AAP Voices Blog

I realized about two years into private practice that I had not learned enough about lactation and how to successfully support breastfeeding mothers. I told the mothers what little I had learned: Feed the baby every 2 to 3 hours; it is normal to have some nipple pain at the beginning; it is OK to use formula; adding formula is a good way to treat jaundice; breastfeeding is hard.

While there is some truth to all of these tips, without skilled feeding evaluations and nuanced advice in each situation, I believe these common statements are contributing to the roughly two-thirds of women in this country who  are not meeting their personal breastfeeding goals. Although about 85% of pregnant women come to the hospital with breastfeeding as their plan after giving birth, a steep drop-off follows, with only one-quarter of women exclusively breastfeeding for the recommended six-month time period.

As AAP policy notes, breastfeeding is associated with a 64% reduction in the incidence of nonspecific gastrointestinal tract infections and offers a host of other benefits, including a decreased risk of obesity, leukemia, asthma, diabetes and pneumonia. And prospective cohort studies have noted an increase in postpartum depression in mothers who do not breastfeed or who wean early.

“It is on us as pediatricians to make sure we know the latest information and have the skills and tools to help mothers who desire to breastfeed reach their goals.”

Mothers also need to be aware that the introduction of formula is associated with early breastfeeding cessation. If a new mom is worried about her supply — why? Is baby not signaling enough?  If so, introducing another way of feeding may complicate the mother and baby learning how to effectively feed at the breast. 

There are strategies and tools outlined in a recent AAP Pediatrics State-of-the-Art-Review article  that can help pediatricians assess the baby’s weight-loss pattern with the Newborn Weight Loss Tool curves, and determine if there is a medical need for supplementation based on the clinical information and assessment, and troubleshoot common questions or problems.

 I want to offer an example of what I call the “old way” of managing breastfeeding by sharing a story, with permission from a colleague in health care.  Her daughter, who recently had a baby, was eager to breastfeed, but when she was admitted to the hospital and delivered her baby, the hospital had no skilled lactation specialists to help her and she had difficulty the first few days.

She was not provided skin-to-skin care, and not permitted to room-in with her baby. At 28 hours of age, the baby's bilirubin was 7.8, which is in the high-intermediate zone on the Bhutani curve, and for a low-risk infant is approximately four points away from the phototherapy level.  The weight loss was 7% or >95 percentile  on the Newborn Weight Loss Tool curve for a breastfeeding infant born by vaginal delivery at that age. The pediatrician recommended supplementation with infant formula, and the mother was not shown how to hand express, or observed, or assisted with latch, or set up with a breast pump. 

The mother and baby were discharged, and there was a follow-up visit a week later.  The mother was not permitted to come for the baby's appointment because she had been hospitalized (despite being COVID negative when she was tested on admission). In addition, the pediatrician gave the baby formula in the office and also provided a gift pack of formula and supplies for the father.

Several questions came to mind instantly when I heard about this case: What sorts of breastfeeding education/preparation did this mother have prior to delivery?  Why were no lactation consultants or skilled lactation professionals available, and why were labor and delivery and postpartum nurses not skilled in the basics of supporting breastfeeding?  Why was this hospital not following the recommended skin-to-skin care and rooming-in for mother and baby?  Why was breastfeeding not observed for nipple pain or compression and milk transfer/audible swallows?  Why was this mother not taught to hand express or pump to see if any milk could be removed and to provide a signal to the mother’s body?  What was the discharge feeding plan?  Did the mother know to decrease the formula as her supply increased? 

The story fortunately has a happy ending. The baby’s grandmother is a nurse and is trained in lactation support as part of the Baby-Friendly hospital journey, and she was able to travel to provide in-home support for her daughter, who is now exclusively breastfeeding. The baby is gaining weight and is no longer jaundiced.

Not everyone has a family member who is formally trained in breastfeeding support, of course, so it is on us as pediatricians to make sure we know the latest information and have the skills and tools to help mothers who desire to breastfeed reach their goals and help set their babies up for a lifetime of good health.

Please check out the review article and a report on how pediatricians can help promote breastfeeding to learn more. Establishing lactation can be challenging, so it’s imperative to support new mothers and assist them in developing and continuing their breastfeeding routine.