide age-appropriate breastfeeding education to children and adults in the medical setting and in ovkeach programs for student and paren Groups, 7. Work collaborativety with the obstetric community to ensure that women receive accurate and sufficient information throughout the perinatal period to make a fully informed decision about infant feeding. 8, Work collaboratively with the dental community to ensure that women are encouraged to continue: jo breastfeed ond use good ora health practices, 9. Promote hospital policies and procedures that facilitate breastfeeding, Work actively toward eliminating hospital policies and practices that discourage breastfeeding. Encourage hospitals to Provide p-depth traning in Breottleecing forall healtncere sto and hove lactation experts, Svailoble at oF mes. 10. Provide effective breost pumps and private lactation areas for al breostteeding mothers in ‘ombulstary and inpatient creas of the hospi 11, Develop office practices that promote and support breastfeeding by using the guidelines ond materials provided by the Americon Academy of Pediatrics Breasifeeding Promotion in Physicians’ Office Practices program 12, Become familar with local breastfeeding resources so that potients can be referred appropriately. When specialized breastfeeding services oTe vied, the extent) fole of ne pediatrician ar the infon!’s primary healihcore professional wiihin the iramework of the medical home needs 10 be clarified for parents. 13. Encourage adequate, routine insurance coverage for necessary breastfeeding services and supplies, including the fime required by pediatricians and other licensed healthcare professionals to ‘8885 and monage breastfeeding and the cost for he rentol of breast pumps. 14, Develop and maintain effective communication and coordination with other healthcare professionals 1 ensure optimal breastfeeding education, support and counseling 18, Advise mothers fo continue their breast salf-examinations on o monthly bass throughout lactation ‘and fe continue to have annual clinical secs! examinations by thei physicians. 16. Encourage the media to portray breastfeeding as positive and normative. 17. Encourage employers to provide appropriate facilis ond adequate time in the workplace for breastfeeding Gnd/or mik expression. 18, Encourage child care providers 1o support breastieeding ond the use of expressed hurman milk provided by the parent 19, Supper the efforts of porents and the cours fo ensure continuation of breastteeding in seporation cand custody proceedings. 20. Provide counsel to adoptive mothers who decide to breastfeed ihrough induced lactation, process requting prafessional suppor) and encouragement. 21. Encourage development and approval of governmentel policies and legislation that are supportive ofa motner's choice fo breastfeed, 22, Promote continued basic and clinical research in the field of breastfeeding. Encourage investigators ‘and funding agencies to pursue studies that further defineate the scientific understandings of lactotion and brecstfescing that lead! fo improved clinical practice n tis medical fil, ‘Adopted fem: Sazton on Breosfeeding. American Academy ef Peciaics. Brecsfeeding ond the use of human mik Ptatics aoosisare soe? O16 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION YOL.97, NO. 7, JULY 2005gain weight without having to supplement with for- mula, the dose of dompcridone can be gradually decreased. Supplementation with an appropriate for- mula is indicated if the infants weight gain is unsat- isfactory or ifthe infant appears to be dehydrated.” Breastfeeding and Breast Milk Jaundice ‘Two types of jaundice associated with breastfeed- ing are recognized. The first type is early-onset breastfeeding jaundice or “breast-nonfeeding jaun- dice” due to infrequent or ineffective breastfeed ing The caloric deprivation and reduced frequency of breastfeeding may increase the enterahepatic cit- culation of bilirubin and cause the jaundice. Breastfeeding jaundice can be prevented or treated by encouraging mothers to nurse as frequently as possible. The second type is later onset, prolonged jaundice, known as breast milk jaundice. Breast milk jaundice affects 2-4% of breastfed infants and is associated with one or more factors in the mater- nal milk itself. Pregnane-30, 20B-diol, free fatty acids, B-glucuronidase and a factor in human milk that increases intestinal bilirubin absorption have been implicated as the possible culprits.** The severity of jaundice can be reduced by phototherapy, when appropriate, and by early optimal breastfeed- ing.” This latter step would minimize the accumu- lated effects of carly breastfeeding jaundice. Supple- mentation with water or glucose water should be avoided, as this reduces breastfeeding frequency and milk production, leading to the infant’s decreased calorie intake o starvation.” Breastfeeding should ‘not be interrupted unless the unconjugated bilirubin level reaches 425 umol/L, Bilirubin encephalopathy ‘may occur ithe unconjugated bilirubin exceeds that level.” These nursing mothers should be provided with positive and enthusiastic support and encour- aged (o maintain lactation using a breast pump or ‘manual expression during the period of interrupted nursing.? When the serum bilirubin decreases to a reasonable level, breastfeeding may be resumed." WHEN AND HOW TO BREASTFEED Breastfeeding should be initiated as soon after delivery as possible, preferably within the first half- hour after birth. Delaying breastfeeding for four ours or more results in a lower incidence of suc- cessful breastfeeding,® Mothers should be encour- aged to nurse on cue, usually 10-12 times a day, including during the night, for as long as the infant seems interested. Frequent feeding is important in establishing a good milk supply.* Supplementary feeding of water, glucose water or formula should be avoided, as these fluids tend to mute the appetite and interfere with lactation. Proper positioning pro- JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION ‘BREAST 15 BEST vides comfort for the mother and the infant and is important in the establishment of an effective latch ‘on and adequate milk intake for the infant, The most frequently used positions that work well are the cra- dle position, football position and side-lying posi- tion. Enough of the areola should be in the infant's ‘mouth to permit the tongue to compress the areola overlying the collecting ducts against the hard palate." The time for suckling should be unrestricted as time for complete milk transfer varies. Signs of successful breastfeeding are listed in Table 2.”* While itis possible that a healthy, breastfed infant ‘may not meet all these criteria, failure to do so war- rants a careful assessment of the situation Ideally, infants should be exclusively breastfed for the first six months of life* Breastfeeding should be continued with the addition of complementary food, atleast through the first 12 months and breast- feeding continued for as long as the mother and infant mutually desire.’ Breastfeeding for the first two year of life should be encouraged.” PROMOTING AND SUPPORTING BREASTFEEDING To promote, protect, and support breastfeeding, the WHO and UNICEF developed the Babyfriendly* Hos- pital Initiative (BFE 10 Steps to Successful Breast- feeding.” The suggested 10 steps are listed in Table 3. A Babyfriendly* hospital should adhere to the WHOMUNICEF International Code of Marketing of Breast-Milk Substitutes and subsequent World Health Assembly (WHA) resolutions (Table 4).” The code secks to protect breastfeeding by preventing inappro- priate marketing of breast milk substitutes, feeding bot tes, soothers and complimentary foods when used to replace breast milk, Interventions, such as antepartum structured educational programs, postpartum support, roomting-in, proper advice to overcome breast-related problems, and peer counseling and encouragement Ihave been shown to improve the initiation and duration, ‘of breastfeeding." Physicians should provide encous- agement, advice and support to help mothers to contin- ue breastfeeding after they renurn to work.* Physicians should promote adoption of international, national and local policies that clearly support breastfeeding,” Breastfeeding mothers should be given the names of breastfeeding resources or support groups and infor- ‘mation about legislation affecting breastfeeding in theit area. Working mothers may consider the use of breast pumps or arrange to have the infant brought to the ‘workplace to be breastfed there.” Working part-time, Jjob-sharing or arranging to do some work at home are other possibilities." The role of pediatricians in pro- ‘moting and protecting breastfeeding has been outlined by the American Academy of Pediatrics (Table 5), Pedi- aricians/family physicians are urged to follow the rec- VOL.97,NO. 7, JULY 2005. 1017BREASTS BEST ‘ommendations so as to provide an optimal environ- ment for breastfeeding, Physicians should be encour- aged to have their offices breastfeeding-friendly. ACKNOWLEDGEMENTS The article has been published in part by Leung and Sauve in the Canadian Journal of Diagnosis,'* with permission from STA Communication Ine. The authors would like to thank Nancy Quon and Michael Chu for expert secretarial assistance, REFERENCES I Leung AK, Sauve RS. Bean! is best for babies: Pat 1. Can J Diagn OLB, 2.Loung AK, Sowe RS. Bcos is best for bcbis: Pat 2. Con J Diagn amt tBssTs. 5. Cancion Pageihic Society, Diethons of Canada. Heath Concda, ‘iron fr Hear Tem rinks, Meo! Pubke Werks cr Governen! Saves! Otawe, Canada, 198 pp. 1218 4. Peocane A. Grain. 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Pola VA, Gube I, When win fe Canadian Tae Force on Re ventive Heoth Care ieventons io promote teas Teeding: pone tho eidorcain nical practice. CMAJ, 20 ITO76978. 77. Secton on Becsteodng, Ametican Acadamy of Podstics, breast. feedingand tae of human ak Petes 05115296506 22. Bingll Reusing to werk whi rwostlaecing. Am For Physician nissa20 208. 17.inn 8. Supporting the employed brecstfeecing mothe. Midwifery Women'sHeath, ANDH5216206 National Medical | Association’ Art In Medicine For those of you who are artists at heart, please submit the summation of your creative efforts to [email protected] for publication consideration in the “Art in Medicine” section of the Journal of the National Medical Association. George Dawson, MD JNMA Art in Medicine Editor JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL.97,NO.7, JULY 2005 1019