Madonna and Child, School of Bruges, Flemish, 15th century colored drawing. (Reproduced with permission from Memorial Art Gallery of the University of Rochester.) Breastfeeding A GUIDE FOR THE MEDICAL PROFESSION Seventh Edition Ruth A. Lawrence, MD Professor of Pediatrics, Obstetrics, and Gynecology Department of Pediatrics University of Rochester School of Medicine and Dentistry Rochester, New York Robert M. Lawrence, MD Clinical Associate Professor Pediatric Immunology, Rheumatology, and Infectious Diseases Department of Pediatrics University of Florida College of Medicine Gainesville, Florida 3251 Riverport Lane Maryland Heights, Missouri 63043 Breastfeeding: A Guide for the Medical Profession ISBN: 978-1-4377-0788-5 Copyright © 2011 by Mosby, an imprint of Elsevier Inc. 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Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identifed, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. The Publisher Previous editions copyrighted 1980, 1985, 1989, 1994, 1999, 2005 Library of Congress Cataloging-in-Publication Data Lawrence, Ruth A. Breastfeeding : a guide for the medical profession / Ruth A. Lawrence, Robert M. Lawrence. -- 7th ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4377-0788-5 (pbk. : alk. paper) 1. Breastfeeding. 2. Breast milk. 3. Lactation. I. Lawrence, Robert M. (Robert Michael), II. Title. [DNLM: 1. Breast Feeding. 2. Lactation. 3. Milk, Human. WS 125] RJ216.L358 2011 649′.33--dc22 2010034029 Acquisitions Editor: Judith Fletcher Developmental Editor: Joanie Milnes Publishing Services Manager: Anne Altepeter Team Manager: Radhika Pallamparthy Senior Project Manager: Beth Hayes Project Manager: Preethi Kerala Varma Design Direction: Ellen Zanolle Printed in the United States of America. Last digit is the print number: 9 8 7 6 5 4 3 2 1 In loving memory of John Charles Lawrence March 5, 1966, to October 9, 2008 and Robert Marshall Lawrence, MD June 28, 1923, to August 13, 2005 —Ruth A. Lawrence Sincerely dedicated to all of the health professionals who continue to support women in their efforts to breastfeed their children —Robert M. Lawrence Foreword The 5 years since the publication of the sixth edition she will, after about 30 minutes, gradually crawl up of this excellent book have been a time of incred- to the mother’s breast, fnd the nipple, self-attach, ible advances in understanding several previously and start to suckle on his or her own. unknown physiologic and behavioral processes It would appear that each of these features—the directly linked or associated with breastfeeding and crawling ability of the infant, the absence of crying beautifully described in this new volume. when skin-to-skin with the mother, and the warm- These fndings change our view of the mother- ing capabilities of the mother’s chest—evolved infant relationship and signal an urgent need to com- genetically more than 400,000 years ago to help pletely review present perinatal care procedures. preserve the infant’s life. These new research results include the observation Research fndings related to the 1991 Baby that, when an infant suckles from the breast, there Friendly Hospital Initiative (BFHI) of WHO and is a large outpouring of 19 different gastrointestinal UNICEF provided insight into an additional basic hormones, including cholecystokinin, gastrin, and process. After the introduction of the BFHI, which insulin, in both mother and infant. Several of these emphasized mother-infant contact with an oppor- hormones stimulate the growth of the baby’s and tunity for suckling in the frst 30 minutes after birth the mother’s intestinal villi, thus increasing the sur- and mother-infant rooming-in throughout the face area for the absorption of additional calories hospital stay, there has been a signifcant drop in with each feeding. The stimulus for these changes neonatal abandonment reported in maternity hos- is touching the nipple of the mother or the inside of pitals in Thailand, Costa Rica, the Philippines, and the infant’s mouth. The stimulus in both infant and St. Petersburg, Russia. mother results in the release of oxytocin in the peri- A key to understanding this behavior is the obser- ventricular area of the brain, which leads to produc- vation that, if the lips of an infant touch the mother’s tion of these hormones via the vagus nerve. These nipple in the frst half hour of life, the mother will pathways were essential for survival thousands of decide to keep the infant in her room 100 minutes years ago, when periods of famine were common, longer on the second and third days of hospital- before the development of modern agriculture and ization than a mother whose infant does not touch the storage of grain. her nipple in the frst 30 minutes. It appears that The discovery of the additional signifcance of these remarkable changes in maternal behavior are a mother’s breast and chest to the infant comes probably related to increased brain oxytocin levels from the studies of Swedish researchers who have shortly after birth. These changes, in conjunction shown that a normal infant, when dried, placed on with known sensory, physiologic, immunologic, the mother’s chest, and covered with a light blan- and behavioral mechanisms, attract the mother and ket, will warm or maintain body temperature as well infant to each other and start their attachment. As as an infant warmed with elaborate, high-tech heat- pointed out in the ffth edition, a strong, affection- ing devices. The same researchers found that, when ate bond is most likely to develop successfully with infants are skin-to-skin with their mothers for the breastfeeding, in which close contact and interac- frst 90 minutes after birth, they hardly cry at all tion occur repeatedly when an infant wishes and at compared with infants who are dried, wrapped in a pace that fts the needs and wishes of the mother a towel, and placed in a bassinet. In addition, the and the infant, resulting in gratifcation for both. researchers demonstrated that if a newborn is left Thus breastfeeding plays a central role in the devel- quietly on the mother’s abdomen after birth he or opment of a strong mother-infant attachment when vii viii   Foreword begun with contact immediately after birth, which 2. C hristensson K, Siles C, Moreno L, et al: Temperature, metabolic adaptation and crying in healthy newborn cared in turn has been shown to be a simple maneuver to for skin-to-skin or in a cot, Acta Paediatr Scand 81:488, 1992. signifcantly increase the success of breastfeeding. 3. U vnäs-Moberg K: The gastrointestinal tract in growth and All of these exciting fndings provide further evi- reproduction, Sci Am 261:78, 1989. dence of why breastfeeding has been so crucial in 4. W idström AM, Ransjo-Arvidson AB, Christensson K, et al: Gastric suction in healthy newborn infants: effects on circu- the past and deserves strong support now. lation and developing feeding behavior, Acta Paediatr Scand In addition, the past few years have been associ- 76:566, 1987. ated with fundamental biochemical fndings, includ- 5. W idström AM, Wahlberg V, Matthiesen AS, et al: Short- ing the importance of docosahexaenoic acid (DHA) term effects of early suckling and touch of the nipple on in optimal brain development. All in all, the many maternal behavior, Early Hum Dev 21:153, 1990. 6. K laus M, Klaus P: Academy of Breastfeeding Medicine new observations described in this seventh edition Founder’s Lecture 2009: maternity care re-evaluated, Breast- place milk and the process of breastfeeding in a key feed Med 5:3, 2010. position in the development of many critical func- tions in human infants and their mothers. We salute John H. Kennell the author for her special skill in bringing together Marshall J. Klaus these many unique and original observations in this new and most valuable book. SUGGESTED READING 1. C hristensson K, Cabrera T, Christensson E, et al: Separa- tion distress call in the human neonate in the absence of maternal body contact. In Kyllike Christensson: Care of the Newborn Infant: Satisfying the Need for Comfort and Energy Conser- vation [thesis]. Stockholm, 1994, Karolinska Institute. Preface Almost four decades ago, work began on the frst the American Academy of Pediatrics reaffrmed that edition of this text. Much has changed in the feld position in 2005 and again in 2010. The health care of human lactation and in the world at large. The provider can promote these goals most effectively trickle of scientifc work on the subject has swol- when armed with suffcient information. len into a river overfowing its banks. The Lactation The intent of this volume is to provide the basic Study Center at the University of Rochester has tools of knowledge and experience that will enable more than 40,000 documents on fle that describe a clinician to provide the thoughtful counseling and peer-reviewed scientifc studies and reports, and guidance to the breastfeeding family that is most there are thousands more unfled documents that applicable to that particular breastfeeding dyad and recount individual experience and anecdotal reports its circumstances, problems, and lifestyle. No pro- of events. The feld has abandoned the dogma tocol should ever replace thinking, however. of rules about breastfeeding that demanded rigid As the feld has become more complex, it is sched uling and specifc management to a period in clear that one of the most diffcult issues centers which thoughtful contemplation and recognition on infection in the mother or infant and sometimes of the variability of the human condition are key. both. Robert Michael Lawrence, MD, Clinical Well-trained, skilled clinicians recognize the value Associate Professor of Pediatrics and Immunology of fexibility and the individualization of care. The at the University of Florida College of Medicine, Baby Friendly approach, which was conceived to has again produced the chapters on immunology set women free from rigid dicta, requires protocols and infectious disease, as well as Appendix F, to and policies. Mothers tell their doctors that they bring the most accurate information in these areas cannot breastfeed because there are too many rules, to these pages. He has also assisted in the editing an impression created by overzealous teaching of of many other chapters. The drug database and too much detail. Medicine, in the era of managed Appendix D, Drugs in Breast Milk and the Effect care, has come forth with care guidelines for one on the Infant, has been thoroughly revamped. disease or circumstance after another. Will breast- Dr. Miriam Labbok MD, MPH, Professor of the feeding be next? Practice of Public Health, University of North In 1994, the Academy of Breastfeeding Medi- Carolina, provided careful review of the chapter cine was founded for the promotion and support of on contraceptive issues. The thousands of queries breastfeeding. It is designed to provide physicians to the Lactation Study Center at the University of around the world and from every discipline a forum Rochester have served as a basis for new topics and for scientifc learning and discussion about breast- new clinical discussions. feeding and human lactation. Its members form a The seventh edition has stepped into cyber- nucleus of medical professionals dedicated to the space. Gone are the days when cut and paste meant advancement of breastfeeding. In December 1997, cut with scissors and paste with glue. A process that the American Academy of Pediatrics proclaimed used to be simple is much more complicated, now with renewed energy that mothers should breastfeed requiring the expertise of computer wizards. David for 6 months exclusively and then continue breast- Lawrence (my son, Rob’s brother) entered every feeding while introducing weaning foods through chapter onto disc. Felicia Fernandez Lawrence, the frst year and for as long thereafter as desired by his talented wife, created the extensive tables and mother and infant. The Section on Breastfeeding of charts, keyboarding with the speed of sound from ix