Adequacy of milk intake can be assessed by voidingand stooling patterns of the infant. A well-hydrated infantvoids six to eight times a day. Each voiding should soak, notmerely moisten, a diaper, and urine should be colorless. By5 to 7 days, loose yellow stools should be passed at least fourtimes a day. Rate of weight gain provides the most objectiveindicator of adequate milk intake. Total weight loss after birthshould not exceed 7%, and birth weight should be regained by10 days. The mean feeding frequency during the early weekspostpartum is 8 to 12 times per day. An infant may be adequately hydrated while not receiving enough milk to achieveadequate energy and nutrient intake. Telephone follow-up isvaluable during the interim between discharge and the firstdoctor visit to monitor the progress of lactation. A follow-upvisit should be scheduled by 3 to 5 days of age, and again by 2 weeks of age.
In the newborn period, elevated concentrations of serumbilirubin are present more often in breastfed infants than in formula-fed infants (Chapter 62). Feeding frequency duringthe first 3 days of life of breastfed infants is inversely relatedto the level of bilirubin; frequent feedings stimulate meconium passage and excretion of bilirubin in the stool. Infantswho have insufficient milk intake and poor weight gain in thefirst week of life may have an increase in unconjugated bilirubin secondary to an exaggerated enterohepatic circulationof bilirubin. This is known as breastfeeding jaundice. Attention should be directed toward improved milk productionand intake. The use of water supplements in breastfed infantshas no effect on bilirubin levels and is not recommended.
0 Rate of initiation Rate of 6 months Rate of exclusive of breastfeeding of any breastfeeding breastfeeding for 6 months
Figure 27-1 The 2010 and 2020 Healthy People Targets and the current 2012 rates of breastfeeding initiation, 6 months of any breastfeeding, and 6 months of exclusive breastfeeding in the United States.
After the first week of life in a breastfed infant, prolongedelevated serum bilirubin may be due to presence of anunknown factor in milk that enhances intestinal absorptionof bilirubin. This is termed breast milk jaundice, which is a diagnosis of exclusion and should be made only if an infantis otherwise thriving, with normal growth and no evidenceof hemolysis, infection, biliary atresia, or metabolic disease(Chapter 62). Breast milk jaundice usually lasts no morethan 1 to 2 weeks. The American Academy of Pediatrics recommends vitamin D supplementation (400 IU/day startingsoon after birth), and, when needed, fluoride after 6 monthsfor breastfed infants.
Breast tenderness, engorgement, and cracked nipples arethe most common problems encountered by breastfeedingmothers. Engorgement, one of the most common causes oflactation failure, should receive prompt attention because milk supply can decrease quickly if the breasts are not adequately emptied. Applying warm or cold compresses to thebreasts before nursing and hand expression or pumping ofsome milk can provide relief to the mother and make the areola easier to grasp by the infant. Nipple tenderness requiresattention to proper latch-on and positioning of the infant.Supportive measures include nursing for shorter periods,beginning feedings on the less sore side, air drying the nipples well after nursing, and applying lanolin cream after eachnursing session. Severe nipple pain and cracking usually indicate improper latch-on. Temporary pumping, which is well tolerated, may be needed. Meeting with a lactation consultantmay help minimize these problems and allow the successfulcontinuation of breastfeeding.