Breastfeeding Pocket Guide for Health Care Providers

Breastfeeding – Simply the Best

Breastfeeding confers unique health benefits to infants and mothers. Health care providers and staff can play a critical role in promoting exclusive breastfeeding and increasing duration of breastfeeding. Your counseling and support efforts should start while the patient is pregnant, and continue through the neonatal period and beyond.

This pocket guide has been developed to support you in this effort. Please help us make breastfeeding the norm.

During Prenatal Care

Encourage expectant mothers to breastfeed exclusively for six months.

What you say to expectant mothers and their families makes a real difference. If you recommend exclusive breastfeeding, more new mothers will breastfeed for longer periods of time. Let them know:

  • "I encourage expectant mothers to breastfeed exclusively for the first six months. I recommend they continue breastfeeding through the baby's first year."
  • "Breast milk is the safest and best food for your baby. Formula just does not give you and your baby the same protection against diseases."
  • "The longer you breastfeed your baby, the better for both of you. It is important to your baby's health and helps you regain your shape. It also lowers your risk for some cancers, diabetes and heart disease."
  • "It can be hard at first for some moms and babies, but it gets easier."
  • "Get off to a good start by requesting that the baby be placed on your chest, skin-to-skin, immediately after birth. Most babies will breastfeed during the first hour."

Mothers Can Breastfeed If They…

Have Cesarean Deliveries

Initiate breastfeeding immediately, using a semi-recumbent position on the side or sitting up.

Take Medications

Most medications can be taken while breastfeeding. Consult the LactMed Database about specific drugs: http://toxnet.nlm.nih.gov.

Have Had Breast Surgery

(including breast augmentation or reduction)

Augmentation mammoplasty
Breastfeed frequently to maintain milk supply.
Breast reduction
Monitor infant growth since milk supply could be insufficient.
Breast biopsy involving an areolar incision
Women can compensate by augmenting production in the unaffected breast, but monitor infant growth since milk supply could be insufficient.

Have Hepatitis B

Initiate breastfeeding after infant receives hepatitis B immune globulin and first dose of the three-dose hepatitis B vaccine series.

Have Hepatitis C

Hepatitis C is not a contraindication for breastfeeding, but reconsider if nipples are cracked or bleeding.

Have Pierced Nipples

Remove nipple accessories before feeding to avoid the risk of infant choking.

Have an Occasional Alcoholic Drink

Avoid breastfeeding for two hours after the drink.

Smoke

Counsel mother about smoking cessation and to avoid infant exposure to secondhand smoke, but breastfeeding is not contraindicated. It is better to breastfeed than not.

Have Latent Tuberculosis (TB): Have a Positive PPD or Gamma Interferon Blood Test

If the mother does not have clinical symptoms of active TB, it is not necessary to wait for CXR results before allowing the mother to breastfeed.

Use Hormonal Contraceptives

Hormones may depress milk supply, but they will not harm the baby.

Develop Infections

Minor acute infections like gastroenteritis, URI, and influenza will not cause the baby to contract the infection through the milk. The specific antibodies in breast milk will help protect the baby.

Mothers Cannot Breastfeed If They…

The following are absolute contraindications

  • Are infected with HIV
  • Are infected with HTLV (Human T-cell Lymphotropic Virus) Type I or II
  • Use illegal drugs
  • Are taking cancer chemotherapy agents that interfere with DNA replication and cell division
  • Are receiving Radiation Therapies; however, Nuclear Medicine Therapies only require breastfeeding to be interrupted temporarily
  • Have active herpes lesions on the breast (shingles, chicken pox)
  • Have an infant who has galactosemia
  • Have untreated, active TB

At the Hospital: Provide leadership in breastfeeding support from delivery through discharge.

Obstetric Providers:

  • Upon arrival to labor and delivery:
    • Verify HIV status is known at labor (mandate rapid test if not known).
    • Check to see that maternal medications are compatible with breastfeeding by consulting the LactMed Database about specific drugs: http://toxnet.nlm.nih.gov.
  • Support early latch:
    • Place baby in immediate skin-to-skin contact to support early latch and breastfeeding. It is ideal to maintain contact for at least 1-2 hours.
    • Ask pediatric team and nursing to minimize medical assessment and interventions for healthy infants until first feeding is attempted.
  • Support continued on-demand feeds:
    • Encourage rooming-in so on-demand feeds are easier. Inform the mother on-demand feeds will improve milk flow and supply.

      "In the first few weeks, you'll find the more often the baby suckles at the breast, the better the flow of milk."

    • When maternal procedures are indicated, schedule them after breastfeeding or arrange for use of hospital electric pump prior to procedure if the mother will be off the floor for more than 2 hours.
  • Describe early feeding:
    • Reinforce that crying is a late feeding cue in a newborn.
    • Educate mothers that they will make colostrum, a small amount of thick, rich milk after the baby is born which will increase every day and is exactly what the baby needs. Tell mothers they will feel a change in their breasts after 3 or 4 days.
    • Reinforce to the mother that she is making the right amount of milk for her baby.

Pediatric Providers:

  • Support early latch:
    • Place baby in immediate skin-to-skin contact to support early latch and breastfeeding. It is ideal to maintain contact for at least 1-2 hours.
    • The opportunity to breastfeed within the first hour after delivery should occur before the administration of Vitamin K.
  • Describe early feeding:
    • Reinforce that crying is a late feeding cue in a newborn.
    • Educate mothers that they will make colostrum, a small amount of thick, rich milk after the baby is born which will increase every day and is exactly what the baby needs. Tell mothers they will feel a change in their breasts after 3 or 4 days.
    • Reinforce to the mother that she is making the right amount of milk for her baby.
  • Optimize breastfeeding in the nursery:
    • Order "exclusive breastfeeding with no supplementation except Vitamin D" unless there are true contraindications.
    • Prescribe vitamin D 400 IU oral drops p.o. daily.
    • Ask the nurse or lactation coordinator/consultant to see the mother as soon as possible to support breastfeeding.
    • Describe colostrum and its benefits. "It is a thick, rich, satisfying early form of breast milk that provides special protection and benefits to newborns."
    • Support rooming-in so on-demand feeds are easier. Inform the mother on-demand feeds will improve flow and supply. "In the first few weeks, you'll find the more often the baby suckles at the breast, the better the flow of milk."
    • Counsel mothers to avoid pacifiers and formula supplementation.
  • Discharge planning:
    • Make certain that the baby is scheduled for routine pediatric care and breastfeeding follow-up visit on his/her 3rd to 5th day of life.

After Discharge From Maternity/Newborn Nursery

During Postpartum/Maternal Care Visit

Continue to encourage and support.

  • Ask about breastfeeding duration and success.
  • Advocate exclusive breastfeeding to 6 months.
  • Be prepared to refer to specific lactation specialists and/or community resources when needed.

During the 3-to 5- Day Pediatric Visit

Assess, prescribe Vitamin D, and plan ahead.

Be sure to initiate a conversation with the patient. Suggested conversation starters include:

  • "How is feeding going?"
  • "Do you have any concerns about your breasts or how breastfeeding is going?"
  • "How often is your baby breastfeeding?"
  • "How is the milk flowing?"
  • "Is your baby latching well?"
Common Medications that are Compatible with Breastfeeding
Anti-Hypertensives Anti-Infectives Diabetes medications Analgesics
  • Methyldopa (Aldomet)
  • Labetalol
  • Nifedipine(Procardia)
  • Clindamycin
  • Ampicillin-sulbactam (Unasyn)
  • Fluconazole
  • Gentamicin
  • Insulin
  • Glyburide (infant's glucose may be monitored but adverse effects are rare)
  • Metformin
  • Morphine and derivatives
  • Acetaminophen
  • Ibuprofen

Consult the LactMed database about specific drugs.

Ideally, observe breastfeeding and look for signs of how breastfeeding is going.

Signs Breastfeeding is Going Well

  • Baby latches onto areola, not just nipple
  • Infant suckles using jaw, not just lips
  • Infant makes swallowing sound
  • Infant can latch on both breasts

Signs Breastfeeding is NOT Going Well

  • ≥ 7% infant weight loss from birth weight at 3-to 5-day pediatric visit
  • Infrequent wet/soiled diapers (fewer than 3-4 urine diapers/24 hrs., fewer than 3-4 stools/24 hrs.)
  • Mother's nipples are red, cracked (likely due to latch problem)

If there are signs breastfeeding is not going well, intervene as necessary, (e.g., provide telephone and in-office support, refer mother to a lactation specialist and/or support group). In addition:

  • Reinforce on-demand feeds – and no supplementation – will increase milk supply.
  • Remind mothers not to take formula samples, if offered.
  • Remind mother to stay hydrated whenever breastfeeding the baby.
  • Discuss benefits of exclusive breastfeeding for the first 6 months of life, and the benefits of continued breastfeeding through 12 months. Explore barriers, work through solutions, and provide resources, support and community referrals.

At Any Visit:

Verify success, anticipate challenges and support prolonged breastfeeding.

  • Remind mother to give the baby 400 IU of oral vitamin D drops daily until at least 1 liter or quart of formula or whole milk is given daily.
  • Refer the mother to a lactation specialist and/or support group whenever needed. Keep referral information in each exam room.
  • Discuss return-to-work plans and breast pump options. Hospital-grade and personal electric pumps are available through WIC programs and via insurance programs, including Medicaid, in select circumstances.
  • Fluoride supplements are not indicated in New York City.

Select Coding Options For Breastfeeding Encounters

  • Feeding problem, newborn: 779.3
  • Feeding problem, infant >28d: 783.3
  • Neonatal jaundice: 774.6
  • Dehydration, neonatal: 775.5
  • Weight loss: 783.21
  • Blocked milk duct: 675.24
  • Breast engorgement, ductal: 676.24
  • Nipple infection: 675.04
  • Nipple, sore: 676.34
  • Supervision of lactation: V24.1
  • Other specified follow-up exam: V67.59 if original problem resolved

Source: www.aap.org/breastfeeding/files/pdf/CODING.pdf (PDF)

Breastfeeding – Key Points

  • Eight to 12 feedings at the breast should be provided every 24 hours, or whenever the baby shows early signs of hunger such as increased alertness, physical activity, mouthing or rooting. Crying is a late sign of hunger in a newborn.
  • In the early weeks after birth, non-demanding infants should be awakened to feed if four hours have elapsed since the beginning of the last feeding.

Breastfeeding techniques

  • Both breasts should be offered at each feeding for as long a period as the infant remains at the breast. The first breast offered should be alternated with each feeding, so that both breasts receive equal stimulation and draining.
  • Pacifiers and bottles should be avoided until breastfeeding is well established.

Nutritional guidelines

  • Water and juice are unnecessary for breastfed infants and may introduce contaminants or allergens.
  • Supplements (water, glucose water, formula, and other fluids) should not be given to breastfeeding newborns, unless medically indicated.
  • All breastfed infants should receive 400 IU of oral vitamin D drops daily beginning in the first few days of life and continuing until the daily consumption of vitamin D-fortified formula or milk is at least one liter or quart per day.
  • Complementary foods rich in iron should be introduced gradually beginning around six months of age.

Resources

For more information about breastfeeding, visit:

Always use commercial-free breastfeeding materials in your office.

Publication 2963 Produced in cooperation with the NYC Department of Health