Prevention of breastfeeding tragedies.

Although successful breastfeeding confers compelling advantages to infants and mothers, inadequate breastfeeding can result in critical infant failure-to-thrive and hypernatremic dehydration. Potential catastrophic infant outcomes can occur when enthusiastic promotion of breastfeeding outpaces necessary support services and management. Such cases often involve underlying maternal and infant breastfeeding risk factors, made deadly by parental and professional misconceptions and knowledge deficits or health care system failures. An early follow-up visit a few days after discharge allows at-risk infants to be identified before they lose excessive weight and at a time when intervention can easily correct most breastfeeding problems before they become complicated by insufficient milk. Those who enthusiastically promote breastfeeding for its many health benefits must confront the reality of breastfeeding failure and implement necessary changes in medical education and support services to foster successful outcomes in breastfed infants.

Clinical aspects of lactation. Promoting breastfeeding success.

Human milk is universally recognized as the preferred nutrition for infants. Exclusive breastfeeding is ideal for approximately 6 months of life, and continued breastfeeding complemented by solid foods is recommended throughout the baby's first year, and longer if desired. This article offers counseling strategies to help physicians promote successful breastfeeding, beginning with effective prenatal education and a screening breast exam to detect lactation risk factors. Optimal initiation of breastfeeding is reviewed, including supportive hospital practices, correct breastfeeding technique, and the regulation of milk production. The early follow-up of the breastfeeding infant and criteria for assessing the successful initiation of breastfeeding are discussed. Practical strategies are offered for preventing and managing common lactation difficulties, such as postpartum breast engorgement, sore nipples, mastitis, maternal employment, and impaired let-down.

The optimization of breast-feeding in the perinatal period.

Mounting scientific evidence documents the diverse health benefits of successful breast-feeding for infants and mothers. The trend toward earlier discharge of newborns, however, has been linked with adverse outcomes in breast-fed babies, including hypernatremic dehydration and hyperbilirubinemia. This article reviews practical strategies for promoting the successful initiation of breast-feeding, beginning with effective prenatal education and a screening breast exam to detect lactation risk factors. Supportive hospital practices are discussed, including the Baby-Friendly Hospital Initiative and correct breast-feeding technique. The importance of regular, effective removal of milk for continued milk production is explained. The early follow-up of infants after hospital discharge and the use of specific maternal and infant criteria to assess the onset of breast-feeding can readily identify mother-baby pairs who require timely intervention to improve breast-feeding outcome.

The management of breast feeding among infants with phenylketonuria.

Treatment for phenylketonuria (PKU) involves using low phenylalanine-free or phenylalanine-free formulas and supplementation with sufficient phenylalanine for normal growth and development. Eighteen infants with phenylketonuria who received breast milk as their primary phenylalanine source were compared with ten other infants with PKU who received their phenylalanine primarily from infant formulas. There were no significant differences between breast-fed and formula-fed infants for serum phenylalanine, serum tyrosine, length, weight, head circumference, haematocrit, haemoglobin, serum iron, total iron binding capacity, percentage iron saturation, ferritin, plasma zinc and total calorie intake. Breast-fed infants did show lower mean corpuscular volume at 3 months and 6 months of age. Breast-fed infants had lower phenylalanine intake at 2, 4, 5 and 6 months of age. Breast-fed infants at 1, 2, 3, 4, 5 and 6 months of age had lower protein intake. Breast feeding may be continued in the newly diagnosed phenylketonuric infant without any apparent adverse nutritional consequences.

Nutrient intake by breast-fed infants during the first five days after birth.

The intakes of milk and specific nutrients during the first 120 hours after birth were measured in 11 full-term, breast-fed infants. Infants were test weighed at all feeds using an electronic balance, and milk samples were obtained from both breasts one to three times daily. Milk was analyzed for levels of fat, protein, lactose, calcium, sodium, and potassium; energy content was calculated using the Atwater factors. The average (+/- SD) intake of milk in the first 24 hours after birth was 13 +/- 16 g/kg (range, 3 to 32 g/kg), increasing to 98 +/- 47 g/kg (50 to 163 g/kg) and 155 +/- 29 g/kg (110 to 196 g/kg) on days 3 and 5, respectively. Mean daily intakes of energy, lactose, calcium, and potassium were less than 12% of the mean day 5 intake on day 1 and less than 25% of the day 5 intake on day 2. In the first few days after birth, the nutrient intake of the solely breast-fed infant is highly variable and is frequently low.

Medical management of successful breast-feeding.

Despite the present climate of professional and lay enthusiasm for breast-feeding, many women experience problems in the initiation of lactation, either because of misinformation, secondary lactation difficulties, or primary failure of lactation. This article provides pediatricians with practical guidelines for the successful initiation of breast-feeding and the prevention and early detection of problems. Recommendations are made for optimal prenatal preparation for breast-feeding, intrapartum routines that facilitate lactation, appropriate early follow-up of nursing infants, and the management of the full normal course of breast-feeding.

Lactation failure due to insufficient glandular development of the breast.

With the present increased incidence of breast-feeding, clinicians need to be prepared to identify and manage problems in lactation. Most problems are related to insufficient knowledge, inappropriate routines, and lack of confidence and are easily managed or prevented by prenatal education, anticipatory guidance, and adequate support. Increasing evidence exists that primary causes of lactation failure also occur and can preclude successful lactation, even among highly motivated women. Three cases are presented in which lactation failure is believed to stem from insufficient glandular tissue within the breasts. Supportive history for this entity include absence of typical breast changes with pregnancy and failure of postpartum breast engorgement to occur. Associated physical findings included a unilateral underdeveloped breast in each woman and palpable patchy areas of glandular tissue in one case. Breast diaphanography, or transillumination, substantiated clinical findings in the two cases in which it was performed. Both multiparous women had a previous unsuccessful breast-feeding experience, whereas the primiparous woman had immediate family members with a history of lactation failure. All three women benefited psychologically from the interpretation that lactation failure was not due to their breast-feeding performance, and each elected to continue nursing long-term despite the need for formula supplement. These cases are presented to emphasize that primary causes of lactation failure do exist and to alert clinicians to the historical and physical findings suggestive of inadequate glandular tissue as an etiology of previously unexplained lactation failure. Preserving the "every woman can nurse" myth contributes to perpetuating a simplistic view of lactation and does a disservice to the small percentage of women with primary causes of unsuccessful lactation.

Oxidative metabolic response and microbicidal activity of human milk macrophages: effect of lipopolysaccharide and muramyl dipeptide.

Mouse macrophages can be primed by exposure in vitro to the bacterial products lipopolysaccharide and muramyl dipeptide (MDP) or in vivo by injection of MDP, so that they produce more of the bactericidal agent superoxide anion (O2-) when stimulated by phagocytosis or by contact with phorbol myristate acetate (PMA). Because little is known about the physiology of human tissue macrophages, we examined release of O2- by milk macrophages obtained from 45 normal women for the ability to undergo priming for greater O2- release. In samples from the same individuals, PMA-stimulated O2- release was similar from colostrum (0 to 3 days postpartum) or from transitional milk (5 to 8 days). Release of O2- by milk macrophages was almost identical to that by blood monocytes from the same women. Milk macrophages phagocytized and killed Candida albicans relatively effectively. Incubation with lipopolysaccharide activated the macrophages in that they were primed for greater PMA-stimulated O2- release. Incubation with the adjuvant MDP or its analog 6-O-(2-tetradecylhexadecanoyl)-MDP did not prime, but incubation with a second analog, 6-O-(stearoyl)-MDP, primed the macrophage for greater O2- release. These results indicated that human tissue macrophages can be primed for greater oxidative response by exposure to bacterial products. Potential exists for the therapeutic use of such immunomodulating agents in the enhancement of host defense.

Contemporary breast-feeding management.

This article updates clinicians in the successful initiation and practical management of nursing couples. Routine breast-feeding anticipatory guidance is provided, and specific problem-solving techniques offered for commonly encountered lactation problems. The physiologic basis of normal lactation is emphasized and related to specific problems. Issues addressed include the management of lactation in the presence of maternal employment, infant failure-to-thrive, maternal drug therapy, and infant prematurity.

Returning to breast-feeding.

PIP: Given the basic prejudice that breastfeeding is superior to bottle feeding, this article outlines proper behavior of clinicians in educating, supporting, and preparing mothers who want to breastfeed their infants. The discussion is broken down into clinician's behavior in the prenatal, intrapartum, and follow-up periods of breastfeeding practice. Prenatally, the obstetrician should educate the mother and should examine the woman for contraindications to breastfeeding, taking care to correct those which are correctable (such as psychological blocks on the part of the mother to handling her breasts or physiological problems with nipple construction). The only absolute contraindications to breastfeeding are maternal hepatitis and maternal herpes simplex virus type 1. During the intrapartum period, physicians should make the mother aware of breastfeeding techniques. In this article, hints on what to do when confronted with engorgement, nipple confusion, sore nipples, jaundice, twin birth or caesarean birth, prematurity, retained placenta, and other infectious diseases are provided. In all cases, lactation should proceed. Topics affecting follow-up include the practice of prolonged lactation for contraception (ineffective) and the weaning of children. A special section on working and nursing counsels women that the 2 functions are not mutually exclusive.^ieng