INTERNATIONAL LACTATION CONSULTANT ASSOCIATION

Clinical Guidelines for the

Establishment of
Exclusive Breastfeeding

June 2005
BLANK
INTERNATIONAL LACTATION CONSULTANT ASSOCIATION

Clinical Guidelines for the

Establishment of
Exclusive Breastfeeding

June 2005
 Revision Task Force – Second Edition
Mary L. Overfield, MN, RN, IBCLC
Lactation Consultant, WakeMed
Chair, Professional Development Committee
International Lactation Consultant Association
Raleigh, North Carolina USA

Carol A. Ryan, MSN, RN, IBCLC

Director, Parenting Services
Perinatal Education & Lactation Services
Georgetown University Hospital
Washington, DC USA

Amy Spangler, MN, RN, IBCLC

Affiliate Faculty, Emory University
Perinatal Education Instructor, Northside Hospital
Atlanta, Georgia USA

Mary Rose Tully, MPH, IBCLC

Adjunct Assistant Professor UNC School of Public Health
Director, Lactation Services
UNC Women’s & Children’s Hospitals
Chapel Hill, North Carolina USA

Partially supported by the Maternal and Child Health Bureau

Health Resources and Services Administration
US Department of Health and Human Services

2
 Preface
Interest in maternal and child health has a Many health care professionals believe that methods of infant feeding should be
long history worldwide. The Universal breastfed infants born in developed measured, is an essential element to be
Declaration of Human Rights, ratified in countries are only marginally different from valued. These strategies are designed to give
1948, states that “motherhood and their formula-fed counterparts. This attitude form to optimal breastfeeding management
childhood are entitled to special care and is reflected in both the absence of lactation and to provide health care professionals
assistance.”182 The Convention on the Rights management education in health care with a clear understanding of both the art of
of the Child, ratified in 1989,181 guarantees professional curricula and the dearth of breastfeeding and the science behind the
children’s right to the highest attainable breastfeeding management skills among art. Several well-respected professional
standard of health. Other conventions and many health care professionals.72, 83, 86, 93, 102, 103, associations have published position
113, 118, 146, 147, 223
international consensus documents focus documents presenting evidence and
on reducing gender-based discrimination rationale for setting a high priority on
In 1991, the World Health Organization and
that might undermine good health, breastfeeding and human lactation
the United Nations Children’s Fund
particularly among young girls and women. management skills for the health care
launched the Baby-friendly Hospital
Most recently, the global community professional.1, 6, 9, 10, 36, 51, 99, 133, 138, 180, 250
Initiative. Baby-friendly is a designation given
declared a commitment to “create an
to hospitals or birthing facilities that Clinical guidelines must be evidence-based
environment—at the national and global
demonstrate compliance with the Ten Steps as well as consistent, accurate, and culturally
levels alike—which is conducive to develop-
to Successful Breastfeeding.248 Data show that appropriate to effectively impact
ment and to the elimination of poverty.”230
for breastfeeding to be successfully initiated breastfeeding initiation, duration, and
Exclusive breastfeeding for six months was
and established, most mothers need exclusivity.133, 165, 187, 203 As in all other areas of
among the most cost effective interventions
appropriate information and support from health care, breastfeeding management is an
identified.
health care professionals.248 evolving field. Therefore, the management
It has been estimated that 4 million of the strategies presented herein reflect current
Among the factors associated with early
130 million babies born each year die in the clinical, educational, and scientific knowl-
introduction of human milk substitutes and
first four weeks of life—the neonatal edge.
discontinuation of breastfeeding are lack of
period.144 This represents 36 percent of the
confidence in ability to breastfeed, particu- Some aspects of breastfeeding management
deaths worldwide in children under the age
larly among first time mothers, lack of are not amenable to the control and
of five years.
support from health care professionals, and randomization of true experimental design,
The health benefits of breastfeeding for a variety of breastfeeding problems.78, 221 This but are based on clinical experience and
mothers, infants, and society are well document focuses on the establishment of logical deductions from known scientific
documented.1, 6, 9, 10, 36, 51, 99, 133, 138, 180, 250 So, too, exclusive breastfeeding for healthy, full-term facts. The supporting references for the
are the health risks and economic costs infants. Common problems that often lead strategies contained in this document range
associated with artificial feeding.43, 46, 238 The to early introduction of human milk from original research to works based on
benefits are even more compelling when substitutes and untimely weaning are years of clinical experience. The quality of
consideration is given to the impact of not addressed. Circumstances and conditions the evidence for each reference is ranked
breastfeeding on maternal and child are identified that may require referral to a using a model developed by the US
morbidity and mortality. skilled lactation professional, an Interna- Preventive Services Task Force (see Appen-
tional Board Certified Lactation Consultant dix 1).227
Global health organizations, governmental
(IBCLC), or a physician, midwife, nurse, or
and non-governmental agencies, and health These clinical guidelines advocate for
dietician with specialized training in
professional associations recommend women and children by giving health care
breastfeeding support.
exclusive breastfeeding for the first six professionals entrusted with their care an
months of life with continued breastfeeding A comprehensive assessment of the mother operational framework. They reflect a
for two years and beyond as the normal way and infant, including the mother’s knowl- continuum of care approach based on the
to feed infants.9, 10, 36, 51, 250 Despite overall edge base and beliefs, is an essential first understanding that the health and interests
improvements in breastfeeding initiation step. Parents’ beliefs and misconceptions of the mother/child dyad should not be
and duration rates during the 1990s, fewer need to be addressed before an appropriate separated. Maternal health is the most
than half of all infants worldwide are now clinical strategy can be implemented. important determinant of neonatal
being exclusively breastfed for up to four Breastfeeding is a health behavior with long- outcome and a healthy newborn is the best
months. Although global levels of continued term consequences9 that is often fraught promise for the future.
breastfeeding are relatively high at one year with personal opinion on the part of both
of age (79%), only half of chidren are the family and the health care provider. The
breastfeeding at two years of age. Thus, the health care professional’s acceptance of
current breastfeeding patterns are far from breastfeeding as the normal way to feed an
the recommended levels.229 infant, the standard against which all

3
4
 Table of Contents
Expected outcomes for breastfeeding mothers and infants ........................................................................................................................................................................................................................6

Management strategies
1. Facilitate breastfeeding within the first hour after birth and provide for continuous
skin-to-skin contact between mother and infant until after the first feeding .................................................................................................................................................... 7
2. Assist the mother and infant in achieving a comfortable position and effective latch (attachment) .......................................................................................... 8
3. Keep the mother and infant together during the entire postpartum stay ............................................................................................................................................................ 9
4. Teach mothers to recognize and respond to early infant feeding cues and confirm
that the baby is being fed at least 8 times in each 24 hours ............................................................................................................................................................................................10
5. Confirm that mothers understand the physiology of milk production, especially the role of milk removal .....................................................................11
6. Confirm that mothers know how to wake a sleepy infant ...............................................................................................................................................................................................11
7. Avoid using pacifiers, artificial nipples, and supplements, unless medically indicated ............................................................................................................................12
8. Observe and document at least one breastfeeding in each eight-hour period during the immediate postpartum period ................................ 13
9. Assess the mother and infant for signs of effective breastfeeding and intervene if transfer of milk is inadequate ........................................................14
10. Identify maternal and infant risk factors that may impact the mother’s or infant’s
ability to breastfeed effectively and provide appropriate assistance and follow-up ..................................................................................................................................15
11. Identify any maternal and infant contraindications to breastfeeding .....................................................................................................................................................................16
12. If medically indicated, provide additional nutrition using a method of supplementation
that is least likely to compromise the transition to exclusive breastfeeding .....................................................................................................................................................17
13. Confirm that the infant has a scheduled appointment with a primary care provider
or health worker within five to seven days after birth ...........................................................................................................................................................................................................17
14. Provide appropriate breastfeeding education materials ......................................................................................................................................................................................................18
15. Support exclusive breastfeeding during any illness or hospitalization of the mother or infant ......................................................................................................18
16. Comply with the International Code of Marketing of Breast-milk Substitutes and subsequent WHA resolutions,
and avoid distribution of infant feeding product samples and advertisements for such products ............................................................................................18
17. Include family members or significant others in breastfeeding education .........................................................................................................................................................18
18. Provide anticipatory guidance for common problems that can interfere with exclusive breastfeeding .................................................................................19
19. Confirm that mothers understand normal breastfed infant behaviors and have
realistic expectations regarding infant care and breastfeeding ......................................................................................................................................................................................21
20. Discuss contraceptive options and their possible effect on milk production .................................................................................................................................................22

Appendix 1. Evaluation Criteria for Quality of Evidence ...............................................................................................................................................................................................................................23

Appendix 2. Review Panel .........................................................................................................................................................................................................................................................................................................23

References ................................................................................................................................................................................................................................................................................................................................................24

5
 Expected Outcomes for
Breastfeeding Mothers and Infants
Healthy, full-term, breastfeeding infants will: Mothers of healthy, full-term, breastfeeding
• lose no more than 7 percent of birth weight14, 149, 152, 155, 164, 201, 209, 224, 255 infants will:
• regain to birth weight by 10 days of age152, 209 • identify and respond appropriately to early infant feeding cues156
• have at least 3 bowel movements each day after day 1* with age • achieve comfortable positioning and effective latch
appropriate color changes (first bowel movement typically occurs (attachment)24, 80, 175, 225
within 8 hours of birth)167, 255 • recognize signs of effective breastfeeding193, 210
• have at least 6 wet diapers each day by day 4 with urine that is • exhibit appropriate breastfeeding knowledge and
clear or pale yellow (first urination typically occurs within 8 hours management skills219
of birth)167, 178, 255
• identify available breastfeeding resources140, 202, 216
• breastfeed without time restriction, on average 8 times in each
24 hours34, 60, 252 • breastfeed through the first year of life and beyond as desired9
• gain weight at a rate that is appropriate for age (about 20 - 35 grams • breastfeed exclusively for the first six months136, 137, 158, 179, 183, 233
or 2/3 - 1 ounce each 24 hours by day 5)68, 69, 88
• breastfeed exclusively for the first six months9, 136, 137, 158, 179, 183, 233
*The first 24 hours after birth is day 1.

6
Management Strategy
1
Facilitate breastfeeding within the first hour
Rationale and References

Initiation of breastfeeding within the first hour

Quality of Evidence

after birth and provide for continuous and continuous skin-to-skin contact are
skin-to-skin contact between mother and associated with:
infant until after the first feeding.
• earlier establishment of effective suckling and Righard II-3,
• Avoid routine procedures until after the first feeding behaviors195, 240, 257 Widstrom II-2,
breastfeeding. Zetterstrom III
• enhanced maternal-infant relationship Matthiesen II-3,
161, 189, 194, 239, 241
Prodromidis II-2,
Renfrew III,
Wiberg II-2,
Widstrom II-2
• improved neonatal temperature control18, 35, 48 Bergman I,
Bystrova I,
Christensson I
• improved infant metabolic stability18, 48 Bergman I,
Christensson I
• improved neonatal blood sugar stability243, 254 Williams III,
Yaumachi II-2
• increased bowel movements and decreased Bertini II-3,
risk for neonatal jaundice20, 205, 208, 252 Salariya II-2,
Semmekrot III,
Yaumachi II-2
• longer duration of breastfeeding61, 168, 239, 252 de Chateau II-2,
Mikiel-Kostyra II-2,
Wiberg II-2,
Yamauchi II-2
• maternal oxytocin release after birth, which Matthiesen II-3
may have significance for uterine contraction,
milk ejection, and mother-infant interaction161
• enhanced ability by infant to organize state Ferber I
and modulate motor system81
Routine procedures, such as prophylactic Awi II-2,
administration of vitamin K and erythromycin Klaus III,
interrupt maternal-infant interaction and delay Righard II-3,
breastfeeding15, 132, 195, 241 Widstrom II-2

7
Management Strategy

Assist the mother in achieving a comfortable

2 Rationale and References

There is clear evidence for the effectiveness of

Quality of Evidence

Sikorski III
position and effective latch (attachment). professional support on the duration of any
breastfeeding, although the strength of its effect
Observe infant for signs of effective positioning: on the rate of exclusive breastfeeding is
uncertain.213
• infant well supported and placed at the level of
the mother’s breast (mother-led attachment) Milk transfer occurs with appropriate positioning Henderson I,
and latch (attachment). The position that best Morton III,
• infant well supported and placed between the
facilitates effective latch will vary among mothers Righard II-2
mother’s breasts (baby-led attachment)
and infants.104, 173, 196
Observe infant for signs of effective latch: Effective positioning and latch minimize nipple Henderson I,
tenderness and trauma.104, 120 Ingram II-2
• wide opened mouth
Effective breastfeeding technique increases the Cernadas II-3,
• flared lips
duration of breastfeeding.41, 120, 196 Ingram II-2,
• chin touching the breast Righard II-2
• asymmetric latch (more areola visible above
the baby’s mouth)

Observe infant for signs of milk transfer:

• sustained rhythmic suckle/swallow/breathe
pattern with periodic pauses
• audible swallowing
• relaxed arms and hands
• moist mouth

Observe mother for signs of milk transfer:

• breast softening while feeding
• relaxation or drowsiness
• thirst
• uterine contractions or increased lochia flow
during or after feeding
• milk leaking from the opposite breast while
feeding
• nipple elongated but not pinched or abraded
after feeding

8
Management Strategy

Keep the mother and infant together during

3 Rationale and References

Rooming-in facilitates breastfeeding.33, 40, 148, 186, 253

Quality of Evidence

Buranasin II-3,
the entire postpartum stay. Centouri II-2,
Lindengerg II-2,
• Conduct examinations and routine tests of the
Perez-Escamilla I,
infant while the infant is in the mother’s room,
Yaumachi II-1
in the mother’s arms, or on the breast.
Breastfeeding frequency is greater and supplemen- Flores-Huerta II-1,
tation with human milk substitutes (formula) Yaumachi II-1,
occurs less often when mothers and infants Yaumachi II-1
room in.84, 252, 253
Mothers do not necessarily get more sleep when Keefe II-2
the infant is taken to the nursery at night.128
Hospital practices and policies impact the Awi II-2,
establishment of effective breastfeeding. Braun II-2,
15, 30, 187, 218, 241, 248
Phillip II-3,
Strembel II-3,
Widstrom II-2,
WHO III
Breastfeeding at birth and at three months is Blair II-2,
strongly associated with mother and infant Quillin II-3
co-sleeping.25, 191
Skin-to-skin contact and breastfeeding provide Carbajal I,
analgesia for painful procedures.37, 91, 92 Gray I,
Gray I

9
Management Strategy
4
Teach mothers to recognize and respond to early
Rationale and References

Breastfeeding in response to early feeding cues

Quality of Evidence

infant feeding cues and confirm that the baby is (as opposed to timed/scheduled feedings):
being fed at least 8 times in each 24 hours.
• helps prevent pathologic engorgement193 Renfrew II-2
Early infant feeding cues include:
• decreases the incidence of sore nipples193 Renfrew II-2
• sucking movements
• ensures that a mother’s milk production is a Daly III,
• sucking sounds reflection of her infant’s appetite56-58 Daly III,
Daly III
• hand-to-mouth movements
• reflects the fact that there is a wide range of pat- Hornell II-2
• rapid eye movements
terns among exclusively breastfed infants110
• soft cooing or sighing sounds
• decreases the incidence of jaundice20, 153, 206, 208 Bertini II-3,
• restlessness Maisels I,
Salariya II-2,
Crying is a late feeding cue and may interfere Semmekrot III
with effective breastfeeding.
• stabilizes neonatal serum glucose levels Adejuyigbe II-2,
4, 63, 73, 79, 254
de Rooy II-2,
Diwakar II-2,
Eidelman III,
Yamauchi II-2
• decreases initial infant weight loss and Semmekrot III
increases rate of weight gain208
• promotes earlier onset of mature milk Humenick II-3,
production117, 231, 252 Uvnas-Moberg II-2,
Yamauchi II-2
• increases the duration of breastfeeding AAP III,
9, 110, 139, 193
Hornell II-2,
Kurinij II-2,
Renfrew II-2
Early stages of the infant’s breast seeking behaviors Blair II-2
should be observed as well as the actual feeding.24
Responding to early feeding readiness cues Marchini II-3,
facilitates effective latch and suckling that Widstrom II-2
subsequently reinforces the mother’s interest in
feeding her infant.156, 241

10
Management Strategy

Confirm that mothers understand the physiol-

5 Rationale and References

Rate of milk synthesis is associated with the

Quality of Evidence

Cregan II-3,
ogy of milk production, especially the role of thoroughness of milk removal in the absence of Daly III,
milk removal. inhibitory feedback.55, 58, 185 Peaker III
To facilitate milk production: The frequency of milk removal may not directly Daly III
affect the volume of milk production; frequency
• breastfeed when the infant exhibits early
of feeding may be associated with the mother’s
feeding cues or approximately every 1-3 hours
storage capacity.56
• breastfeed on the first breast until the infant
Total time breastfeeding is positively correlated with Dewey II-1
seems satisfied (on average 15-20 minutes)
infant intake and weight at 3 months of age.67
before offering the second breast
Infants whose mother’s milk has a lower fat Tyson I,
NOTE: Some infants are satisfied with one breast,
content will breastfeed longer to obtain sufficient Woolridge II-2
while others will breastfeed on both breasts at
calories.226, 246
every feeding.

Management Strategy

Confirm that mothers know how to wake a

6 Rationale and References

Infants have several states: deep sleep, light sleep,

Quality of Evidence

Brandt III,
sleepy infant. drowsy, quiet alert, fussy or active alert, and crying. Brazelton III
It is easiest to initiate feedings when the infant is in
• Wake when early feeding cues are exhibited
the drowsy, quiet alert, or active alert state.29, 32
(see Management Strategy #4) or at least 8
times in each 24 hours. Some infants go to sleep as a means of coping Brazelton III
with discomfort, over-stimulation, or hunger.31
Strategies to wake the infant include:
• remove any blankets
• change the infant’s diaper
• place the infant skin-to-skin
• massage the infant’s back, abdomen, arms,
and legs

11
Management Strategy
7
Avoid using pacifiers, artificial nipples, and
Rationale and References

Human milk provides all of the fluid and nutrients

Quality of Evidence

Kramer I,
supplements, unless medically indicated. necessary for optimal infant growth.136, 137, 158, 233 Kramer III,
Marques II-2,
van’t Hof II-2
A longer duration of exclusive breastfeeding is Cernadas II-3
significantly associated with positive maternal
attitudes toward breastfeeding, adequate family
support, good mother-infant bonding, appropri-
ate suckling technique, and avoidance of nipple
problems.41
Healthy infants have the ability to generate de Rooy II-2
alternative fuels when blood glucose values are
low. Routine formula supplementation should not
be recommended.63
Additional water is unnecessary even in hot Ashraf II-2,
climates.13, 204 Sachdev I
Early use of supplements or pacifiers is associated Barros II-2,
with an increased risk for early weaning. Blomquist II-2,
17, 26, 39, 106, 114, 134, 139, 157, 197, 228, 234
Casiday II-2,
Hill II-2,
Howard II-2,
Kramer I,
Kurinij II-2,
Marques II-2,
Righard II-2,
Ullah II-2,
Victora II-2
The effect of supplemental feedings on the Howard I,
frequency and duration of breastfeeding remains Schubiger I
controversial.114, 207

12
Management Strategy

Observe and document at least one

8 Rationale and References

Direct observation is an essential part of

Quality of Evidence

Hall II-2,
breastfeeding in each eight-hour period breastfeeding assessment. Assessment is a Matthews III,
during the immediate postpartum period. prerequisite to intervention and provides Riordan II-2
opportunity for positive reinforcement and
Document the following to assess effective reassurance.97, 160, 198
latch:
• comfort of mother
• condition of both breasts and nipples
• shape of nipple on release
• signs of milk transfer
• number of feedings
• number of urinations
• number and character of bowel movements
• daily weight gain/loss

13
Management Strategy

Assess the mother and infant for signs of

9 Rationale and References

Although a single sign may not indicate ineffective

Quality of Evidence

Neifert III
effective breastfeeding and intervene if breastfeeding, further investigation and follow-up
transfer of milk is inadequate. are appropriate.174
Healthy full-term infants:
Signs of effective breastfeeding in the infant
include: • lose less than 7 percent of birth weight in the Avoa II-2,
first 3 days14, 152, 155, 164, 201, 209, 255 Macdonald II-2,
• weight loss less than 7 percent
Marchini II-3,
• at least 3 bowel movements in each 24 hours Merlob II-2,
after day 1* Rodriguez II-2,
Shrago II-2,
• seedy, yellow bowel movements by day 5
Yaseen II-2
• at least 6 urinations a day by day 4 with urine
• gain approximately 20 - 35 grams or 2/3 - 1 Dewey II-1,
that is clear or pale yellow
ounce each day by day 568, 135 Kramer I
• satisfied and content after feedings
• regain to birth weight by day 10152, 209 Macdonald II-2,
• audible swallowing during feedings Shrago II-2
• no weight loss after day 3 Lack of bowel movements in the breastfed infant Metaj II-3,
is a key indicator of inadequate caloric intake.167, 178, Nyhan II-1,
• weight gain by day 5 209, 255
Shrago II-2,
• back to birth weight by day 10 Yaseen II-2
*The first 24 hours after birth is day 1. Continued weight loss on day 3 is strongly Macdonald II-2,
correlated with untimely weaning.152, 164 Merlob II-2
Signs of effective breastfeeding in the mother
Breastfeeding duration increases when there is on- Dennis I,
include:
going support and evaluation as well as appropri- AAP III,
• noticeable increase in firmness, weight, and size ate intervention.9, 64, 140, 212, 213 Labarere I,
of breasts and noticeable increase in milk Sikorski II-1,
volume and composition by day 5 Sikorski II-1
• nipples show no evidence of damage Exclusively breastfed newborns have adequate Adejuyigbe II-2
glucose supply and are not at risk of having
• breast fullness relieved by breastfeeding
hypoglycemia in the first 48 hours of life.4
If effective breastfeeding, as indicated by milk The rate of milk synthesis is greatest when the Cregan II-3
transfer, is not observed within the first 12 breast is most drained of milk.55
hours:
Supplementation is seldom medically indicated AAP III,
• re-evaluate breastfeeding techniques but when mothers or infants cannot breastfeed Blomquist II-2,
(see Management Strategy #2) another method of feeding must be identified. Kramer I,
2, 26, 137, 251
WHO III
• initiate milk expression using manual
expression or a breast pump
• if medically indicated, initiate supplementation
(see Management Strategy #12)
• delay discharge from care until effective
breastfeeding has been observed
• refer to a health care professional with
breastfeeding expertise, such as an Interna-
tional Board Certified Lactation Consultant
(IBCLC), physician, midwife, nurse, or dietician
• coordinate care with the infant’s health care
provider

14
Management Strategy
10
Identify maternal and infant risk factors that
Rationale and References

Risk factors may signal a need for added support

Quality of Evidence

Lawrence III
may impact the mother’s or infant’s ability to but are seldom a contraindication to
breastfeed effectively and provide appropriate breastfeeding.145
assistance and follow-up.
When risk factors are identified, appropriate and Loughlin II-2
timely intervention can reduce the likelihood of
Infant risk factors include but are not limited
early weaning.150
to:
It is possible to predict babies at risk for short- Mizuno II-2
• birth interventions and/or trauma
term breastfeeding, based on their sucking
• less than 38 weeks gestation behavior at the breast in the early neonatal
period.169
• inconsistent ability to maintain an effective latch
Potentially modifiable risk factors can affect the Ballard II-2,
• ineffective suck
infant’s ability to breastfeed effectively.16, 70, 166 Dewey II-2,
• persistent sleepiness or irritability Messner II-2
• long intervals between feedings Certain perinatal events are predictive that a Hall II-3
mother will stop breastfeeding by 7-10 days
• hyperbilirubinemia or hypoglycemia
postpartum unless she receives extra assistance.97
• small (SGA) or large (LGA) for gestational age
Most breastfeeding problems and concerns are Cooke II-3,
or intrauterine growth restriction (IUGR)
amenable to treatment and support.27, 52, 89, 108, 109, 215 Giugliani II-2,
• tight frenulum Hill II-3,
Hillervik-Lindquist II-2,
• multiple birth
Souto II-2
• neuromotor deficits
Maternal breastfeeding self-efficacy is a significant Blyth II-3
• chromosomal abnormalities, e.g. Down predictor of breastfeeding duration.27
syndrome
Health care professionals are responsible for Ingram II-3
• oral anomalies, e.g. cleft lip/palate encouraging women to breastfeed all their
children, regardless of their previous experience.119
• acute or chronic illness, e.g. cardiac disease
Reports of insufficient milk production persist. Marasco III
• use of pacifier or artificial [bottle] nipple
A possible cause may be polycystic ovarian
syndrome.154
Maternal risk factors include but are not
limited to:
• previous breastfeeding difficulty
• birth interventions
• separation from infant
• absence of prenatal breast changes
• damaged, cracked or bleeding nipples
• unrelieved fullness or engorgement
• persistent breast pain
• mother’s perception of insufficient milk
• acute or chronic disease
• medication use
• breast or nipple abnormality
• breast surgery or trauma
• hormonal disorders e.g. polycystic ovarian
syndrome

15
Management Strategy

Identify any maternal and infant

11 Rationale and References

While breastfeeding is seldom contraindicated,

Quality of Evidence

AAP III,
contraindications to breastfeeding. there may be situations in which the potential Lawrence III
risks outweigh the benefits.7, 145
Maternal contraindications include:
HIV can be transmitted through human milk. The Bertolli III,
• HIV seropositivity (provided safe and sufficient relative role of breastfeeding in the epidemiology Coutsoudis II-1
quantities of human milk substitutes are of HIV infection is still uncertain. Until more
available) information is available, HIV infected women
• HTLV-1 seropositivity should be encouraged not to breastfeed when
safe and sufficient quantities of artificial infant
• substance abuse formula are available.22, 54
• chemotherapy The milk of HIV positive women can be pasteur- Jeffery II-3,
• radioactive isotope therapy (interrupt ized and fed to their infants.124-126 Jeffery II-3,
breastfeeding only until the isotope has been Jeffery II-3
eliminated from the mother’s body)
HTLV-1 can be transmitted through human milk. Ando II-3,
• active tuberculosis (if only the mother is However, freeze-thaw processing can eliminate the Carles II-3
infected, isolate the mother until treatment is HTLV-I virus from a mother’s milk. This process
initiated and the mother is no longer conta- allows HTLV-1 positive mothers to use their
gious; the mother’s expressed milk can be fed processed milk to feed their infants.12, 38
to her infant; if mother and infant are infected,
Most medications are compatible with Anderson III,
isolate them together)
breastfeeding. Notable exceptions include Chaves III,
• active varicella (if maternal rash develops antineoplastic drugs, radiopharmaceuticals and Hale III
within 5 days prior to birth or 2 days after drugs of abuse.11, 45, 96
birth, isolate the mother until she is no longer
contagious; expressed milk can be fed to her Individuals with active tuberculosis remain Menzies III
infant; if both mother and infant are infected, contagious for at least two weeks after the start of
isolate them together) drug therapy.163

• active herpes lesion(s) on breast (breastfeed on Pasteurization prevents the transmission of Bittencourt III,
unaffected breast or interrupt breastfeeding Chagas’ disease and allows infants of mothers with Ferreira III
only until lesion(s) heal) this disease to be fed their own mother’s milk.23, 82

• Chagas’ disease caused by a South American Galactosemia is characterized by an inability to Chen III
parasite (interrupt breastfeeding during the metabolize galactose, the primary sugar in human
acute phase only; the mother’s expressed, milk.47
pasteurized milk can be fed to the infant)

Infant contraindications include: Recommendations regarding the appropriate Berlin III,

• galactosemia response to the presence of environmental Grandjean II-2,
chemicals in human milk must carefully consider LaKind III
Note: Some conditions are incorrectly the health risks and benefits associated with
identified as contraindications. These include: breastfeeding and formula-feeding.19, 90, 142
• maternal fever in the absence of a contraindi- Alcohol (beer, wine, liquor) passes readily into de Araujo Burgos III,
cation listed above human milk. While an occasional drink is Mennella II-2
• hepatitis B or C infection considered safe, further studies are needed to
determine the minimum level of alcohol needed
• exposure to low-level environmental contaminants to produce adverse outcomes in breastfeeding
• alcohol use (advise mothers to limit intake to mothers and infants.59, 162
an occasional drink) Maternal smoking is associated with shortened Horta II-2,
• tobacco use (advise mothers to stop smoking exclusive and total breastfeeding duration.111, 244 Wojdan-Godek II-2
or if unable to stop make every effort to avoid
VLBW preterm infants are at greater risk for Hamprecht II-3,
exposing infant to second-hand smoke)
symptomatic CMV infection. Pasteurization of Yasuda II-3
• cytomegalovirus (CMV) infection human milk can reduce the viral load.98, 256

16
Management Strategy
12
If medically indicated, provide additional
Rationale and References

Offering additional nutrition at the breast will

Quality of Evidence

Edgehouse III,
nutrition using a method of supplementation provide the mother with suckling stimulation and Frantz III
that is least likely to compromise the transi- decrease the time required for feeding.77, 85
tion to exclusive breastfeeding.
Additional methods of offering nutrition include a Howard I,
cup, spoon, dropper or bottle.114, 143 Lang III
Guidelines for supplementation:
Use of cup feeding requires instruction and skill. Dowling II-2,
• use mother’s own milk first 75, 114
Howard I
• pasteurize the mother’s milk if she is HIV positive
Exclusive breastfeeding or feeding with a partial AAP III,
• pasteurized donor milk is the next best whey hydrolysate formula is associated with lower Chandra I,
alternative to the mother’s own milk incidence of atopic disease and food allergy. The Hanson II-2,
effect appears even stronger in children with van Odijk II-2
• human milk substitute (formula) is the last
atopic heredity.8, 42, 100, 232
choice
• reassure mother that her infant will benefit
from any amount of her milk provided
• the selection of a human milk substitute
should take into account any family history of
allergic disease

Management Strategy

Confirm that the infant has a scheduled

13 Rationale and References

Infant weight and other clinical signs that indicate

Quality of Evidence

ABM III,
appointment with a primary care provider or effective breastfeeding require on-going evaluation.3, 9 AAP III
health worker within five to seven days after
Knowledgeable and skilled breastfeeding support Albernaz II-1,
birth.
increases breastfeeding initiation, duration, and Chapman I,
Schedule additional visits as needed until a exclusivity rates.5, 44, 62, 65, 66, 95, 131, 140, 172, 212, 213, 235 Dennis II-2,
consistent weight gain pattern has been Dennis I,
established. de Oliveira III,
Haider I,
Identify breastfeeding support resources within
Kistin I,
the community such as:
Labarere I,
• International Board Certified Lactation Morrow I,
Consultants (IBCLCs) Sikorski II-1,
Sikorski II-1,
• community health workers and home visitors
Vittoz II-3
trained to provide breastfeeding support
Inconsistent or inaccurate information given by Freed II-3
• breastfeeding clinic staff
health care professionals contributes to maternal
• health department staff confusion and premature weaning.87
• volunteer breastfeeding support groups Attitudes of health care professionals can affect DiGirolamo II-3
breastfeeding duration.72
• breastfeeding peer counselors
Provider encouragement significantly increases Lu II-2,
• telephone center for breastfeeding advice
breastfeeding initiation among American women Taveras II-2,
• breast pump rental and sales outlets of all social and ethnic backgrounds.151, 221, 223 Taveras II-2
Mothers’ reports of breastfeeding advice given dur- Johnston I,
ing routine preventive visits identifies areas in which Taveras II-2
unintentional communication gaps may occur, in-
cluding specifics about breastfeeding duration.127, 222

17
Management Strategy
14
Provide appropriate breastfeeding education
Rationale and References

Educational programs are the most effective single

Quality of Evidence

Guise II-2
materials. intervention for improving breastfeeding initiation
and duration.94
Appropriate materials are:
Prevalence of and factors influencing the decision Wiemann II-3
• clinically accurate to breastfeed differ by race and ethnicity among
adolescent mothers.242
• consistent
Targeting specific mothers and members of their Bertini II-3
• positive
support system, educating them before and
• reading-level appropriate during pregnancy, and stressing benefits of
breastfeeding while eliminating misinformation,
• culturally sensitive
may be important intervention strategies for
• free of commercial advertising promoting breastfeeding.21
• compliant with the International Code of An analysis of printed breastfeeding education Vnuk III
Marketing of Breast-milk Substitutes and materials reveals a presence of negative
subsequent WHA resolutions breastfeeding messages that is of concern.236
Materials containing commercial advertisements Walker III
often transmit subtle, undesirable messages, reinforce
stereotypes, and/or contradict verbal messages.237
Exposure to formula promotion materials Howard I
significantly increases breastfeeding cessation in
the first 2 weeks. In addition, among women with
uncertain goals or breastfeeding goals of 12 weeks
or less, the period of exclusive breastfeeding and
overall breastfeeding duration are shortened.112

Management Strategy
15
Support exclusive breastfeeding during any
Rationale and References

Continued breastfeeding during illness or

Quality of Evidence

AAP III,
illness or hospitalization of the mother or the hospitalization is important for the well-being of Howard II-2
infant. both the mother and infant.9, 115

Management Strategy
16
Comply with the International Code of Market-
Rationale and References

Distribution of infant feeding products decreases

Quality of Evidence

Howard I,
ing of Breast-milk Substitutes and subsequent breastfeeding duration.112, 237, 247 Walker III,
WHA resolutions, and avoid distribution of WHA III
infant feeding product samples and advertise-
The distribution of commercial hospital discharge Donnelly III
ments for such products.
packs decreases the duration of exclusive
breastfeeding in all populations.74

Management Strategy
17
Include family members or significant others
Rationale and References

Support of family members and significant others

Quality of Evidence

Ingram II-2,
in breastfeeding education. increases the duration of breastfeeding.122, 213, 245 Sikorski II-1,
Wolfberg I

18
Management Strategy
18
Provide anticipatory guidance for common
Rationale and References

Anticipatory guidance by health care providers

Quality of Evidence

Blyth II-3,
problems that can interfere with exclusive can increase maternal confidence, enhance the Giugliani II-2,
breastfeeding. breastfeeding experience, and reduce the risk of Hill II-3,
early weaning.28, 89, 105, 127, 188 Johnston I,
Nipple pain: Porteus II-2
• many mothers report mild discomfort at the Normal infant sucking may induce nipple changes Ziemer II-3
beginning of a feeding when the infant latches that some women perceive as painful.258
onto the breast
Inconsistent or inaccurate education on postpar- Henderson I
• all pain should be evaluated tum positioning and attachment may negatively
affect breastfeeding.104
• pain is often the result of ineffective position-
ing and latch Mammary candidosis (fungal infection) may be a Morrill II-2
significant factor contributing to premature
• consider other causes such as bacterial or
weaning.171
fungal infection
Previous breastfeeding experience and current Hill II-3,
Engorgement (as opposed to normal fullness): feeding routine can play an important role in the Moon II-3
timing and level of breast engorgement. Anticipa-
• normal fullness is relieved with frequent,
tory guidance may minimize engorgement and
effective breastfeeding
enhance the breastfeeding experience.105, 170
• engorgement occurs in some mothers
Use of intermittent compression has been shown Cotterman III,
approximately 3-5 days after birth (breasts can
to reduce swelling.53, 217 Stockle I
be painful and swollen)
Application of cold has been shown to reduce pain Snowden II-2
• unrelieved swelling (engorgement) requires
and swelling; however, its effectiveness in relieving
treatment
breast engorgement has not been well studied.214
• focus treatment on measures to reduce
Cabbage leaves and chilled gel packs are widely Nikodem I,
swelling and relieve pain, including breast
used to relieve engorgement.177, 199, 200, 214 Roberts II-2,
massage, hand expression or pumping,
Roberts II-2,
intermittent compression (reverse pressure
Snowden II-2
softening), application of cold, and anti-
inflammatory medication Perceived insufficient milk supply occurs in up to Cooke II-3,
50% of all breastfeeding mothers and is a significant Hillervik-Lindquist II-3
• avoid the use of heat unless the breasts are
cause of untimely weaning.52, 107
leaking freely
The perception of insufficient milk seems real to Hillervik-Lindquist II-3
Perceived insufficient milk supply: many mothers, but in most cases it is not valid.
Supporting the mother to continue breastfeeding
• a mother may think that she has insufficient
through this perceived low milk supply “crisis”
milk because her breasts are soft after birth
increases breastfeeding duration without affecting
• milk volume increases within several days and infant growth.108
is usually accompanied by breast fullness
Mothers produce 30-100 ml of colostrum in the Humenick II-2
• in the second week of life, initial breast fullness first 24 hours; 2-10 ml per feeding on day 1 and
decreases but this does not signal a decrease in 5-15 ml per feeding on day 2.116
milk production
• infants have recurring growth or appetite
spurts, during which more frequent feedings
increase milk production and thus caloric
intake
• if a fussy infant is having normal output and is
gaining weight, low milk supply is not the
cause of fussiness

(continued on next page)

19
 18
(continued from previous page)

Management Strategy Rationale and References Quality of Evidence

Infant crying: Infant may be in pain.49 Clifford II-3

• no crying should go unattended Breastfeeding can act as an analgesic.37, 92 Carbajal I,
Gray I
• crying may be a sign of hunger or a sign of
distress—if the infant is not exhibiting feeding Analgesia given to the mother during labor may Ransjo-Arvidson II-3
cues, parents can try other comfort measures interfere with the newborn’s spontaneous breast-
before offering the breast seeking and breastfeeding behaviors and increase
the newborn’s temperature and crying.192
Maternal diet:
Infants identified as crying excessively were less Loughlin II-2
• dietary restrictions are seldom necessary; few likely to be breastfeeding at 2 weeks of age.150
infants are affected by foods eaten by the
Dietary myths can be a barrier to breastfeeding IOM III
mother
and seldom are fact-based.123
• the mother should eat a variety of foods and
Increased maternal fluid intake does not affect the Dusdieker I
drink to satisfy thirst
quantity of milk produced.76
Breastfeeding does not preclude leaving home Maternal weight reduction associated with Sichieri II-2
with or without the baby. breastfeeding may be minimal.211
Breastfeeding can be accommodated in most Neilsen III
It is possible to maintain exclusive
situations in which a mother must be away from
breastfeeding by:
her infant.176
• planning feedings around the mother’s or
Maternal employment is less of a barrier to Cohen II-3,
family’s activities
breastfeeding when worksite lactation support is Ortiz II-3
• breastfeeding any time and in any place provided.50, 184
• expressing, collecting, and storing milk to leave
with the child care provider

20
Management Strategy

Confirm that mothers understand normal

19 Rationale and References

Parent knowledge of normal breastfed infant

Quality of Evidence

Susin II-2
breastfed newborn/infant behaviors and have behavior correlates with increased breastfeeding
realistic expectations regarding infant care rates.219
and breastfeeding.
Realistic expectations can prevent premature Neifert III
weaning.174
Frequency and duration of feedings:
• 8-12 feedings in each 24 hours is typical;
however, feeding frequency can vary
• some infants will cluster-feed (feed every hour
for 2-6 hours and then sleep for a longer
period) and others will breastfeed every 2-3
hours day and night
• on average, infants will feed 15-20 minutes on
each breast at a feeding; some will feed longer
and some are satisfied with only one breast
• sleepy infants need to be awakened for
feedings until an appropriate weight gain
pattern is established

Infant output:
• at least 3 bowel movements each day with age
appropriate color changes (first bowel
movement typically occurs within 8 hours of
birth)
• at least 6 urinations each 24 hours by day 4
with urine that is clear or pale yellow
(first urination typically occurs within 8 hours
of birth)
• bowel movements change from black and
sticky to yellow, soft and watery by day 4

Infant weight loss/gain

• expect less than 7 percent weight loss the first
week
• expect return to birth weight by 10 days of age
• expect weight gain of approximately 20-35
grams or 2/3 - 1 ounce each day for the first
3 months

21
Management Strategy
20
Discuss contraceptive options and their
Rationale and References

The lactational amenorrhea method (LAM) is

Quality of Evidence

Kennedy II-1,
possible effect on milk production. 98% effective in preventing pregnancy during the Labbok II-2,
first 6 months, provided the infant is breastfed WHO II-2
Contraceptive options include: exclusively, the interval between feedings is less
than 6 hours, and the mother has not resumed
• lactational amenorrhea method (LAM)
menstruation.130, 141, 249
• barrier devices
The use of pacifiers and infant formula are Ingram II-2
• hormonal methods associated with an earlier return to menstrua-
tion.121
• surgical procedures
Barrier devices typically do not contain synthetic Hatcher II-2
• fertility awareness
hormones and therefore do not interfere with
• abstinence milk production.101
Synthetic hormones can reduce milk production Hatcher II-2,
and subsequently interfere with infant growth. Queenan III,
101, 190, 220
Tankeyoon II-2
Specifically:
• estrogen-containing pills may decrease milk
production
• progestin-only pills, rings, patches, injections or Diaz II-3,
implants may inhibit milk production when Massai II-2
initiated before lactogenesis stage II occurs—
most manufacturer guidelines suggest delaying
initiation for at least 6 weeks71, 159
• progestin-only methods begun after 6 weeks Kennedy II-2
often do not impact milk production; however,
a trial period using pills that can be easily
discontinued may be preferred over injections
or implants, the effects of which cannot be
reversed129
Surgical sterilization does not impact Hatcher II-2
breastfeeding.101

22
 Appendix 1.
Evaluation Criteria for Type of Evidence
(based on US Preventive Services model)226

Code Criteria
I Evidence obtained from at least one properly randomized study.
II-1 Evidence obtained from well-organized, controlled trials without randomization.
II-2 Evidence obtained from well-designed cohort or case-control analytic studies
preferably from more than one center or research program.
II-3 Evidence obtained from multiple time series with or without the intervention.
Dramatic results in uncontrolled experiments (such as the results of the introduction
of penicillin treatment in the 1940s) could also be regarded as this type of evidence.
III Opinions of respected authorities, based on clinical experience, descriptive studies
and case reports, or reports of expert committees.

Appendix 2.
Review Panel
Doraine Bailey, MA, IBCLC, RLC Cathy Carothers, BLA, IBCLC, RLC
Suzanne Cox, AM, RN, RM, IBCLC Maureen Fjeld PT/OT, IBCLC, RLC
Elsa Giugliani, MD, PhD, IBCLC Jacki Glover, RN, MN, IBCLC, RLC
Larry Grummer-Strawn, PhD Heather Jackson, RGON, RM, IBCLC, MA
Judith Lauwers, BA, IBCLC, RLC Rebecca Mannel, BS, IBCLC, RLC
Angela Smith, RN, BA, IBCLC Anna Swisher, MBA, IBCLC
Virginia Thorley, OAM, DipEd, MA, IBCLC Nancy E. Wight MD, IBCLC, FABM, FAAP

23
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