About this course:
This learning activity reviews the anatomy and physiology of the breast and addresses the prevalence, recommendations, benefits, contraindications, and complications of breastfeeding. It outlines proper infant positioning on the breast, care of breastfeeding patients, and promotion of breastfeeding in the hospital setting.
This learning activity reviews the anatomy and physiology of the breast and addresses the prevalence, recommendations, benefits, contraindications, and complications of breastfeeding. It outlines proper infant positioning on the breast, care of breastfeeding patients, and promotion of breastfeeding in the hospital setting.
By completing this activity, learners will be able to:
review anatomic and physiologic aspects of breastfeeding
describe current recommendations for infant feeding
discuss the benefits of breastfeeding for infants, parents, families, and society
analyze common problems associated with breastfeeding and interventions to resolve them
explain maternal and infant indicators of effective feeding
note the implications for nursing care and future research on breastfeeding
Anatomy and Physiology
Adult breasts appear on the thorax's ventral side, extending from the second to sixth or seventh intercostal space. Breasts begin to develop in utero, and a rudimentary mammary ductal system is present at birth. After birth, areola and nipple growth mimics the growth of other body tissues. This is as far as male breast tissue progresses. During female puberty, insulin-like growth factor and estrogen stimulate mammary growth. This breast development (thelarche) is usually the first indication in a female that puberty is beginning. Complete maturation and differentiation of the tissue continue for the next 4 years. Many hormones influence breast development, such as progesterone, estrogen, prolactin, growth hormone, thyroid and parathyroid hormones, insulin, and cortisol (McCance & Huether, 2019).
A fully developed female breast has 15 to 20 pyramid-shaped lobes supported by Cooper ligaments. Each lobe consists of 20 to 40 lobules subdivided into functional units known as acini (also called alveoli). The acini are lined with epithelial cells that can secrete milk and myoepithelial cells that can squeeze the milk out of the acini. The acini empty into lobular collecting ducts, which open into the interlobular collection and ejecting ducts. These ducts reach the skin through pores in the nipple (see Figure 1; Lowdermilk et al., 2020; McCance & Huether, 2019).
During pregnancy, a person's breasts remodel into milk-secreting organs because estrogen, progesterone, and placental lactogen stimulate glandular and adipose tissue growth. The ratio of glandular to adipose tissue is 1:1 in a nonlactating breast and 2:1 in a lactating breast. Blood flow to the breast nearly doubles, causing the veins in lactating breasts to become more prominent. The nipples and areolas enlarge, along with Montgomery glands on the areola. Montgomery glands are sebaceous glands that produce an oily substance that protects against infection and mechanical stress caused by the infant's sucking (Lowdermilk et al., 2020; McCance & Huether, 2019).
Stages of Human Milk Production
Lactogenesis is the process of developing the ability to produce and secrete milk. There are three stages of lactogenesis. Stage 1 occurs during the second half of pregnancy. In this stage, the placenta releases high progesterone levels, stimulating the breasts to prepare for milk production by producing colostrum (prepartum milk). By late pregnancy, some patients can hand express colostrum from their breasts. Stage 2 begins once the placenta is removed after delivery, initiating a rapid drop in progesterone levels and a rise in prolactin, cortisol, and insulin. For the first 2-3 days following delivery, the infant receives co
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Two hormones—prolactin and oxytocin—play essential roles in successful lactation. The anterior pituitary gland secretes prolactin in response to nipple stimulation. Its release is inhibited by dopamine from the hypothalamus. Oxytocin is vital in the let-down reflex. The posterior pituitary gland releases oxytocin when the infant starts to suckle at the breast. A suckling infant stimulates touch receptors around the nipple and areola, activating the dorsal root ganglia via the intercostal nerves. These impulses ascend the spinal cord along an afferent neuronal pathway to the paraventricular nuclei of the hypothalamus, where oxytocin is synthesized and secreted by the pituitary gland. Stimulating the nuclei causes oxytocin to be released into the posterior pituitary gland, where it is stored. The posterior pituitary gland releases oxytocin to adjacent capillaries, traveling to the mammary myoepithelial cell receptors to stimulate cell contraction. Oxytocin causes the contraction of the myoepithelial cells that line the ducts of the breast; when stimulated, these cells expel milk from the alveoli into the ducts and subareolar sinuses that empty through the nipple. Catecholamine production due to pain or stress may inhibit this process (McGuire, 2018).
Human Milk Composition
Human milk (human breast milk, or HBM) is the ideal food for infants. Each individual's milk composition is unique, and changes based on their nutritional intake and the infant's specific nutritional and immunologic needs. HBM contains immunoglobulins that protect infants against pathogens. It is also composed of macronutrients, vitamins, minerals, hormones, and growth factors (Lowdermilk et al., 2020).
HBM is composed of 87%-88% water and 124 g/L of macronutrients. Mature milk usually contains 65-70 kcal per 100 mL of energy, with 50% of calories from fat and 40% from carbohydrates. The macronutrient levels within colostrum and mature milk are described in Table 1 (Kim & Yi, 2020).
Vitamins and Minerals
Although a lactating patient's diet can influence HBM components, it usually contains all the vitamins and minerals their infant needs to grow. The vitamins HBM lacks in sufficient amounts are vitamins D and K, and an exclusively breastfed infant may require supplementation. This is especially true for vitamin D in climates without extended sun exposure. The vitamin and mineral composition of HBM is described in Table 2. One study by Hollis and colleagues (2015) compared maternal supplementation with 6,400 IU of vitamin D per day against maternal and infant supplementation with 400 IU per day. After reviewing the vitamin D levels of the 334 mother-infant pairs studied, researchers determined that maternal vitamin D supplementation with 6,400 IU/day confers enough vitamin D to meet infant requirements and offers an alternative to infant supplementation (Hollis et al., 2015; Kim & Yi, 2020).
Hormones and Growth Factors
The functions of hormones in HBM are not entirely understood at this time; however, they serve as various bioactive proteins and peptides. Hormones in HBM include parathyroid hormone, insulin, leptin, ghrelin, apelin, nesfatin-1, obestatin, and adiponectin. The effects of these hormones on infants are not entirely understood. In contrast, many growth factors have been studied extensively and are known to have various effects on the gastrointestinal system, vasculature, nervous system, and endocrine system. Growth factors and their function are detailed in Table 3 (Kim & Yi, 2020).
The American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG), World Health Organization (WHO), and other medical authorities recommend exclusive breastfeeding for the first 6 months of an infant's life with a continuation of breastfeeding until 2 years old or beyond in conjunction with complementary foods. Despite these recommendations, the WHO reports that globally only 41% of infants are exclusively breastfed for the first 6 months of life. The WHO estimates that 820,000 children's lives could be saved annually if all children under 2 were breastfed. The Centers for Disease Control and Prevention (CDC) estimated that 46.3% of infants in the US were exclusively breastfed for the first 3 months in 2018. In the same year, 83.9% of infants had some exposure to HBM in the first 3 months, with 56.7% continuing at 6 months and 35% at 12 months. Healthy People 2030 objectives include increasing the proportion of exclusively breastfed infants through 6 months and 1 year. There has been little or no detectable change in these objectives from Healthy People 2020. The target is that 42.4% of infants will be exclusively breastfed until 6 months of age, in contrast to the current rate of 25.8%. The target for infants who are breastfed until 1 year is 54.21%, in contrast to the current rate of 35% (CDC, 2021; Healthy People 2030, n.d.; Lowdermilk et al., 2020; Meek & Noble, 2022; WHO, 2021).
Extensive evidence demonstrates the health benefits of breastfeeding for infants and breastfeeding parents (see Table 4). An estimated $13 billion per year in healthcare costs and 900 infant deaths could be avoided if 90% of infants were exclusively breastfed for the first 6 months of life. Even if a breastfeeding parent is ill, the antibodies produced by their body will pass to the infant. This passive immunity significantly decreases a breastfeeding baby's risk of becoming sick. Some of the benefits even extend into adulthood. Exclusive breastfeeding for a longer duration increases these benefits. The AAP reports that infants who breastfed exclusively for at least 4 months were less likely than formula-fed babies to be hospitalized for croup, bronchiolitis, pneumonia, or a similar lower respiratory tract infection (AAP, 2021; Lowdermilk et al., 2020).
Listing several other potential benefits of breastfeeding, the AAP cites evidence that breastfeeding protects babies born to families with a history of allergies compared to formula-fed babies. In these at-risk families, babies exclusively breastfed for at least 4 months had a lower risk of cows' milk allergy, atopic dermatitis, eczema, and asthma. The long-term benefits of breastfeeding on allergies remain unclear, and studies have not carefully evaluated the impact on families without a history of allergies. Breastfed infants also have a reduced risk of gastrointestinal infections, necrotizing enterocolitis, childhood-onset inflammatory bowel disease (IBS), Crohn's disease, and ulcerative colitis. Infants who breastfeed for more than 6 months are less likely to develop childhood acute leukemia and lymphoma as compared to those who receive formula. Although the etiology is not fully understood, studies indicate a 36%–50% reduction in sudden infant death syndrome (SIDS) risk among breastfed infants. Recent research suggests that breastfed infants are less likely to be obese in adolescence and adulthood and less vulnerable to type 1 and type 2 diabetes (AAP, 2021; Lowdermilk et al., 2020).
Parents also experience benefits from breastfeeding. Initiating breastfeeding after birth can decrease postpartum bleeding and the time of uterine involution. Over time, breastfeeding reduces an individual's risk of developing premenopausal ovarian, endometrial, and breast cancer; thyroid cancer; type 2 diabetes; rheumatoid arthritis; hypertension; hypercholesterolemia; and cardiovascular disease. Breastfeeding can also promote the bonding experience between a breastfeeding parent and their infant (AAP, 2021; Lowdermilk et al., 2020).
Breastfeeding also has economic benefits. Less waste (e.g., formula packaging, bottles, nipples, and other equipment) is deposited into landfills when families opt to breastfeed. Breastfeeding also reduces the overall cost of caring for an infant. Infant formula can financially burden families with limited income. Additionally, breastfeeding can protect parents from having to navigate finding formula during a shortage, such as the production drop and subsequent decrease of availability in 2022. For individuals with hyperlactation, extra milk can be donated to help those unable to breastfeed. Breastfeeding also reduces absenteeism due to the benefits to the immune system and reduction in illnesses. When an infant feeds directly from the breast, the milk comes out at the ideal temperature for consumption and requires no prep time (HHS, 2022; Lowdermilk et al., 2020).
In some circumstances, breastfeeding is contraindicated for the patient or the infant. Infants diagnosed with galactosemia should not receive HBM. Breastfeeding is contraindicated for individuals with T-cell lymphotropic virus types I or II, untreated brucellosis, use of illicit street drugs, human immunodeficiency virus (HIV), or suspected or confirmed Ebola virus disease. However, even these are not absolute contraindications. For example, the American Academy of Family Physicians (AAFP, 2021) suggests exclusive breastfeeding for the first 6 months and continued breastfeeding for 12 months, including for HIV-positive individuals who reside in areas with high rates of infant diarrhea and respiratory illness. These individuals and babies should be treated adequately with antiviral medications if indicated. Patients with herpes simplex lesions on the breast should avoid breastfeeding from the affected breast but are encouraged to continue breastfeeding from the contralateral side until the lesions heal. Breastfeeding parents with active tuberculosis (TB), varicella, or herpes simplex lesions on the breast should be quarantined away from their infant and not directly feed the infant from the breast; however, they can express milk for another individual to feed the infant (AAFP, 2021; AAP, 2021; Lowdermilk et al., 2020).
Breastfeeding is also contraindicated for patients taking certain medications. In 2014 the Food and Drug Administration (FDA) amended the regulation governing the content and prescription labeling format for the pregnancy, labor and delivery, and breastfeeding section. Per the new regulation, all labeling must include the risks of using a particular drug during pregnancy and lactation. The National Library of Medicine maintains a database called LactMed on drugs and other chemicals that may be passed to infants through HBM. It includes information on the levels of these substances found in HBM, the amount transmitted to the infant, and possible adverse effects (Department of Health and Human Services [HHS], 2014; National Library of Medicine, n.d.).
Nurses can show breastfeeding patients multiple breastfeeding holds or positions, such as the cross-cradle hold, the cradle hold, the clutch or football hold, the straddle hold, and the side-lying position (ACOG, 2020; Lowdermilk et al., 2020; Office on Women's Health [OASH], 2021).
The football or clutch hold (see Figure 2) is helpful for patients who have had a cesarean birth or have large breasts, flat or inverted nipples, or a strong let-down reflex. The baby is held at the patient's side, lying on their back, with their head at the level of the nipple and their legs and feet extending along the patient's side and behind them. The patient supports the baby's head by placing their palm at the base of the baby's head.
The cross-cradle or across-the-lap hold (see Figure 3) is helpful for premature babies or babies with a weak suck, as it gives extra head support and may help the baby stay latched. The baby is held with the arm opposite the breast while the infant's body faces the patient. The patient supports the baby's head by placing their palm at the base of the baby's head.
The cradle hold is the most commonly used position (see Figure 4). This position involves placing the baby's head on the patient's forearm near the elbow bend with their body facing the patient.
The side-lying position (see Figure 5) allows the patient to rest while the baby breastfeeds and is especially helpful after a cesarean section. The patient lies on one side with the baby facing them.
The straddle or laid-back hold (see Figure 6) is a more relaxed and baby-led approach. The patient lies back on a pillow and places the baby against their body with the baby's head just above and between the breasts. When hungry, the baby will gravitate to and wiggle toward a nipple. The patient supports the baby's head and shoulders as needed. An advantage of this hold is increased comfort for the patient and improved positioning for the child without occupying one or both of the patient's hands.
A latch is the "placement of the infant's mouth over the nipple, areola, and breast, making a seal between the mouth and breast to create adequate suction for milk removal" (Lowdermilk et al., 2020, p. 611). A proper latch is essential for successful breastfeeding (see Figures 7 and 8). Signs of a good latch include the following (Lowdermilk et al., 2020; OASH, 2021):
The breastfeeding parent feels a firm tugging sensation on the nipple without pain.
The infant's cheeks are rounded, not dimpled.
The infant's jaw glides smoothly when sucking.
Swallowing is audible.
The infant's chin touches the breast.
The areola is entirely in the infant's mouth.
The infant's lips turn out.
The infant's ears wiggle when sucking.
Some infants may have difficulty latching. Several tips that nurses can share with patients include tickling the infant's lips with the nipple to entice the infant to open wide, drawing the infant close so their chin and lower jaw move into the breast first, and watching the baby's lower lip to aim it far from the base of the nipple, helping the baby enclose the areola. If breastfeeding is painful, the patient should break the infant's latch by placing a clean finger into the corner of the infant's mouth. Then, attempt to latch again. Breastfeeding should be comfortable and pain-free. Some infants may have ankyloglossia, more commonly known as "tongue-tie." These infants have a tight or short lingual frenulum, which is the piece of tissue attaching the tongue to the floor of the mouth. They may be unable to extend their tongue past their lower gum line or properly latch onto the breast, causing slow weight gain in the baby and nipple pain for the parent (Lowdermilk et al., 2020; OHSA, 2021).
Indicators of Effective Feeding
One of the most common concerns among breastfeeding patients is that their infant is not receiving enough HBM. This is especially true in the early days of breastfeeding. Parents must be taught the signs that indicate their infant is consuming enough milk:
latches without difficulty
has 6-8 wet diapers and 2-3 loose, seedy bowel movements per day after the first 24 hours of life
switches between short sleeping periods and wakeful, alert periods
is satisfied and content after feedings
easily releases the breast after feeding
has bursts of 15 to 20 sucks/swallows at a time
notices the breasts feel softer after feeding
feels relaxed and drowsy during feedings
notices increased thirst
leaks milk from the opposite breast during feedings (Lowdermilk et al., 2020)
Milk can be expressed from the breasts using hand or mechanical expression. The most common type of expression is pumping. Pumping is not usually recommended until a patient's milk supply is well established and their infant can latch and breastfeed successfully. There are, however, exceptions to this recommendation. If an infant is born premature or ill, requiring medical intervention that prohibits the parent from breastfeeding, pumping should be initiated as soon as possible following birth and continue at regular intervals until the infant can be breastfed. Pumping can also help if an infant is not latching correctly or has an issue with milk transfer. If breastfeeding is interrupted for any other reason, the breastfeeding parent should pump to maintain a sufficient milk supply. This is especially true if a breastfeeding parent must return to work outside the home or travel away from their infant (Lowdermilk et al., 2020).
Although milk can be expressed by hand, an electric pump is often more efficient. Most electric pumps allow breastfeeding parents to pump from both breasts simultaneously (i.e., double pumping), decreasing the time commitment. The amount of milk obtained when pumping depends on many variables, including the pump being used, time of day, time since the last pumping session or feeding, comfort level, and milk supply. Various electric pumps are available for commercial use, and breastfeeding parents can often locate one within their price range that meets their needs. Commercial health insurance policies are now required to cover the cost of a breast pump; however, the insurance provider chooses whether the pump is a rental or owned, electric or manual, and its delivery time. Insurance companies may also limit the frequency of obtaining a breast pump if an individual has multiple children within a short time (US Centers for Medicare & Medicaid Services, n.d.; Lowdermilk et al., 2020).
Storage of HBM
If HBM needs to be collected and not used immediately, it can be stored. Various factors (e.g., milk volume, room temperature when milk was expressed, temperature fluctuations in the refrigerator and freezer, and cleanliness of the environment) can affect how long HBM can be stored safely. The following guidelines cover the proper storage of HBM (see Table 4; CDC, 2022).
Before storing or handling HBM, the caregiver should wash their hands with soap and water to prevent contamination. When HBM is expressed by hand or with a manual or electric pump, it should always be stored in breast-milk-specific storage bags; clean, food-grade glass; or BPA-free plastic containers with tight-fitting lids. HBM should not be stored in the fridge or freezer door to ensure constant temperatures during storage. If it will not be used within 4 days, freeze HBM immediately after expressing to ensure optimal quality. When filling storage containers for freezing, leave room in the container to allow for expansion. Label bags with the date the milk was expressed and the amount for ease of use later. Frozen HBM can be safely stored in an insulated cooler with ice packs for up to 24 hours when traveling. The oldest HBM should always be thawed and used first. Thaw HBM in the refrigerator (use within 24 hours) or warm water if needed (use within 2 hours), but do not refreeze. If heating HBM, do not use a microwave, as this can destroy vital nutrients and create hot spots, which can cause burns. Instead, serve HBM cold, at room temperature, or heated in a sealed container in a bottle warmer or pot of warm water. Once an infant begins feeding with expressed HBM, contamination occurs. The recommendation in this situation is to discard any remaining milk within 1-2 hours of the end of the feeding; however, there are many different variables, including bacterial load, and some individuals may feel more comfortable discarding any remaining HBM immediately after the feeding (CDC, 2022; Eglash et al., 2017; Lowdermilk et al., 2020).
Lactating parents who have returned to work will likely need to express their milk regularly during the workday. Expressed milk does not require the same special handling (i.e., universal precautions) as other bodily fluids. HBM can be stored in the workplace refrigerator, among other stored food. This practice may not be socially acceptable in a particular work environment, and some individuals may feel more comfortable storing expressed HBM inside a discreet container within the refrigerator or in a personal cooler with a freezer pack (Eglash et al., 2017).
Although many government and professional organizations recommend that infants are exclusively fed HBM for 6 months, many individuals experience problems that deter them from breastfeeding. Common problems faced by patients include plugged ducts, sore nipples, engorgement, mastitis, low milk supply, and fungal infections. Nurses should encourage patients to get as much sleep as possible, maintain adequate nutrition and fluid intake, and wear a supportive, well-fitting bra to avoid many of these problems.
Engorgement occurs when the breasts are not fully emptied and accumulate milk. This can happen during the transition from colostrum to mature milk or after missed feedings or pumping sessions. Engorgement presents as breasts that are firm, warm, red, tender, full, and painful and may also be accompanied by a low-grade fever. Engorgement usually resolves in a few days but can lead to plugged ducts or a breast infection if not addressed. Nurses should encourage patients to breastfeed first from the engorged breast and promote let down and milk flow by applying a warm washcloth to the breasts or taking a warm shower before feeding. The nurse should educate the individual that engorgement may affect the infant's ability to latch, so they may need to express HBM before nursing or attempt a reverse-pressure softening massage while breastfeeding to make it easier for the infant to latch. The duration or frequency of feedings or pumping sessions should be increased to relieve symptoms and prevent further engorgement. If the patient is pumping, there should be no more than 4 hours between pumping sessions. Nurses should advise feeding the infant every 2 hours on one breast until soft while pumping the other. Between feedings, the patient can place cold compresses on the breasts to reduce swelling and pain. The recommended rotation is 15-20 minutes on and 45 minutes off. Putting raw cabbage leaves directly on the breasts between feedings can also help relieve engorgement. If needed, acetaminophen (Tylenol) or ibuprofen (Motrin) can be used to reduce pain, fever, or inflammation (Lowdermilk et al., 2020; Spencer, 2021).
Mild nipple soreness is expected in the early days of breastfeeding. Abnormal findings include soreness that becomes severe and a nipple that appears irritated, cracked, or bleeding. Sore nipples may be related to an incorrect latch or poor positioning. A good latch and proper positioning can help decrease nipple soreness and prevent further damage. After breastfeeding, nurses should encourage patients to express a few drops of milk and gently rub it on the nipples with clean hands, as HBM has natural healing properties and soothing oils. Education should also include allowing the nipples to air-dry after feeding and wearing soft cotton shirts. Breastfeeding patients should wear a supportive bra that is not too tight and does not put pressure on the nipples. Nursing pads should be changed often to keep the nipples clean and dry. Patients should avoid using harsh soaps or ointments that contain astringents on the nipples. They can wash their nipples and breasts with clean water. Creams, hydrogel pads, or a nipple shield may be used, but usually not until after a consultation with a lactation consultant (Lowdermilk et al., 2020; Spencer, 2021).
Plugged Milk Ducts
A plugged duct occurs due to improper drainage, causing pressure to build within the duct and inflammation in the surrounding tissue. This condition usually affects one breast at a time and presents as a sore, tender lump with no associated fever. Common causes include poor feeding technique, not changing feeding positions, wearing a tight or ill-fitting bra, engorgement, infection, or a sudden decrease in feeding frequency. To treat a plugged duct, nurses should encourage patients to breastfeed as often as every 2 hours on the affected side. The nurse should also instruct the patient to massage the area behind and above the plugged duct, apply warm compresses, and wear a well-fitting, supportive bra (Lowdermilk et al., 2020; Spencer, 2021).
Insufficient Milk Supply
Whether real or perceived, lactation insufficiency or low milk supply is cited as the most common reason for discontinuing breastfeeding. Lactation insufficiency can be caused by mammary tissue insufficiency, hormone imbalance, or ineffective milk removal from the breast, triggering a negative feedback loop and decreasing milk production. Some patients have difficulty producing enough HBM after a complicated labor, delayed breastfeeding initiation, separation due to preterm birth, formula substitution, cracked nipples, or maternal illness. Nurses should offer a referral to a lactation consultant who can assist with breastfeeding (Lowdermilk et al., 2020; McBride et al., 2021; McGuire, 2018).
The first line of treatment for low supply includes non-pharmacological interventions such as ensuring a proper latch and positioning and increasing feeding frequency. Beyond this, some individuals use galactagogues, substances thought to increase milk production. Prescription metoclopramide (Reglan) has been used off-label as a galactagogue since it increases prolactin levels and milk production. The breast changes needed to increase milk production takes approximately 2 weeks of daily medication, although a slight increase in prolactin can happen as early as 8 hours after the first dose (McBride et al., 2021; McGuire, 2018).
Using herbs as galactagogues is a centuries-old folk medicine practice. Some herbs used include fenugreek, blessed thistle, goat's rue, alfalfa, dill, fennel, raspberry leaf, and Shatavari. Fenugreek is the most commonly used herb to increase milk production (at 3.5-6 grams daily). Blessed thistle can also be used but is best used in conjunction with fenugreek. Blessed thistle comes in a capsule or tea form and is taken three times daily. Alfalfa and goat's rue are galactagogues typically taken along with a blend of fenugreek and other herbs. They are available as dry leaves for tea or capsules (Lowdermilk et al., 2020; McGuire, 2018).
Nurses should encourage breastfeeding patients to focus on adequate hydration, frequently breastfeeding with a proper latch and positioning, pumping immediately after feeding to ensure the breasts are empty, and offering both breasts at each feeding to increase milk supply. The concern about not producing enough milk is common; however, most breastfeeding patients produce enough HBM to feed their babies. Finally, nurses should calmly review the signs of adequate infant nutrition, such as wet diaper and bowel movement frequency, and behavioral signals of satiety (Lowdermilk et al., 2020).
Mastitis is inflammation of the breast. Although not always caused by an infection, it is usually associated with an infection of the breast. Infection can occur anytime during lactation, but most cases occur during the first 6 weeks of breastfeeding. Mastitis most commonly occurs in the superior lateral portion of the breast and can affect one or both breasts (Lowdermillk et al., 2020). Signs and symptoms of mastitis include:
breast tenderness and warmth
thickening of breast tissue
pain or burning sensation continuously or while breastfeeding
skin redness, possibly in a wedge-shaped pattern
yellowish discharge from the nipple resembling colostrum
fever of 101°F (38.3°C) or greater
nausea and vomiting
flu-like symptoms, muscle aches, chills, and malaise (Blackmon et al., 2022; Lowdermilk et al., 2020; Spencer, 2021)
As milk stasis (i.e., inadequate breast emptying) is often the initial causative factor for mastitis, nurses should educate all patients on the importance of frequent feedings or regular pumping sessions that empty the breasts. Mastitis can also be related to plugged ducts, engorgement, abrupt weaning, sore and cracked nipples, and wearing an inappropriate bra (e.g., one with an underwire). Stress, fatigue, illness, and poor maternal nutrition can also provoke mastitis. Nurses should encourage patients with mastitis to breastfeed or pump more frequently (at least every 2 hours) by starting on the affected breast, positioning the infant at the breast with the chin or nose pointing toward the blockage, massaging the breast from the blocked areas to the nipple, and expressing milk to assist with milk drainage. Initial mastitis treatment focuses on symptom management and education; however, a 10-day course of antibiotics may be needed if symptoms do not improve within 12-24 hours or if the patient becomes acutely ill. The most common pathogen in mastitis is Staphylococcus aureus. The preferred antibiotics are dicloxacillin (Dycill, Dynapill, Pathocil) or cephalexin (Keflex). If the patient is allergic to penicillin, erythromycin (Erythrocin) can be substituted. The patient may also take over-the-counter pain relievers such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) for symptom relief (Blackmon et al., 2022; Lowdermilk et al., 2020; Spencer, 2021).
Fungal infections can form on the nipple or the breast due to an overgrowth of the Candida organism. Signs of a fungal infection include:
nipple soreness that lasts more than a few days and is out of proportion to any apparent cause
pink, flaky, shiny, itchy, or cracked nipples
deep pink and blistered nipples
breasts that ache
shooting pains in the breast during or after feedings (Spencer, 2021)
Topical antifungals like nystatin (Mycostatin) cream are commonly prescribed. Gentian violet can also be used to treat the infection. It is applied directly to the infected area. Due to the color of the medication, it may stain the patient's skin and the infant's mouth purple. For resistant cases, fluconazole (Diflucan) treatment is typically recommended for 2 weeks. During treatment, patients can continue breastfeeding. Fungal infections can take weeks to resolve. To avoid spreading the infection, nurses should instruct patients to change disposable nursing pads often, wash any towels or clothing that come in contact with the affected breast in very hot water (above 122 °F), wear a clean bra every day, and wash their hands and the baby's hands often. Boil all breast pump parts that touch HBM, pacifiers, bottle nipples, or toys the baby puts in their mouth daily. After a week of treatment, instruct caregivers to replace all pacifiers and bottle nipples (Spencer, 2021).
Breastfeeding Promotion in Hospitals
The WHO and UNICEF launched the Baby-Friendly Hospital Initiative (BFHI) to help motivate facilities providing maternity and newborn services worldwide to implement the Ten Steps to Successful Breastfeeding. The implementation guidance for BFHI emphasizes strategies to scale up to universal coverage and ensure sustainability over time. The goal is to integrate the program fully into the healthcare system and ensure all facilities in a country implement the steps uniformly (UNICEF & WHO, 2018).
The steps are as follows (UNICEF & WHO, 2018, pg. 8):
1a. Comply fully with the International Code of Marketing of Breast-Milk Substitutes and relevant World Health Assembly resolutions.
1b. Have a written infant feeding policy that is routinely communicated to staff and parents.
1c. Establish ongoing monitoring and data-management systems.
2. Ensure staff members have sufficient knowledge, competence, and skills to support breastfeeding.
3. Discuss the importance and management of breastfeeding with pregnant patients and their families.
4. Facilitate immediate and uninterrupted skin-to-skin contact and encourage patients to initiate breastfeeding as soon as possible after birth.
5. Support patients to initiate and maintain breastfeeding and manage common difficulties.
6. Do not give breastfed newborns any food or fluids other than HBM unless medically indicated.
7. Enable patients and their infants to remain together and practice rooming-in 24 hours a day.
8. Educate patients to recognize and respond to their infant's cues for feeding.
9. Counsel patients on the use and risks of feeding bottles, teats, and pacifiers.
10. Coordinate discharge, so parents and their infants have timely access to ongoing support and care.
Given the documented health benefits of breastfeeding for both patients and infants, breastfeeding patients must be supported, and breastfeeding should be made more socially acceptable. Public health initiatives seek to ensure the right to breastfeed, increase the rate of initiating and maintaining exclusive breastfeeding in the US, raise awareness of breastfeeding benefits, and expand breastfeeding research (US Breastfeeding Committee [USBC], 2022). Such initiatives include the following:
protecting individuals who choose to breastfeed in public and private locations with legislation while ensuring breastfeeding is not included in indecency legislation
launching public health campaigns that encourage individuals of all cultures to breastfeed, especially families of African American, Native American, and Asian‐Pacific Islander descent
allowing lactation to qualify as a valid exemption from jury duty (or defer service for a year)
ensuring the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the CDC have adequate funding and support for peer counselors, federal breastfeeding campaigns, and other resources
ensuring public and private health insurance plans adequately cover lactation services and breastfeeding supplies (scales, pumps, etc.)
supporting lactating women in the workplace with requisite breaks and private areas (not bathrooms) to pump or breastfeed through legislation and corporate policy
increasing the opportunity to establish and maintain exclusive breastfeeding and flexible scheduling to continue breastfeeding for up to a year through paid maternity leave via enhanced family medical leave policies
ensuring the NIH and other organizations receive adequate funding for breastfeeding research
clarifying the marketing recommendations for artificial nipples/bottles within the International Code of Marketing of Breast‐Milk Substitutes
developing and maintaining nurse home-visiting programs to help patients with breastfeeding after discharge through funding and other support
establishing or improving access to donor human milk through enhanced insurance coverage in public and private
American Academy of Family Physicians. (2021). Breastfeeding, family physicians supporting (position paper). https://www.aafp.org/about/policies/all/breastfeeding-position-paper.html
American Academy of Pediatrics. (2021). Breastfeeding overview. https://www.aap.org/en/patient-care/breastfeeding/breastfeeding-overview
American College of Obstetricians and Gynecologists. (2020). Breastfeeding your baby: Breastfeeding positions. https://www.acog.org/womens-health/infographics/breastfeeding-your-baby-breastfeeding-positions
Blackmon, M. M., Nguyen, H., & Mukherji, P. (2022). Acute mastitis. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK557782
BruceBlaus. (2016a). Breastfeeding – cradle hold [Image]. https://commons.wikimedia.org/wiki/File:Breastfeeding_-_Cradle_Hold.png
BruceBlaus. (2016b). Breastfeeding – cross cradle position [Image]. https://commons.wikimedia.org/wiki/File:Breastfeeding_-_Cross_Cradle_Position.png
BruceBlaus. (2016c). Breastfeeding – football hold [Image]. https://commons.wikimedia.org/wiki/File:Breastfeeding_-_Football_Hold.png
BruceBlaus. (2016d). Breastfeeding – side-lying position [Image]. https://commons.wikimedia.org/wiki/File:Breastfeeding_-_Side-Lying_Position.png
BruceBlaus. (2016e). Breastfeeding – supine position [Image]. https://commons.wikimedia.org/wiki/File:Breastfeeding_-_Supine_Position.png
Centers for Disease Control and Prevention. (2021). Results: Breastfeeding rates. https://www.cdc.gov/breastfeeding/data/nis_data/results.html
Centers for Disease Control and Prevention. (2022). Proper storage and preparation of breast milk. https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm
Eglash, A., Simon, L., & The Academy of Breastfeeding Medicine. (2017). AMB clinical protocol #8: Human milk storage information for home use for full-term infants, revised 2017. Breastfeeding Medicine, 12(7), 390-395. https://doi.org/10.1089/bfm.2017.29047.aje
Haggstrom, M. (2019). Lobules and ducts of the breast [Image]. https://commons.wikimedia.org/wiki/File:Lobules_and_ducts_of_the_breast.jpg
Healthy People 2030. (n.d.). Nutrition and healthy eating. Retrieved June 18, 2022, from https://health.gov/healthypeople/objectives-and-data/browse-objectives/nutrition-and-healthy-eating
Hollis, B. W., Wagner, C. L., Howard, C. R., Ebeling, M., Shary J. R., Smith, P. G., Taylor, S. N., Morella, K., Lawrence, R. A., & Hulsey, T. C. (2015). Maternal versus infant vitamin D supplementation during lactation: A randomized controlled trial. Pediatrics, 136(4), 625-634. https://doi.org/10.1542/peds.2015-1669
Kim, S. Y., & Yi, D. Y. (2020). Components of human breast milk: From macronutrient to microbiome and microRNA. Clinical Experimental Pediatrics, 63(8), 301-309. https://doi.org/10.3345/cep.2020.00059
Lowdermilk, D. L., Perry, S. E., Cashion, K., Alden, K. R., & Olshansky, E. F. (2020). Maternity & women’s healthcare (12th ed.). Elsevier.
McBride, G. M., Stevenson, R., Zizzo, G., Rumbold, A. R., Amir, L. H., Keir, A. K., & Grzeskowiak, L. E. (2021). Use and experiences of galactagogues while breastfeeding among Australian women. PLOS ONE, 16(7), e0254049. https://doi.org/10.1371/journal.pone.0254049
McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Elsevier.
McGuire, T. M. (2018). Drugs affecting milk supply during lactation. Australian Prescriber, 41, 7-9. https://doi.org/10.18773/austprescr.2018.002
Meek, J. Y., & Noble, L. (2022). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 150(1), e2022057988. https://doi.org/10.1542/peds.2022-057988
National Library of Medicine. (n.d.). Drugs and lactation database (LacMed). Retrieved July 10, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK501922/
Newman, J. (2016a). Example and indicators of a good, asymmetric latch [Image]. https://commons.wikimedia.org/wiki/File:Good_Latch.jpg
Newman, J. (2016b). Example and indicators of a shallow latch [Image]. https://commons.wikimedia.org/wiki/File:Shallow_Latch.jpg
Office on Women’s Health. (2021). Getting a good latch. https://www.womenshealth.gov/breastfeeding/learning-breastfeed/getting-good-latch
Pillay, J., & David, T. J. (2021). Physiology, lactation. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK499981
Spencer, J. (2021). Patient education: Common breastfeeding problems (beyond the basics). UpToDate. Retrieved June 18, 2022, from https://www.uptodate.com/contents/common-breastfeeding-problems-beyond-the-basics#H17013976
UNICEF, & World Health Organization. (2018). Protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services: The revised baby-friendly-hospital initiative. https://www.who.int/publications/i/item/9789241513807#cms
US Breastfeeding Committee. (2022). Federal policies, programs, & initiatives. http://www.usbreastfeeding.org/p/cm/ld/fid=26
US Centers for Medicare & Medicaid Services. (n.d.). Health benefits & coverage: Breastfeeding benefits. Retrieved July 10, 2022, from https://www.healthcare.gov/coverage/breast-feeding-benefits
US Department of Health and Human Services. (2014). Content and format of labeling for human prescription drug and biological products; Requirements for pregnancy and lactation labeling; pregnancy, lactation, and reproductive potential: Labeling for human prescription drug and biological products. Federal Register, 79(233), 72063-72103. https://www.govinfo.gov/content/pkg/FR-2014-12-04/pdf/2014-28241.pdf
US Department of Health and Human Services. (2022). Information for families during the formula shortage. https://www.hhs.gov/formula/index.html
World Health Organization. (2021). Infant and young child feeding. https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding