The World Health Organization (WHO) recommends exclusive breastfeeding for all infants for the first six months of life, with continued breastfeeding for two or more years as mutually desired by the mother and child. Unfortunately, Puerto Rico falls well below the WHO recommendations for both breastfeeding initiation and duration.

On the other hand, breastfeeding trends have changed significantly in Puerto Rico over the past 50 years. Before 1960, the mean duration of breastfeeding in Puerto Rico was about eight months, and 59% of all infants were breastfed for at least some period of time.¹ Between 1970 and 1974, only 25% of infants were ever breastfed (mean duration of about five months), and between 1980 and 1982, the rate of breastfeeding increased to 38%. However, the mean duration dropped to about three and a half months.¹ More recently, other researchers reported that while 61% of their mothers initiated breastfeeding between 1995 and 2000, the median duration of breastfeeding was only three weeks.² The CDC's 2003 data is consistent with this reporting at a 50% initiation rate, but only 14% of infants were reported being breastfed at 6 months.³

According to a survey by the Puerto Rico Department of Health, only 42% of mothers leave the hospital breastfeeding at all. This data does not take into account partial versus exclusive breastfeeding, which can influence both breastfeeding duration and the over all benefit of the human milk to the infant.² The Puerto Rico Health Department launched a Breastfeeding Promotion Policy in 1995 to bring back breastfeeding as the cultural norm in Puerto Rico. However, to achieve this goal, work needs to be done at many levels. One of the first places to begin is to educate all health care providers about the profound benefits of human milk and breastfeeding for both infants and mothers and how health care providers can educate and provide appropriate research-based breastfeeding care and support.⁴

As a nurse, you are crucial in assisting mothers in achieving breastfeeding success. Nurses have the most frequent and regular exposure to pregnant and postpartum women and can greatly facilitate their decision to breastfeed as well as their success in breastfeeding following initiation. This module will provide you with breastfeeding basics and empower you with the necessary knowledge to assist all mothers with making the decision to breastfeed and to be successful in their breastfeeding experience.

How Does A Woman's Body Know To Produce Breast Milk?

Understanding the anatomy and physiology of the breast is essential for all breastfeeding education and support that you as a nurse will provide. Having a working knowledge base regarding the anatomy of the breast will assist you in teaching mothers about proper latch on and positioning. Understanding the physiology behind breast milk production is essential in preventing practices that would interrupt normal breast milk production and for the nurse to be able to appropriately educate the breastfeeding family.

Breast development begins in utero as early as five weeks gestation. At birth, distinct mammary glands are present and palpable. During infancy and childhood, the breasts are in a quiet state until the onset of puberty when due to the influence of estrogen and progesterone, the breast begins its maturation process.⁵ Estrogen influences the growth of the primary and secondary ducts and the formation of the club-shaped end buds. During each menstrual cycle, the buds continue to develop into new branches and small ductules of areolar buds, which will become the acini or alveoli in the mature female breast. Complete development of mammary function occurs during pregnancy and lactation. During pregnancy, the secretory function of the breast begins. From approximately 16 weeks gestation, the mother's breasts are secreting the early breast milk known as colostrums or premilk.⁶ This is an important concept to teach mothers so that they understand that their breasts are already prepared for lactation and that even if they deliver a very preterm infant, breastfeeding and lactation are still possible.

The breast is composed of many integrated parts that work together during lactation. The areola is the dark pigmented area that surrounds the nipple. The areola and nipple color varies according to complexion. Women with darker pigmentation will also note a darker areola and nipple coloration. The nipple itself should be protractile and this can be assessed by gently compressing the areola area behind the nipple (called the "pinch" test). Many women prior to or early in pregnancy do not have nipples that are very protractile. However, protractility of the nipple gradually improves during pregnancy and with suckling of the infant at the breast. In fact, the nipple can stretch to about two times its resting length when the infant is properly latched on and suckling. Within the areola lie small sebaceous glands called the Tubercles of Montgomery glands. The Tubercles of Montgomery range in number from four to 48 on each breast, and they often enlarge during pregnancy.⁷ Although some texts report that their function is to lubricate the breast, their actual function remains rather unclear. When further externally assessing the breast, one should observe for the overall shape and symmetry of the breasts. In most women, one breast may be slightly larger than the other. This generally poses no problems for breastfeeding or lactation, except in the case of marked breast asymmetry that is associated with no or little glandular development. This, however, is rare.⁶ Another important factor to teach mothers is that their overall breast size does not indicate their ability to produce milk. Breast size is mostly determined by the amount of adipose tissue in the breast and does not have influence on the secretory capacity of the breast. Women who have had breast surgery (augmentation or reduction) should be referred to a lactation specialist. In general, women who have had augmentation surgery are more successful in achieving a full milk supply than women who have had a breast reduction.

Internally, the essential units for lactation are the alveoli, which are composed of secretory acini units that are responsible for milk production. Each alveolus is surrounded by myoepithelial cells that cause the ejection of milk into the ductules. A series of ductules merge into a larger collecting duct called the lactiferous duct. Recently researchers have identified that lactiferous sinuses do not exist, but in fact, the lactiferous duct on ultrasound examination actually changes a great deal in diameter during milk ejection.⁸ When an infant begins to suckle at the breast, the release of oxytocin and the milk ejection reflex cause the diameter of the ductile to greatly expand, and the milk travels out through the nipple openings into the infant's mouth. The nipple itself has 15 to 20 nipple pores or openings at the tip through which the milk flows to the infant.⁶

The five stages of lactation are mammogenesis, lactogenesis - stage one, lactogenesis - stage two, galactopoesis, and involution. Mammogenesis is the period of breast growth with the focus of proliferation of the ductule structures as influenced by estrogen and progesterone. Lactogenesis - stage one occurs during pregnancy when the breasts initiate the synthesis of colostrum. Following delivery of the infant, initial milk production is triggered by the delivery of the placenta, which causes a rapid decline in progesterone and estrogen levels while levels of prolactin remain high. During lactogenesis - stage two, which lasts from approximately day two to day three postdelivery to approximately day eight, the process of milk production switches from being endocrine (hormonally) controlled to being autocrine (supply and demand) controlled. During this time, mothers experience fullness and warmth in their breasts and the onset of copious milk production.⁶

Galactopoesis - the maintenance of milk supply - is autocrine controlled (supply and demand) and the crucial hormone, prolactin, is responsible for milk synthesis. The frequency, intensity, and duration of nipple stimulation affect plasma prolactin levels. Without nipple stimulation, prolactin levels usually return to a nonpregnant state within seven days. However, prolactin levels in blood double in response to suckling, and more than eight breastfeedings per 24 hours prevents the decline of the concentration of prolactin before the next feed.⁶ This is why it is so crucial to encourage early and frequent nipple stimulation by suckling or pumping during the initial postpartum period. While prolactin is responsible for milk synthesis, the hormone, oxytocin, is responsible for ejecting the milk in response to suckling. This is known as the milk ejection reflex or milk "let-down." While some mothers report being able to feel let-down, others do not. This is a normal variation among women. Oxytocin, which is produced by the posterior pituitary gland, is also responsible for contracting the mother's uterus, which helps to control uterine bleeding and return the uterus to its normal size.⁶ The period of breast involution begins with regular additions of supplementation to breastfeeding and on average lasts 40 days after the last breastfeeding.

During galactopoesis, there is a great range of "normal" milk production, in general, between 440 milliliters and 1,220 milliliters per 24-hour period. Researchers have further noted that the fat content of breast milk varies greatly over a 24 hour period and from woman to woman.⁹ Women who have the ability to store large quantities of milk in the breast have milk that changes more dramatically from low calorie to very high calorie during feeding sessions. Women with smaller storage capacities will have a change in caloric density between fore milk and hind milk, but the change will be much less dramatic.⁹ This new research demonstrates even further a woman's ability to make milk uniquely suited for her infant.

Advantages of Breastfeeding for Preterm and Term Infants

According to the American Academy of Pediatrics (AAP), human milk is the preferred feeding method for all infants, including premature and sick infants. In 2005, the AAP recommended exclusive breastfeeding for the first six months followed by continued breastfeeding for at least the first year of life and beyond for as long as mutually desired by mother and child. There is no upper limit to the duration of breastfeeding and no evidence of psychological or developmental harm from breastfeeding into the third year of life or longer. Breast milk provides unique benefits for infants that are absent in infant formulas and may be able to provide protection against certain diseases.¹⁰ Breastfeeding has been associated with a decrease in the incidence and severity of otitis media.¹¹ Breastfeeding also provides protection to the infant from diarrheal infections¹² and respiratory infections.¹³

Breastfeeding promotes maternal-infant attachment. Numerous studies have now demonstrated that breastfeeding enhances intelligence and development. An 18-year longitudinal study conducted in New Zealand with over 1,000 children found that those who were breastfed demonstrated greater academic achievement and higher intelligence scores than their formula fed counterparts.¹⁴ Similar findings have been noted in exclusively preterm infants where researchers have noted that breast milk can enhance neurocognitive and developmental outcomes, as well as improve retinal maturation and visual acuity.¹⁵ It has been proposed that the presence of omega-3 fatty acids, which are present in breast milk, but were previously not available in formula, are responsible for improved retinal function.¹⁶ Also, preterm infants can better tolerate enteral feedings and achieve full enteral feedings more quickly on breast milk than on formula.¹⁷ Breast milk also reduces the risk of necrotizing enterocolitis, which is one of the most serious GI diseases seen in preterm infants.¹⁸ A reduced risk and reduced severity of both long- and short-term infections, including diarrhea, sepsis, and bacteremia, as well as a reduced risk of atopic disease (i.e., eczema, food/drug allergies, wheezing, or asthma) for infants with a family history have been cited as further benefits of breast milk.^19,20 Mothers of preterm infants produce milk specifically designed for their infant with higher calories, protein, sodium, chloride, and iron.⁶

Research has also demonstrated that both term and preterm infants have greater physiologic stability during breastfeeding compared to bottle-feeding. Investigations conducted with term infants found that bottle-fed infants were more likely to have bradycardia and a pulse oxygenation of less than 90% during bottle feeding.²¹ Research with preterm infants has noted similar positive findings for breastfeeding. Preterm infants exhibit higher temperatures and higher oxygen saturation during breastfeeding than bottle-feeding, and are less likely to desaturate below 90% during breastfeeding.^22,23

Breastfeeding Basics

To establish a copious milk supply, it is important that an infant breastfeed frequently. Breastfed infants should be fed eight to 12 times per day or every two hours to three hours. Ideally, the first breastfeeding session should be attempted immediately following delivery providing there are no maternal or infant complications. During the first two hours after birth, the infant is in a reactive state and will be most interested in breastfeeding. During this reactive state immediately after birth, the infant will be alert, active, and interested in his or her surroundings. The infant will move arms and legs vigorously, root, and appear hungry. In fact, video footage has documented that infants, when placed on their mothers' abdomens, will "crawl" up their mothers' stomach and self attach to the breast.²⁴ Following the initial period of reactivity, infants go into a period of sleep, which may last four hours to six hours. Unfortunately, in many settings, this is when the infant is brought to the mother for the first breastfeeding attempt. This practice should be avoided because it causes undue stress on the mother and in most cases does not result in a successful breastfeeding session.

During the immediate days following delivery, both mother and infant can have periods of sleepiness. The nurse's role is to encourage and support frequent breastfeeding attempts during this time. A new mother should be encouraged to undress her infant and place him or her skin to skin, lying on her breasts. This closeness promotes attachment and assists the infant with learning the smell of his or her mother's milk. The best time to initiate breastfeeding is when the infant is in the quiet alert state. The nurse should teach the mother to observe for feeding cues, such as rooting, hand to mouth movements, and sucking motions of the infant's mouth. Once an infant successfully latches on and breastfeeds, the mother should allow the infant to feed completely from the first breast before switching to the second breast. Breast milk composition changes during the course of the feed and the infant needs to be able to consume the hind milk at the end of the feed that is very high in fat and calories. The first milk a baby consumes is called fore milk. This milk is low in calories and provides all the hydration that the infant needs.

Helping a mother to get comfortable before breastfeeding is a key to success. Ensure that the mother and infant have privacy and find a comfortable chair for the mother to sit in. Offering pillows to place under her arms and behind her back and on her belly will help maximize comfort. The infant should be brought to the level of the breast and the infant's nose should be across from the nipple. It may be helpful to brush the infant's upper lip with the nipple. Four positions for breastfeeding are as follows:

Cross-Cradle hold: This is an excellent position for breastfeeding, providing for good head support and control.

• The baby is supported by the mother's opposite forearm with his or her head in her hand.
• The baby is on his or her side, tummy to tummy with the mother. The baby should be in a straight line from ear to hip.
• The mother supports her breast with the free hand, fingers on the bottom of the breast and the thumb on top.
• This position is excellent for preterm and vulnerable infants.

Football hold: Also called the clutch hold, this is a practical and easy position for most mothers to use, particularly good for small or preterm infants or after a cesarean section.

• Have the mother hold the baby alongside her at breast level, using the same hand to support the baby's head and shoulders.
• The baby should be in a straight line alongside the mother's body, feeding from the breast on the same side of the body.
• The baby's bottom and legs wrap around the side of the mother's body and their feet can either hang downwards or be tucked under the mother's arm.
• Side lying: This position has been noted to decrease maternal fatigue and is an excellent choice for nighttime feedings.
• The mother should be resting comfortably on her side. Pillows are useful under the mother's head and behind her back, as well as one between the knees.
• Lay the baby on his or her side, in a straight line from ear to hip, directly next to the mother. It is helpful to put a rolled blanket behind the infant for support.
• Mother and baby should be tummy to tummy.
• The mother should offer her infant the breast that is closet to the bed and use her upper arm to pull the infant close in to her breast.
• The mother can change sides by holding the infant on her chest and rolling over.

Cradle hold: This is the most commonly pictured hold.

• The baby should be on his or her side, in a straight line from ear to hip.
• Mother and baby should be tummy to tummy.
• Support the breast with the free hand, fingers on the bottom of the breast and thumb on top.
• Quickly guide the baby to the breast with the arm supporting him or her.
• This is also the most difficult position to use in the beginning, particularly with a sleepy or uncooperative baby.

Guidelines for successful latch-on of the infant follow.

• Instruct the mother to offer the breast by supporting her breast with her hand, all fingers below the breast and the thumb on top. The fingers should be well behind the edge of the areola.
• To encourage latch-on, have the mother brush the infant's upper lip gently with the nipple to stimulate the rooting reflex.
• When the infant's mouth is at its widest, quickly bring the baby to the breast.
• Both the upper and lower lips should be flanged and the nose resting gently against the surface of the breast. Look for a wide-open "V" where the baby's mouth covers the breast. If the angle of the baby's lips forms a narrow "V," this indicates that the baby has not latched well.
• With proper latch-on, you will be able to visualize movement in the baby's temples with suckling. If you see dimpling or hollow cheeks, or if you hear clicking or popping sounds, then this indicates that the baby is not latched correctly.
• Proper latch is the key to effective breastfeeding and milk transfer.
• When the infant is latched well, the mother will feel the tugging of the infant's suckling, but it should not be painful.
• If the mother is experiencing pain, remove the infant from the breast by breaking the suction with mother's pinky finger and have mother start again.

The mother will know that the infant is getting enough milk if the infant is producing six to eight wet diapers per day with urine that is clear and pale, not dark or concentrated. The number of wet diapers will be less during the first days of lactation while the milk supply is being established. A general rule of minimums is: Day 1 - one wet diaper, Day 2 - two wet diapers, Day 3 - three to four wet diapers, Day 4 - >six wet diapers. A "good" wet diaper is equivalent to 45 cc of urine. If a mother is having difficulty assessing the urine output, the mother can be instructed to put three tablespoons of water in a diaper and feel the weight of that diaper as compared to her infants.

More important in the initial days of lactation is stool output. Colostrum serves as a laxative to clear meconium from the infant's gut. By day three to day four (when maternal milk production should be increasing), stools should be changing from meconium to transitional stools and by the end of the first week the infant should be having a minimum of four yellow stools per day.

Indicators that a feeding session was effective include:

• Suckling at the breast stops.
• The infant detaches from the breast.
• The infant falls asleep after feeding or appears satiated and in a quiet-alert state.
• Audible swallowing is noted during the feeding session.
• Maternal breast is softer after feeding.

Nurses should educate mothers about these important clinical cues. In addition, mothers often feel sleepy after breastfeeding due to the release of hormones in the maternal bloodstream.

It is important that mothers are well hydrated when breastfeeding. The best indicator of the mother's hydration is to have her watch her urine daily. Her urine should be clear to pale yellow; if it is dark and concentrated, she is not drinking enough water. A good reminder for mothers is to tell them to have a glass of water each time they breastfeed the baby. Mothers also need an extra 500 calories per day for breastfeeding if they are of ideal body weight.⁶

The infant will also go through growth spurts at regular intervals. These commonly occur at approximately two weeks, six weeks, and three months. During this time, the infant will always seem hungry. The most important thing for the mother to do is to allow the infant to breastfeed as much as possible. Within a few days, her milk supply will increase to meet the baby's demand.

Barriers to Breastfeeding Success

The three major barriers to a woman's breastfeeding success can be grouped into categories of personal knowledge, provider knowledge, and hospital/clinic practices. Breastfeeding rates vary significantly from country to country, and factors such as race, income, level of education, and partner support have all been noted to influence both breastfeeding initiation and duration. For example, in Puerto Rico, breastfeeding rates are lower than in the U.S. and Latin America. Factors that have led to the decline of breastfeeding in Puerto Rico include the medicalization of childbirth in Puerto Rico, the incorporation of women into the workforce, and the marketing strategies of formula companies, which underscore the profound benefit of human milk. The lack of social and legal support for breastfeeding in Puerto Rico has led to a median duration of breastfeeding of only three weeks in Puerto Rico.²

Nurses have a responsibility to ensure that a mother and her family make a truly "informed consent" regarding their infant feeding choice. All mothers should be educated before delivery about the benefits of breastfeeding and human milk. Societal, economic, and familial benefits must also be presented. Mothers must be informed that no infant formula is comparable to human milk, which has unique components, such as live white blood cells, enzymes, and hormones, that are not present in artificial formulas.

Health care providers are sometimes uninformed and not adequately educated about breastfeeding. Few nursing and medical schools include information in their curricula that address breastfeeding. It therefore becomes the responsibility of the health care provider to seek out additional training regarding breastfeeding so they can provide informed, research-based breastfeeding care and support to mothers for whom they care.

Hospital and clinic practices also impede a mother's ability to be successful with breastfeeding. Ideally, a woman should learn about the benefits of breastfeeding before conception. If this is not the case, a significant time investment during prenatal care must be made to educate both the woman and her family members and support networks. It is often helpful to start out with a phrase, such as "Tell me what you have heard about breastfeeding." The provider can then use this opportunity to clear up any myths or misconceptions and introduce teaching about breastfeeding. Breasts and nipples should be inspected as part of the physical assessment as well as a thorough history conducted. If there are any "red flags," such as a history of breast surgery, a referral can be made prenatally. During the course of prenatal care, breastfeeding should be discussed as a routine part of every visit. During the birth process and immediately postdelivery, it is also important that hospital practices not interfere with breastfeeding.

How Health Care Professionals Can Promote Breastfeeding

In 1992, the Baby-Friendly Hospital Initiative was launched by the World Health Organization and UNICEF to promote hospital compliance with the WHO's Ten Steps to Successful Breastfeeding and to eliminate poor institutional practices. Since the inception of the Baby-Friendly Hospital Initiative, more than 16,000 hospitals and birth centers in more than 125 countries have received this designation. However, only 48 hospitals in the U.S. have received this designation. In conducting searches through the Baby-Friendly Hospital Initiative and the World Breastfeeding Alliance, no hospitals could be found that have received this designation in Puerto Rico. All health care providers who have the potential to interact with breastfeeding families should be aware of these strategies for promoting breastfeeding. The WHO states that every facility that provides maternity services and care for newborn infants should:

1. Have a written policy regarding breastfeeding that is routinely communicated to all health care staff. One method for developing such a policy is through the implementation of a hospital-wide breastfeeding task force or committee. The committee can be responsible for literature review and policy development that can be filtered through appropriate hospital channels. During policy development, it is important to have representation from all health professionals involved in breastfeeding decisions, for example, nurses, physicians, dietitians, and managers.
2. Train all health care staff in skills necessary to implement this policy. Training of hospital personnel can occur in a variety of fashions, however, what is important is that training and updates be provided on an annual basis. Basic breastfeeding education should be included as part of nursing orientation for all nurses who will be exposed to breastfeeding mothers or infants. Self-learning modules may be developed that meet the needs of certain breastfeeding populations, for example, the initiation of breastfeeding when maternal-infant separation occurs. Physicians should also be required to have a minimum competency regarding breastfeeding knowledge. This training of health care providers requires an institutional commitment of both time and money.
3. Inform all pregnant women about the benefits and management of breastfeeding. Once the mother makes an informed decision, she must be guided through the initial breastfeeding process and be instructed on where to get further assistance. Mothers should be provided with both verbal and written instructions.
4. Help mothers initiate breastfeeding within 30 minutes after birth. This step requires an institutional and health care provider commitment to keep mother and infant together following birth. Ideally, the infant should be placed immediately on the mother's abdomen and be allowed to "crawl" up to the breast or placed on the breast and given time to latch-on and breastfeed. The infant can be dried while on the mother's abdomen and covered with warm blankets. Assessments can also be conducted with the infant in this position. The mother should be made physically comfortable during this time and be provided with positive verbal coaching.
5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants. This step is critical for vulnerable infants. If maternal infant separation occurs, mothers should be educated on the importance of initiating pumping ideally within the first 24 hours postdelivery. A mother needs access to a hospital grade electric pump. Frequent pumping (every two hours to three hours) during the first week after birth stimulates prolactin levels and optimizes milk yield. Mothers should be instructed particularly to watch milk flow and to pump for an extra two minutes after milk flow stops. This ensures complete "emptying" of the breast, which triggers the need for increased milk production and also ensures that all the high-calorie hind milk is emptied from the breast. At one hospital, the recommendation to mothers who have infants in the intensive care unit is to pump eight to 12 times per day until they yield a production of between 500 cc to 1000 cc in a 24-hour period. Once this volume of production has occurred, the mother may be able to cut back to six to eight pumping sessions per 24 hours as long as her 24-hour milk production remains stable.
6. Give newborn infants no food or drink other than breastmilk, unless medically indicated. This step again requires an institutional and health care provider commitment. Providers must be knowledgeable regarding typical breastfeeding behaviors and normal urine and stool output in the initial days following birth. Institutions must have specific policies regarding what is "medically indicated" to prevent the routine supplementation of infants with formula, dextrose water, or sterile water. New mothers must be educated that infants receive everything that they need from maternal breast milk and that supplementation is not necessary and may impair the normal process of lactation and the transition to production of mature milk.
7. Practice rooming-in to allow mothers and infants to remain together 24 hours a day. This step also requires institutional and health care provider commitment. Maternity units should be designed in fashions that promote both rooming-in and health care provider convenience. All infant examinations and evaluations should be conducted in the room, in front of the mother. This scenario presents an ideal venue for patient education. When the infant is with the mother at all times, she can be taught to observe for infant feeding cues. Crying is a late hunger cue; however, it is the one that health care providers respond to, if the infant is separated from its mother in a separate nursery area. Early feeding cues - quiet, alert state, hand-to-mouth motions, and drooling, soft noises from the infant - are easy for a mother to observe if the infant is with her.
8. Encourage breastfeeding on demand. If an infant is with the mother, breastfeeding on demand is much easier to accomplish. Breastfeeding sessions should not be limited in length or in frequency. A mother should be encouraged to put the infant to the breast at least every two hours to three hours. The stimulation of the nipple causes a prolactin surge after breastfeeding, which in turn results in milk synthesis. By allowing a mother to breastfeed on demand, a copious milk supply can be established.
9. Give no artificial teats or pacifiers to breastfeeding infants. If a mother is using a pacifier (also called dummies or soothers) with her infant before the establishment of a copious milk supply, her breasts are not receiving the maximum stimulation to increase prolactin levels and ultimately this may affect her milk supply. Again, instruction of the mother as to why early and frequent breast and nipple stimulation and breast emptying is critical will result in an increased compliance with this step. Health care providers should also note that if the infant is rooming-in with its mother, pacifiers are not needed to sooth crying babies in the nursery.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. Before leaving the hospital or clinic, mothers should be given verbal and written instruction about where to find breastfeeding support after discharge. La Leche League International is an excellent place to begin and they can be reached by calling 1-800-LALECHE or at www.laleche.org. Another useful number is the Breastfeeding National Network by Medela (800-TELL-YOU), which provides names of lactation specialists and pump and scale rental access by zip code.²⁵

Strategies for Maternal-Infant Separation

Mothers of infants who require hospitalization due to prematurity or other complications must initiate and maintain lactation with a hospital-grade electric breast pump until their infants can be put to the breast. Spatz outlines Ten Steps for Promoting and Protecting Breastfeeding in Vulnerable Infants.²⁶ These steps are outlined as:

1) Informed decision: All mothers should be fully informed regarding how human milk would make their infant healthier. All members of the health care team must convey this message.

2) Establishment of milk supply: Frequent pumping using a double pump set-up (pumping both breasts at the same time) every two hours to three hours during the first week after birth stimulates prolactin levels and optimizes milk yield as noted in the prior section.

3) Breast milk management: When breast milk is stored for later use, the milk must be clearly labeled so that the right milk is fed to the right infant. Breast milk may be stored for 48 hours in the refrigerator. If frozen milk must be used, once thawed, it is only good for 24 hours. Fresh milk is preferred because of the live white blood cells. These cells are destroyed with freezing. Colostrum should be fed to the infant first (even if previously frozen), but then after 24 hours to 48 hours of colostrum, fresh milk should be used.

4) Skin-to-skin care (SCC): Along with mothers maintaining a good milk supply through pumping, skin-to-skin care should also be initiated as soon as the infant is stable. Skin-to-skin care, or kangaroo care, is the process in which a preterm infant is placed upright, chest-to-chest with his or her parent, wearing only a diaper.²⁷ The infant can either be enclosed in the parent's shirt or can be covered with a blanket, and is kept in this position for a period of time. There is no scientific rationale to support restricting or dictating the length of time spent in skin-to-skin care, unless the infant becomes physiologically unstable while on the parent's chest.⁵ Ideally, skin-to-skin care should last at least an hour because dressing and undressing the infant and moving from the crib to the parent's chest can be potentially physiologically taxing.²⁸ However, skin-to-skin care can occur for less time if the parent has limited time availability.

Skin-to-skin care provides benefits for both the infant and the parents. The preterm infant achieves greater stability during this care, evidenced by increased oxygenation; increased cardiorespiratory stabilization through decreased variation of heart and respiratory rates; and decreased episodes of apnea, bradycardia, and periodic breathing.²⁷ For the parents, skin-to-skin care can provide a special time for bonding with the infant. It is also extremely beneficial for mothers because it can increase the duration of lactation.²⁹ Women who held their infants skin-to-skin for at least 36 minutes a day had a four-week increase in duration of lactation as compared to women who held their dressed infants. Also, a majority of the women were able to lactate for more than six weeks, which increases the amount of time the preterm infants receive the benefits of breast milk.³⁰

5) Nonnutritive suckling at the breast: The next progression is to nonnutritive suckling at the empty breast. Nonnutritive suckling refers to either spontaneous suckling without anything being put into the infant's mouth, or suckling as a result of a breast being placed in the infant's mouth. Nonnutritive suckling may be used during gavage feedings to facilitate the transition from gavage to the breast. The rationale for this intervention is that it facilitates the development of suckling behavior and improves digestion of enteral feedings in preterm infants.³¹ Nonnutritive suckling can also occur at the "emptied" breast. This intervention involves having the mother express her milk to empty both breasts, allowing the infant to suck at the breasts, and then providing a determined amount of breastmilk through a gavage tube. Research has found that this intervention is successful in stimulating suckling, promoting milk flow, and prolonging the duration of lactation in mothers with preterm infants.³²

Nonnutritive suckling in preterm infants has also been shown to increase peristalsis, enhance the secretion of digestive fluids, and decrease crying in these infants. Initiating nonnutritive suckling at the emptied breast provides a maternal stimulus that is different from routine breast pump use and may increase milk yield. It also helps to orient the infant to the breast and helps them realize that this is where food comes from. Mothers also receive instant reinforcement from the infant's behaviors that reflects enjoyment and physiological stability while lying skin-to-skin at the breast.⁵

6) Feeding of breast milk: Research has indicated that early breastfeeding is less stressful on the preterm infant than bottle-feeding as evidenced by more stable oxygenation and body temperature.²¹ Infants who are 34 weeks to 35 weeks adjusted gestational age are more likely to have a 1:1 ratio of suck/breathe patterns, and will have less breathing interruption during breastfeeding. Bottle-feeding infants do not develop this 1:1 suck/breathe ratio as quickly, and this ratio may not occur until the infant is several weeks older.⁶ During a bottle-feed, infants often have shorter sucking bursts and longer periods of breath holding, which can cause a greater decrease in oxygen saturation. Breastfeeding is easier for preterm infants because they can control the flow of milk better than they can during bottle-feeding.³³ There are no universal criteria for initiating breastfeeding in preterm infants; however, once an infant demonstrates stability during enteral feeding, breastfeeding can be slowly introduced.⁶

Breastfeeding sessions should begin once a day and increase in frequency as tolerated by the infant. Milk should be introduced in small amounts to prevent closing off the airway too long in order to swallow. Mothers can pump some of the milk from their breast to reduce the milk-ejection flow and gradually pump less out before feedings if the infant is able to tolerate the amount and flow received.⁶

7) Transition to breast: Many preterm infants have problems sustaining the milk flow needed for effective milk transfer due to their immaturity and their inconsistency in suckling. Therefore, until the infant reaches full-term status by corrected age, strategies are often necessary to increase their effectiveness of suckling. The use of a small, thin silicone nipple shield has been shown to help preterm infants maintain attachment to the breast and extract larger quantities of milk.³⁴

Nipple shields can be used to increase milk transfer by increasing the effectiveness of the infant's suck. They accomplish this by extending the nipple further back into the infant's mouth and keeping it in the correct position even in the absence of strong sucking pressures. The infant can use expression pressures in combination with relatively weak suction to extract larger quantities of milk. Mothers need to be shown how to support the breast with the shield in place so that the infant can achieve an effective latch and suck.⁶

8) Measuring milk transfer: Using clinical cues for breastfeeding assessment of vulnerable infants is not sufficient. With vulnerable infants, health care providers need to know exactly how much an infant is receiving. Test weights are considered the "gold standard" for measuring milk transfer. Test-weighing is the most accurate way of determining how much an infant has consumed.³⁵ This process involves weighing an infant before and after breastfeeding under the same conditions (i.e., wearing the same amount of clothing and using the same scale). Test weights should be conducted using an electronic scale that is accurate to 1 g to 2 g. The amount of weight gain (in grams) is equivalent to the volume (mL) of milk consumed by the infant.⁶

Test weighing is extremely useful in determining an infant's 24-hour fluid intake, and is also useful in helping practitioners and mothers determine whether the infant is getting enough milk. Previously, the use of clinical indices, such as milk letdown; infant latch, sucking and swallowing; sucking consistency, as well as prefeed alertness and postfeed satiety, were thought to be effective in determining milk intake. However, research has demonstrated that these indices are not as accurate as test weighing, even when a certified lactation consultant performs the intake evaluation. Clinical indices should not be used as the sole evaluation of intake because they can either over- or underestimate the intake of the infant.³⁵ Test weights document the amount of milk transfer from the mother to the infant, and should continue until the infant consistently proves that she or he transfers enough milk when breastfeeding.

When performing test weights, technique is important. The infant should be fully dressed and wrapped, blankets should not hang off the side of the scale to prevent user error. In addition, all monitor leads should be detached and placed on the scale during the pre- and postweight. Any tubing that cannot be disconnected, such as IV or oxygen tubing, should be marked with a piece of tape so the exact same amount of tubing is measured for both the pre- and postweights. These simple steps will prevent user error.

9) Preparation for discharge: In order to prepare the mother and infant for discharge, the mother should be afforded maximal opportunities to breastfeed her infant. The infant should be allowed to "demand feed" while the mother visits, and test weights should be utilized to determine milk transfer. The mother should be given a 24-hour minimum intake that the infant should receive. This can then be further broken down into smaller intervals. The mother does not have to supplement after every feed. She will be able to determine when and if supplementation is needed based on the pre- and postweights.

10) Appropriate follow-up: Mothers of preterm infants must be given realistic expectations for postdischarge care. The mother will probably have to do some combination of pumping, breastfeeding, and supplementation of pumped breast milk via bottle, tube or other alternative feeding method. The goal of follow-up is to ensure adequate weight gain and full transition to breastfeeding.

Alternative Feeding Methods

Cup feeding is an alternative when an infant is unable to suckle at the breast. A small cup with rounded edges is ideal and medicine cups that are readily available in hospitals work very well. A baby should be in an upright sitting position for cup feeding. The cup is brought up to the baby's mouth and only tipped slightly. The infant should be allowed to lap the milk at his or her own pace. One of the limitations of cup feeding is the potential for spillage. Care should be taken to allow the infant to consume the milk slowly and to observe for milk dribbling out of the sides of the infant's mouth.³⁶

Medicine droppers can also be used for infants who are unable to suckle at the breast or who are having difficulty latching on. The dropper is used in a similar fashion as the cup, in that a small amount of milk is dropped onto the infant's tongue and the infant can lap the milk back and then swallow. Medicine droppers are useful, as they are inexpensive and usually readily available. However, they are only functional for feeding small volumes of milk for a short term, as a dropper only holds 3 mL to 5 mL so it could become a very time intensive process. A similar alternative to this is to use a 3-mL or 5-mL syringe (without the needle) to drip the milk into the infant's mouth. Infants should not be allowed to suck on the tip of the dropper/syringe. The milk should be dripped onto their tongue.

A variety of tube-feeding devices are available, such as the supplemental nurser system and the lactaid.⁶ These devices allow the infant to receive extra milk while suckling at the breast. For such a system to be effective, the infant must have the ability to latch-on and suckle for a sustained period of time at the breast. Indications for use would be a late onset of copious milk production, low maternal milk supply, or a mother who wishes to induce lactation for an adopted infant.

Maternal Medications

Mothers should be asked if they are taking any medications while they are breastfeeding or pumping their breast milk. It is usually not necessary for the mother to wean or stop pumping merely because she is taking medication. However, it is important to assess the type of medication she is taking, as well as the reasons for using the medication. This includes all prescription medications, over-the-counter drugs, and herbal preparations. A good source of information about medication transfer in human milk can be found in the book, Medications and Mothers' Milk, which is published biannually.³⁷ This book provides the necessary information on whether a drug or medication crosses into the breast milk and provides a lactation risk rating of the medication, as well as providing information about alternatives if a medication is completely contraindicated in breastfeeding. The book also contains information on the effect a drug will have on milk volume and the half-life of the drug. There are three important things to keep in mind about drugs and breast milk:

• Most drugs will be passed into the breast milk.
• While almost all medication will be present in breast milk, the presence is usually small and less than 1% of the dose taken by the mother.
• There are very few drugs that are contraindicated for breastfeeding.

Preterm infants are at risk for developing higher plasma drug concentrations than full-term infants because of their immature liver and hepatic system, which slows the clearance of drugs and medication from their system. The number of times per day the infant is receiving breast milk will also determine the amount of medication that is being transferred. An infant who is only receiving breast milk once a day will have significantly less medication in his or her system than an infant who is being exclusively fed with breast milk. Some helpful guidelines for mothers who are breastfeeding or pumping and taking medication are to:

• Take the lowest dose available for the shortest amount of time.
• Ask the provider to prescribe a drug that transfers the smallest amount into breast milk.

If a mother does have to interrupt breastfeeding due to a medication, she should pump her breasts to maintain her milk supply, but discard the milk. Once the medication is finished she can return to breastfeeding her infant without experiencing a decrease in her milk supply.

Women who use street drugs or are heavy alcohol users should not breastfeed. In addition, women who are HIV positive should not breastfeed.

Contraception and Breastfeeding

The lactational amenorrhea method (LAM) uses the physiologic effects of full breastfeeding around the clock without supplements to achieve contraception. The development of the LAM is the result of the collaboration of researchers and the development of the Bellagio Consensus.⁵ Breastfeeding prolongs anovulation because follicle stimulating hormone (FSH) and luteinizing hormone (LH) production are inhibited by the intense suckling of the infant. During the first six months after delivery, LAM is 98% effective if full or exclusive breastfeeding is practiced and the mother breastfeeds more than seven times per 24 hours for at least 10 minutes each feeding and with no more than six hours between nighttime feedings and less than four hours between daytime feedings.^38,39

Nonhormonal contraception methods are a good choice for the breastfeeding mother. These include barrier methods, such as male and female condoms and the diaphragm and cervical cap (mothers must be refitted for these at their postpartum visit). The use of complementary spermicides will increase effectiveness of the barrier methods.

Intrauterine devices (IUDs) are a highly effective method of birth control and are compatible with breastfeeding.³⁹ The IUD should be placed at the postpartum visit and it is important to counsel the woman that the IUD provides no protection from sexually transmitted diseases or HIV.

Hormonal methods of birth control should be limited to progestin only pills, implants, or injections. Methods that contain estrogen are not recommended because estrogen is known to inhibit milk production. Progestin-only products (POPs) may reduce a mother's milk supply; therefore, it is recommended that a mother's milk supply be established before taking POPs. Once established, low-dose POPs have no effect on the duration of breastfeeding or an infant's general condition or weight gain.³⁹

The benefits of breastfeeding have been discussed in numerous scientific studies. Breastfeeding is extremely important for all infants because of the protective effects and beneficial aspects of breastmilk. Nurses play an important role in helping a mother initiate and maintain lactation. The use of research-based interventions and practices are important in supporting breastfeeding in both the healthy term infant population and in the neonatal intensive care environment.

Puerto Rico faces a significant challenge to improve both breastfeeding initiation and duration rates. A commitment to this challenge is essential in order to improve the health of Puerto Rican mothers and their infants. A nurse can be a major facilitator for improving breastfeeding initiation by being well versed on the benefits of breastfeeding for both the mother and infant and by being able to articulate these benefits to all pregnant women with whom he or she has contact. Furthermore, the educated nurse can provide appropriate education and support following delivery in order to improve breastfeeding duration.