Professional Documents
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Introduction
Research demonstrates the overwhelming health benefits of breastfeeding over formula. The
question is no longer whether newborns should breastfeed but how best to support successful
long-term breastfeeding. Breastfeeding results in decreased illness for infants and children,
including decreased rates of infectious illness, some cancers, allergies and obesity. For
women, studies have shown decreased rates coronary artery disease, protection against
ovarian and breast cancer, and potentially decreased rates of osteoporosis. In increasing the
percentage of exclusively breastfed infants to six months of life, it is estimated that the
potential cost savings to the US economy from improved health outcomes, and decreased
costs of production, purchasing and disposal of formula supplies, could reach up to $14 billion
dollars per year.
The American Academy of Pediatrics and American Academy of Family Physicians support
exclusive breastfeeding for the first 6 months of life, with continuation of breastfeeding with
complementary foods until one year of life and beyond. The American College of Obstetricians
and Gynecologists, the World Health Organization, the US Centers for Disease Control, and
WIC also recommend and support breastfeeding. The goal set by Healthy People 2010 is to
“increase the proportion of mothers who breastfeed their babies” to 75% in immediate post-
partum period, to 50% at 6 months postpartum, and to 25% at 12 months postpartum.
Data from the CDC (2006 data) show that approximately 74% of women will attempt
breastfeeding after delivery; 33% will exclusively feed through 3 months; by six months 43% of
women are breastfeeding but only 14% are exclusively breastfeeding. The sharpest decrease
in breastfeeding, ~20%, occurs within the first month after discharge.
It is our imperative as healthcare providers to promote and encourage healthy choices for our
patients. Many women do not choose to breastfeed because they are unaware of the benefits
of breastfeeding for themselves and their infants. Many women and healthcare providers
believe that human milk and formula are equivalent in their nutritional profiles, and that
breastfeeding is more of a lifestyle choice than a medical one. Many well-intentioned providers
hasten the cessation of breast milk production in new mothers by encouraging
supplementation with formula. Many physicians advise mothers to stop breastfeeding
prematurely due to assumed incompatibility of common medications, disease states and infant
conditions with breastfeeding.
Table of Contents
Breastfeeding Step-by-Step for Clinicians
Appendix
Breastfeeding Policies: AAP, AAFP, ACOG
The Baby Friendly Hospital Initiative
Healthy People 2010 Breastfeeding Goals
Medication Tables, Vaccines, Imaging / Radiocontrast Agents
Hyperbiilirubinemia Risk and Phototherapy Nomograms
Basic Lactation and Breastfeeding Physiology
Evaluation of Breastfeeding Technique: Positioning, Latch, Milk Transfer
Methods of Human Milk Expression
Alternative Methods to Bottle Feeding Infants
Reverse Pressure Softening for Breast Engorgement
Sample Breastfeeding Intake and Elimination Log
Galactogogues
Donor Breastmilk / Breastmilk Banking
CDC: Breastfeeding and Swine Flu (2009)
Travel Recommendations for the Nursing Mother
Online Clinician Breastfeeding Education and Training Options
PHQ9 Screening Tool for Depression
California Breastfeeding Laws and Legislation
KP and Community Patient Breastfeeding Resources
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2. Educate all women and their families on the medical benefits of breastfeeding for mothers
and infants, and encourage them to breastfeed.
4. Encourage all pregnant women to attend a breastfeeding class prior to delivery to assist in
the family’s preparation for breastfeeding.
5. Assist women in making a breastfeeding plan for their delivery prior to their due date.
7. Discourage routine pacifier, artificial nipple and bottle use in breastfeeding infants;
encourage women to delay pacifier use until one month of life.
8. Know the medical reasons to supplement with formula, and use formula only when
medically necessary.
9. Understand normal newborn physiology, and know that most newborns do not need
supplementation of during the first few days of life.
10. Instruct women to breastfeed their infants “on demand,” i.e., based on their infant’s feeding
cues and not on a schedule. Educate women that infants feed up to 16 times per day
during the first week of life, and that this is normal.
11. Ensure that women who are separated from their infants are given a breast pump to
simulate nursing, and tell them to use it at least every three hours for at least 15 minutes.
This ensures that breast milk production will not drop off during the separation.
12. Ensure adequate evaluation and instruction of breastfeeding in the hospital post-delivery,
and ensure close follow-up and evaluation of both mother and infant post-discharge.
13. Educate women about potential breastfeeding difficulties, such as growth spurts, returning
to work, and maternal medication use. Assist mothers in getting a lactation consultation if
needed.
14. Reiterate that our goal is to have all infants breastfeed for one year and beyond, and
support our patients’ long-term breastfeeding efforts!
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For mothers
A 2009 study of nearly 140,000 women found that women who breastfed for at least one
year were 10-15% less likely to have high blood pressure, diabetes, high cholesterol,
and cardiovascular disease compared to mothers who never breastfed. Benefits were seen
in women who breastfed for a minimum duration of 6 months, but the longer a woman
breastfed, the better. (2)
For families
• Significant cost savings; formula costs between $1200 to $3,000 per year per infant
• Decreased healthcare costs due to less MD visits and less prescription medications
• Decreased missed days from work due to infants with less illness
Other infections
• HIV or HTLV virus infection in women is not compatible with breastfeeding.
• Women with active HSV lesions on breast should not breastfeed.
• Active, untreated tuberculosis in the mother is not compatible with breastfeeding;
however, the infant may be given expressed breastmilk from the mother (it does not contain
the mycobacterium) until treatment is completed and she is considered non-infectious.
• A woman with primary active varicella infection (not zoster) should neither breastfeed
nor should her infant be fed her expressed breast milk; after the infant has received VZIG
the mother can provide expressed breastmilk as long as there are no active lesions on the
breast; mother should be isolated from the infant until she is considered non-infectious, at
which time she may resume breastfeeding.
• Zoster / shingles affected women may breastfeed as long as there are no lesions on the
breast; lesions should be kept covered.
• Women infected with CMV will have both virus and antibodies in their breastmilk. Because
of this, otherwise healthy infants born at term with congenital or acquired CMV infections
usually are not affected by the virus if they are breastfed. A study of infants who developed
infections during breastfeeding found that the infants also developed an immune response,
did not develop the disease, and rarely manifested symptoms.
Maternal medication use is a major reason why many women stop breastfeeding, usually due
to an unfounded fear that the medicine will be harmful to the infant. Many well-intentioned
healthcare providers also incorrectly tell breastfeeding mothers that their medications are not
compatible with breastfeeding. Almost all prescription and OTC medicines are compatible
with breastfeeding; very few are not.
Almost all medications pass in some capacity into breast milk; however, most appear at
clinically insignificant levels, or are not harmful to the infant. Surveys in western countries
indicate that 90% to 99% of women who breastfeed receive at least one medication during
their first week postpartum.
Clinicians must weigh the risks of breastfeeding cessation to the risks of medication exposure
via breastfeeding before they advise women to cease or suspend breastfeeding.
The following medications are those that pose potential risk to breastfeeding infants:
• Amiodarone ! Anticancer Agents: cyclophosphamide, cyclosporine,
• Bromocriptine methotrexate, doxorubicin
• Doxepin ! Illicit / illegal / recreational drugs
• Lithium
• Radioactive iodine
• Chloramphenicol
• Ergot Alkaloids
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Minimizing Potential Risk to Nursing Infants from Maternal Medication Use
General considerations
• Use reliable references for obtaining information on medications in breast milk (see next
page).
• Medications that are safe for administration to an infant are considered compatible with
breastfeeding.
• Medications that are safe in pregnancy are not always compatible with breastfeeding.
• Use topical therapy when possible.
• Caution is advised when prescribing medications for breastfeeding mothers of
premature or otherwise compromised newborns than for breastfeeding mothers of older,
healthy infants.
Medication dosing
• If concern exists for exposure to the infant, single daily-dose medications can be
administered just before the longest sleep interval for the infant, usually after the infant’s
bed-time feeding.
• Infants can be breastfed immediately before medication administration when multiple
daily doses are needed.
Alcohol
• Occasional use of alcohol in limited amounts is compatible with breastfeeding; this is
equal to 0.5 g of alcohol per kg body weight or 1- 2 drinks per day.
• A breastfeeding mother may want to wait until the alcohol clears her system, which
usually takes two hours. A rule of thumb is that if the mother is feeling the effects of
alcohol, it will be excreted in her breastmilk.
• Alcohol may have a negative impact on oxytocin levels and inhibit letdown.
Maternal Smoking
• If women smoke, they should smoke outside, away from their infants.
• Research suggests that infants of smoking mothers are healthier if they are breastfed.
Breastfeeding offers the infant protection against SIDS, which has found to be higher in
infants born to mothers who smoke.
• A negligible amount of nicotine metabolites are found in breastmilk in the form of
cotinine; no adverse effects on breastfeeding infants have been reported from exposure
to this substance.
• Recommendation: Ideally, the best recommendation is to quit smoking, but if the mother
is unwilling to quit she should continue breastfeeding and smoke outside.
Caffeine
• Moderate intake causes no problems for most breastfeeding infants
• The amount of caffeine excreted into breastmilk is usually less than 1% of the amount
ingested by the mother, and this has not been found to be harmful to the infant.
Online Resources
Textbook Resources
Medications and Mother’s Milk 2008 by Thomas Hale
The mother’s support person should be included in breastfeeding education and promotion
efforts at every office visit. Support from a significant other has been identified as one of the
most important factors for those who chose to formula-feed.
• Discuss maternal medical conditions that can affect breastfeeding due to possible
decreased milk productions. Women with these conditions can breastfeed but they and
their infants may need close post-partum follow-up:
o History of hormone-related infertility / PCOS
o Depression
o Contraception use
o Hypothyroidism
o Diabetes
Breast Symmetry:
• Slight asymmetry of breasts is considered normal.
• Significant asymmetry should raise red flags for such issues as inadequately developed
breasts or hormone deficiencies; consider specialty evaluation.
In regards to the safety of breastfeeding from breasts that have silicone implants (American
Academy of Pediatrics “The Transfer of Drugs and Other Chemicals into Human Milk,” 2001):
“There are only a few instances of the polymer being assayed in the milk of women with
implants; the concentrations are not elevated over control samples. There is no evidence at
the present time that this polymer is directly toxic to human tissues...the anticolic compound
simethicone [which is routinely given to infants] is a silicone and has a structure very similar to
the silicone compound in breast implants… The [AAP] Committee on Drugs does not feel that
the evidence currently justifies classifying silicone implants as a contraindication to
breastfeeding.”
Women who have had breast surgery involving periareolar incisions, or women who have had
breast reductions should been seen prenatally by a lactation consultant to prepare for
breastfeeding. They should also be counseled about frequent follow-ups postnatally to
evaluate breastfeeding success and infant growth, as they are at increased risk of producing
an insufficient supply of milk. Patient information on breastfeeding after breast surgery can be
found at: www.bfar.org (Breastfeeding after Nipple and Breast Surgery) and on the La Leche
League website: www.llli.org.
Breastfeeding Multiples
Mothers of twins should be encouraged to breastfeed and reassured that they can expect to
fully support their infants’ nutritional needs via exclusive breastfeeding. However, nursing
more than one infant can be very challenging, and early and frequent follow-up with a
pediatrician and lactation consultant following delivery is advised. Breast milk production is
infant-driven, and mothers of regularly breastfed twins will produce twice the quantity of milk
than mothers of singletons. Mothers of higher order multiples will likely need to supplement
their breast milk. Support groups can be especially helpful for mothers of multiples.
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From ACOG 2007: “Women need to know that breastfeeding, like other aspects of
having a new baby, has its demands as well as its rewards.”
Clinicians can assist women and their partners by eliciting concerns, answering questions, and
confronting misperceptions about breastfeeding:
• Informed consent: clinicians can give women information about the medical benefits
of breastfeeding.
• Prenatal education: women can be encouraged to attend prenatal classes where they
will learn about and increase their confidence about breastfeeding.
• Cesarean sections: women who have a cesarean section should be reassured that
they can breastfeed their infant as well as women who delivery vaginally, and that post-
partum pain medications are compatible with breastfeeding.
• Separation from infant: information can be given to women about milk expression and
storage to assist with their plants to return to work while continuing to breastfeed.
• Assistance and teaching: patients can be reassured that assistance and follow-up will
be provided in the hospital and post-partum to ensure proper breastfeeding technique
and infant weight gain.
• Breastfeeding rights and legislation: women can be reassured that in California
there are state laws to protect a woman’s right to breastfeed in public and to express
her breastmilk while at work.
Many families find their own solutions to their concerns and fears as they come to understand
the substantial medical benefits of breastfeeding to both women and infants.
Some women will decide that the challenges of breastfeeding outweigh the benefits for
themselves and their babies. These women should be reassured that they will receive
assistance and teaching about infant feeding during their hospital stay and post-partum, and
that they won’t be “abandoned” or made to feel guilty for their decision not to breastfeed.
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Cesarean Deliveries
The rate of cesarean sections has climbed to over 50% in the past few years. (CDC, 2008)
Women should be reassured that they can breastfeed successfully after cesarean sections like
women who delivery vaginally. If a cesarean section is planned, the clinician can reassure the
mother that medications routinely used during the procedure, including anesthetics and
analgesics, are compatible with breastfeeding (see appendix). A woman’s intent to breastfeed
should be communicated to the operating surgeon and hospital staff, and a plan to reunite the
mother and infant as soon as medically possible following the procedure should be made.
Research on this initial contact has shown that babies placed skin-to-skin immediately
after birth breastfeed for an average of 2.5 times longer than babies who were not. This
may be due to the increased confidence of infant and mother, of the robust bonding
experience that occurs at these initial moments, initiation of signals promoting copious milk
production, or more.
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Breastfeeding Essentials
Initiation of Breastfeeding after Delivery
Skin-to-Skin
Cesarean Deliveries
Newborn Physiology Pertinent to Breastfeeding Management
Elimination Patterns of Normal Newborns in First Week of Life
Normal Weight Change in the Newborn
Feeding Patterns and Hunger Cues of Breastfeeding Infants
Sleepy infant / “won’t wake to feed”
Nipple Confusion
Milk Expression / Separation of Mother and Infant
Hypoglycemia
Medical indications for Formula Supplementation
Lactogenesis 2 “the milk coming in”
Breastfeeding the Late-preterm Infant
Decision Not to Breastfeed
Hospital Discharge Checklist
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Of note, the longer a woman and her infant are separated following delivery, the more likely it
is that the infant will receive formula supplementation. Routine nursery procedures, such as
weighing and bathing the infant, administering injections, and applying erythromycin eye
ointment can wait until after this first feed and preferably done in the mother’s room following
delivery.
Skin-to-skin
Early breastfeeding and skin-to-skin contact has been shown to increase long-term
breastfeeding rates in infants. Research has shown many physiologic benefits of prolonged
skin-to-skin contact for both infants and parents:
• Infants cry less and spend more time in deep sleep
• Infants show less apnea and periodic breathing
• Protection of thermoregulation in the infant
• Improved oxygen saturation rates
• Premature babies may come out of incubators and move to cribs faster
• Babies may feed earlier, breast feed more successfully, and may even show faster
weight gain
• Kangaroo care, a type of skin-to-skin contact used in the NICU, promotes breastfeeding
and increases milk production in mothers
• Facilitates infant / parent bonding
• Can increase confidence in ability to parent in mothers
• Breastfeeding rates are lower in mothers who delivery via c-section. This is thought
to be due to many factors, including separation of the mother and infant following the
procedure, post-surgical pain, concern about exposing a newborn to mother’s pain
medications via breast milk, and possibly a feeling of ‘failure’ on the mother’s part for not
having delivered vaginally, which can inhibit let-down.
• The clinician can reassure the mother that medications routinely used during the
cesarean sections, including anesthetics and analgesics, are compatible with
breastfeeding (see appendix.)
• As soon as a woman can respond to her infant, she should be reunited with her infant and
encouraged to breastfeed skin-to-skin.
• Most mothers will need assistance with positioning while avoiding incision area (side-lying
hold, football hold, etc.)
• If a woman has undergone general anesthesia, she can breastfeed as soon as she
can respond to her infant.
• The agents used for general anesthesia are compatible with breastfeeding; there is no
reason to delay breastfeeding following their administration.
Rooming-in
Rooming-in refers to infants and mothers sleeping in the same room in the hospital.
Traditionally, infants were kept in newborn nurseries with the intention of letting the mother rest
following delivery. However, allowing a mother and infant to room-in together has many
benefits:
• Rooming-in and skin-to-skin contact between mother and infant allows the mother to
recognize her infant’s hunger cues and “feed on demand.”
• Research shows that rooming-in allows infants to cry less, sleep more, and become
adept at breastfeeding sooner.
• Clinicians may be reassured to know that studies of mothers who room-in with their
infants 24 hours a day while in the hospital show that they sleep better and have
increased milk production.
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Bowel Movements
• Meconium is the first stool after birth and is black, thick and tarry.
• After 2 - 3 days of life the stools will look greenish in color.
• At 4 - 5 days after birth the stool should be yellow and “seedy.”
Newborns are expected to lose weight at birth, and are generally allowed up to 8%
weight loss of birth weight during the first week of life before supplementation is
considered.
It is important to inform mothers of this normal newborn physiology and the physiology of
normal breast milk production, as new mothers will often question the adequacy of their milk
supply and whether they are making enough milk to feed their infants.
Lack of confidence that the infant is getting enough to eat, whether on the part of the
mother, the mother’s support person, or the hospital staff, is the number one reason for
formula supplementation in the newborn period. It is essential that staff and parents
understand normal newborn physiology to avoid unnecessary formula
supplementation.
One way to reassure a mother that she is making enough breast milk is to weigh the infant,
and educate the family on appropriate / normal weight loss:
Calculate weight loss: Weight loss / Birthweight = 0.0X = X% weight loss (50 g weight loss /
3500 g birth weight = 0.01 = 1% weight loss
Other ways to reassure the family about adequate nutrition and breastmilk production is to
review normal feeding and elimination patterns with them.
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Mothers should be instructed to recognize their infant’s feeding/hunger cues and nurse
accordingly. Newborns often feed 8 – 12 times (or more) in the first week of life. This is
normal. The quiet alert state is the best time to initiate breastfeeding. If a baby is crying, he
may need to be soothed prior to breastfeeding.
A mother should not wait until an infant is crying to breastfeed. Crying is considered a “late”
hunger sign. Late hunger feeding signs / cues include:
• Crying
• Moving head back and forth
• Falling asleep
Infants also “cluster feed” at times, where they feed every hour (or more frequently) for a few
feeds, then sleep for a few hours.
A mother may report that her infant is “sleepy.” A mother should be encouraged to breastfeed
8 – 12 times per 24 hours based on her infant’s feeding cues. However, if an infant is sleeping
for longer than 4 hours at a time during the first 1 – 2 weeks, he may need to be woken up to
feed. Frequent feedings ensure proper nutritional support of the infant and appropriate
stimulation to mother’s breasts, thus ensuring continued breast milk production in the
mother.
To promote alertness in a sleepy infant, a mother can remove the infant’s clothing and
place infant skin-to-skin on her bare chest. Rubbing the infant’s feet can also assist in making
the infant more alert. Excessive sleepiness or lethargy is not normal and should be evaluated
immediately by an experienced health professional.
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Nipple Confusion
Nipple confusion can occur when an infant has not had adequate opportunities to establish
correct mouth movements for breastfeeding. This is thought to be caused by early and
frequent exposure to artificial nipples and pacifiers. It is also believed to contribute to
breastfeeding problems and early weaning
In order to breastfeed successfully, infants must learn to attach and suckle properly at the
breast.
• an infant must open his mouth widely to accommodate breast tissue
• an infant then protrudes his tongue over his bottom lip and use a peristaltic motion to
“milk” the breast and extract milk
A bottle-feeding infant utilizes a mouth position and technique that is much different
than that used for breastfeeding. The mouth position is much narrower and accommodates
a small artificial nipple in the mouth. The technique utilizes passive suction / negative pressure
for milk extraction by creating a partial vacuum with his mouth; no tongue action is needed.
When an infant applies a bottle-feeding technique to the breast it can have many negative
consequences:
• Breast milk may not be expressed efficiently from the breast, and the infant will become
frustrated.
• Improper breastfeeding mouth position and technique in the infant can cause a lot of
pain to the mother. Maternal pain can inhibit the letdown of milk.
• Incomplete emptying of the breast will inhibit the mother’s body in adequate breast milk
production. This is due to a substance in the breast milk that tells the mother’s body to
produce less milk for the next feeding.
These situations can then ultimately lead to the decreased future production of breast milk,
which then leads to formula supplementation and thus early weaning:
ineffective suckle ! less milk to infant and pain in mother ! diminished let-down !
inadequate emptying of breast ! decreased milk production ! earlier weaning
There are other ways to feed an infant besides bottle-feeding, which will in turn protect against
nipple confusion in an infant. These methods include cup feeding, spoon-feeding, syringe
feeding, and using a supplemental nursing system. Please see the appendix for diagrams
and instructions.
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Mothers who are separated from their infants (i.e. infants transferred to the NICU)
should be provided with a breast pump and instructed to use the pump for at least 15
minutes, 8 times during the day and once during the night.
The reason for breast-pumping during the immediate newborn period is not to provide
breast milk to the infant, but to provide stimulation to the mother’s breasts.
Mothers may find that they express little or no milk in the immediate post-partum
period. Mothers should be reassured that this does not mean they are not producing
enough milk!
During the first day or two of life, prior to lactogenesis 2 (milk coming in), there is only drops of
colostrum and breast milk present in the breasts. This is normal, and is due to the inhibitory
effect of pregnancy hormones on breast milk production at this time.
Adequate breast stimulation via breast pumping ensures adequate breast milk production for
when lactogenesis 2 does finally occur. If this stimulation is not applied, lactogenesis 2 may
be delayed, or the mother may produce inadequate quantities of breast milk. Mothers can
expect more copious milk production to occur at around 60 hours of life, when lactogenesis 2
occurs. However, any expressed milk that is obtained via breast pumping may be fed to the
infant.
Manual expression can be more effective in expressing colostrum during the first few
days of life. Although infants can draw out colostrum due to their mouth latch and peristaltic
motion of their tongue, breast pumps often cannot express the thick fluid by mere vacuum /
suction.
Please see the appendices for more information regarding milk expression and storage and
lactation physiology.
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Hypoglycemia Management
Transient hypoglycemia is common and physiologic in newborn mammals during the
first few hours of birth. In full-term, asymptomatic, healthy, appropriate for gestation age
(AGA) babies, there is little reason to routinely monitor glucose levels during the newborn
period. It is believed that in the event of transient or prolonged hypoglycemia, most infants are
capable of a robust ketogenic response to prevent neurologic sequelae.
Early breastfeeding is not precluded just because an infant meets the criteria for
glucose monitoring.
Early and exclusive breastfeeding meets the nutritional and metabolic needs of healthy,
term newborn infants. To ensure breastfeeding success:
• Initiate breastfeeding within 30 to 60 minutes of life and continue on demand.
• Feedings should be frequent; 10 to 12 times per 24 hours in the first few days after birth.
• Avoid supplementation unless medically indicated.
• Facilitate skin-to-skin contact of mother and infant.
During these interventions, either supplementing or using IV, it is important to keep the infant
at the breast, or return the infant to the breast as soon as possible. Skin-to-skin care is
easily done with an IV and may lessen the trauma of an intervention, while also providing
physiologic thermoregulation, and assist in returning the infant to metabolic homeostasis.
Ensure that the mother is given a breast pump to provide breast stimulation if she is separated
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from her infant during the newborn period.
In other cases, such as excessive infant weight loss, the goal is to feed the infant and optimize
maternal milk supply while determining the cause of poor feeding and/or inadequate milk
transfer. All infants should be evaluated for position, latch and milk transfer prior to the
provision of supplemental feedings. Lactation consultants are very helpful in these cases.
Formula supplementation is not without risk, and can prevent the establishment of
maternal milk supply, have adverse effects on breastfeeding (e.g. delayed lactogenesis 2,
maternal engorgement, mastitis), alter infant bowel flora, sensitize the infant to allergens, and
interfere with maternal-infant bonding. The physician must always decide if the benefits of
supplementation outweigh the potential risks of these feedings.
Banked / donor milk should be considered when supplementation is necessary. Despite the
pasteurization of donor milk, very few biologically active compounds are destroyed, leaving
banked milk with many protective immunologic and anti-infective components of non-banked
human milk.
Infants who should not receive breast milk or any other milk except specialized
formula:
• Infants with classic galactosemia
• Infants with maple syrup urine disease
• Infants with PKU
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Infants for whom breast milk remains the best feeding option but
who may need other food in addition to breast milk for a limited
period:
• Infants with increased metabolic or fluid needs (surgery, phototherapy, symptomatic
hypoglycemia)
• Rapid weight loss over 7 - 8% in first 48 hours with poor latching and suck skills.
• Weight loss of 8 – 10% accompanied by delayed lactogenesis 2 (day 5 or later)
• Delayed bowel movements or continued meconium stools on day 5
• Hyperbilirubinemia
o Jaundice where intake is poor despite adequate intervention
o Breastmilk jaundice when levels reach >20 – 25 mg/dL in an otherwise thriving
infant and where diagnostic interruption of breastfeeding might be helpful
• Low birth weight
o When sufficient milk is not available
o When nutrient supplementation is indicated
• Infant is unable to feed at the breast: premature <37 weeks, floppy babies, babies with
poor tone, Down’s Syndrome, cleft palate
• Infants born weighing <1500g (very low birthweight)
• Infants born at less than 32 weeks of gestation (very preterm)
Lactogenesis 2 can occur between 24 – 100 hours of life, but usually occurs around 60
hours post-partum.
Conditions that can delay or lessen milk production during lactogenesis 2 include:
• Separation of mother and infant
• Preterm birth
• Endocrine problems including PCOS and hypothyroidism
• Breast surgery, specifically breast reduction
• Retained placenta
• Hormonal birth control (i.e. depo provera after delivery)
• Maternal obesity
• Maternal diabetes or hypertension-etiology unknown
• Sheehan’s syndrome
“Failed” lactogenesis 2 is the inability of a woman to achieve full lactation due to either primary
inability to produce or issues with breastfeeding or infant health.
Using a breast pump for 1 – 5 minutes prior to feeding can soften the breasts during this time
and allow the infant to latch easily. The engorgement will resolve over the following days and
weeks.
Lactogenesis 1 is the production of milk and colostrum during pregnancy and during the first
few days post-partum.
See also appendix for more information about the physiology of lactation.
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The reasons for the higher morbidity in late-preterm infants are many, including
neurodevelopmental immaturity which can cause these infants to have an uncoordinated suck-
swallow mechanism, mild hypotonia, and less alert/awake periods. They also have increased
metabolic requirements due to less glycogen and fat stores, having not benefited from the final
deposit of nutrition at the end of pregnancy that full-term infants experience.
Late-preterm infants who are exclusively breastfed are at risk for hyperbilirubinemia. This is
likely due to the reasons listed above, which can result in the poor intake of breast milk during
the newborn period, in the setting of higher metabolic needs. In addition, late-preterm infants
often have less stamina to breastfeed than full-term infants.
Less acutely, these infants are at a higher risk for breastfeeding problems of all types, and are
less likely to achieve “full” breastfeeding status. Poor breastfeeding technique can result in
decreased maternal breast stimulation, thus decreased breast emptying, then decreased milk
intake by the infant due to decreased milk production by the mother. This then leads to
decreased stool production therefore inadequate bilirubin excretion, leading to potentially
dangerous levels of bilirubin in the infant.
However, preterm and late-preterm infants benefit greatly from the immune protection of
breastmilk, and their mother should be encouraged to breastfeed if infant is stable.
Hormone treatment to stop milk production is not recommended. Options for symptom relief
during this period include a well-fitting support bra, analgesics and ice packs.
She also can be assured that if she changes her mind, she may still be able to initiate
breastfeeding within the first few days post-partum.
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Sleeping arrangements
• Decreased amount of sleep is common for parents when taking care of newborns.
• New mothers may feel overwhelmed with the demands of breastfeeding, and lack of
sleep contributes to this feeling.
• A common piece of advice given to mothers is “sleep when your baby sleeps.” A
woman can breastfeed her newborn and nap when the infant naps.
• She should plan on sleeping in periods throughout the day and night until her infant
begins sleeping in longer stretches during the night, which often begins around 8 weeks
of age.
• Discuss the demands of breastfeeding and that many tasks and duties may need
to be deferred for her to conserve her energy; duties of cleaning the house,
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shopping, and caring for other children may need to be transferred to other caregivers in
order for her to get adequate rest.
• Although the AAP does not recommend co—sleeping or bed sharing due to concern
over SIDS, most children in the world sleep with their mothers in early periods of life.
• Many breastfeeding advocates promote co-sleeping as a way of fostering closeness
between mother and infant, as well as promoting frequent nursing which then promotes
adequate milk production and longer duration of breastfeeding.
• It is important that women and families understand the risks of co-sleeping and
bedsharing.
• If a woman wishes to co-sleep, discuss safe-sleeping arrangements with her (see “Co-
Sleeping” in this section.)
Reiterate the medical benefits for infants of mothers of breastfeeding for one year and
beyond.
Congratulate the woman for her decision to breastfeed! Acknowledge that breastfeeding,
like parenting, has its demands and rewards, and provide reassurance that help is available to
her if she needs it.
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ineffective suckle ! less milk to infant ! pain in mother ! less let down ! less milk
! earlier weaning
• Pacifiers should not be given routinely to breastfeeding infants until 4 - 6 weeks of life, at
which point breastfeeding is usually well established.
Breast Engorgement
A very common breastfeeding scenario is a woman who breastfed without difficulty in the
hospital and then is unable to latch her infant to breastfeed after lactogenesis 2. This is most
commonly due to engorgement, where the breasts become large and firm and the nipple is
often effaced making it difficult for the infant to latch.
Engorgement is common in the first week post-partum; this is due to presence of milk in the
breast, but also due to edema in the breast tissues. To soften the breasts and nipples and
enable easier latch is to have the woman pump her breasts for 1-5 minutes; this often results
in successful latch and breastfeeding.
A mother can also experience engorgement during lactation when milk is not removed
regularly.
Hyperbilirubinemia
Jaundice is common in the newborn period. If an infant is jaundiced and bilirubin levels are
below phototherapy guidelines, the infant is well, and the elevated bilirubin level cannot be
attributed to any specific factor, it is considered “physiologic jaundice.”
There are risk factors for potentially dangerous levels of bilirubin. One risk factor is hemolysis
due to ABO incompatibility. However, the increasing number of cases of kernicterus in this
country over the past few decades is postulated to be due to short hospital stays (24 - 72
hours) and the increase in breastfeeding rates. Education of the mother, adequate post-
partum follow-up of the infant and proper management of breastfeeding can minimize the
occurrence of dangerous hyperbilirubinemia.
Late-preterm birth, primiparity, and exclusive breastfed status are risk factors for
hyperbilirubinemia. Bilirubin levels should be plotted using the Bhutani curve (see
appendix), with consideration of risk factors for hyperbilirubinemia, and infants should be risk-
stratified. Infants should be admitted for phototherapy if levels indicate (see also appendix).
Otherwise, a mother should be encouraged to continue breastfeeding but follow-up frequently
for infant assessment.
Breastfeeding Jaundice
Breastfeeding jaundice, also called “non-feeding jaundice,” is caused by a low intake of
breastmilk. This can be due to delayed lactogenesis, poor latch and/or breastfeeding
technique, or infrequent feedings in a newborn infant. Poor intake of breastmilk results in low
stool output. Low stool production results in less excretion of bilirubin. Adequate stool output
is essential in adequate excretion of bilirubin during the newborn period. When an infant
cannot breastfeed adequately and/or there is a delay in lactogenesis 2, breastfeeding jaundice
can occur.
However, if an infant’s weight loss and elimination patterns are appropriate, encourage the
mother to continue breastfeeding. A “trial” of formula is not indicated in this situation.
Bili blankets are an option for home use; they are used as prophylaxis in infants where there is
concern for significant hyperbilirubinemia. They are not a substitute for intensive / treatment
phototherapy.
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In cases of breastmilk jaundice, the total bilirubin levels can range from 12 – 20 mg/dL and
may be elevated for 1 – 3 months.
It is important to evaluate the jaundice with direct and total bilirubin tests to avoid missing
significant pathology. Pathology such as liver disease, congenital hypothyroidism and
galactosemia are serious conditions associated with jaundice at this age.
If the baby’s physical exam is normal and urine and stool output are normal, the infant can be
observed and followed without intervention. A “trial” of formula is not necessary and may
result in decreased breastmilk production, prompting the need for continued formula
supplementation.
Ankyloglossia or “tongue-tie”
• Perceived or actual short sublingual frenulum that prevents tongue from elevating or
extending anteriorly
• Occurs in 3 – 5% of infants
• Infants with ankyloglossia comprise 13% of infants with breastfeeding problems
• Problems with breastfeeding include nipple trauma or failure of infant to breastfeed
effectively
• Previous belief that ankyloglossia can cause speech defects has been proven to be
unfounded.
Management:
• Determine breastfeeding success:
o Weigh infant, ensure adequate growth
o Review feeding and elimination patterns
o Observe breastfeeding and evaluate infant latch
o Evaluate pain in mother with breastfeeding
• If breastfeeding is unsuccessful due to improper latch, or there is substantial pain in the
mother despite lactation consultation, the clinician can consider the frenotomy procedure:
o “snipping” of frenulum
o no local anesthesia
o well-tolerated by infant, mother can breastfeed immediately after
o usually done by ENT at KP LAMC
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Indications for Post-Partum Lactation Consultation
Consider referring the mother to a lactation consultant when the following conditions are
present:
• Mother in ICU or other complication
• Breasts or nipples that require assistive devices for proper latch
• Infant born at gestation <38 weeks / late - preterm
• Absence of lactogenesis 2 by day 3
• Failure to thrive / excessive weight loss
• Pain in mother while breastfeeding
• Ankyloglossia / tongue tie
• Mother of infant with congenital anomalies
• Mother attempting to breastfeed multiple infants
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65
Growth spurts
Growth spurts usually occur at standard intervals where an infant who was breastfeeding
successfully will suddenly become fussy, appear hungrier and feed more frequently. Growth
spurts are often accompanied by an increase in crying frequency and duration; often the
mother will believe that she is “running out of milk.”
Growth spurts most commonly occur at 2 – 3 weeks, 6 weeks, 3 months and 6 months
of life, however, they can happen at any time.
• Growth spurts usually resolve in 2-3 days.
• Encourage mother to continue to breast feed her infant when based on feeding cues.
• Avoid formula supplementation, which will decrease breast milk production.
• Reassure mother that she is capable of producing enough milk for her infant.
• Growth spurt behavior is the infant’s way to promote continued breast milk production in the
mother.
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Milk Expression
Breast milk can be expressed via hand expression, manual pump, or automatic / electric
breast pump. Hand expression can be cheap and convenient, as no extra materials are
involved; however, electric pumps are more efficient, as pumping both breasts simultaneously
is more effective and saves time.
Storage containers:
• Should be hard-sided, such as hard plastic or glass
• Should have airtight seal
• Plastic bags specifically designed for human milk storage can be used for short-term milk
storage (<72 hours); long term is not recommended as the bags may spill or leak, and milk
components may adhere to the soft plastic
• Use containers that have been washed in hot, soapy water and rinsed. Cleaning in a
dishwasher is acceptable.
• Do not fill container completely to the top as breast milk will expand as it freezes.
The average time to first ovulation is 45 days post partum, with a range of 25 – 72 days in non-
breastfeeding women. When exclusive breastfeeding occurs, ovulation can be delayed via the
lactation amenorrhea method.
Per ACOG in their 2007 statement: “Due to absence of well-designed clinical trials proving an
association of hormonal contraception and decreased breast milk production, a clinician may
decide to initiate progestin-only methods before hospital discharge, and initiate estrogen-
containing hormonal contraception after the period of hypercoagulability associated with
pregnancy has resolved (2 – 4 weeks.)”
The most common cause of true decreased production of breast milk is supplementation with
formula, infrequent feeds, separation of mother and infant, or improper latch. Other causes
include:
Maternal causes
• Endocrine problems including PCOS and hypothyroidism
• Breast surgery, specifically breast reduction
• Retained placenta
• Unrelieved engorgement
• Return of menstruation
• OTC medications
• Hormonal birth control
• Obesity (thought to be due to increased circulating estrogen / androgens)
Infant causes
• Infrequent feeding or frequent supplementation with formula
• Pacifier use
• Ineffective suck, prematurity, neuromotor problems
• Oral anatomic problems such as cleft lip or palate
In cases of true insufficient milk supply, galactogogues may be used. See “Galactogogues”
section in the appendix for more information.
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Causes
• The most common cause is poor latch or position and attachment at the breast
• Frictional trauma is caused by inadequate amounts of breast tissue being drawn into the
the infant’s mouth.
• Infants that use pacifiers typically have a superficial sucking pattern which can cause
frictional trauma
• Other causes: Nipple shape, engorgement, improper use of nipple shields or pumps.
• The breast may also be tender from a candida infection/thrush, impetigo, eczema, or
herpes; irritation from laundry detergents; food particles in the toddler’s mouth; or dried
colostrum or milk causing nipple to stick to bra or breast pads
• The infant’s oral structure: ankyloglossia, high or bubble palate, short tongue can also
cause frictional trauma.
Mastitis
Mastitis is an infection of the breast, not the breast milk. The most common cause of mastitis
is bacterial overgrowth (staph aureus) from milk stasis. It is safe and appropriate to continue
breastfeeding with mastitis.
• Occurs in 2-3 % of lactating women
• Occurs most commonly in the second and third week post-partum
• Flu-like symptoms occur with marked redness on the affected breast
• Most common cause is non-MRSA staph aureus (40%); other causes include
haemophilus influenza, H parainfluenzae, E coli, enterococcus, klebsiella, enterobacter,
serratia, group B streptocci, and pseudomonas.
Treatment
• Continue frequent, effective breastmilk removal, even after starting antibiotics!
• Discarding the milk from the affected breast is not necessary or recommended;
the infant can safely breastfeed from affected breast.
• Antibiotics for staph aureus: dicloxacillin 500mg QID for 10 days, or cephalexin for 10
days (clindamycin is indicated in pcn-allergic women); delayed initiation of antibiotics
can result in abscess formation (see below).
• Warm or cool compresses on the sore breast.
• Analgesics such as ibuprofen or Tylenol may be used for mother’s comfort and are safe
in breastfeeding.
• Culture and sensitivity should be obtained if there is no response to antibiotics within
two days; consider treating for MRSA (trimethoprim-sulfa and vancomycin are safe and
compatible with breastfeeding).
Breast Abscess
• Abscess is indicated by presence of palpable mass and fever that persist for 48 – 72
hours after appropriate management is initiated.
• Up to ~3% of mastitis cases will progress to abscess
• Abscesses are generally treated with incision and drainage. Ultrasound guided
aspiration has also been successfully used.
• Breast milk should be discarded for the first 24 hours after surgery, with
breastfeeding resuming if there is no drainage of exudate into breastmilk.
Prevention of breast infections: frequent nursing; if a mother and infant are separated, mother
can pump in between feedings with infant; sometimes mother may need to wake up and pump
if infant is sleeping through the night and engorgement is uncomfortable or mastitis is
recurrent.
Consider: inflammatory breast cancer. The major feature that distinguishes mastitis from
inflammatory breast cancer is knowledge of previous negative breast exam during pregnancy.
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Risk factors
• Diabetes
• Steroid use
• Immune deficiency
• Antibiotic use
• Nipple trauma
• Use of plastic-line breast pads that trap moisture
Management:
• Candida is often difficult to prove as the causative organism in all situations, as milk and
skin cultures are not helpful.
• Infant often has thrush in this context, and mother and infant should be treated together
Objects that contact breast or infants mouth should be sterilized, including pumping
supplies, bottles, and pacifiers
• Antifungal treatment consists of:
o Maternal treatment: nystatin suspension/ cream or clotrimazole applied after each
nursing; do not need to wash off before feeds.
o Infant: nystatin (100,000 u/ml) 1 cc po qid inside mouth to breast after each nursing.
o Oral fluconazole — may be prescribed if nipples are not significantly better after
several days of topical treatment, or in cases of reccurrence.
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General guidelines:
• Parents should be educated about risks and benefits of co-sleeping and unsafe co-
sleeping practices.
• Safe sleeping practices include:
o Placing babies to sleep in supine position
o Using a firm flat surface for sleeping
o Avoiding soft bedding, waterbeds, pillows, sofas or recliners
o Ensuring that infant’s head will not be covered while sleeping
o Never leaving infant alone in an adult bed
o Ensuring that there are no spaces between mattress and headboard, or between
mattress and wall where infant can fall and become trapped.
• Unsafe sleeping practices include:
o Environmental smoke exposure and maternal smoking
o Sharing sofas or couches with sleeping infant
o Placement of infant in side or prone position
o Use of alcohol of drugs by adults who are bed sharing
o Bed sharing with other children
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Post-partum Depression
Most antidepressants are safe and compatible with breastfeeding. Postpartum
depression is not uncommon. At least 10% to 20% of postpartum mothers suffer from
depression, and 10% to 16% of pregnant women fulfill the American Psychiatric Association
Diagnostic and Statistical Manual, edition 4 (DSM-IV) diagnostic criteria for major depression.
These numbers are higher in mothers of multiples. The incidence of psychiatric illness is
higher in the postnatal period than at any other period in a woman’s life. Children of mothers
with post-partum depression can have lasting adverse health outcomes, including depressed
mood, difficulty with social, cognitive and behavioral development, attachment difficulties, and
are more likely to be victims of abuse and neglect.
Many women experience the “baby blues,” up to 50% in some studies. This is a common,
temporary condition which resolves in two weeks post-partum or less.
Women may not volunteer information regarding their depressed mood or negative feelings.
Mothers may worry about being judged for having these feelings, or having feelings of harming
their child. Also, normal post-partum period changes, including weight loss, sleep disruption,
fatigue, concentration difficulties and guilt, are difficult to distinguish from symptoms of true
depression. Mothers may also not identify their feelings as depression, but may describe
themselves as being “worried” or “anxious.”
Predictors of PPD include prenatal depression, low self-esteem, childcare stress, low social
support and socioeconomic status, unplanned pregnancy, poor marital relationship, or multiple
gestation. Mothers of infants with “difficult temperaments” are also at risk for PPD.
Therefore, all clinicians, including obstetricians, pediatricians, and lactation consultants, are
encouraged to offer non-judgmental, open ended inquiry regarding a mother’s mood and
feelings during the post-partum period. Screening tools exist to assist clinicians in identifying
women who may qualify for the diagnosis of post-partum depression, or who could benefit from
counseling and/or antidepressants. One screening tool that is commonly used is the PHQ-9
Depression Screening Tool (available in appendix).
Mothers may be relieved that their feelings of depression, anxiety or guilt have a diagnosis and
a treatment option. Women should be encouraged to accept treatment for symptoms that
suggest or qualify for post-partum depression. Cognitive therapy and counseling is helpful and
indicated for all cases of PPD, however, many women do not have the time or resources for
this treatment.
Treatment
If an antidepressant is indicated for PPD treatment, women can be reassured about the safety
and compatibility of most antidepressant medication with breastfeeding. Concern may arise
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over the demands of breastfeeding in depressed mothers; the decision to discontinue
breastfeeding a part of a PPD treatment regimen should be made on an individual basis, with
the mother aware of the benefits of continued breastfeeding and risks of formula.
Please see the medications tables in appendix for more information on selected anti-
depressant use and breastfeeding.
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Return to Work
A woman who wishes to return to work can continue to breastfeed her infant and provide her
with breast milk via milk expression and storage. However, working outside the home is
related to a shorter duration of breastfeeding, and intentions to work full time are significantly
associated with lower rates of breastfeeding initiation and shorter duration.
A breastfeeding plan can help the working mother anticipate logistic problems and devise a
practical pumping schedule. Barriers to expressing milk at work include a lack of flexibility for
milk expression in the work schedule, lack of accommodations to pump or store breast milk,
concerns about support from employers and colleagues and real or perceived low milk supply.
Women and clinicians may need to educate employers about the necessity of time and
resources (i.e. suitable location) required to express milk during the workday. Employers can
be reminded of the medical benefits of breastfeeding to infants, and the relationship between
healthier infants and less missed days of work by parents caring for sick infants (see below).
The influence of a clinician in this situation can be invaluable, and can be expressed in a letter
or a phone call.
For example: an employee absence of one day costs the Los Angeles Department of Water
and Power average $360 (for a $15 per hour employee).
From http://www.breastfeedingworks.org/econ.htm
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Weaning
Weaning is the time of gradually transitioning infants from mother’s milk to complementary
foods or an older child’s diet. Complete weaning, or complete cessation of breastfeeding,
ideally should be a gradual process accomplished over a long period..
There are several weaning techniques that can be recommended when a mother wishes to
encourage the process. In general, gradual weaning is preferred.
Appendix
Breastfeeding Policies: AAP, AAFP, ACOG
The Baby Friendly Hospital Initiative
Healthy People 2010 Breastfeeding Goals
Medication Tables, Vaccines, Imaging / Radiocontrast Agents
Hyperbiilirubinemia Risk and Phototherapy Nomograms
Basic Lactation and Breastfeeding Physiology
Evaluation of Breastfeeding Technique: Positioning, Latch,
Milk Transfer
Methods of Human Milk Expression
Alternative Methods to Bottle Feeding Infants
Reverse Pressure Softening for Breast Engorgement
Sample Breastfeeding Intake and Elimination Log
Galactogogues
Donor Breastmilk / Breastmilk Banking
CDC: Breastfeeding and Swine Flu (2009)
Travel Recommendations for the Nursing Mother
Online Clinician Breastfeeding Education and Training Options
PHQ9 Screening Tool for Depression
California Breastfeeding Laws and Legislation
KP and Community Patient Breastfeeding Resources
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• Exclusive breastfeeding for approximately the first six months and support for
breastfeeding for the first year and beyond as long as mutually desired by mother
and child.
• Mother and infant should sleep in proximity to each other to facilitate breastfeeding;
• Self-examination of mother's breasts for lumps is recommended throughout lactation,
not just after weaning.
• Clinicians should support efforts of parents and the courts to ensure continuation of
breastfeeding in cases of separation, custody and visitation.
• Pediatricians should counsel adoptive mothers on the benefits of induced lactation
through hormonal therapy or mechanical stimulation.
• Recognize and work with cultural diversity in breastfeeding practices.
• A pediatrician or other knowledgeable and experienced health care professional should
evaluate a newborn breastfed infant at 3 to 5 days of age and again at 2 to 3 weeks of
age to be sure the infant is feeding and growing well.
Added in 2007:
• To increase to 60% the proportion of mothers who exclusively breastfeed their babies
for the first three months of life.
• To increase to 25% the proportion of mothers who exclusively breastfeed their babies
for six months.
“Healthy People 2010 is a set of health objectives for the Nation to achieve over the first
decade of the new century. It can be used by many different people, states, communities,
professional organizations, and others to help them develop programs to improve health.
Healthy People 2010 builds on initiatives pursued over the past two decades. The 1979
Surgeon General's Report, Healthy People, and Healthy People 2000: National Health
Promotion and Disease Prevention Objectives both established national health objectives and
served as the basis for the development of State and community plans. Like its predecessors,
Healthy People 2010 was developed through a broad consultation process, built on the best
scientific knowledge and designed to measure programs over time.”
Healthy People 2020 goals were in development at the creation of this document.
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Medication Tables
Information from these tables was obtained by TOXNET of the NIH, and Dr. Thomas Hale’s text “Medications and
Mother’s Milk.”
Analgesics
General Guideline for maternal analgesic use: If infant exposure is a concern, mothers can breast-feed
their infants before taking the analgesics, and low to moderate dosages can be used.
Maternal Medication Safe / compatible with breastfeeding?
Acetominophen Yes
NSAIDS
Ibuprofen, ketorolac Yes; preferred NSAIDs.
Naprosyn, sulindac, piroxicam, Less preferred; probably safe for short-term
indomethacin use; longer half-life of these medications raise
concerns of accumulation with prolonged use.
Aspirin Not recommended due to association with
Reye Syndrome, however, transfer into milk is
negligible.
Opiates
Methadone Yes, transfer into milk is very low; however,
amount expressed in breastmilk is insufficient
to prevent a withdrawal syndrome following
chronic prenatal exposure of methadone.
Morphine Yes, very low transfer into milk following oral
and IV dosing.
Fentanyl Yes
Codeine Considered safe when used in moderate –
low doses.
Hydrocodone Considered safe by AAP. Vicodin is the most
commonly used opiate analgesic immediately
post-partum. Total exposure of infant to drug
levels via colostrum in first 1 – 2 days is
negligible; however, after lactogenesis 2 non-
narcotic pain relievers are preferred; if used,
max dose of 30mg of hydrocodone is
recommended and monitor infant for
drowsiness and appropriate weight gain.
Meperidine Not recommended; metabolite has very long
half-life; increasing reports in literature of
sedation, decreased Apgar scores, and lower
oxygen saturations in newborns after perinatal
administration.
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Anesthetics
Maternal Medication Safe / compatible with breastfeeding?
Epidural medications: bupivicaine, lidocaine, Yes
morphine, fentanyl, sufentanil
Propofol, thiopental sodium, enflurane Yes. Negligible amounts of these agents
found in breast milk. In general, a healthy
term infant can safely nurse as soon after
surgery as the mother is awake and alert.
Antibiotics
Maternal Medication Safe / compatible with breastfeeding?
Penicillins Yes
Cephalosporins Yes
Erythromycin, azithromycin Yes
Trimethoprim-sulfamethoxazole Yes, however, use should be avoided when
nursing infants less than two months of age due to
potential for causing increased bilirubin levels.
Tetracycline Yes, however, for long-term use, other classes are
preferred.
Doxycycline, minocycline Not recommended due to higher absorption by
infants.
Ciprofloxacin Yes
Metronidazole Topical and vaginal preparations are safe in
breastfeeding. With oral or IV use, no adverse
effects have been reported, however, use of high
maternal doses, such as 2 g for treatment of
trichomoniasis, may produce higher milk
concentrations, and mothers should be advised to
interrupt breastfeeding for about 12 to 24 hours
after administration; IV metronidazole mothers
should be advised to discontinue breastfeeding for
2 to 3 hours until the plasma concentrations have
dropped to values similar to those seen with oral
dosing; metronidazole may impart a metallic taste
to milk, and some infants may discontinue
breastfeeding simply because they do not like the
taste.”
Vancomycin Yes
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Antifungals
Maternal Medication Safe / compatible with breastfeeding?
Fluconazole (oral and topical) Yes
Topical agents: clotrimazole, miconazole Yes
(Monistat), nystatin
Antivirals
Maternal Medication Safe / compatible with breastfeeding?
Acyclovir Yes
Tamiflu Yes
Relenza Yes
Cardiovascular Medications
Maternal Medication Safe / compatible with breastfeeding?
Hydrochlorothiazide Yes
Beta blockers Beta blockers vary widely in the amount
excreted into breastmilk.
Propranolol, metoprolol, labetalol Yes
Atenolol, nadolol, sotalol No. Reports of cyanosis, bradycardia and
hypotension exist in conjunction with use of
these agents in breastfeeding women.
ACE inhibitors Caution in early post-partum; captopril and
enalapril have lowest milk concentrations.
Calcium channel blockers Yes; nifedipine and verapamil are preferred.
Hydralazine Yes
Methyldopa Yes
Magnesium sulfate Yes
Asthma medications
Maternal Medication Safe / compatible with breastfeeding?
Albuterol Yes
Ipatroprium No data currently available on this drug.
Inhaled steroids Yes; fluticasone has lowest serum levels of
inhaled steroids.
Oral steroids: prednisone, prednisolone Yes; if concern exists, withholding nursing for
four hours after taking the medication can
minimize infant exposure.
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Anticonvulsants
Maternal Medication Safe / compatible with breastfeeding?
Topiramate (Topamax) Yes
Phenytoin (Dilantin) Yes
Carbamazepine (Tegretol) Yes
Valproic acid (Depakote, Depakene) Yes
Phenobarbital Generally yes. Per Toxnet: “there is a great deal
of inter- and intrapatient variability in excretion of
phenobarbital into breastmilk. Phenobarbital in
breastmilk apparently can decrease withdrawal
symptoms in infants who were exposed in utero,
but it can also cause drowsiness in some infants,
especially when used with other sedating drugs. If
phenobarbital is required by the mother, it is not
necessarily a reason to discontinue breastfeeding.
Monitor the infant for drowsiness, adequate weight
gain, and developmental milestones, especially in
younger, exclusively breastfed infants and when
using combinations of psychotropic drugs.
Sometimes breastfeeding might have to be limited
or discontinued because of excessive drowsiness
and poor weight gain. If there is concern, infant
serum concentrations of phenobarbital can be
obtained. Measurement of an infant serum level
might help rule out toxicity if there is a concern.”
Lamotrigine Generally yes; amount transferred is
moderate, however, no reports of ill effects on
infants have been reported.
Psychotherapeutic Medications
There is extensive research that shows the compatibility of breastfeeding with maternal use of
most psychotherapeutic medications. Women should be reassured that they can continue
treatment with most medications and still continue to safely breastfeed their infants.
General guidelines:
Exercise caution with the use of these medications in breastfeeding mothers of newborns and
premature infants, infants who have metabolic or renal disorders, infants with seizure
disorders, and infants who are subject to apnea.
Antidepressants
Maternal Medication Safe / compatible with breastfeeding?
SSRIs Generally the first choice for treatment of
depression in breastfeeding mothers.
Sertraline, paroxetine Yes, preferred SSRIs.
Fluoxetine Less preferred SSRI; although it has been well
studied in pregnant women and is considered
safe, it’s long half-life and potential for
accumulation in breast milk makes it’s use
controversial during breastfeeding, however, the
relative risk of problems is low. 3 case reports of
fussiness and tremulousness exist for breastfed
infants of mothers taking fluoxetine.
Citalopram (Celexa), escitalopram Due to a few reports of somnolence in
(Lexapro) breastfed infants, caution recommended in
breastfeeding infants less than 6 months old.
Venlafaxine (Effexor) Yes; small amount of metabolite is excreted in
breastmilk but no untoward effects have been
reported. Newborn and preterm breastfed infants
should be monitored for sedation and adequate
weight gain. Consider checking levels of
metabolite in infant (desvenlafaxine).
Tricyclic antidepressants: amitriptyline, Yes
desipramine, nortriptyline, and amoxapine
Buproprion Yes, although some unconfirmed cases of
reduced milk production have been reported;
mothers of infants with seizure disorders should
not take this medication and breastfeed.
Trazodone Yes
Mirtazapine Yes
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Vaccines*
In general, vaccines are safe for administration in breastfeeding women. Both inactivated and
live viruses are safe and compatible with breastfeeding. Breastfeeding does not affect the
immune response of the vaccine.
Radiocontrast agents
Contrast agents have been studied and found not to enter milk in substantial amounts. Due to
minimal transfer to milk and the poor oral bioavailability of these agents, discontinuation of
breastfeeding is not necessary following an imaging study using contrast.
From Clinical Practice Guideline: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Subcommittee
on Hyperbilirubinemia. PEDIATRICS Vol. 114 No. 1 July 2004, pp. 297-316.
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Many hormones are involved in lactation. Prolactin and placental lactogen stimulate nipple
and areolar growth and estrogen facilitates the proliferation and differentiation of the ductal
system. Progesterone increases the size of lobes, lobules, and alveoli.
Very small amounts of milk and colostrum are present in the breasts at delivery. The secretion
of milk remains small until serum progesterone and estrogen concentrations fall; this process
begins with the delivery of the placenta. The negative feedback by these hormones on
pituitary prolactin release is then lost, which allows prolactin concentrations rise, leading to
increased milk synthesis and the start of lactogenesis 2.
When the infant suckles at the breast, oxytocin is released from the posterior pituitary which
causes the milk-ejection reflex or “letdown,” which is accomplished through the effect of
oxytocin on the myoepithelial cells surrounding the alveoli. Their contraction allows for the
breastmilk to be expressed from the breasts.
The rate of breast milk production can vary after each feed and is related to the degree of milk
emptying of the breast. The more empty a breast is of milk, the faster it will replenish fully. If
milk is left in the breasts after feeding, the presence of residual milk will negatively feedback on
further breastmilk production.
Certain medical conditions can inhibit lactogenesis 2, such as type 1 diabetes mellitus, obesity,
polycystic ovary syndrome, hypothyroidism, placental retention, and stress, can delay or inhibit
lactogenesis 2.
Colostrum
The first milk secreted into the breasts is colostrum, which differs from mature milk in its lower
energy value (67 kcal/100 mL compared with the 75 kcal/100 mL of mature milk), and its
higher percentage of protein, fat-soluble vitamins, and minerals. The volume of colostrum will
vary with parity of the mother and the number of feedings of the infant in the early post-partum
period.
There is a large amount of antibodies in colostrum that provides protection to the newborn
against infection, particularly bacteria and viruses present in the birth canal. Colostrum also
facilitates the passage of meconium and helps establish beneficial bacteria (i.e. lactobacillus
bifidus) in the infant’s gut.
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Mature Milk
Triglycerides are the primary constituents of the fat in breast milk, which provide essential fatty
acids and about 50% of its calories. Human milk is rich in long-chain polyunsaturated fatty
acids, including docosahexanoic acid and arachidonic acid, which have been associated with
higher visual acuity and cognitive ability in the infant.
• Many substances in the breast milk play a dual role of nutrition and immune protection /
activation
• Infants do not begin making secretory IgA until 4 months of life, and the process is not fully
established until 12 months of life.
• Fully breastfed babies receive about 0.5 to 1g of secretory IgA daily.
• Human milk contains many immunomodulating agents which assist in developing an
infant’s immune system in the gut and to protect him against infection; these agents include
interferon, growth hormone, lactoferrin, white blood cells, etc.
In women, breastfeeding has been shown to be protective against ovarian cancer, breast
cancer, post-menopausal hip fractures, and cardiovascular disease. The exact mechanisms
for these protections are unknown, but it is thought that decreased cycles of ovulation and
possibly increased utilization of fat stores both play a role.
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Lower scores (<5) can indicate the need for assistance for better success at breastfeeding.
Breastfeeding Positioning
In particular, look for:
• Maternal Comfort — Mother sits in comfortable chair or sits up in bed; pillows can provide
support; if she appears uncomfortable, you can suggest different positions, pillows, or a
nursing stool for feet.
• Infant Position — head, shoulders, and hips should be aligned and the infant should face /
be parallel to the mother’s body. The head should not be turned to the side.
• Infant should be brought to the breast (not the breast to the infant).
Cradle Hold
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Football Hold
Side-lying position
Breastfeeding position photos from Community Hospital of the Monterey Peninsula Hospital website:
http://www.chomp.org/conditions/pregnancy/feeding/positioning.aspx
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The Infant Breastfeeding Technique: The nipple is drawn well into the mouth, extending back to the
junction of the hard and soft palate. The infant's jaw then moves his or her tongue toward the areola,
compressing it. This process causes the milk to travel from the lactiferous sinuses to the infant's mouth.
The infant then raises the anterior portion of the tongue to complete the process. Milk is extracted by a
peristaltic action from the tip of the tongue to the base (not by negative pressure). Throughout the
suckling cycle, the nipple should not move in the infant's mouth if it is correctly positioned.
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Step 1: Step 2:
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Infants can be fed by a spoon using a similar technique: a spoon is used to offer small
amounts of milk to the infant by placing the tip of the spoon on the lower lip. The child will take
the milk at his own pace.
The physiologic stability of an infant while cup-feeding has been confirmed in a number of
studies.
Cups made especially for infant feeding are available from lactation consultants and from La Leche League
International (www.llli.org).
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Syringe feeding
This method uses a syringe to drop milk into the infant’s mouth while being held and supported
in an upright position (see cup-feeding picture on previous page.) A regular plastic syringe or
one with a periodontal tip can be used. The technique involves angling the tip towards the
infant’s cheeks and depositing a small amount of milk for the infant to swallow. This technique
of feeding can also be accomplished with an eyedropper.
Periodontal syringe
Lactation consultation is advised when nursing this method, both for evaluation of appropriate
method as well as proper teaching of system. Nursing supplementers can be used for
premature infants and those infants who have trouble latching adequately to the breast i.e.
infants with developmental or neurologic or neurologic problems. The supplemental nursing
system is also used by mothers who are nursing adopted babies, as well as by mothers who
are relactating (reestablishing a milk supply after weaning).
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Reverse pressure softening briefly moves some swelling backward and upward into the breast
to soften the areola so it can change shape and the nipple can extend easily. It also helps elicit
the milk-ejection reflex. It can also assist in manual milk expression.
Delayed or skipped feedings may also increase edema in the breasts. Intravenous (IV) fluid or
drugs such as pitocin may also increase edema, which can take 7-14 days to resolve.
Reverse pressure softening is useful when a woman feels that her breast and areola are
swollen and difficult to compress. Reverse pressure softening can be used prior to each feed.
It is important to soften the areola in the entire one-inch area. Reverse pressure softening
should cause no discomfort.
Sequence can be repeated as often as is needed. Pressure may also be applied by pressing
with a ring made by cutting off the nipple part of an artificial nipple.
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Galactogogues
Galactogogues are medications used to intitiate, maintain or augment breast milk production.
Galactogogues generally increase the secretion of prolactin from the hypothalamus and
therefore increase, but don’t necessarily maintain, maternal milk supply.
Galactogogues are frequently used to augment breast milk production in mothers with infants
in the neonatal intensive care unit. Other uses include relactation (e.g. reestablishing milk
supply after weaning), adoptive nursing, increasing a mother’s milk supply due to maternal or
infant illness or separation, or increasing milk production in women who have had a breast
reduction.
Use of galactogogues should only be used after a thorough evaluation for treatable causes of
decreased milk production has been completed. Also, a trial of increasing the frequency of
breastfeeding or breastmilk expression should also be attempted prior to galactogogue use.
The assistance of a lactation consultant in these situations is very helpful.
There is no research to suggest that starting galactogogues prenatally or within the first
postpartum week is helpful in establishing or maintaining an adequate milk supply.
Short-term use of galactogogues is advised (1-3 weeks). These substances are secreted in
negligible amounts into breastmilk and are considered safe for use in breastfeeding.
The effects of long-term use of domperidone and fenugreek are not known, but these
substances are likely safe. Long-term (>6 months) usage of metoclopramide is associated
with irreversible tardive dyskinesia, and earned the medication a black-box warning in 2009.
Metoclopramide
Metoclopramide (Reglan) is the most well studied and most commonly used galactagogue in
the United States, and increases prolactin levels by antagonizing dopamine release, thereby
promoting breastmilk production.
Despite the fact that domperidone is approved for use in most of the developed world and has
been used for many years with an excellent safety record, the U.S. Food and Drug
Administration (FDA) issued a warning against its use based on safety concerns with IV use
and risks associated with drug importation. There is no evidence that oral administration is
associated with toxicity in either mother or infant.
Domperidone is available from overseas pharmacies and from compounding pharmacies in the
US. The quality of such products cannot be assured, and the FDA has warned against their
use.
The excretion of domperidone into breastmilk is negligible and no adverse effects have been
reported in breastfed infants whose mothers were taking domperidone.
Side effects in mothers taking domperidone are uncommon; they include dry mouth, headache
and abdominal cramping. Domperidone is contraindicated in patients with known sensitivity to
the drug and in situations in which gastrointestinal stimulation might be dangerous (e.g.,
gastrointestinal hemorrhage, mechanical obstruction, or perforation).
Fenugreek is the most commonly used herbal galactogogue. It is a member of the pea family
listed as GRAS (generally regarded as safe) by the U.S. Food and Drug Administration.
Usual dose is one to four capsules (580–610 mg) three to four times per day, although as with
most herbal remedies there is no standard dosing. Alternatively, it can be taken as one cup of
strained tea three times per day (1/4 tsp seeds steeped in 8 oz water for 10 minutes).
Reported side effects are rare but include maple like odor to sweat, milk, and urine; diarrhea;
and increased asthmatic symptoms. Use during pregnancy is not recommended due to its
uterine stimulant effects.
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The benefits to infants consuming donor milk are similar to breastfed infants, including
decreased rates of necrotizing enterocolitis, sepsis and possible support of long-term positive
neurodevelopmental outcomes in very low- and extremely-low birthweight infants.
Human milk banks in the United States follow the Human Milk Banking Association of North
America (HMBANA) screening standards:
• Potential donors are cleared initially by their own physicians to assure that their health
and welfare are protected.
• Potential donors undergo a screening history similar to the one used to screen potential
blood donors.
Donors are taught carefully how to pump and collect their milk safely and cleanly and
how to keep their pumps and collection systems sterile.
Donor milk is frozen in sterile containers immediately after collection and maintained in
the frozen state until processed by the receiving bank.
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Donor milk is cultured for bacterial contamination when received by the bank, and milk
that has abnormal findings is not processed for distribution. Such findings include:
• Milk that has a high degree of bacterial contamination (ie, > 100 colony-forming
units).
• Milk contaminated with specific problematic flora (eg, Staphylococcus aureus,
Bacillus sp).
Donor milk that has passed all of the previous screening steps is then Holder
pasteurized at 62.5°C for 30 minutes, a process demonstrated to eliminate known
bacterial and viral pathogens.
Aliquots of milk are recultured after pasteurization to assure sterility; the presence of
any bacterial growth at this point in the process requires discarding of the contaminated
batch.
Of note, milk banks do not screen potential donors for cytomegalovirus (CMV). The prevalence
of CMV seropositivity for pregnant women in North America ranges from about 40% to 60%,
therefore, a large proportion of potential donors would be expected to be CMV-positive. Rather
than screening and eliminating a very high percentage of potential donors, milk banks have
relied on pasteurization to protect against transmission of CMV and other viruses.
Pasteurization has been found to be effective in eliminating the virus from the milk. In the past,
freezing had been used in an attempt to eliminate the virus but was found to be less effective.
Case reports of infants being infected from their own mother’s milk have resulted in relatively
mild infection, probably due to passive transfer of antibodies both in utero and through the
mother's milk. In terms of CMV, pasteurized donor milk actually may be safer for babies than
fresh maternal milk.
The current price (as of 2010) of donor breast milk is approximately $3.50 per fluid ounce.
“Infants who are not breastfeeding are particularly vulnerable to infection and hospitalization
for severe respiratory illness. Women who deliver should be encouraged to initiate
breastfeeding early and feed frequently. Ideally, babies should receive most of their nutrition
from breast milk. Eliminate unnecessary formula supplementation, so the infant can receive as
much maternal antibodies as possible.
If a woman is ill, she should continue breastfeeding and increase feeding frequency. If
maternal illness prevents safe feeding at the breast, but she can still pump, encourage her to
do so. The risk for swine influenza transmission through breast milk is unknown. However,
reports of viremia with seasonal influenza infection are rare.
Expressed milk should be used for infants too ill to feed at the breast. In certain situations,
infants may be able to use donor human milk from a certified milk bank. Antiviral medication
treatment or prophylaxis is not a contraindication for breastfeeding.”
Excerpts from CDC “Novel H1N1 Flu (Swine Flu) and Feeding
your Baby: What Parents Should Know”
http://www.cdc.gov/h1n1flu/infantfeeding.htm#c
A mother planning a long separation from her nursing infant or child might wish to work with an
International Lactation Consultant (IBCLC) or her pediatrician to obtain assistance and
suggestions specific to her situation. Mothers can find an IBCLC in the United States online by
visiting the websites for the International Lactation Consultants Association or The
International Board of Lactation Consultant Examiners.
Mothers may wish to identify breastfeeding support local to her destination. In this way,
support may be only a phone call away at any time throughout the trip. Visit La Leche League
International (www.llli.org) to find support groups and breastfeeding experts in other countries.
To locate lactation consultants worldwide, visit The International Board of Lactation Consultant
Examiners.”
Air Travel
“No special precautions are necessary for airport security screenings while breastfeeding. A
breastfeeding mother expressing her own milk while traveling does not need to declare her
milk at U.S. Customs when returning to the United States. Electric breast pumps are
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considered personal items during air travel and may be carried on and stowed underneath the
passenger seat, similar to a laptop computer, purse, or diaper bag.”
From: http://www.cdc.gov/breastfeeding/recommendations/travel_recommendations.htm
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Wellstart International is a nonprofit organization that is active and influential in many global
events related to the protection, promotion and support of optimal infant and young child
feeding. They offer a free breastfeeding basics curriculum self-study course that can be
downloaded from their website:
www.wellstart.org
!
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Over the last 2 weeks, how often have you been Not at all Several days More than Nearly every
bothered by any of the following problems? half the days day
Total: ___________________________________
10. If you checked off any problems, how difficult have these ____ Not difficult at all
problems made it for you to do your work, take care of things ____ Somewhat difficult
at home, or get along with other people? ____ Very difficult
____ Extremely difficult
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1031. The employer shall make reasonable efforts to provide the employee with
the use of a room or other location, other than a toilet stall, in close proximity to
the employee’s work area, for the employee to express milk in private. The room
or location may include the place where the employee normally works if it
otherwise meets the requirements of this section.
1032. An employer is not required to provide break time under this chapter if to
do so would seriously disrupt the operations of the employer.
1033. (a) An employer who violates any provision of this chapter shall be subject
to civil penalty in the amount of one hundred dollars ($100) for each violation
Jury duty
California Civil Code 210.5 (2000)
Allows mother of breastfed child to postpone jury duty for one year and specifically
eliminates the need for the mother to appear in court to request the postponement. The
law also provides that the one-year period may be extended upon written request of the
mother (Chap. 266 [AB 1814]
Breastfeeding in Public
California Civil Code 43.3 (1997)
Allows a mother to breastfeed her child in any location, public or private, except the
private home or residence of another, where the mother and the child are otherwise
authorized to be present [AB 157]
Online
Neonatal and Perinatal Home Page: Southern California Region
http://kpnet.kp.org/california/scpmg/NeoPeri/index.html
A Mother’s Haven
Prenatal breastfeeding classes, pre- and post-natal yoga, post-natal breastfeeding support,
breast pump sales, nursing accessories. After hours lactation support: 818/ 601-5381
Encino 15928 Ventura Blvd # 116 818/380-3111
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