Marianne R. Neifert

Overcoming Clinical Barriers to Exclusive Breastfeeding

Although a large majority of US mothers now begin breastfeeding, exclusive breastfeeding rates fall far below national health objectives, with vulnerable populations being least likely to breastfeed exclusively. This article explores common personal and societal barriers to exclusive breastfeeding and offers evidence-based strategies to support mothers to breastfeed exclusively, such as ensuring prenatal education, supportive maternity practices, timely follow-up, and management of lactation challenges. The article also addresses common reasons nursing mothers discontinue exclusive breastfeeding, including the perception of insufficient milk, misinterpretation of infant crying, returning to work or school, early introduction of solid foods, and lack of support.

Medical management of successful breast-feeding.

Despite the present climate of professional and lay enthusiasm for breast-feeding, many women experience problems in the initiation of lactation, either because of misinformation, secondary lactation difficulties, or primary failure of lactation. This article provides pediatricians with practical guidelines for the successful initiation of breast-feeding and the prevention and early detection of problems. Recommendations are made for optimal prenatal preparation for breast-feeding, intrapartum routines that facilitate lactation, appropriate early follow-up of nursing infants, and the management of the full normal course of breast-feeding.

Routine Management of Breast-Feeding

In recent years, renewed scientific interest in breast-feeding has led to acceptance of human milk as the optimal food for the first several months of life.1–5 Professional endorsement of natural infant feeding, together with rising consumer demand, have led to an increase in the incidence and duration of breast-feeding throughout the country during the past decade. In 1971, 24.7% of newborns were breast-fed in the hospital, while only 5.5% were; still receiving any breast milk at 5 to 6 months of age. By 1979, comparable figures were 51.0% and 23.0%. Currently, the typical breastfeeding mother is a primipara with some college education, in a higher family income group. Her infant is under the care of a pediatrician, and she lives in an urban area within the Mountain region of the United States. However, a trend of increased breast-feeding can be found among all demographic populations surveyed and within each U.S. census region.6

Infant Problems in Breast-Feeding

Empirical contraindications to breast-feeding long antedate modern medicine. In ancient Greek societies, upper-class women were discouraged from nursing if their labor had been particularly difficult, and colostrum was often considered unsuitable for feeding during the first several days of life.1 Soranus’ advice for selecting a wet nurse stressed that the personal characteristics and appearance of the woman, in addition to the appearance of her milk, were major determinants of breast-feeding capabilities.2 In modern times, employment outside the home, social activities required by the husband’s job, any chronic illness in the mother, or the necessity for supplemental formula have been cited as contraindications to nursing.3 Within the past decade, post partum fever, maternal mastitis,4 prematurity of the infant, drug therapy in the mother, and even resumption of menstruation, have been suggested, often inappropriately, to contraindicate breast-feeding.

Mammary Gland Anomalies and Lactation Failure

Human milk is universally recognized as optimal infant nutrition, and international attention is being focused on strategies to increase the present incidence and duration of lactation. Despite both professional and lay enthusiasm for breast-feeding, many women experience lactation difficulties, most often attributable to breast-feeding mismanagement. However, primary and secondary breast anatomical problems remain infrequently acknowledged causes of lactation insufficiency. Unfortunately, such causes often go unrecognized since a thorough examination of the breast, with emphasis on its functional potential, is frequently overlooked in routine prenatal care.

An Introduction to Lactation and Breast-Feeding

An essential characteristic of mammals is the capacity of the female to nourish her offspring with milk, the secretion of the mammary glands. This fluid provides not only nutrients for physical growth but also both immune and nonimmune elements for protection against disease and an opportunity for interaction between newborn and mother which may, at least in higher species of mammals, initiate the learning process necessary to the transition to independent living. In this introductory chapter, we will begin by viewing human lactation from an evolutionary standpoint. Two sections will then be devoted to the historical development of our understanding of milk secretion and its hormonal control. Finally, we will consider breast-feeding in its historical context, a discussion which provides a perspective from which to view the controversy over breast milk versus formula in underdeveloped countries.