Breastfeeding: Parental education and support

INTRODUCTION — 

Breastfeeding (or, when necessary, feeding expressed breast milk) is recognized as the normative standard for virtually all infants because of its health benefits to infants and their mothers. There is broad consensus recommending exclusive breastfeeding for approximately the first six months and continued breastfeeding, along with the introduction of solid foods, for at least two years after birth, as long as it is mutually desired by parent and infant [1-5].

Unfortunately, despite the strong recommendations, actual breastfeeding practice falls short of these goals in many countries and cultures. In the United States, more than 80 percent of birthing parents initiate breastfeeding, but less than 60 percent continue through six months postpartum and less than 40 percent are breastfeeding at 12 months [6]. Exclusive breastfeeding is practiced by less than one-half of birthing parents at three months postpartum and only one-quarter at six months. These observations call for collaboration among the birthing parent, their partners and families, communities, clinicians, health care facilities, and employers to actively support optimal breastfeeding [7].

We recognize that not all lactating individuals identify as women or mothers. This topic review is focused on lactation and breast/chest-feeding, regardless of the lactating individual's gender identity, family structure, or other social context. Using gender-inclusive language, however, is not possible in all languages and all countries and for all of our readers. Therefore, this topic will use the term "breast" to signify the mammary glands and "maternal" to identify the lactating individual (regardless of gender identity). We encourage clinicians to supportively inquire about their patients' family structure and social supports and to use their preferred pronouns. For additional information on inclusive language during lactation, see the Academy of Breastfeeding Medicine's statement on infant feeding and lactation-related language and gender.

Anticipatory guidance and ongoing counseling and education for new families are discussed below. Detailed discussions on steps to initiate breastfeeding and address common problems of breastfeeding are presented separately. (See "Initiation of breastfeeding" and "Common problems of breastfeeding and weaning".)

FACTORS IN PARENTAL INFANT FEEDING DECISIONS — 

Expectant parents often make decisions about how they will feed their infant very early in pregnancy or before conceiving [8]. Understanding which factors affect parental choices about infant feeding is essential to providing appropriate education and support. In addition, counseling is enhanced by recognizing common misconceptions and barriers about breastfeeding and how to overcome them. Similarly, public resources and policy should be directed at removing and addressing the common obstacles to breastfeeding in a population.

●Intention to breastfeed – Intention to breastfeed is a strong predictor of initiation and duration of breastfeeding [9-11]. Asking about intentions to breastfeed enables the clinician to provide extra counseling and support for those who are hesitant or undecided. New parents are more likely to intend to breastfeed if they have prior successful experience with breastfeeding and if this decision is supported by their family, community, and workplace. Conversely, a parent is less likely to intend to breastfeed if they face economic challenges (lower household income and/or need to return to work), have health problems or "hassles" during pregnancy, are pregnant with twins, are younger, and/or have limited access to health care [12,13].

●Clinician advice – Receiving encouragement from a clinician to breastfeed is associated with a higher incidence of breastfeeding initiation [14]. Moreover, routine ongoing support and guidance during antenatal and postnatal care is associated with longer duration of breastfeeding (exclusive and partial) [15]. This support is optimally tailored to the setting and needs of the individual lactating parent and their community and may include a variety of professional or lay/peer counselors. Unfortunately, many families do not have access to appropriate and accurate guidance about the benefits of breastfeeding [16].

●Common myths about breastfeeding – Several common myths could hinder successful initiation of breastfeeding [17-19]. These include a perception that breastfeeding is inherently painful, that many people are unable to produce sufficient breast milk, and that infants have poor weight gain with breastfeeding. Addressing each of these concerns is an important component of counseling during the antenatal and perinatal periods while the parent(s) solidify their plans about breastfeeding. (See 'Address common concerns' below.)

●Attitudes and social norms – Attitudes and social norms play a large role in a parent's decision about whether to breastfeed and overall breastfeeding success [20]. This includes their perception of whether or not it is acceptable to breastfeed in public. New parents may need help feeling comfortable and empowered to feed their babies in public and may benefit from positive messages and learning strategies to maintain their desired level of modesty while doing so. Exposure to media images, advertising, and positive or negative breastfeeding messages also influence individual decisions about initiation and continuation of breastfeeding [21,22].

•Lost generations – In the late 1970s and early 1980s in the United States, breastfeeding initiation rates were as low as 25 percent [23]. This means that an entire generation of new families, grandparents, and clinicians witnessed most infants consuming formula and few parents even attempted to breastfeed. Now that the importance of breastfeeding is widely recognized [6], new and expectant families need further education about why breastfeeding is recommended and what to expect and clinicians need to develop skills to support breastfeeding; professional support is especially valuable in the first days and weeks postpartum.

•Self-efficacy – Breastfeeding self-efficacy (confidence in one's ability to breastfeed) is a strong predictor of breastfeeding initiation and duration [24]. Accordingly, counseling should be designed to boost the parent's confidence, including methods to confirm that breastfeeding is going well and that the infant is getting adequate nourishment.

●Cultural norms – It is important to practice cultural humility when speaking with a family about infant feeding to find out what is important to them and what their culture believes, teaches, and practices with regard to infant feeding. For example, they may have beliefs about the importance of certain foods or temperatures of foods. Asking about what they know about breastfeeding and what their goals are and why can help determine how best to counsel them.

●Marketing of infant formulas – Marketing of artificial breast milk substitutes (formulas) often has a negative influence on breastfeeding initiation [25]. Marketing messages overtly or covertly intensify parents' anxieties and aspirations (eg, by claiming to solve common infant problems such as reflux or allergies), imply that formulas are very similar to breast milk, make health and nutrition claims based on marginal evidence, and encourage unnecessary use of toddler formula (after 12 months of age) [26-30]. Marketing is accomplished through a variety of platforms that effectively promote formula feeding, including targeted digital marketing methods to consumers and various methods that influence health professionals [31]. Countermeasures, such as professional education and Baby-Friendly Hospital Initiatives, are valuable but often insufficient. Marketing messages reach families in both low- and high-income countries, although the economic and structural drivers, market saturation, and balance between marketing and countermeasures vary substantially [25,32].

PROGRAMMATIC APPROACHES AND PROFESSIONAL RESOURCES

●Baby-Friendly Hospital – The Baby-Friendly Hospital Initiative (a program promoted by the World Health Organization) outlines 10 steps that hospitals and clinicians should take to facilitate successful breastfeeding (table 1) [33]. These include counseling throughout the pregnancy about the benefits of breastfeeding and how to manage breastfeeding, identifying and addressing common concerns, and adopting hospital practices to encourage breastfeeding initiation. (See "Initiation of breastfeeding", section on 'Hospital policy and environment'.)

●Breastfeeding-friendly office environment – Several organizations have recommendations for how to make office practices more supportive or "friendly" for breastfeeding parents. There are data indicating that these types of changes at the practice level can improve rates of breastfeeding initiation and duration [34-36].

●Professional support for breastfeeding – The clinician and practice should develop familiarity and referral relationships with professional resources to support breastfeeding [1,37]. New families need to be aware of all of the ways in which they can receive timely professional help if they encounter a problem with breastfeeding. Timely help is crucial to address any problem before a parent starts supplementing with formula when it is not medically necessary or stops breastfeeding completely.

Examples of professional support include:

•Breastfeeding and Lactation Medicine Doctors/Physicians – Since 2023, the North American Board of Breastfeeding and Lactation Medicine (NABBLM) has certified medical doctors with special training in lactation, designated by the credentials "NABBLM-C." These clinicians are uniquely qualified to diagnose and manage breastfeeding and lactation-related problems.

•Other advanced practice clinicians – Clinicians in a variety of medical fields may develop special expertise in breastfeeding medicine, through affiliation, education, and training with the following organizations:

-American Academy of Pediatrics (AAP) Section on Breastfeeding

-Academy of Breastfeeding Medicine

•International Board-Certified Lactation Consultants (IBCLCs) – Certification as an IBCLC requires collegiate-level health sciences courses, over 90 hours of lactation-specific education, logging 300 to 1000 clinical practice hours, and successful completion of a criterion-referenced examination offered by an independent international board of examiners [38].

•Breastfeeding counselors – For families with basic breastfeeding concerns, breastfeeding guidance can be provided by a certified lactation counselor or certified breastfeeding educator [38]. Certification requires 20 to 120 hours of special training and passing a written examination offered by the training organization.

•Home visiting professionals – Home visits from a nurse, midwife, or postpartum doula with expertise in breastfeeding can help overcome some of the initial challenges with breastfeeding [39-41].

•Comprehensive postpartum follow-up programs – These programs are available in some health care systems and include nurses, pediatric specialists, obstetricians, lactation consultants, and, sometimes, psychologists. This wraparound care has proven to be promising in helping new families get off to a good start with breastfeeding [42,43].

•Telephone support – Telephone support for breastfeeding is available from hotlines such as the National Office on Women's Health Helpline: 1-(800)-994-9662.

●Peer support – The clinician can facilitate peer support by providing a list of available local resources and making referrals when appropriate. Peer support helps facilitate the success of new and expectant parents by promoting breastfeeding as a social norm, enhancing self-efficacy, and encouraging them to reach out for social support and help with breastfeeding problems [44]. Examples of peer counseling include:

•Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in the United States offers breastfeeding peer counselors [45-50]

•La Leche League International groups

•Postpartum Support International

•Depending on locality, there are likely other breastfeeding or postpartum support groups

INITIAL CLINICAL ASSESSMENT AND SUPPORT — 

All birthing parents should have an initial assessment and counseling regarding breastfeeding by a clinician with experience in this area. This could be an obstetrician or midwife, general practitioner or family medicine clinician, pediatrician, or lactation consultant. Ideally, this assessment and counseling should occur at several points during prenatal care and be reinforced in late prenatal or early postnatal visits.

Initial assessment — The initial assessment involves assessing the parent's knowledge about breastfeeding, identifying psychosocial and physiologic risk factors for breastfeeding problems, and providing tailored education to reduce these risks.

●Assess knowledge and concerns – To initiate counseling, it is helpful to start with an open-ended question such as "What have you heard about breastfeeding?" or "What are your thoughts about breastfeeding?" rather than asking "How do you plan to feed your baby?" The open-ended questions help to determine the parent's level of knowledge, comfort, and self-efficacy with breastfeeding, so that the conversation and counseling are tailored to their prior experiences and needs [51].

Identifying any concerns about breastfeeding can help the clinician focus counseling and support. Common concerns include nipple pain or worry that they might not be able to produce enough milk [52]. (See 'Address common concerns' below.)

All birthing parents and their families deserve to be given accurate and current information about the health benefits, recommendations, and management of breastfeeding to make a truly informed decision about infant feeding and then offered all of the education and support needed to achieve their personal feeding goals. (See "Maternal and economic benefits of breastfeeding" and "Infant benefits of breastfeeding".)

●Identify any risks for breastfeeding problems – Risk factors for breastfeeding problems and/or low milk supply are outlined in the table (table 2).

Parents with risk factors for breastfeeding problems or low milk production may benefit from extra lactation support, including prenatal consultation with a lactation consultant and special education and attention during initiation of breastfeeding, as outlined below.

●Breast examination – The breast examination may identify anatomic features that predict increased risk for breastfeeding problems. These patients should be given extra support and monitoring during breastfeeding initiation.

•Insufficient glandular tissue – Rarely, the breasts may have insufficient glandular tissue, as suggested by appearing misshapen, triangular, or widely spaced and "less full" between the areolar complex and the chest wall (figure 1). Although these features are risk factors for insufficient milk supply, they do not consistently predict the likelihood of successful breastfeeding.

For those who may have insufficient glandular tissue, the clinician should provide focused lactation counseling to manage expectations and guidance to optimize the chances of successful breastfeeding. This includes guidance to establish an effective latch from the very start and frequent expression of milk to maximize breast milk production. Even if a parent is unable to produce the quantity of milk needed for exclusive breastfeeding, it is likely that they can at least produce drops of colostrum, which have important health benefits for the baby. The parent can also have a breastfeeding relationship with the infant, offering suckling at the breast for comfort and possibly using a device that allows the infant to get supplemental feeds at the breast while suckling (figure 2).

•Other anatomic risk factors – Prenatal breast assessments are helpful to identify anatomic conditions that may affect latching or milk supply, such as scar tissue, previous surgeries, previous or current nipple piercings, or flat or inverted nipples (picture 1 and figure 3). It is difficult to predict whether these findings will interfere with breastfeeding. However, education and assistance during breastfeeding initiation can optimize the chance of successful breastfeeding. Key goals of counseling are frequent milk removal to maximize the milk supply and techniques to achieve and sustain an effective latch and avoid nipple trauma. (See "Nipple inversion" and "Initiation of breastfeeding", section on 'Flat or inverted nipples'.)

Contraindications to breastfeeding — There are very few contraindications to breastfeeding [5]. Contraindications may be permanent or temporary. In some cases, the infant may be fed expressed breast milk until it is safe to resume direct breastfeeding, as listed in the table (table 3).

Considerations for breastfeeding for a parent with coronavirus disease 2019 (COVID-19) are discussed separately. (See "COVID-19: Intrapartum and postpartum issues", section on 'Breastfeeding and formula feeding'.)

If one of these contraindications exist, the clinician should educate and support the family on how to feed their infant safely and effectively in another manner. If the condition requires only temporary suspension of breastfeeding, the lactating parent will need to express milk frequently with either a breast pump or hand expression to maintain milk supply until it is safe to resume breastfeeding.

Some parents who are unable to proceed with breastfeeding experience disappointment and even guilt. The clinician can help by recognizing and validating those feelings and encouraging the parent(s) to explore other ways to nurture and bond with their infant. (See 'Support for mothers who are not able to fully breastfeed' below.)

Support during breastfeeding initiation — Most birthing parents produce enough milk for their infants if they have appropriate guidance, support, and maternity care. To optimize milk supply and promote direct breastfeeding, key goals are:

●Frequent feeding and emptying of the breast (including hand expression if needed) beginning immediately after birth and then at least 8 to 12 times in each 24-hour period until the breast milk supply is fully established

●Avoid formula supplementation unless medically necessary

●Avoid artificial nipples (bottle feeding)

To achieve these goals, recommended practices include:

●Immediate skin-to-skin contact after birth

●Initiate feeding in the first hour or two after birth, and feed with every cue from the baby

●24-hour rooming-in with the infant to help the parent notice and respond to every feeding cue

●Guidance to achieve a comfortable breastfeeding position(s) and how to achieve an effective latch for every feed

Parents should be encouraged to ask for help with breastfeeding, which may include hands-on assistance with positioning, troubleshooting problems such as nipple pain, and addressing any concerns about whether the infant is feeding well. By observing a feeding and other clinical data, an experienced clinician can determine whether feeding and milk production are progressing as expected and provide appropriate guidance and reassurance. In addition, they should be taught techniques for hand expression of colostrum to provide signaling for their body in the case of a sleepy baby or if they are separated and to ensure optimal intake for the infant.

Details about how to support successful breastfeeding initiation are discussed in a separate topic review. (See "Initiation of breastfeeding".)

Address common concerns

Pain — Pain during breastfeeding is a common concern that can and should be addressed promptly. Pain is usually a signal that the baby is compressing or rubbing the nipple during suckling, which can cause nipple damage and impede milk flow. In most cases, discomfort can be eliminated by minor adjustments in the technique, particularly with regard to the angle that the infant approaches the breast, and how far away the baby's lower lip is from the nipple. Altering the latch even by millimeters can make a huge difference in both comfort and effectiveness of milk transfer. When a parent experiences pain during suckling, they should gently break the seal by inserting a finger at the corner of the baby's mouth, then reposition the baby using techniques to achieve a good latch (figure 4). If the parent experiences recurrent problems, the clinician should directly observe breastfeeding and help adjust the technique. (See "Initiation of breastfeeding", section on 'Evaluating a latch for effectiveness'.)

Feeding a sleepy baby — Healthy babies wake easily and often to feed and should be fed with every feeding cue (eg, stirring, lip smacking, rooting, opening the mouth, turning the head, or sucking on fingers).

A newborn should feed at least eight times in 24 hours and more frequently if they are giving feeding cues. Newborns often feed in "clusters" followed by breaks of up to four hours. In addition, they often fall asleep at the breast because this is where they are most comfortable. To address this, the parent can try to arouse the infant by taking "burp breaks"; changing the diaper; or rubbing the infant's head, back, arms, or feet. Techniques to promote milk flow during the feed (eg, hand expression and breast compression) might also encourage the baby to continue feeding.

Concerns about milk supply — Most birthing parents make enough milk to feed their baby without need for any supplementation. Understanding the normal progression of lactation after delivery will help the parent focus on steps to enhance lactation and shape their expectations about early milk volume. (See "Initiation of breastfeeding".)

In the first few days after birth, the breasts will feel the same as before while they are producing colostrum, which is measured in drops rather than ounces. Colostrum is very concentrated with antibodies and other nutrients and is all that the baby needs for the first few days under normal circumstances. Because the volumes are small, babies will need to feed frequently. Significant milk volume (ounces) should not be expected until day 3 to 4 after birth.

In the meantime, the baby's nutrition and hydration can be monitored by comparing their weight and other signs to typical newborns:

●Healthy infants typically lose weight during the first three to five days of life, and then their weight begins to increase by 15 to 30 g/day to regain their birth weight by 10 to 14 days. All healthy infants should regain their birth weight by three weeks of age [53].

●Infants should be evaluated more closely if they drop below the 75^th percentile curve on the newborn weight loss tool (NEWT) nomogram within the first 48 to 72 hours after birth. (See "Initiation of breastfeeding", section on 'Assessment of intake'.)

●Other signs that warrant close monitoring include difficulty latching on or absence of effective suckling, maternal nipple pain or compression, presence of urate crystals in the diaper, or other signs suggesting dehydration [54,55].

Postpartum exhaustion — Caring for a newborn is exhausting work, with a 24-hour/7-days-a-week schedule. Strategies for self-care can help a parent tolerate and even thrive during this challenging and often overwhelming time. Suggestions to cope with exhaustion and facilitate self-care are summarized in the table (table 4).

In addition, all birthing parents should be screened for perinatal mood and anxiety disorders at each health maintenance visit for at least the first six months after birth. This can be done with a validated screening tool, such as the Edinburgh Postnatal Depression Scale. (See 'Perinatal mood and anxiety disorders' below.)

POSTNATAL MEDICAL SUPERVISION

Frequency of follow-up — Breastfeeding parent-infant dyads should have frequent follow-up with a clinician until breastfeeding is well established. For those who appear to have effectively initiated breastfeeding in the hospital and have no risk factors for breastfeeding problems (table 2), routine follow-up in the primary care office may be sufficient. The initial visit usually should be within 24 to 48 hours after discharge. The timing of subsequent follow-up visits depends on the infant's feeding and risk factors, such as prematurity or excessive weight loss, or any other medical problems. Some infants may need to be seen one or more times again prior to the routine two-week visit. (See "Overview of the routine management of the healthy newborn infant".)

Parent-infant dyads with any problems with breastfeeding and/or poor infant weight gain should be seen more often and may benefit from professional breastfeeding assistance, such as a breastfeeding and lactation medicine clinician or a lactation consultant. (See 'Programmatic approaches and professional resources' above and "Initiation of breastfeeding", section on 'Assessment of intake'.)

Signs that breastfeeding is well established are:

●The infant has regained their birth weight, continues to gain weight well, and is cueing to feed appropriately

●Lactogenesis II has occurred (increase in milk volume to ounces, which typically occurs approximately three to four days postpartum)

●Breastfeeding is not causing nipple pain or discomfort

Once these milestones are reached, follow-up can be performed in the form of check-ins about breastfeeding during routine well-child visits, with additional visits as needed should any problems arise.

Maternal diet — Maternal nutritional needs during lactation and frequently asked questions about diet and weight management are discussed in a separate topic review. (See "Maternal nutrition during lactation".)

Maternal alcohol use — A small percentage of alcohol is transferred into breast milk. The amount of alcohol considered to be "safe" while breastfeeding is controversial. If a breastfeeding parent chooses to drink alcohol, we suggest that they avoid breastfeeding for two hours after a single serving of alcohol (12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof liquor) and four hours for two servings of alcohol [56]. It is not necessary to express and discard milk after consuming alcohol, unless the breasts become uncomfortably engorged before enough time has elapsed for the alcohol to leave the system.

Regardless of how the infant is fed, parents and caregivers should avoid heavy alcohol intake, which can impair judgement and childcare abilities. Further details about the pharmacokinetics and effects of alcohol use during lactation are available in the LactMed database.

Maternal cannabis use — Cannabis metabolites are secreted into breast milk. Effects on the infant's neurodevelopment have been suggested but not established [5,57-61]. We advise avoiding all forms of cannabis during pregnancy and lactation, consistent with the recommendation in the American Academy of Pediatrics (AAP) Clinical Report, based on the available data on potential adverse effects on fetal growth and child development [59]. This applies to either ingestible or inhaled cannabis. Use of inhaled cannabis near the infant has the additional hazard of passively exposing the infant to the secondhand smoke or vapor. Use of topical preparations by a caregiver could expose the infant via direct skin contact.

Of note, cannabis metabolites are often detectable for one or more weeks after the last use [62]. Because of this long half-life, pumping and discarding breast milk is not a useful strategy for cannabis. Written materials to support counseling about cannabis use and breastfeeding include factsheets in multiple languages from the Colorado Department of Public Health. For pregnant and breastfeeding people who are unable to stop cannabis use, referral for further intervention and treatment should be offered. (See "Substance use during pregnancy: Overview of selected drugs", section on 'Cannabis (marijuana)'.)

Although counseling to avoid cannabis use is important, it should be coupled with ongoing encouragement and support for breastfeeding. While advising against cannabis use, the AAP and several other expert groups do not consider cannabis use an absolute contraindication to breastfeeding [63-65].

Maternal medication safety — Most medications are compatible with breastfeeding. Although most medications diffuse into and out of breast milk via their concentration gradient with the maternal serum, the amount transferred is usually quite small and unlikely to adversely affect the infant [5,66,67]. The following general considerations help to guide decisions:

●If the medication could otherwise be prescribed to the infant for a medical condition, it is generally considered safe to take while breastfeeding. The doses transferred via breast milk are generally much lower than the therapeutic doses given directly to an infant.

●The risk of medication toxicity is higher in preterm and ill infants and is low in infants over six months of age [66].

●Infant medication exposure can be minimized by taking the medications after nursing and before prolonged infant sleep. The utility of this approach depends on the half-life of the medication.

●Medications that are highly protein bound, have low lipid solubility, or have large molecular weights do not appreciably enter breast milk.

●Breastfed infants are generally not affected by medications with poor oral bioavailability, such as insulin or heparin.

●Some medications decrease breast milk volume, including dopamine agonists (eg, bromocriptine), decongestants, and estrogens (eg, in hormonal contraceptives). Consider alternative medications if possible to reduce impact on milk production.

●Classes of drugs that are generally not compatible with breastfeeding are statins, amphetamines, ergotamines (antimigraine agents), and chemotherapy agents [5].

●Most analgesics are safe while breastfeeding. Codeine and tramadol should be avoided because they can suppress the infant's respiratory drive, and oxycodone and aspirin should be used with caution. Management of pain during lactation is discussed separately. (See "Overview of the postpartum period: Normal physiology and routine maternal care", section on 'Safety of common analgesics in breastfeeding individuals'.)

The LactMed Drugs and Lactation Database (LactMed), produced by the National Library of Medicine, is a free, authoritative reference for lactation compatibility for prescription and over-the-counter drugs. This resource provides data on potential adverse effects on breastfeeding infants and lactation, case reports of infant exposures, and recommendations for alternative medications. It incorporates data on maternal plasma concentration and protein binding of each drug, size of the molecule, degree of ionization, lipid solubility, and maternal pharmacogenomics. Another useful website for information about medications during lactation is the Infant Risk Center, at Texas Tech University [68].

Detailed discussions about specific classes of drugs can be found in the following UpToDate topics:

●(See "Contraception: Postpartum counseling and methods", section on 'Impact of contraception on breastfeeding'.)

●(See "Safety of infant exposure to antidepressants and benzodiazepines through breastfeeding".)

●(See "Breastfeeding infants: Safety of exposure to antipsychotics, lithium, stimulants, and medications for substance use disorders".)

●(See "Neonatal abstinence syndrome (NAS): Management and outcome", section on 'Feeding'.)

●(See "Hyperthyroidism during pregnancy: Treatment", section on 'Breastfeeding'.)

Maternal anesthesia or radiographic procedures

●Anesthesia – There is no need to discard expressed breast milk after anesthesia. Guidance about perioperative care for breastfeeding women is discussed separately. (See "Preoperative evaluation for noncardiac surgery in adults", section on 'Breastfeeding patients'.)

●Imaging – Breastfeeding does not need to be interrupted when iodinated or gadolinium contrast is administered for radiologic imaging. However, if radiopharmaceuticals or radioactive medications are required, it may be necessary to interrupt breastfeeding temporarily (table 3) [66]. (See "Diagnostic imaging in pregnant and lactating patients".)

Safe sleep and breastfeeding — To minimize the risk for sudden infant death syndrome (SIDS), it is essential that parents follow recommended practices for safe infant sleep, including positioning the infant supine for every sleep; they should always sleep on a separate sleep surface designed for infants and never in an adult bed, waterbed, sofa, or any other soft surface. (See "Sudden infant death syndrome: Risk factors and risk reduction strategies".)

Breastfeeding is associated with a reduced risk for SIDS, in addition to its other infant health benefits [69]. To facilitate breastfeeding while maintaining safe sleep practices, we suggest that the infant sleep in the parent's bedroom but always on a separate sleep surface and not in the adult bed.

Due to exhaustion, it is not uncommon for parents to fall asleep while breastfeeding. For this reason, if they are feeling sleepy, the safest approach is to breastfeed in the adult bed (not a couch, sofa, or chair), but without any pillows, blankets, or soft bedding, and then return the infant to a nearby crib or bassinet after the feeding, as recommended by the AAP [69,70].

Perinatal mood and anxiety disorders — It is important for parents to be aware of the difference between postpartum blues and other more serious disorders such as depression, anxiety, and even postpartum psychosis. All of these disorders can interfere with breastfeeding and are very treatable if recognized and diagnosed. Many of the risk factors for perinatal mood and anxiety disorders can also lead to breastfeeding problems such as extreme maternal exhaustion, history of infertility, and traumatic birth experience. (See "Postpartum blues" and "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis".)

Of note, perinatal mood and anxiety disorders are distinct from dysphoric milk ejection reflex, which is an uncommon condition characterized by unpleasant feelings that occur only with milk letdown and last a few minutes. (See "Common problems of breastfeeding and weaning", section on 'Dysphoric milk ejection reflex'.)

Breastfeeding during a subsequent pregnancy — It is generally safe to breastfeed during a subsequent pregnancy, as well as to "tandem" breastfeed an older infant along with a newborn [71-74]. In fact, these practices are common in many cultures. Mothers with risk factors for pregnancy loss or preterm labor who would like to continue to breastfeed their older child during the pregnancy should discuss the potential risks and benefits with their obstetrical clinician [75]. After the birth, the newborn should be allowed to feed first for each feeding, before offering the breast to the older child, to ensure that the newborn has adequate intake until a good weight gain pattern is established [72,76].

Special situations

Late preterm or early term infants — Mothers of late preterm infants (gestational age 34 to <37 weeks) and some early term infants may need additional support to establish effective breastfeeding and an adequate milk supply. Although these infants are healthy and do not require intensive care, they are immature and should not be expected to be "good breastfeeders" until they reach approximately two to three weeks beyond their original due date. Strategies are designed to empty the breasts frequently and effectively to ensure adequate intake and signaling by the lactating parent's body to promote sufficient milk production. Details are discussed in a separate topic review. (See "Breastfeeding the preterm infant", section on 'Late preterm infants'.)

Twins — Twins and other multiples pose a challenge for new families because they all require frequent feedings and often are born early. The breastfeeding parent may need extra help with positioning the infants at the breast and with general infant care. Tandem nursing (breastfeeding two infants simultaneously) can help by synchronizing the infants' feedings but initially may be awkward and difficult to achieve without assistance. As long as both/all of the infants are going to the breast with every feeding cue, the lactating parent's body will generally adapt and produce the amount of milk that the infants require.

Infant jaundice — All newborns develop jaundice to some extent, which is considered physiologic and may even be protective because bilirubin is a powerful antioxidant. The baseline levels of bilirubin in breastfed infants are higher than in those who are formula feeding; however, unless there is inadequate intake, breastfeeding alone does not cause the bilirubin to rise to pathologic levels. To reduce the risk of pathologic jaundice due to insufficient milk intake, all infants should receive optimal support of breastfeeding from birth to help ensure an adequate milk supply. Infants with jaundice should have focused feeding evaluations to ensure a comfortable, effective latch and milk transfer to ensure adequate intake. Unless there are signs of insufficient intake, infants who are breastfeeding should not require supplementation with anything other than expressed breast milk [54,77]. Breastfeeding should only be suspended in cases of extreme jaundice, in which the bilirubin levels come close to the threshold for an exchange transfusion. (See "Unconjugated hyperbilirubinemia in term and late preterm newborns: Initial management".)

Early-onset pathologic jaundice has multiple potential causes, including hemolysis, infection, and underlying genetic disorders, and requires evaluation and management. (See "Unconjugated hyperbilirubinemia in neonates: Etiology and pathogenesis".)

Infant hypoglycemia — Similar to jaundice, most infants do not develop pathologic hypoglycemia. Measurement of infant blood glucose is recommended only for infants with risk factors for hypoglycemia, such as a diabetic mother, prematurity, or being small for gestational age [78]. Strategies to prevent neonatal hypoglycemia include early breastfeeding within the first hour after birth and frequent feedings thereafter. In addition, it may help to hand express a few additional drops of colostrum after each feeding to feed to the infant and promote milk production. Evaluation and management of neonatal hypoglycemia are discussed separately. (See "Pathogenesis, screening, and diagnosis of neonatal hypoglycemia" and "Management and outcome of neonatal hypoglycemia".)

Relactation or induced lactation — It is possible for a person who has lactated before to reestablish and maintain a milk supply. It is also possible, although more challenging, to induce lactation in people who have not previously lactated. Protocols for inducing lactation are not well studied but typically include both hormonal preparation and breast signaling (nipple stimulation) with pumping [79-82]. The resulting milk production varies but can often support at least partial breastfeeding. These infants require close follow-up to ensure that the infant is getting sufficient milk.

Induced lactation may be particularly valuable for adopting families [5] or other nongestational parents who wish to breastfeed/chestfeed [83,84]. This may include members of same-sex couples or transgender and nonbinary people, including transgender women [85-89]. Because the possibility of induced lactation is not widely recognized, including in the medical community, the clinician should specifically raise this question and offer assistance to adoptive parents or families with nontraditional structures.

Support for mothers who are not able to fully breastfeed — Some people encounter problems with establishing breastfeeding that are beyond their control. The clinician's role is to provide accurate information in a culturally sensitive manner, so that the parent(s) can make a truly informed choice about breastfeeding and to identify and remove barriers to breastfeeding if possible [90]. The clinician should offer their presence, listening skills, expertise, and guidance, so that the parent(s) can fully participate in shared decision-making about breastfeeding.

If breastfeeding is not possible, or if the parent has decided not to breastfeed, the clinician should guide them toward a plan for feeding, bonding, and interacting with the infant that will be as close as possible to meeting their original, personal feeding goals. This process will help to minimize any experience of guilt or shame and ensure that the parent and infant are safe, healthy, and have every opportunity to bond and thrive.

SUPPORT FOR MAINTENANCE OF BREASTFEEDING

Support to maintain milk production — All people who are breastfeeding need a technique to express milk, either by hand or with a manual or electric breast pump, in case they are ever separated from their infant. In general, maintenance of supply requires frequent signaling of the breasts, either with frequent feedings or with milk expression. This frequent signaling can be accomplished by pumping the breasts at least once every time the infant does not breastfeed directly or feeds anything other than expressed breast milk. If milk production is diminishing, increasing the frequency and amount of breastfeeding and/or milk expression for a day or two will usually increase the production within 24 to 48 hours, similar to when an infant feeds more frequently during a growth spurt. Further information on equipment and technique is discussed separately. (See "Breastfeeding the preterm infant".)

General support for ongoing breastfeeding — Recommendations for optimal infant feeding include exclusive breastfeeding for the first six months, followed by continued breastfeeding with the introduction of complementary foods for at least two years [2,5]. However, many parents are unable to meet these targets [6]. In the Infant Feeding Practices Study II, only 32.4 percent of mothers were able to meet their own personal feeding goals and most of those personal goals were shorter than the recommendations [91].

To help new families come as close as possible to these goals for optimal infant feeding, clinicians can take the following steps:

●Recommend breastfeeding, rather than just asking "Are you going to breastfeed or formula feed?" as if they are equal choices

●Encourage new parents to set their own personal goal for breastfeeding duration

●Provide anticipatory guidance for the common obstacles to breastfeeding, such as pain, concern about supply, and return to work or school (see 'Address common concerns' above)

●Reassure new parents that the infant will have frequent checks and feeding evaluations to ensure that they are healthy as they get started with breastfeeding

●Develop skills in evaluating the parent and infant during breastfeeding, noting signs that the latch is effective and comfortable and evidence of milk transfer (see "Initiation of breastfeeding", section on 'Principles of breastfeeding')

●Troubleshoot common problems such as latch difficulties or nipple pain, and provide assistance if needed (see "Common problems of breastfeeding and weaning")

●Adhere to the recommendations for a breastfeeding-friendly office (see 'Programmatic approaches and professional resources' above)

●Collaborate and communicate with local obstetrical providers and maternity care centers to ensure that evidence-based best practices are in place

●Become a role model in the community, and advocate for lactation support in the workplace, support mothers breastfeeding in public, and elicit community support

This guidance should ideally be part of each routine visit while the infant is breastfeeding. To maintain a positive therapeutic relationship, all discussions should be nonjudgmental, focused on problem-solving, include accurate information, and respect the parent's informed decision concerning the feeding plan for their infant. With optimal education and support, the vast majority of parents are able to breastfeed their babies.

Return to work — Returning to work is a known challenge for initiation of breastfeeding and duration of continued breastfeeding [7,92]. The clinician should provide anticipatory guidance about strategies to continue breastfeeding while working, pumping and expressing milk, and navigating workplace laws and accommodations and offer solutions for pumping and expressing in various different types of workplace environments [93].

Suggested guidance for parents who plan to return to work includes:

●Consider a gradual return to work, such as starting at the end of the week and then having the weekend to recover and troubleshoot any concerns, or working part-time for a period of time.

●Make sure that there is an effective and efficient way to express breast milk on a regular basis while at work. A high-quality, dual-electric breast pump is ideal but not required. A practical approach is to check with the health care insurer to determine which pumps are covered. Some breastfeeding parents prefer the newer, hands-free pumps that allow greater flexibility. A manual pump or hand expression may suffice if there are cost constraints or limited access to electrical outlets in the workplace.

●If a breastfeeding parent is uncertain about where and when to pump while at work, encourage them to ask a supervisor or human resources representative [94].

●Recommend milk expression at least once for every time the baby feeds other than at the breast.

●Suggest keeping a blanket that smells like the baby nearby and a picture or video of the baby to view when pumping to help trigger the let-down reflex.

●Review the current guidelines for milk storage. When possible, fresh refrigerated breast milk (pumped the day before) should be used rather than frozen breast milk because this helps to preserve some of the beneficial properties of breast milk, including some of the live cellular components that help to prevent infection. The composition of breast milk changes over the infant's different developmental stages, and using fresh refrigerated milk ensures that the infant receives the milk that is optimally suited to their stage. However, frozen milk is also nutritious and, for practical reasons, it is helpful to keep a few days' supply of expressed breast milk in the freezer for emergencies.

●Encourage use of local lactation support resources and working mother support groups.

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Breastfeeding and infant nutrition".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Breastfeeding (The Basics)" and "Patient education: Deciding to breastfeed (The Basics)" and "Patient education: Common breastfeeding problems (The Basics)" and "Patient education: Pumping and storing breast milk (The Basics)" and "Patient education: Health and nutrition during breastfeeding (The Basics)" and "Patient education: Medicines and breastfeeding (The Basics)" and "Patient education: Weaning from breastfeeding (The Basics)")

●Beyond the Basics topics (see "Patient education: Breastfeeding guide (Beyond the Basics)" and "Patient education: Deciding to breastfeed (Beyond the Basics)" and "Patient education: Common breastfeeding problems (Beyond the Basics)" and "Patient education: Pumping breast milk (Beyond the Basics)" and "Patient education: Health and nutrition during breastfeeding (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Breastfeeding education – Routine ongoing support and guidance during antenatal and postnatal care are associated with longer duration of breastfeeding (exclusive and partial). This support is optimally tailored to the setting and needs of the population and individual patient and may include a variety of professional or lay/peer counselors. (See 'Factors in parental infant feeding decisions' above.)

●Initial assessment – During prenatal care or early postnatal visits, all birthing parents should have an initial assessment by a clinician with expertise in breastfeeding. This involves:

•Assessment of the parent's knowledge about breastfeeding, to identify psychosocial and physiologic risk factors for breastfeeding problems (table 2), and providing tailored education to reduce these risks.

•Breast examination to identify anatomic differences in the breasts that may complicate breastfeeding, including flat or inverted nipples (picture 1 and figure 3) or hypoplastic breasts, which are rare (figure 1) but may require extra breastfeeding support. (See 'Initial clinical assessment and support' above.)

●Contraindications to breastfeeding – There are very few contraindications to breastfeeding (table 3). In some cases, the contraindication is temporary and the infant may be fed expressed breast milk until it is safe to resume direct breastfeeding. (See 'Contraindications to breastfeeding' above.)

●Common concerns

•A common concern is that breastfeeding is inherently painful, which is not the case. "Tugging," "pressure," and an unfamiliar sensation are common. Nipple pain or compression are not normal and require immediate attention because they usually indicate that the latch is ineffective and that milk flow is impaired. The clinician should address this concern by observing a feeding and providing guidance and assistance during breastfeeding initiation to ensure proper technique, including an effective latch (figure 4).

•Counseling during breastfeeding initiation can also help with other common concerns, including feeding a sleepy baby, ensuring sufficient milk supply, and addressing maternal exhaustion (table 4). (See 'Address common concerns' above.)

●Postnatal supervision – Postnatal medical supervision for breastfeeding includes advice on safe infant sleep, monitoring for perinatal mood and anxiety disorders, and addressing any breastfeeding problems as they arise. (See 'Postnatal medical supervision' above and "Common problems of breastfeeding and weaning".)

●Medications and breastfeeding – Most, but not all, therapeutic drugs are compatible with breastfeeding. The safest medications are those that are safe to administer directly to an infant and those that are not orally bioavailable. The LactMed database is a free online database with reliable information about medication compatibility. (See 'Maternal medication safety' above and 'Maternal anesthesia or radiographic procedures' above.)

●Situations requiring additional attention – Early and focused guidance to optimize breastfeeding is particularly important for certain infants, including those born late, preterm, or early term; twins; or those with other risk factors for breastfeeding problems as well as for those with jaundice or hypoglycemia. The clinician should also be aware of the possibility of inducing lactation for a nongestational parent, including adoptive parents, members of same-sex couples, or transgender and nonbinary people. (See 'Special situations' above.)

●Long-term support to maintain breastfeeding – A majority of families do not meet targets for sustained breastfeeding, which are exclusive breastfeeding for the first six months followed by continued breastfeeding with complementary foods for at least two years. To help new families come as close as possible to these goals, the clinician should ensure that the lactating parent has an effective technique for breast milk expression to establish and maintain milk production when breastfeed directly is not possible and provide anticipatory guidance about strategies to continue breastfeeding while returning to work or other activities. (See 'Support for maintenance of breastfeeding' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Richard J Schanler, MD, and Debra C Potak, MD, who contributed to earlier versions of this topic review.