Breast Is Best for Babies 

Alexander K.C. Leung, MBBS, FRCPC, FRCP (UK & Irel), FRCPCH 
and Reginald S. Sauve, MD, FRCPC Calgory, Alberta, Canada 
Breastfeeding is the optimal method of infant feeding. Breast 
milk provides almost all the necessary nutrients, term feeding 
erand The role growth include prevention development; 
insulin-dependent lution ing maternal are breast after the 
Breastfeeding. breast however, milk, breastfeeding, 
Baby-FrendlyOHospital is United management not to is delivery 
infant less of cancer. play discussed. theinfant, engorgement, 
factors reduction contraindications mothers the ingestion 
expensive is Nations of in contraindicated uterus, needs. 
promoting as allergies; and From Healthcore and the possible. 
include and Breasffeeding diabetes of of Children's prevention 
of enhanced World immunological theeconomic Other common than 
incidences reduction medications sore Initidtive posible and 
lactation To Health to formula professionals nipples, mellitus. 
advantages promote, breasffeeding. protecting Fund in bonding 
breasffeeding of in infants enhancement (BFHI) should and 
obesity, Organization incidence perspective, amenorrhea, and 
(UNICEF) feeding. mostitis components Health severity 10Steps 
protect with be between maternal breastfeeding. have of 
hypertension initiated gains and developed galactosemia. of 
Breastfeeding, breastfeeding In issues, an of toSuccessful and 
ovarian most of breastfeed- (WHO) insufficient early infections; 
for the important a infections cognitive healthy 
as support such breast- cases, moth- invo- 
soon 
and and 
and 
the as 
support Key words: breasffeeding U advantages U promote U 
© and reprint K.C. (403) 2005. Leung, the 230-3322; requests From University 
#200,233-16th the e-mail: for Department ofCalgary, J NatI aleung@ucalgary.ca 
Med Ave. Calgary, of Assoc. NW, Pediatrics, Calgary, 2005;97:1010-1019 
 Alberta. the Alberta Send Alberta T2M correspondence Children's OH5, to: Dr. 
Canada; Alexander Hospital and 
fax: 

breastfeeding been the is feeding is exclusivity fessionals 

iarize and lems shown universally beneficial The medical be 
well associated themselves well that advantages for 
documented who the ofbreastfeeding profession's benefits 
versed to accepted is first deal the withbreastfeeding. 
clear withvarious ofbreastfeeding mother-infant year with in 
and increase the in as of obligation lactating the 
unequivocal. the handling life up literature.'-5 optimal 
aspects and to with six dyad.'-5 mothers thereafter in are 
ofpotential months.6 the the method ofbreastfeeding 
Healthcare many Breastfeeding duration promotion Studies 
must as and As of long famil- infant 
prob- such, have 
have 
pro- and as 
of 
prolactin period, produce tion Prolactin, high the tant 
tocin tocin the usuallydescribed more At breast mother 
growth gland, gen amounts alveoli as feedback secrete 
stimulation PHYSIOLOGY the The Endocrine this release 
areolar and factor of levels is normal causes that mother's 
stimulates to the milk. empties and the time, released 
progesterone first significant at ofprolactin, contract 
inhibitor which maintains alveolar in ofprolactin area. of 
anterior fromsuckling.7 the proliferation Lactation it the 
levels an half control estrogen alveolar her is This 
baseline ongoing by as myoepithelial is the andpropel the of 
breast, structure of at pituitary the atingling amounts OF 
secreted the decline is milk removal secretory about 
pregnancy which lactation duringpregnancy and and cell 
posterior supplanted of supply LACTATION release levels the 
 Inresponse ejection the progesterone, receptor interfere 
three abruptly milkto and ofmilk. gland by sensation. more 
stimulates of ductal of cells in cells ofprolactin the 
pituitary formation of milk months is by milk.8 the milk 
(let-down releases prolactin level. the with anterior 
characterized in system, The autocrine in surrounding to (in 
milk) the milk isproduced.8 is the suckling, the The which 
the As postpartum.8 most particular, gland. inhibited 
postpartum of very alveoli alveoli sinuses the return 
reflex) from arboriza- action more pituitary is lobules. 
control impor- inhibit 
nipple estro- 
Oxy- large 
oxy- 
the 
the the by 
by 
of to 
to 
to in is 
a 
1010 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 7, JULY 2005 
 
BREAST IS BEST ADVANTAGES OF BREASTFEEDING Nutritional 
Considerations ofprotein, for and K min-D whey/casein mately 
mulas than hand, which the brain. brosides, adequate of Whey 
milk may found mately renal may human absorption which cose 
are glycerol amounts soft in are from leaving flora 
linolenic acids and at the human Human The Triglycerides, 
Lactose optimal growing present readily K.9"10All 
cholesterol. flocculent birth, be lead casein, and than in 
needing solute the (docosahexaenoic stomach. in Human 
proteins in range one-third are supplementation renal 
18:82.10 essential milk. the a lower by turn which 
galactose, source to of amounts wider milk acid), in milk 
and carbohydrates, accounts and growth, in poorly gut. 
dehydration.' broken load infant. which lipase. essential 
newborn whole ratio through solute helps much to milk 
Lactose concentrations breastfed are The is promotes are The 
curds contains Lactose of margin excrete that helps for 
long-chain the approximately of acidified forms Glucose of 
vitamin essential tolerated prevent with Human ensures amino 
important down load cow's whey/casein higher premature for 
ofwhole methionine main whole that fatty infants 18:82, to 
enhances most the a of the metabolizes infants acid tough, 
protect of until the fat, into acids large milk. are D. the 
concentrations is constituent safety acids milk a 
tobraindevelopment. human exception in appropriate cow's of 
polyunsaturated should growth an by supply 60:40 and 
minerals in The cow's more sources the growth the infants. 
free hard-to-digest the taurine solute should essential 
human These the 72:28, and provides some ratio (linoleic 
calcium arachidonic stomach, whey/casein in diet milk milk 
carbohydrates or infant's fatty milk. easily receive 
ofgalactocere- of phenylalanine, situations readily 
ofvitamins of of in load, and of On 100% amino receive and 
milk."I provides infants, whereas lactobacilli, proportions 
is is pathogenic fuel infant energy acids The milk in 
 generous the and acid approxi- digested vitamins 
approxi- cysteine forming 
kidneys vitamin 
thereby human to for whey. curds 
small acids other 
acid) fatty vita- 
ratio 
fats, iron 
glu- that for- 
and 
and are the 
the for an 
in D 
Table 1. Drugs during Usually Breasffeeding 
Contraindicated 
3. 4. 2. 5. 6. 1. Tetracycline Cytotoxic 
Illegal Chloramphenicol Radioactive Phenindione 
drugs of agents 
abuse 

necessary ration tions highly the higher phosphorous, term 

human milk iron calcium of ofthat ofgrowth.'3 in fortifiers 
slightly the lactoferrin.'2 Although Human Milk human (0.3 
may and very infants.'0 of in concentrations bioavailable, 
milk lower and from whole the are enhanced mg/L be for milk 
milk premature To alone human phosphorous available 
required.9"'0"14 gastrointestinal energy concentrations 
mothers compared correct cow's is also to Approximately For 
absorbed, does 1 immune milk contains mg/L), possibly 
metabolism, the infants, milk. of in the of not powdered 
fat, has to very preterm content Commercial nutritional 
function. meet compared protein milk iron of only 
nucleotides, tract, fortification because lactose, premature 
50% the in growth a form and or infants enzymatic small and 
human high liquid of to inadequacies the of human calcium 
mothers sodium the about amount and which the ofhuman 
presence 
demands contains 
infants, 
form.'3 milk iron matu- lower reac- 
milk 10% 
and but are 
of of 
in is 
prevent macrophages breast nates vision the Breastfeeding 
tract tion,'920 Anti-infective divided components, levels 
concentrations immungolobulins, complements, dase, and Human 
ofgastrointestinal Immunological The growth epidermal 
infection,4"17 in oligosaccharides, in of milk protective 
meningitis,2' milk human the into colostrum, local of is 
growth contains cellular and decreases bifidus growth 
lactobacillus produced.'5 protection including but milk 
otitis neutrophils, properties lysozyme, tract in Advantages 
and of septicemia and activated factor. glucosamines, 
factor, or and media,7",8 pathogenic infection,'6 vitamin 
the they plays humoral to T Humoral incidence the bifidus, 
Secretory nucleotides, persist interferon, of and a are 
andnecrotizing forms mucosal vital human B12 urinary at 
lower factors. flora B-lymphocytes, in binding factors 
especially which which role and/or for IgA milk milk 
lactoperoxi- membrane. 
tract respiratory lactoferrin, in in as predomi- 
promote Cellular 
helps in the the severity include long protein can infec- 
 lower 
ente- high 
pro- 
gut. be 
as 
to 
Table 2. Signs in the of Successful Early Weeks 
Breasffeeding 
2. 3. 4. 5. 6. 7. 1. Satisfactory Audible At At At Urine Infant 
least least least pale alert two six eight swallowing 
and wet and weight bowel feedings diapers odorless active 
movements gain per per day day 
per day 
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 7, JULY 2005 1011 
 
BREAST IS BEST 

rocolitis.22 actively stimulates There is the also immune 

evidence system that ofthe breastfeeding infant.23 
Prevention of Allergies tion, um, ry proteins hastens 
gen.30Finally, development mechanisms. gut, Colostrum 
Breastfeeding an maternal infant's Transfer infant tion 
avoidance the tects during asthma dren.27'28 ingested 
oftenrecommended.27 IgE incidence studies exclusive solid 
sibly infant's Breastfeeding and development and thereby 
thereby to epidermal foods prevent, against stimulates the 
(n=8,183) gastrointestinal atopy.24-26 rates maturation 
gastrointestinal a of Because and by positive of IgA 
breastfeeding gastrointestinal first of also (until 
cell-mediated strengthening atopy the preventing during 
several allergenic Colostrum ofallergic the reduces thus the 
to months prevents growth mother IgA of six A suggests 
development does family the onset in small preventing of 
atopic meta-analysis months childhood.25 studies infants 
synthesis Infants the infant, intestinal have of tract 
factor foods of the with history are is diseases.29 
infections the amount amounts life tract the that disease. 
immunity food responsible have entrance with ofage) a from 
excreted adherence with delayed is thereby mucosal 
protective by present exclusive in and an of of mucosa 
associated allergy shown a In lactating the of elevated 
absorbing atopy Breastfeeding allergy genetic allergic 
passively of may of Thus, high-risk may foreign infant.29 of 
from introduction in in 12 protecting barrier food for that 
of in breastfeeding large delay, are and effect human breast 
lead prospective an cord pathogens. predisposi- 
sealing some by mothers with mother response. protein 
respirato- at antigens. transfers 
epitheli- antigens 
allergy- In infants, foreign to several risk or to on serum 
 lower 
milk, 
addi- milk chil- 
anti- pos- 
pro- 
the the the the 
for 
to of 
in is 
preventive a reduction effect in the ofbreastfeeding number 
ofinfections may be in the secondary infant. 
to 
Enhanced Cognitive Development tion the and Anderson ies 
opment infants infants.3' function findings fed sible status 
Children effect that and cognitive of confounding and 
breastfeeding formula-fed reported score" comparing 
(n=7,081) The may than et maternal al. who meta-analysis 
outcome. last performed was children unadjusted are well 
variables, cognitive infants.3' education, 3.16 breastfed 
compared correlated into A points who a recent adulthood.32 
meta-analysis also such After and development have the are 
found higher study with covariate-adjusted with as adjusting 
"cognitive higher formula-fed.3' socioeconomic that 
development suggests formula-fed in on breastfed of 
cognitive the for 11 breast- devel- 
dura- stud- 
pos- 
that 32 
Prevention of Obesity tus, ty that had mation hood ined 
eight founders.33 associated to Breastfeeding hypertension 
been had prevalence a showed obesity moderate on a breastfed 
the The morbidity, sample a may exclusivity three lower of 
extent.33-35 and reduces obesity after size persist 
"negative" hypercholesterolemia.33 risk such controlling 
of.100 the ofobesity in ofbreastfeeding.33 as Of into 
children risk type-2 11 studies per adult of studies for 
childhood in feeding >3 diabetes potential children obesity 
lacked years that 34 
group, 
Child- exam- 
melli- of obesi- 
infor- 
with con- who age 
milk Prevention Diabetes An protein association and Mellitus 

of risk between Insulin-Dependent 

for insulin-dependent early exposure to diabetes cow's 
Table 3. Ten Steps to Successful Breasffeeding 
Every facility or agency providing maternity services and care 
of newborn infants should: 
1. Have a written breastfeeding policy that is routinely 
communicated to all health-care staff. 2. Train all health-care 
staff in skills necessary to implement this policy. 3. Inform 
all pregnant women about the benefits and management of 
breastfeeding. 4. Help mothers initiate breastfeeding within a 
half-hour of birth. 5. Show from their mothers infants. 
how to breastfeed and how to maintain lactation even if they 
should be separated 
6. Give newborn infants no food or drink other than breast milk 
unless medically indicated. 7. Practise rooming-in (allow 
mothers and infants to remain together 24 hours a day). 8. 
Encourage breastfeeding on demand. 9. Give no artificial teats 
or pacifiers (also called dummies or soothers) to breastfeeding 
infants. 10. from Foster the the hospital 
establishment or 
clinic. 
of breastfeeding support groups and refer mothers to them on discharge 
Adapted WHO/UNICEF from: statement. WHO/UNICEF. Int J Protecting, Gynaecol Obstet. 
promoting 1990:31 and (suppl supporting 1):1 71-183.72 
breastfeeding: The special role of maternity services. A joint 
1012 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 7, JULY 2005 
 
BREAST IS BEST 

mellitus which tein, Bovine ical destruction Destruction 

ment ucts surface of ance first insulin-dependent Pediatrics 
response containing year p of of then 69.3637 serum 
commercially of diabetes has of beta cross-reacts by life of 
recommends in The been albumin exposing beta intact 
genetically in cells mellitus. diabetes expression families 
reported cells available cow's is may with believed them may 
breastfeeding The mellitus.38 
provoke with susceptible milk a of beta-cell in cow's lead 
to American this a protein many immune to strong to an milk 
protein mediate the immunolog- surface individuals, 
studies.3637 
and during history Academy and develop- attack.37 on avoid- 
prod- their pro- the 
the of 
Prevention of Hypertension tion against recent months Hg and 
There reduction may in study, blood ofbreastfeeding, high 
have is evidence Martin in pressure, blood important 
systolic et pressure that al. though blood public the 
breastfeeding found children pressure.41 in health small, 
that later for implications.4 had is life.394' may every 
significant The a 0.2-mm protect 
reduc- three In a 

may Gastrointestinal Prevention Several 

prevent studies or of delay have Certain 
Diseases the suggested onset of that celiac breastfeeding 
disease, 
Crohn's can mend conditions studies be that made. are 
disease breastfeed mothers necessary Nevertheless, and with 
exclusively before ulcerative a family it a definitive is 
colitis.42-44 prudent for history six months. 
 conclusion to of Further recom- these 
may drome.4546None for sure.3 Prevention Death Several the 
be Thus, sleeping protective Syndrome 
studies a casual ofthe position of have against Sudden 
relationship studies, suggested and sudden household 
however, Infant 
remains that infant has breastfeeding 
smoke unproven. 
death controlled expo- syn- 
Maternal Health Benefits between lactation weight and 
Hormonal ducted group decreased ing, from every decrease 
Health breast early 47 12 found loss, in epidemiological of 
amenorrhea, months breastfeeding by gains Factors 
cancer.30,47-49 30 involution 7% and that 4.3% countries 
(5-9; for protection the ofbreastfeeding in (95% 
breastfeeding Breast p<0.0001) relative decreased The of and 
CI to studies the Collaborative against 2.9-5.8; Cancer 
examine breast risk uterus, for postpartum (n=50,302) 
mothers of in each ovarian combined p<0.0001) cancer.50 
breast addition the postpartum birth. Group relation include 
cancer 
cancer bleed- 
con- data 
The 
to The for on 
a 
Table 4. Summary of the WHO/UNICEF Subsequent International WHA 
Code Resolutions 
of Marketing of Breast Milk Substitutes and 
1. No advertising of products under the scope of the Code to the 
public. 2. No free samples to mothers. 3. supplies. 
No promotion of products in health-care facilities, including 
the distribution of free or low- cost 
4. No company representatives to advise mothers. 5. No gifts or 
personal samples to health workers. 6. product. 
No words or pictures idealizing artificial feeding, including 
the pictures of infants on the labels of the 
7. Information to health workers should be scientific and 
factual. 8. All and information all costs and on hazards 
artificial associated feeding, including with artificial the 
labels, feeding. 
should explain the benefits of breastfeeding 
9. Unsuitable products, such as sweetened condensed milk, should 
not be promoted for babies. 10. All the products country where 
should they be of are a high used. 
quality and take into account the climatic and storage 
conditions of 
11. food or Foster maintenance or appropriate drink given of 
complementary before breastfeeding. 
complementary feeding feeding from the is age nutritionally of 
about required six months, may recognizing interfere with that 
initiation 
any 
12. and Ensure sustained that complementary breastfeeding. 
foods are not marketed for or used in ways that undermine 
exclusive 
13. support Financial for assistance breastfeeding from the and 
infant should feeding be avoided. 
industry may interfere with professionals' unequivocal 
* Organization: WHO: World 
International Health 
Organization; Code of UNICEF: Marketing United of Breast-Milk Nations Children's 
Substitutes, Fund; WHO, WHA: Geneva, World 
Health 1981 and Assembly; subsequent Adapted WHA from resolutions.73 
World Health 
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 7, JULY 2005 1013 
 
BREAST IS BEST 

the maternal-infant longer ed against mother women breast a 

breastfeed, sense bonding. 
cancer. of fulfillment the Breastfeeding more they and are 
also enhances protect- gives 
Economic Benefits various less is also savings 
environmentally From expensive promotes illnesses for the 
medical economic child-spacing.30 
than in friendly. formula breastfed care. perspective, 
Exclusive The feeding. infants decreased breastfeeding 
Breastfeeding breastfeeding translate rates into of is 

TO POTENTIAL BREASTFEEDING 
CONTRAINDICATIONS 
Drugs the breastfed theirhigh city, For cated in 
clofazimine, ganciclovir, lants, salts, on can ed 
1).3,10305152 only during some Generally, usually the 
maternal metronidazole should antidepressants, during small 
limited breastfed lactation excretion child. In be 
cyclosporine, addition, amounts lactation, lamotrigine, 
drugs be dosage.30 found. number Several avoided infants as 
into given and Bromocriptine it in lithium, tetracycline, 
may a the of Most human drugs, salicylates safe and 
anticonvulsants, to drugs ergotamine, breast during inhibit 
nursing may alternative drugs prozac, however, milk, that 
milk be milkproduction.'0 sulfa lactation may should mothers 
ofconcern.'0'52-55 are usually are and amniodarone, 
mefloquine, 
have drugs, medication safe contraindi- because anticoagu- 
their be <1% appear effects (Table 
avoid- in toxi- 
gold the of of 
Environmental Chemical Agents nents, chemical Maternal is 
not agents, a exposure contraindication such to as low-level 
organochlorine to breastfeeding.56'57 
environmental compo- 
Maternal Infections breastfeed adequate provided but 
untreated tact feeding.58 traindications breastfeeding from 
infants agents Neonatal In Tuberculosis can with most an 
during have be by therapy infected their active their 
Mothers transmitted cases, breastfeeding already herpes the 
to at infants, infants is tuberculosis breastfeeding. and a 
prodromal maternal mother.3 rarely time with been are virus 
only by when regardless considered transmitted is active 
exposed exposure As infection after infections 
counterproductive.58 period, should antibodies such, For 
they tuberculosis to most of noninfectious.3 and by to not 
mothers the have can the are the breast to infections, be 
infectious are mode not interrupt 
received be sputum in being milk 
very with con- 
con- 
may of tions ness the them there ple."8 nipple, transmitted 
nancy through tries, not when ensured and death ment the a 
as cumstances virus quate feeding should severe. range 
possible Human majority primary breastfeed fed and to are 
where is infection it children If breast if or breastfeeding 
be no is Nevertheless, decide breastfeeding substantially to 
they a of uninterrupted death.62 breastfeeding. not 
recommended herpetic to active them, to from socioeconomic 
immunodeficiency and causes infectious ofwomen milk promote 
fulfilled-in are women their born what can supporting In the 
not herpetic they substitutes most of continue infants.60 to 
lesion mother is breastfed.6' is who increases is women 
death and while are most diseases a The 
contraindicated.58'59 access 5_20%.58 countries, mother that 
lesions are at is particular, protect them conditions, to 
transmission during appropriate In breastfeeding, offering 
that present less living HIV-infected HIV-positive, her 
developing to children's virus and in with When are In risk 
on infant nutritionally breastfeeding theirchoice. policy 
infancy, with malnutrition developed or safely as on in 
(HIV) of active near much these and during for an rate or 
HIV illness must risk countries, provided 
prepared 
their environ- artificial near enabling mothers the the of 
can herpes condi- 
choice can of coun- cover preg- HIV 
ade- nip- 
aim and 
cir- the 
are 
ill- 
for be 
be 
Certain Metabolic Disorders Because lalanine-free glycemia. 
in ciency degrade infants supplemented excluded of infants 
the In Infants infants liver, may of breast phenylalanine 
from with phenylalanine As with be mental formula with such, 
with partially galactosemia. 
the phenylketonuria, milk diet galactosemia, an 
breastfeeding retardation, and is approximate breastfed 
early low are via hydroxylase, closely in in the life 
phenylalanine, provided cataracts because galactose tyrosine 
is amount to monitored.58 
contraindicated avoid are of they and unable ofpheny- 
pathway. cirrhosis the must can hypo- defi- 
such be 
be to 
Breast Cancer probably breastcancerdoes lactin ofprolactin 
is in still the A mother levels in breastfed dispute.63 
should in remain with stimulating not female On notjustify a 
high breastfeed newly the during offspring other the 
diagnosed avoidingbreastfeeding.63 growth hand, lactation, 
her of infant the ofbreast a breast fear women and since 
ofcancer the cancer cancer 
with pro- role 

MANAGEMENT BREASTFEEDING OF ISSUES 

COMMON 
Breast Engorgement 
Postpartum engorgement is a transitory condition 
1014 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 7, JULY 2005 
 
BREAST IS BEST 

be to due prevents result warm flow ing. or such enhance 

pumping prevented Management to as and in and lymphatic 
ibuprofen, discomfort, difficulty adequate maternal cold 
before by early, compresses includes may and nursing, in 
milk comfort.2 difficulty latch-on.f4 vascular effective 
sometimes flow. rest to and The soften and in congestion, 
and Engorgement Engorgement establishing be use mild hand 
frequent necessary.2 
the of analgesics, alternating expression breast which nurs- 
milk 
and can 
can 
weaning, whelms the waiting ting Milk Oversupply Hyperactive 
infant the Ejection infant for the from gas the infant. to 
and the milk let-down the or Reflex 
breast breast Management breast.T4 Overactive 
flow when to refusal may slow result let-down includes when 
down in before milk occurs premature removing over- 
put- and 
Plugged Ducts milk breast.65 white be with cation mild, 
Plugged frequent supply, spot ofheat Clinically, local on 
ducts a the nursing and tenderness. tight nipple massage may 
bra a plugged in result or or avariety Treatment incomplete 
as towards a from duct breast ofpositions.65 
the may an consists lump. emptying nipple, overly manifest 
There ofappli- together copious of may as the a 
Inverted Nipples breastfeeding nipple mother 
breastfeed.30'66 the before the as of the the Infants infant 
nipples infant degree feeding into with will are the between 
to inverted ofinversion experts breastfed overcome Treatment 
to grasp mouth, help the believe nipples the the and flat 
there areolar consists does thumb nipples or not that should 
 inverted is not nipple-fed. tissue proper no and ofgently 
stand affect reason not index and nipples. up.30 latch-on 
the be draw As rolling able why ability 
finger Some long 
the 
of to a 
Sore Nipples present, poor breastfeeding mouth with 
Engorgement may cracked can Nipple be also positioning each 
managed on should nipples soreness the contribute feeding 
nipple, and and, be by and and treated monilial is proper 
and breast if often to alternating latch-on uncorrected, 
optimizing nipple appropriately. 
positioning  the  infection.30  infections  result  of  soreness 
nursing  the  oftrauma  nipple  infant  ofthe  may  of  Sore  the 
which, positions lead nipples infant's 
care.765 during 
nipple from 
to 
if 
Mastitis ence Approximately mastitis.30 Predisposing 1-5% of 
nursing factors mothers include experi- a 
Klebsiella decrease milk causative commonly, Treatment 
breastfeeding, gesics inadequate supply, and in organism 
antibiotics.65 
pneumoniae nursing consists drainage it cracked may rest be 
frequency is and nipples of in Staphylococcus caused a and 
heat, the mother judicious Streptococcus and leading by 
massage, fatigue.2 with Escherichia to aureus.2 use an milk 
continued The abundant 
of species. stasis, 
usual 
anal- Less coli, 
Monilial Infection breast ed monilial burning and Both 
monilial infant.65 ant sists with Monilial cases, areolae 
oftopical the or pain nipple The vaginitis infection in 
mother ketoconazole the also infection in condition 
application infant's damage, the may and during is nipples 
diagnosed be of the mouth.2 
red usually the use or pregnancy infant ofnystatin when 
fluconazole and nipple ofantibiotics, on itchy. presents 
nursing. should either has and cream. Treatment been can 
thrush be the The as treated maternal associat- 
In mother's be intense, nipples 
resist- in used. con- the 
if 
Breast Abscess tied or consists and should mastitis Breast 
analgesics. by continue gentle of abscess complicating 
incision mechanical The to may feed and affected result from 
drainage, a plugged pumping, from the breast opposite 
untreated antibiotic duct.65 should and breast.65 
Treatment the be mastitis therapy 
infant emp- 
Mammoplasty breastfeed whether areola augmentation In 
general, are the completely nerve after breastfeeding 
surgery and reduction severed.66 
blood or mastopexy.2 supply is surgery usually tothe The 
possible depends nipple ability with and on to 
Insufficient Milk breast pumping mammary after maternal more 
With milk recommended If mother's lying always once 
compression dose there Insufficient production, every cause 
reduction may common a emptying, correct continued is milk 
diet, and no be hypoplasia/aplasia, two should can the 
production improvement or increased dose milk the in hours, 
 surgery, heavy and use primiparous be anxiety, be latch 
problem may ofdomperidone used this treated ofdomperidone 
should smoking.7'67 first. be to is infrequent may to 
sufficient exhaustion, secondary 30 of within ifpossible. be 
increase Frequent be women." supply, mg postmastectomy 
encouraged. worth The a QID. or is for few may to milk 20 
nursing, mechanical condition a incomplete One inadequate 
The the congenital trial.2 Once days, mg increase supply. 
baby under- should 
Breast 
QID. The 
the the i.e. or 
to is 
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 7, JULY 2005 1015 
 
BREAST IS BEST 

Table 5. Role of Physicians in Promoting and Protecting 

Breasffeeding 
1. Promote, support and protect breastfeeding enthusiastically. 
In consideration of the extensively 
published evidence for improved health and developmental 
outcomes in breastfed infants and their mothers, a strong 
position on behalf of breastfeeding is warranted. 2. Promote 
breastfeeding as a cultural norm and encourage family and 
societal support for 
breastfeeding. 3. Recognize the effect of cultural diversity on 
breastfeeding attitudes and practices and encourage variations, 
if appropriate, that effectively promote and support 
breastfeeding in different cultures. 4. Become knowledgeable and 
skilled in the physiology and the current clinical management of 
breastfeeding. 5. Encourage development of formal training in 
breastfeeding and lactation in medical schools, in 
residency and fellowship training programs, and for practicing 
pediatricians. 6. Use every opportunity to provide 
age-appropriate breastfeeding education to children and adults 
in 
the medical setting and in outreach programs for student and 
parent groups. 7. Work collaboratively with the obstetric 
community to ensure that women receive accurate and sufficient 
information throughout the perinatal period to make a fully 
informed decision about infant feeding. 8. Work collaboratively 
with the dental community to ensure that women are encouraged to 
continue 
to breastfeed and use good oral health practices. 9. Promote 
hospital policies and procedures that facilitate breastfeeding. 
Work actively toward 
eliminating hospital policies and practices that discourage 
breastfeeding. Encourage hospitals to provide in-depth training 
in breastfeeding for all healthcare staff and have lactation 
experts available at all times. 10. Provide effective breast 
pumps and private lactation areas for all breastfeeding mothers 
in 
ambulatory and inpatient areas of the hospital. 11. Develop 
office practices that promote and support breastfeeding by using 
the guidelines and 
materials provided by the American Academy of Pediatrics 
Breastfeeding Promotion in Physicians' Office Practices program. 
12. Become familiar with local breastfeeding resources so that 
patients can be referred appropriately. 
When specialized breastfeeding services are used, the essential 
role of the pediatrician as the infant's primary healthcare 
professional within the framework of the medical home needs to 
be clarified for parents. 13. Encourage adequate, routine 
insurance coverage for necessary breastfeeding services and 
supplies, including the time required by pediatricians and other 
licensed healthcare professionals to assess and manage 
breastfeeding and the cost for the rental of breast pumps. 14. 
Develop and maintain effective communication and coordination 
with other healthcare 
professionals to ensure optimal breastfeeding education, 
support and counseling. 15. Advise mothers to continue their 
breast self-examinations on a monthly basis throughout lactation 
and to continue to have annual clinical breast examinations by 
their physicians. 16. Encourage the media to portray 
breastfeeding as positive and normative. 17. Encourage employers 
to provide appropriate facilities and adequate time in the 
workplace for 
breastfeeding and/or milk expression. 18. Encourage child care 
providers to support breastfeeding and the use of expressed 
human milk 
provided by the parent. 19. Support the efforts of parents and 
the courts to ensure continuation of breastfeeding in separation 
and custody proceedings. 20. Provide counsel to adoptive 
mothers who decide to breastfeed through induced lactation, a 
process requiring professional support and encouragement. 21. 
Encourage development and approval of governmental policies and 
legislation that are supportive 
of a mother's choice to breastfeed. 22. Promote continued 
basic and clinical research in the field of breastfeeding. 
Encourage investigators 
and funding agencies to pursue studies that further delineate 
the scientific understandings of lactation and breastfeeding 
that lead to improved clinical practice in this medical field. 
Adapted from: Section on Breastfeeding, American Academy of Pediatrics. 
Breastfeeding and the use of human milk. Pediatrics 2005;1 15:496-506.77 
1016 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 7, JULY 2005 
 
BREAST IS BEST 

mula, mula gain decreased. isfactory weight is the indicated 

or dose Supplementation ifthe without of ifthe infant 
domperidone having infant's appears to with supplement 
weight to an can be appropriate dehydrated.65'67 gain be 
gradually with is unsat- for- 
for- 
jaundice, that been milk not breastfeeding by possible. milk 
nal acids, when mentation avoided, caloric level Milk ing 
dice" of culation Breastfeeding is severity ing.3069 lated 
ing.44 Breasffeeding associated breastfeeding Two 
encouraging be milk are increases jaundice reaches effects 
production, The implicated appropriate, due Jaundice 
f-glucuronidase interrupted This types intake ofjaundice 
recognized. as The itself. of caloric known to with this 
latter of with 425 bilirubin ofjaundice infrequent jaundice 
second affects or jaundice intestinal early reduces 
Pregnane-3a, water may mothers deprivation starvation.69 
step as leading as one unless and can and breastfeeding the 
The breast 2-4% increase type would or by or or 
breastfeeding and be and can associated bilirubin the or 
more possible to glucose early to "breast-nonfeeding first 
reduced is Breast of a be ineffective nurse milk 
unconjugated cause the and minimize later Breastfeeding 
factor the breastfed factors prevented 20f-diol, type 
optimal infant's reduced jaundice. enterohepatic jaundice. 
onset, water absorption byphototherapy, as culprits.68'69 
with the in is frequency frequently in human the breastfeed- 
early-onset 
breastfeed- breastfeed- 
infants jaundice.44 prolonged 
the decreased should frequency free or bilirubin accumu- 
Supple- treated 
should Breast 
mater- jaun- 
fatty 
have milk 
The 
and and cir- 
be as 
tion.30 mouth palate.10 two vides overlying as While may 
rants be infant important on dle for food, feeding 
frequently successful time Ideally, and continued the 
position, year not a at comfort Enough mutually it careful 
first to adequate least for The meet continued of is permit 
in used the infants possible breastfeeding life complete six 
time the through football with all assessment of for months 
should collecting positions desire.5 milk establishment the 
these the for the should the for that tongue suckling areola 
the milk intake position be mother of criteria, addition as 
Breastfeeding a first encouraged.7" that life.5 ofthe are be 
healthy, long ducts transfer should for to exclusively work 
should 12 and Breastfeeding listed of and compress failure 
the situation. as of months an against the be breastfed 
infant. the well complementary side-lying varies. effective 
be in in to infant mother for unrestricted Table are the and 
do the breastfed The the Signs the the so infant's breast- 
should areola and infant latch- 
posi- 
2.30,70 most 
hard 
war- 
first cra- 
and of is 
with manual nursing.2 reasonable may level.69 aged occur 
positive to These expression maintain When if level, the and 
nursing unconjugated the breastfeeding gmol/L. 
lactation enthusiastic during serum mothers Bilirubin the 
bilirubin using bilirubin period may support should a be 
breast encephalopathy decreases of resumed.2'68 be and 
exceeds interrupted provided pump encour- to that or 
a 
establishing avoided, hours feeding interfere hour cessful 
aged including seems WHEN delivery Breastfeeding after to or 
interested. breastfeeding.53 ofwater, nurse as as AND more 
with during birth.2 these possible, a lactation.5'0 on 
results good HOW fluids glucose the should Frequent Delaying 
cue, preferably night, milk in tend usually Mothers TO water 
a be supply.2 Proper lower for to feeding breastfeeding 
initiated BREASTFEED mute or as within 10-12 should formula 
incidence long positioning the Supplementary is as the 
important times as be soon the first for encour- of a infant 
after half- four suc- 
day, 
in 
appetite should pro- and be job-sharing bytheAmericanAcademy 
breastfeeding pumps moting pital priate tles, replace 
rooming-in, problems, have ue Breastfeeding mation workplace 
otherpossibilities.78'79 atricians/family WHO A WHO/UNICEF 
Assembly structured ofbreastfeeding.7477 agement, should 
local area.78 feeding.72 Breast-Milk seeks PROMOTING 
BREASTFEEDING breastfeeding To Babyfriendlyg soothers been 
Initiative marketing to policies promote, Working and 
promote about and or breast protect advice The shown 
educational UNICEF arrange to (WHA) and protecting or proper 
Substitutes legislation be and milk. resources suggested 
arranging mothers (BFHI) that mothers peer protect, 
physicians adoption breastfeeding and ofbreast breastfed 
after International to complimentary AND to hospital 
resolutions improve advice Physicians Interventions, 
developed support clearly counseling The they have 
breastfeeding programs, 10 should and affectingbreastfeeding 
may and to or 10 ofinternational, milk role ofPediatrics 
Steps return there.78 SUPPORTING are to do support the steps 
support the to subsequent consider support overcome should 
urged some substitutes, by ofpediatricians the Code help 
should be infant (Table initiation to to and postpartum are 
preventing foods Working given Babyfriendly® such Successful 
mothers work.78 groups breastfeeding, work has to 
ofMarketing listed the breastfeeding.79 encouragement 
provide adhere brought (Table 4).72 follow as breast-related 
been World when the use and national feeding at antepartum 
Physicians in and part-time, The to names home ofbreast 
inappro- 
5). duration support, 
outlined Table encour- the Breast- used contin- in to in 
Health to infor- 
Pedi- Hos- 
code 
their 
pro- bot- 
rec- and 
the the 
are the 
of of 
to 3. 
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 97, NO. 7, JULY 2005 1017 
 
BREAST IS BEST 

ommendations ment aged to for have breastfeeding. 

theiroffilces so as to Physicians provide 
breastfeeding-friendly. 
an should optimal be environ- encour- 
ACKNOWLEDGEMENTS and with authors Michael The Sauve 
permission article Chu would in for the has from expert like 
Canadian been STA to secretarial published thank 
Communication Journal Nancy assistance. 
in ofDiagnosis,1'2 part Quon by Inc. Leung The and 
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