Strategies to help more of your patients breastfeed longer
Pamela D. Berens, MD
Dr. Berens is Professor and Vice Chair Clinical Affairs, Department of Obstetrics and Gynecology, University of Texas Health Science Center, Houston.
She has no conflicts of interest to report with respect to the content of this article.
Most ob/gyns are aware of the benefits of breastfeeding and the risks of not doing so. However, many do not appreciate the significant role that they play in supporting their patients’ breastfeeding efforts. Ob/gyns who are aware of some commonly held myths and who are familiar with strategies for breastfeeding can play a crucial role in a new mother’s breastfeeding success.
Myth #1: Breastfeeding and formula feeding are essentially equivalent.
Reality #1: Breastfeeding has significant benefits to both infants and mothers that are not matched by formula.
An abundance of scientific evidence confirms that breastfeeding conveys health advantages to both infants and mothers. Formula-fed infants have a higher incidence of both short-term illness and adverse health outcomes later in life. These adverse effects include, but are not limited to, an increased risk of gastroenteritis (necrotizing enterocolitis), lower respiratory infections, otitis media, and asthma when compared to breastfed infants.1 Formula-fed infants are more likely to experience sudden infant death, childhood leukemias, type I and type II diabetes, and obesity compared to those who are breastfed.1 Mothers who breastfeed have a reduced risk of breast and ovarian cancer, type II diabetes, and maternal cardiovascular disease. Breastfeeding also uses additional calories, which can assist in postpartum weight reduction.1-3 Breastfeeding costs less for families than does bottle-feeding, and the healthcare cost to society also is reduced.4,5
Strategies for the obstetrician: Information about breastfeeding as the preferred method of infant feeding should be presented at every opportunity, from preconception care through postnatal visits. To encourage conversation, it is helpful to use positively framed, open-ended questions such as: “Are you planning to breastfeed?” or “What have you heard about breastfeeding?” Ideally, this discussion occurs when the father, partner, or other support person is present.
If the expectant mother indicates she is not planning to breastfeed, the physician should respectfully explore her reasoning and provide supportive information addressing any misperceptions.
Myth #2: Prenatal breastfeeding education doesn’t make a difference (and it takes too long).
Reality #2: The obstetrician can positively influence intent to breastfeed, breastfeeding duration, and exclusivity. Education should be incorporated into routine obstetric practice.
The American College of Obstetricians and Gynecologists (ACOG) strongly supports breastfeeding “as the preferred method of feeding for newborns and infants and recommends exclusive breastfeeding until the infant is approximately 6 months of age.”9 Research has shown that antenatal advice increases breastfeeding intent. Attendance at prenatal classes, breastfeeding promotion interventions, and professional breastfeeding support increase initiation and support prolonged exclusive breastfeeding and breastfeeding rates at 6 months.6-8
Strategies for the obstetrician: Prenatal breastfeeding education can be successfully incorporated into routine obstetric care by spreading education throughout prenatal visits, seeking assistance from educated office support staff, and using appropriate educational materials. During the initial obstetric history, ask questions about prior breastfeeding experience. If an expectant mother fails to meet her prior breastfeeding goals, the possible reasons should be explored and noted in the obstetric history (Table 1).
Other information that may affect breastfeeding success includes prior breast surgery (breast biopsy, augmentation, or reduction) and medical history and use of medication that may impact lactation (Table 2). Patients should be provided with written or electronic sources of information on breastfeeding. Distribution of nutrition information and promotional materials provided by formula manufacturers is best avoided. Literature and posters supportive of breastfeeding are available from ACOG, the American Academy of Pediatrics (AAP), the department of health, and WIC offices and can be displayed and distributed.
In addition, practical breastfeeding information should be provided during the late midtrimester and during prenatal educational classes. Topics for discussion should include a woman’s breastfeeding goals, importance of early exclusivity, and correct latch and positioning and their association with establishing a good milk supply. Encourage your office staff to incorporate this education into their work flow.
Breastfeeding and anticipated hospital events should be revisited during the third trimester. Review the rationale and importance of early skin-to-skin contact, delaying of routine interventions, rooming-in, and the limited medical indications for supplementation. Patients should be encouraged to feel comfortable about questioning the indication for formula supplementation if it is suggested in the hospital. Any relevant breastfeeding concerns should be communicated to an infant’s care provider. For example, if the mother has a history of breast reduction surgery, close monitoring of infant weight and urinary output is indicated and the pediatrician should be informed.
Myth #3: Labor and delivery practices don’t affect breastfeeding success.
Reality #3: ACOG encourages support of “Ten Hospital Practices to Encourage and Support Breastfeeding” (Table 3).9
These practices are based on the steps of the Baby Friendly Hospital Initiative (BFHI). Research has shown that rates of any and exclusive breastfeeding increase when these steps are incorporated into hospital routines.10,11 In addition, mothers who experience more steps generally have higher breastfeeding rates.12,13
The impact of labor and delivery procedures on breastfeeding success can be difficult to interpret due to confounding influences. Early term or otherwise ill infants may require separation and additional breastfeeding support. Cesarean delivery may be associated with a delay in breastfeeding initiation and decrease in early breastfeeding frequency. Hospital routines should be structured to minimize these differences. Cesarean delivery may be associated with a change in timing of when a mother’s milk comes in, possibly resulting in early supplement use.14
The 2005–2007 Infant Feeding Practices Study II found the likelihood of experiencing 6 Baby Friendly steps was as follows: breastfeeding in the first hour after birth (62%), no in-hospital use of supplement (60%), rooming in (58%), feeding on demand (57%), avoiding pacifiers (47%), and providing information on breastfeeding support (73%). Antenatally, 85% of the women in the study intended to exclusively breastfeed for 3 months or more, yet only 32% met their goal.15 Women experiencing all 6 parameters were 2.7 times more likely to achieve their exclusive breastfeeding intent.15
There is improvement yet to be made in routinely providing an optimally supportive hospital environment for breastfeeding. Delay in breastfeeding initiation and in-hospital use of formula supplement are risk factors for early termination of breastfeeding.12 One Healthy People 2020 goal is to reduce the percentage of newborns receiving formula supplement in the first 2 days of life to 14.2%.18 (The 2011 US rate was 19.4%.19) Breastfeeding exclusivity rates vary significantly by state. Women in Montana and Oregon maintain 3-month exclusivity rates approaching 50%, while other states’ rates are well below 20%.19
Strategies for the obstetrician: For a vigorous term infant and healthy mother, skin-to-skin contact at delivery improves breastfeeding success in addition to providing other health benefits.16 After the infant is dried, place him or her on the maternal abdomen, skin-to-skin, and cover the dyad with warm blankets. Newborn assessment, Apgar scores, and cord clamping and cutting can be performed in this position. Routine infant procedures can be delayed while the infant remains skin-to-skin until after the first breastfeeding. Indicated procedures, such as glucose monitoring for infants of diabetic mothers, can be performed while the infant and mother remain skin-to-skin. Transitioning the infant in the delivery room is ideal.
Rooming in, demand feeding, and teaching the family early hunger cues should be incorporated into hospital routine. For term breastfeeding infants, pacifier use should be restricted to painful procedures such as circumcision, and bottle nipples should be avoided until breastfeeding is well established. The AAP recommends offering use of a pacifier because of an association with a reduced risk of sudden infant death but suggests delaying it “until breastfeeding has been firmly established, usually by 3 to 4 weeks of age.”17 Formula supplementation should be reserved for medical indications, which should be documented in the medical record and discussed with the mother. This allows the family to gain an understanding of the medical need for formula so it is perceived as treatment instead of a routine feeding method.
Skin-to-skin contact at delivery, early breastfeeding initiation, rooming in, and avoidance of supplementation without a medical indication can all be supported by the obstetrician at delivery and reinforced during the postpartum hospitalization.
Myth #4: Postpartum breastfeeding support is the pediatrician’s purview.
Reality #4: It is the obligation of the obstetrician to be familiar with common breastfeeding problems and issues to avoid misinformation that might impede the breastfeeding process.
Obstetricians are well suited to address many issues related to breastfeeding. An obstetrician with education in lactation should be consulted for concerns such as chronic breast or nipple pain, oversupply, engorgement, recurrent plugged ducts, and insufficient milk supply. Almost every mother can breastfeed, but lactation, like any physiologic process, can fail. Recognizing and managing complications is critical to avoid adverse outcomes. A close working relationship with an international board-certified lactation consultant can be helpful when managing postpartum breastfeeding difficulties.
Strategies for the obstetrician: Obstetricians should be familiar with correct medical information regarding numerous issues. For example, providing mothers with accurate dietary information improves breastfeeding success. Postpartum weight retention contributes significantly to later-life obesity, with increasing parity associated with increased body mass index (BMI). More than 600 kcal per day is required to produce an exclusive breast milk supply.3 Breastfeeding has been associated with lower postpartum weight retention in all pre-pregnancy BMI groups.20
Women can safely lose weight and exercise while breastfeeding, and obstetricians are ideally positioned to discuss recommendations related to healthy diet and exercise regimens. Similarly, inter-pregnancy interval and contraception can impact breastfeeding and are best reviewed with a woman’s obstetrician or midwife. Immediate postpartum introduction of exogenous progesterone has been theorized to adversely impact lactation because the postpartum withdrawal of progesterone plays a key role in establishing lactogenesis.21 The benefits of contraception should be weighed against the potential adverse effects on milk production when considering the use of progestin agents immediately postpartum. Contraceptive options initiated around the time of the routine postpartum visit (4 to 6 weeks), when breastfeeding and milk supply are well established, have less potential risk.
In most circumstances, contemporary contraceptives have not been proven to adversely impact established lactation. When choosing contraception in lactating women, adequacy of milk supply, prior contraceptive use, and interval between pregnancies should all be considered.
Postpartum women should be routinely screened for depression at follow-up and obstetricians should be knowledgeable about treatment options and their effects on the breastfeeding infant.
Obstetricians are well positioned to discuss postpartum medication use. The impact of medications used during pregnancy and/or postpartum on lactation or the breastfeeding infant should be discussed before delivery. Drug safety in pregnancy and lactation are not equivalent. The effects a drug could have on a newborn may depend on: impact on milk supply; specific drug characteristics; half-life (both maternal and infant); infant age, health, and metabolism; the percentage of infant diet that breast milk comprises; and the relative infant dose of drug. Resources regarding medication use during breastfeeding should be investigated to provide accurate and up-to-date information.
Urgent issues such as mastitis and breast abscess are best evaluated by an obstetrician. Nipple trauma and unresolved engorgement are predisposing factors for mastitis and should be addressed to prevent recurrence. When a woman is diagnosed with mastitis, she should continue breastfeeding, pumping, or expressing from the affected breast, because weaning during infection increases abscess risk. Circumstances that may prompt consideration of milk culture include recent hospitalization, prematurity, recurrence, and exclusive pumping. Breast milk produced while a woman has mastitis is not harmful to a healthy term infant, and continued breastfeeding without interruption is typically encouraged with appropriate antibiotics. Breast abscess symptoms are similar to mastitis but a fluctuant mass is present. Serial ultrasound-guided aspiration (sometimes with the use of a drain) while using appropriate antibiotics is usually successful.22
Knowledge of sensitivity patterns in your hospital and community is useful when choosing antibiotic therapy because methicillin-resistant staphylococcus aureus may be a consideration in certain areas.23 Incision and drainage is typically reserved for failure of conservative therapy or unusual cases.
By addressing these myths, obstetricians should recognize that they are pivotal in helping their patients achieve their breastfeeding goals. Many resources are available for assistance (Table 4). Breastfeeding is an important component of obstetrics and women’s healthcare and obstetricians are integral to our patients’ success.
1. Agency for Healthcare Research and Quality. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. www.ahrq.gov. AHRQ Publication No. 07-E007, April 2007.
2. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50302 women with breast cancer and 96973 women without the disease. Lancet. 2002;360(9328):187–195.
3. Butte NF, King JC. Energy requirements during pregnancy and lactation. Public Health Nutr. 2005;8(7A):1010–1027.
4. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010;125(5):e1048–1056.
5. Bartick MC, Stuebe AM, Schwarz EB, Luongo C, Reinhold AG, Foster EM. Cost analysis of maternal disease associated with suboptimal breastfeeding. Obstet Gynecol. 2013;122(1):111–119.
6. Britton C, McCormick FM, Renfrew MJ, Wade A, King SE. Support for breastfeeding mothers. Cochrane Database Syst Rev. 2007;(1):CD001141.
7. Rosen IM, Krueger MV, Carney LM, Graham JA. Prenatal breastfeeding education and breastfeeding outcomes. MCN Am J Matern Child Nurs. 2008;33(5):315–319.
8. Imdad A, Yakoob MY, Bhutta ZA. Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries. BMC Public Health. 2011;11 Suppl 3:S24.
9. American College of Obstetricians and Gynecologists Women's Health Care Physicians; Committee on Health Care for Underserved Women. Committee Opinion No. 570: breastfeeding in underserved women: increasing initiation and continuation of breastfeeding. Obstet Gynecol. 2013;122(2 Pt 1):423–428.
10. Philipp BL, Merewood A, Miller LW, et al. Baby-friendly hospital initiative improves breastfeeding initiation rates in a US hospital setting. Pediatrics. 2001;108(3):677–681.
11. Merewood A, Mehta SD, Chamberlain LB, Philipp BL, Bauchner H. Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics. 2005;116(3):628–634.
12. DiGirolamo AM, Grummer-Strawn LM, Fein S. Maternity care practices: implications for breastfeeding. Birth. 2001;28(2):94–100.
13. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding. Pediatrics. 2008;122 Suppl 2:S43–9.
14. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics. 2003; 112(3 Pt 1):607–619.
15. Perrine CG, Scanlon KS, Li R, Odom E, Grummer-Strawn LM. Baby-Friendly hospital practices and meeting exclusive breastfeeding intention. Pediatrics. 2012;130(1):54–60.
16. Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2012;5:CD003519.
17. Task Force on Sudden Infant Death Syndrome, Moon RY. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. 2011;128(5):1030–1039.
18. U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC.
19. Breastfeeding Among U.S. Children Born 2001–2011, CDC National Immunization Survey, http://www.cdc.gov/breastfeeding/data/reportcard.htm.
20. Baker JL, Gamborg M, Heitmann BL, Lissner L, Sørensen TI, Rasmussen KM. Breastfeeding reduces postpartum weight retention. Am J Clin Nutr. 2008;88(6):1543–1551.
21. Brownell EA, Fernandez ID, Howard CR, et al. A systematic review of early postpartum medroxyprogesterone receipt and early breastfeeding cessation: evaluating the methodological rigor of the evidence. Breastfeed Med. 2012;7(1):10–18.
22. Christensen AF, Al-Suliman N, Nielsen KR, et al. Ultrasound-guided drainage of breast abscesses: results in 151 patients. Br J Radiol. 2005;78(927):186–188.
23. Berens P, Swaim L, Peterson B. Incidence of methicillin-resistant Staphylococcus aureus in postpartum breast abscesses. Breastfeed Med. 2010;5(3):113–115.