Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 5

Guidelines for Breastfeeding

Amy L. Feldman

Candida albicans,112.9

 

Pathologic jaundice, 774.6

Engorgement, 611.79

 

Staphylococcus aureus, 041.11

Galactosemia, 271.1

 

Thrush, 771.7

Jaundice, 782.4

 

Weight gain, 783.1

Mastitis, 611

   

I. INTRODUCTION

A. Breastfeeding provides optimal nutrition for newborns and infants, protecting against many diseases and infections and improving maternal and infant health. Exclusive breastfeeding is recommended for the first 6 months of life, with continued breastfeeding throughout the first year and beyond with the addition of appropriate complementary foods.

II. PHYSIOLOGY OF LACTATION

A. Mammary glands are complex organs that function independently in response to an intricate combination of hormones and stimulation to produce milk. After expulsion of the placenta following delivery, a significant drop in progesterone readies the body for milk production (Figure 5-1).

B. Oxytocin and prolactin are two of many important hormones in controlling lactation.

C. Optimal milk production depends on several factors including release of lactation hormones, frequent, effective milk removal, and adequate breast stimulation.

D. Full lactation can be produced by breasts from 16 weeks of pregnancy forward.

E. Important to understand balance of supply and demand to optimize lactation.

F. Lactation begins as a result of hormonal control (endocrine) but changes to autocrine (frequent emptying of breasts) over time.

Figure 5-1 Physiology of lactation.

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Source: Thibodeau GA, Patton KT. Anatomy and Phiysiology. 5th ed. St Louis: Mosby; 2003.

III. HUMAN MILK

A. Human milk is exceptional in its ability to sustain appropriate growth and development for infants.

B. “Liquid gold,” as human milk is often referred to, is living tissue, which encompasses fats, proteins, carbohydrates, antibodies, and hundreds of components.

C. Composition of human milk changes to provide optimal nutrition as infant grows.

1. Colostrum, the first milk, is produced during pregnancy and is considered the infant's first immunization, providing protection to the newborn from viruses and bacteria.

2. Transitional milk is produced after colostrum, then mature milk as lactogenesis stage II (production of large quantities of milk) begins.

IV. CONTRAINDICATIONS FOR BREASTFEEDING

A. Occasionally there are circumstances that preclude mothers from breastfeeding.

1. Maternal contraindications include:

a. HIV positive mother (in the United States).

b. Maternal drug abuse.

c. Maternal chemotherapy.

d. Herpetic lesions on mother's nipple, areola.

e. Untreated, active tuberculosis.

f. Certain radioactive compounds and other medications may require temporary cessation of breastfeeding.

g. Positive HTLV-I and HTLV-II (human T-cell lymphotropic virus).

2. Infant contraindications include:

a. Galactosemia.

V. MATERNAL ASSESSMENT

A. Breastfeeding goals and family support.

B. Previous breastfeeding experience.

C. General health and nutritional status.

D. Breast, nipple, or thoracic surgery.

E. Medications, prescriptions, supplements, and OTC.

F. Pregnancy, labor, birth history.

G. Inverted or flat nipples.

VI. INFANT ASSESSMENT

A. General health, including gestational age.

B. Congenital circumstances.

C. Birth history.

D. Medications received and procedures experienced.

E. Initial feeding attempts.

F. Oral facial assessment.

VII. BREASTFEEDING IN THE EARLY DAYS

A. Initial feedings.

1. Facilitate skin-to-skin contact immediately after birth and as often as possible.

2. Encourage breastfeeding within first hour after birth during quiet alert phase. Do not restrict length or frequency of feedings.

3. Promote rooming in 24 hours a day.

4. Encourage exclusive breastfeeding; this helps to establish and maintain a sufficient milk supply.

5. Instruct parents in correct latch-on techniques.

6. Educate parents regarding initial feedings of colostrum: quantity is very small, but sufficient nutrition as baby is learning to breastfeed.

7. Discourage use of any supplements unless medically indicated.

8. Avoid use of bottles and pacifiers until breastfeeding is well established.

9. Teach parents to breastfeed in response to infant feeding cues (rooting, increased alertness, fists in mouth), at least 8-12 times/day. Crying is a late sign of hunger.

10. Baby should finish feeding on one breast, then be offered second if he/ she will take more. Fat content of milk is higher at end of feeding than at beginning. Forcing baby to switch breasts too soon may decrease amount of higher calorie milk consumed.

11. Babies who sleep for long periods of time without eating or feed only for few minutes should be encouraged to nurse (i.e., unwrap, rub feet).

B. Positioning and latch.

1. Mother and infant should be comfortable with infant on his/her side at nipple height supported by pillows or blankets.

2. Support infant's head so he/she can easily reach areola without turning neck.

3. Infant's ear, shoulder, hips should be in alignment.

4. Mother can align her nipple with infant's nose, quickly bringing infant to breast only when his mouth opens widely getting more of the areola on the bottom than top into his mouth, creating an asymmetrical latch (see Figure 5-2).

5. Infant's lips should be flanged outward with chin touching breast. When latched properly, the tongue is drawn back to the junction of the hard and soft palate (see Figure 5-3).

6. Infant's tongue will protrude over gum ridge and “cup” breast.

7. If baby latches incorrectly, the mother can insert her finger to break the suction, and repeat latch-on attempts until baby is latched correctly.

8. Common breastfeeding positions are cradle position (see Figure 5-4),cross cradle and football holds, (see Figure 5-5) and side-lying position (see Figure 5-6).

9. Trained practitioners should regularly observe latch-on, milk transfer, and feeding during hospitalization.

Figure 5-2 Positioning the baby nipple to nose (3 photos).

images

Source: Lauwers J, Swisher A. Counseling the Nursing Mother: A Lactation Consultant's Guide. 5th ed. Sudbury, MA: Jones & Bartlett Learning; 2011.

Figure 5-3 Sucking action (breast and bottle).

images

Source: Lauwers J, Swisher A. Counseling the Nursing Mother: A Lactation Consultants Guide. 5th ed. Sudbury, MA: Jones & Bartlett Learning; 2011.

Figure 5-4 Madonna (cradle) position: A) front view, B) side view.

images

Source: Riordan J, Wambach K. Breastfeeding and Human Lactation. 4th ed. Sudbury, MA: Jones & Bartlett Learning; 2010.

Figure 5-5 A) Cross-cradle hold, B) football hold.

images

Source: Riordan J, Wambach K. Breastfeeding and Human Lactation. 4th ed. Sudbury, MA: Jones & Bartlett Learning; 2010.

Figure 5-6 Side-lying position.

images

Source: Riordan J, Wambach K. Breastfeeding and Human Lactation. 4th ed. Sudbury, MA: Jones & Bartlett Learning; 2010.

10. The mother's nipple should not be pinched, bruised, or creased at the end of a feeding (see Figure 5-7).

C. Signs of milk transfer in infant.

1. Observe sustained, rhythmic suck/swallow pattern with intermittent pauses.

2. Listen for audible swallowing.

3. Baby's arms and hands should be relaxed at the end of the feeding.

4. Baby's oral mucous membranes should be moist after feedings.

5. Baby should appear satisfied after feedings.

D. Signs of milk transfer in mother.

1. Mother feels strong tugging sensation when baby is sucking that is not painful.

2. Mother feels uterine contractions and increased lochia flow during initial days postpartum.

3. Milk may leak from opposite breast during feedings.

4. Mother may feel relaxed or drowsy during feedings.

5. Breast softens after feeding (after milk supply is established).

6. Nipples are elongated, but not pinched or bruised after release of latch.

E. Assessing infant weight gain.

1. Parents should be aware of baby's birth and discharge weight.

2. Encourage parents to keep daily journal of first week to track feedings, output.

3. Healthy, breastfeeding infants may lose 3-7% of birth weight in initial days.

4. After Mom's milk is in, infant should gain 0.5-1 oz/day (4-7 oz/week).

5. Babies often regain birth weight by 10-14 days of age, double it by 6 months, triple it by 1 year.

6. Exclusively breastfed infants tend to be leaner than bottle-fed infants in second 6 months of life.

Figure 5-7 Normal nipple postfeed and creased nipple postfeed.

images

Source: Riordan J, Wambach K. Breastfeeding and Human Lactation. 4th ed. Sudbury, MA: Jones &Bartlett Learning; 2010.

F. Assessing infant output.

1. Colostrum acts as laxative, encouraging expulsion of meconium in first days.

2. Effective and regular breastfeeding helps to prevent jaundice in early days.

3. Infants showing signs of jaundice should be assessed carefully for ineffective breastfeeding.

4. Bowel movements become lighter in color, then turn to a mustard color, seedy consistency by day 4 or 5.

5. Babies who are breastfeeding well should have 2-3 large mustard color, seedy stools/day.

6. Inadequate stools are a red flag for ineffective breastfeeding.

7. Stool output may decrease to one stool every few days after first few weeks.

8. Urine output is less helpful than stool output in assessing adequate milk intake.

9. Exclusively breastfed baby should produce one wet diaper on day 1, two on day 2, three on day 3, and so on, for first week.

10. By end of first week, baby should have six soaking wet, pale yellow diapers/day.

VIII. SEPARATION OF MOTHER AND INFANT

A. Pumping.

1. All mothers should be taught how to hand express their milk after birth.

2. If small number of feedings must be missed, Mom can hand express or use a battery-operated pump to express milk from both breasts every few hours.

3. Lengthy separation warrants use of hospital-grade, piston-style pump with double hookup system to efficiently remove breastmilk 6-8 times/ 24 hours for approximately 15 minutes each session.

4. Even the smallest quantity of expressed colostrum or milk can be fed to infant via eyedropper, syringe, or cup.

B. Milk collection and storage.

1. Recommendations for collection and storage of mother's milk for hospitalized infant differ from that of the following instructions for the well child at home.

2. Mothers should wash hands thoroughly prior to pumping.

3. Follow manufacturer's instructions for cleaning of pump parts.

4. Glass containers with lids are a good choice for storing milk. Hard plastic (polypropylene) can also be used. Avoid bottles made with bisphenol A.

5. Mother can encourage milk let down by looking at picture of baby, smelling piece of baby's clothing.

6. Warm, wet washcloths on breast combined with breast massage may be helpful in starting milk flow.

7. Breastfeeding on one breast while pumping from other breast is an option.

8. All pumps are different. Encourage mother to find one that creates comfortable seal, which provides appropriate suction. Pumping should not be painful.

9. For specific information on storing milk for home use for full-term infants see the Academy of Breastfeeding Medicine Revised Protocol #8 March 2010.

IX. SUPPORTING BREASTFEEDING PAST THE EARLY DAYS

A. Follow up.

1. Breastfeeding infants should be evaluated by an appropriate healthcare professional at 3-5 days of age and again at 2-3 weeks for successful feeding and appropriate weight gain. Infants should always be evaluated in between scheduled visits for any concerns.

2. Breastfeeding mothers should be referred to a breastfeeding support group following hospital discharge.

B. Maternal diet.

1. Encourage mother to eat a wide variety of healthy foods, eating when hungry, drinking to quench her thirst.

a. Forcing large quantities of fluids will not increase her milk production.

b. No specific foods must be avoided by breastfeeding mothers.

c. Most foods do not bother most babies.

d. If particular food seems to bother baby, decrease/eliminate for a week to 10 days.

2. It is recommended that all breastfed babies be supplemented with vitamin D 400 IU starting soon after birth.

3. Families with significant allergies should receive knowledgeable dietary counseling regarding possible need to eliminate certain foods while breastfeeding.

C. Growth spurts.

1. Regardless of culture, women frequently worry about ability to provide enough milk for baby.

2. Teach parents that growth spurts (periods when babies want to nurse more frequently to meet rapid growth) usually occur around 2-3 weeks, 6 weeks, 3 months.

3. Feed as often as baby wants to nurse to increase, then maintain adequate milk supply.

4. Reinforce concept of supply and demand.

5. Supplementing with formula is strongly discouraged; mother's milk supply will not increase without adequate stimulation to meet baby's growing demand for more milk.

D. Medications and breastfeeding.

1. It is imperative that healthcare providers give information to mothers who breastfeed on the safety of medications based on appropriate, current research, citing the source. Each infant's individual situation must be assessed prior to determining the appropriate use of any medication during breastfeeding. An excellent reference guide such as Hale (2010) should be available in every clinical setting that deals with breastfeeding mothers. Drugs listed are assigned a lactation risk category from L1 (safest) to L5 (contraindicated).

2. Many of the medications likely to be prescribed to breastfeeding mothers should not affect maternal milk supply or infant's safety. Ibuprofen is a commonly used analgesic postpartum and is considered compatible with breastfeeding. Penicillins and cephalosporins, along with several of the selective serotonin reuptake inhibitors (SSRIs) often used for depression, are also generally considered compatible.

3. Dose of medication transferred through breastmilk is almost always too low to be clinically significant or it is poorly bioavailable to infant.

4. It is preferable for mothers to avoid using medication whenever possible.

5. Extensive benefits of breastfeeding far outweigh any potential risks in majority of cases.

a. Medications should be safe for infants to consume.

b. Choose drugs with breastfeeding information whenever possible.

c. Choose shortest acting form of medication.

d. Encourage feeding when maternal drug level is lowest.

e. Educate parents as to potential side effects to observe in infant, and affect on milk supply.

f. Be extra cautious with preterm, low birth-weight or sick infants.

g. Certain herbal substances may be harmful to infants.

h. Drugs of abuse are contraindicated in breastfeeding and temporary cessation of breastfeeding is necessary with certain radioactive compounds, and a few medications. Consult appropriate resources for detailed information.

E. Maternal employment.

1. Women who return to work must be well supported in effort to continue providing breastmilk for infant.

2. Women need a private, clean place to pump every few hours while separated from infant.

3. Expressed milk can be kept at room temperature for short periods, in insulated bag with cooler pack, or, if available, in refrigerator. Encourage mothers to rent or purchase pump that is comfortable and is efficient for their particular needs.

4. Provide information on how to introduce bottle to the infant, as well as suggestions for caregiver that will promote extended breastfeeding (i.e., not bottle feeding immediately before mother will pick up infant, proper handling, storage of breastmilk).

5. Returning to workplace while continuing to provide breastmilk for baby may initially seem overwhelming to some mothers. Strong encouragement, praise, support can make difference between mother being successful and giving up.

6. Some employers are now required to provide break time for nursing mothers under the Patient Protection and Affordable Care Act, signed in to law on March 23, 2010.

X. COMMON PROBLEMS

A. Mothers can complain about pain even when damage is not visible on the breast or nipple. Determine that baby is positioned properly at breast height with adequate support and is latching on correctly. Mothers often describe sensation of baby feeding as strong tugging sensation. Breastfeeding should not be painful. Nipples do not “toughen up” as breastfeeding proceeds. Assess for other causes of sore nipples such as trauma, improper latch and release, thrush, milk plugs on nipple, incorrect use of breastfeeding devices or tight frenulum (see Figure 5-8). Paget's disease, an uncommon type of breast cancer, must also be ruled out. Breastfeeding issues that do not resolve quickly should promptly be referred to pediatric or maternal experts for further management.

B. Sore nipples management includes:

1. Correct positioning and latch-on.

2. Teach mothers to express colostrum/hindmilk to apply to nipples after each feeding.

3. Allow nipples to dry before putting bra back on.

4. Offer use of breast shells to prevent fabric from rubbing against sore nipples.

5. Breastfeed from least sore side first.

6. Change positions at each feeding to decrease pressure on sore area.

Figure 5-8 Tight frenulum.

images

Source: Riordan J, Wambach K. Breastfeeding and Human Lactation. 4th ed. Sudbury, MA: Jones & Bartlett Learning; 2010.

7. Suggest moist wound healing methods (i.e., modified lanolin or hydrogel dressings).

8. Analgesics as needed.

C. Flat or inverted nipples.

1. Can initially make breastfeeding more of a challenge, may be difficult for baby to latch on, suck well. Provide adequate support to ensure successful feedings.

2. ”Pinch test”: determines if nipple is flat or inverted upon compression. With thumb behind nipple and first two fingers underneath, grasp about 1 in. back from base of nipple and compress skin.

a. Normal nipple will evert.

b. Flat nipple remains flat with compression.

c. Inverted nipple looks sunken in.

d. Nipples can look flat or inverted, but evert on compression.

3. Flat or inverted management includes:

a. Encouraging deepest possible latch onto breast.

b. Making sure infant is at breast height and well supported to prevent sliding to base of nipple.

c. Release latch and repeat attempts until proper latch is obtained. Allowing baby to suck at base of nipple prevents stimulating milk supply, will cause sore nipples.

d. Encourage offering flat/inverted breast first when baby is hungriest and sucking is strongest.

e. Teach mother to evert nipple with gentle pulling/rolling immediately prior to latch.

f. Hand express few drops of colostrum to entice baby to latch on.

g. Use hand/electric pump for few minutes immediately prior to latch.

h. If supplement is medically indicated, use expressed milk first using an eyedropper, syringe, cup, or feeding tube at the breast.

i. Avoid pacifiers and bottle nipples until breastfeeding is well established.

D. Severe engorgement.

1. Milk stasis caused by inefficient, infrequent removal of milk, results in extremely full, swollen, lumpy, painful breasts.

2. Result is different from transient breast fullness associated with milk “coming in” 2-4 days after birth.

3. Breastfeeding emergency: milk stasis can cause damage to tissue, decrease milk supply, and make it difficult to impossible for infant to compress areola and remove milk.

4. Severe engorgement management includes:

a. Analgesics as necessary.

b. Warm, wet compresses to breast prior to feedings to help increase milk flow.

c. Soften areola using hand expression so baby can latch properly.

d. Use breast compression during feedings to improve milk flow. Using her thumb on top of breast and her fingers underneath, the mother brings her fingers together, which compresses breast.

e. Use of cold compresses may help to decrease engorgement after feeding. Some mothers like to use this prior to feeding as well.

f. Use of chilled green cabbage leaves left on breast for short period several times/day can be helpful to some mothers. Stop using this as soon as engorgement decreases.

g. Express milk after feeding as needed for comfort. Any expressed milk can be fed to baby using alternative feeding methods.

E. Mastitis.

1. Infection of breast, usually caused by Staphylococcus aureus.

2. Frequently occurs in upper outer quadrant of breast, often by 2-3 weeks postpartum.

3. Symptoms commonly include hard, swollen, reddened area on breast accompanied by flu-like symptoms.

4. Difficult to differentiate between engorgement, plugged duct, mastitis (Table 5-1).

5. Mastitis management includes:

a. Rest (decrease stress and fatigue by enlisting support from friends, family).

b. Antibiotics; encourage completing full course as prescribed.

c. Increase maternal fluid intake.

d. Frequent, effective emptying of breasts (important to continue breastfeeding, milk is not infected, fine for baby).

e. Abrupt weaning can predispose to an abscess.

f. Analgesics as needed.

g. Correct latch to prevent further nipple trauma (cracked, bleeding nipples allow bacteria to enter milk ducts).

h. Mother's preference of warm or cool packs for comfort.

Table 5-1 Comparison of Findings of Engorgement, Plugged Duct, and Mastitis

images

Source: Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. 6th ed. St Louis: Mosby; 2005.

F. Jaundice.

1. Rarely requires cessation of breastfeeding.

2. Pathologic jaundice, with onset in first 24 hours of life, warrants medical evaluation in addition to lactation support.

3. Encourage early initiation of breastfeeding, then frequent, effective, unrestricted feedings to minimize jaundice.

4. Colostrum acts as laxative, eliminating bilirubin through meconium expulsion.

5. Physiologic jaundice, which begins 48-72 hours after birth and peaks on day 3-5, is seen in thriving infants with normal weight gain and output.

6. Observe for effective breastfeeding and continue assessment for normal weight gain and output. Onset and peak of breastfeeding associated with jaundice is similar to physiologic jaundice, but infant is fussy/sleepy with poor feeding and inadequate weight gain, output.

7. Assist with frequent, unrestricted, effective breastfeeding.

8. Teach parents to watch for signs of milk transfer during feedings. If necessary, express milk in addition to feedings, use alternate feeding methods to give baby milk.

G. Thrush.

1. Often described as burning, itching, stinging lasting throughout feeding and beyond, radiating from nipple and breast to shoulder and back.

2. Nipple or areolar skin is often red and shiny.

3. May have period of pain-free nursing, then have sudden onset of pain.

4. Pain from poor latch is often described as feeling like a knife or being stabbed, dissipates as feeding progresses, frequently limited to nipple and areola.

5. Regardless of nipple pain, poor latch must be corrected immediately.

6. Broken skin is perfect environment for organisms to invade.

7. Signs in infant may range from nothing to white patches on buccal mucosa, tongue, and palate, which may bleed when scraped with tongue blade. Fiery red diaper rash with shiny red patches and pustules may also be present.

8. Both mother and baby should be treated simultaneously with appropriate antifungal medications to prevent reinfection from one to the other.

9. All objects (pumping supplies, pacifiers, bottles) coming in contact with baby's mouth should be boiled daily.

10. Mothers should be encouraged to continue breastfeeding while treating infection.

11. Candida albicans thrives in warm, moist, dark areas. Nipples can be rinsed with clear water or vinegar solution of 1 tablespoon vinegar in 1 cup of water after each feeding, exposing to air after each feeding.

12. Bed linens, sheets, bras can be rinsed in vinegar solution after hot wash cycle. Breast pads should be disposable and changed as soon as wet.

13. Sexual contact between mother and partner can spread infection. Partner should be treated appropriately.

H. Weight gain concerns.

1. Breastfed infants gaining less than appropriate amount for age should be carefully evaluated. Often, correcting latch and positioning is enough to facilitate efficient breastfeeding and improve weight gain.

2. Do not recommend formula supplementation without evaluating breastfeeding. If extra calories are needed, have mother hand express or pump in addition to breastfeeding and use alternative feeding methods to give baby milk.

3. Allowing baby to finish feeding on one breast before feeding on second allows sufficient amounts of higher calorie breastmilk.

4. Review with parents appropriate signs of infant hunger, encourage frequent (8-12 or more/24 hours) unrestricted feedings.

5. Keeping written log of feedings and output is also helpful. Imperative that infant have adequate caloric intake.

6. If after evaluation and management with skilled breastfeeding consultant, breastfeeding is not going well, formula supplementation is appropriate. Plan for maintaining/increasing mother's milk supply must be implemented.

7. Return office visit within 24-48 hours to monitor situation should be scheduled. Frequent phone follow up, support are necessary.

8. Global growth charts released by the World Health Organization (WHO) in 2006 reflect standards on how children should grow based on breastfeeding as the norm.

XI. HELPFUL BREASTFEEDING RESOURCES

A. Locating a board-certified lactation consultant:

International Lactation Consultant Association

919-861-5577

www.ilca.org

International Board of Lactation Consultant Examiners

703-560-7330

www.iblce.org

Breastfeeding National Network (BNN)

1-800-TELL-YOU

www.medela.com

B. Books.

Biancuzzo M, Breastfeeding the Newborn: Clinical Strategies for Nurses. 2nd ed. St. Louis, MO: Mosby; 2003.

Hale TW. Medications and Mother's Milk. 14th ed. Amarillo, TX: Hale Publishing, L.P.; 2010.

Lauwers J, Swisher A. Counseling the Nursing Mother: A Lactation Consultant's Guide. 5th ed. Sudbury, MA: Jones & Bartlett Learning; 2011.

Newman J, Pitman T. The Ultimate Breastfeeding Book of Answers. NY: Three Rivers Press; 2006.

Riordan J, Wambach K. Breastfeeding and Human Lactation. 14th ed. Sudbury, MA: Jones & Bartlett Learning; 2010.

Wilson-Clay B, Hoover K. The Breastfeeding Atlas. 4th ed. Manchaca, TX: LactNews Press; 2008.

C. Online resources.

American Academy of Breastfeeding Medicine: www.bfmed.org

American Academy of Pediatrics: www.aap.org

Breastfeeding Pharmacology (Dr. Thomas Hale): http://neonatal.ttuhsc.edu/lact/

Human Milk Banking Association of North America:www.hmbana.com

La Leche League International: www.lalecheleague.org

UNICEF's 10 Steps to Successful Breastfeeding: www.unicef.org/newsline/tenstps.htm

U.S. Breastfeeding Committee: www.usbreastfeeding.org

World Alliance for Breastfeeding Advocacy: http://waba.org/my/

BIBLIOGRAPHY

Academy of Breastfeeding Medicine. ABM Clinical Protocol #8: Human Milk Storage Information for Home Use for Full-Term Infants (original Protocol March 2004 Revision #1 March 2010). Academy of Breastfeeding website: http://www.bfmed.org/Resources/Protocols.aspx. Accessed September 2, 2010.

American Academy of Breastfeeding Section on Breastfeeding. Breastfeeding and the use of human milk.Pediatrics. 2005;115(2):496-506.

American Academy of Family Physicians. Position Paper on Breastfeeding. American Academy of Family Physicians website: http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpa-per.html. Accessed September 2, 2010.

American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics. 2001;108(3):776-789.

American Academy of Pediatrics. Wagner CL, Greer FR, and the Section on Breastfeeding and Committeee on Nutrition. Clinical report–Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008;122(5):1142-1152. doi:10.1542/peds.2008-1862.

Riordan J, Wambach K. Breastfeeding and Human Lactation. 4th ed. Sudbury, MA: Jones & Bartlett Learning; 2010.

Hale TW. Medications and Mother's Milk. 14th ed. Amarillo, Texas: Hale Publishing, L.P.; 2010.

International Lactation Consultant Association. Clinical Guidelines for the Establishment of Exclusive Breastfeeding. 2nd ed. 2005:http://www.ilca.org/files/education_and_research/independent_study_modules/ILCA%20documents/Doc%20ClinicalGuidelines2005.pdf. Accessed September 2, 2010.

Lu MC, et al. Provider encouragement of breast-feeding: Evidence from a national survey. Obstet Gynecol. 2001;97(2):290 -295.

Marks JM, Spatz DL. Medications and lactation: What PNPs need to know. J Pediatr Health Care 2003;17(6):311-319.

NAPNAP Position statement on breastfeeding. J Pediatr Health Care. 2007;21:39A-40A.

Newman J, Pitman T. The Ultimate Breastfeeding Book of Answers. New York: Three Rivers Press; 2006.

U.S. Breastfeeding Committee. Breastfeeding in the United States: A National Agenda. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau; 2001.

U.S. Department of Health and Human Services. HHS Blueprint for Action on Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office on Women's Health; 2000.

U.S. Dept of Labor-Wage and Hour Division (WHD). Fact Sheet #73: Break Time for Nursing Mothers under the FLSA. http://www.dol.gov/whd/regs/compliance/whdfs73.htm. Accessed September 1, 2010.

World Health Organization. The launch of the WHO Child Growth Standards. http://www.who.int/childgrowth/launch/en/index.html. Accessed September 3, 2010.



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