Allattamento materno

TITLE:
Breastfeeding and the use of human milk.

SOURCE(S):
Pediatrics 1997 Dec;100(6):1035-9 [111 references]

MAJOR RECOMMENDATIONS:
Recommended Breastfeeding Practices

Human milk is the preferred feeding for all infants, including premature and sick newborns, with rare exceptions. The ultimate decision on feeding of the infant is the mother's. Pediatricians should provide parents with complete, current information on the benefits and methods of breastfeeding to ensure that the feeding decision is a fully informed one. When direct breastfeeding is not possible, expressed human milk, fortified when necessary for the premature infant, should be provided. Before advising against breastfeeding or recommending premature weaning, the practitioner should weigh thoughtfully the benefits of breastfeeding against the risks of not receiving human milk.

Breastfeeding should begin as soon as possible after birth, usually within the first hour. Except under special circumstances, the newborn infant should remain with the mother throughout the recovery period. Procedures that may interfere with breastfeeding or traumatize the infant should be avoided or minimized.

Newborns should be nursed whenever they show signs of hunger, such as increased alertness or activity, mouthing, or rooting. Crying is a late indicator of hunger. Newborns should be nursed approximately 8 to 12 times every 24 hours until satiety, usually 10 to 15 minutes on each breast. In the early weeks after birth, nondemanding babies should be aroused to feed if 4 hours have elapsed since the last nursing. Appropriate initiation of breastfeeding is facilitated by continuous rooming-in. Formal evaluation of breastfeeding performance should be undertaken by trained observers and fully documented in the record during the first 24 to 48 hours after delivery and again at the early follow-up visit, which should occur 48 to 72 hours after discharge. Maternal recording of the time of each breastfeeding and its duration, as well as voidings and stoolings during the early days of breastfeeding in the hospital and at home, greatly facilitates the evaluation process.

No supplements (water, glucose water, formula, and so forth) should be given to breastfeeding newborns unless a medical indication exists. With sound breastfeeding knowledge and practices, supplements rarely are needed. Supplements and pacifiers should be avoided whenever possible and, if used at all, only after breastfeeding is well established.

When discharged <48 hours after delivery, all breastfeeding mothers and their newborns should be seen by a pediatrician or other knowledgeable health care practitioner when the newborn is 2 to 4 days of age. In addition to determination of infant weight and general health assessment, breastfeeding should be observed and evaluated for evidence of successful breastfeeding behavior. The infant should be assessed for jaundice, adequate hydration, and age-appropriate elimination patterns (at least six urinations per day and three to four stools per day) by 5 to 7 days of age. All newborns should be seen by 1 month of age.

Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth. Infants weaned before 12 months of age should not receive cow's milk feedings but should receive iron-fortified infant formula. Gradual introduction of iron-enriched solid foods in the second half of the first year should complement the breast milk diet. It is recommended that breastfeeding continue for at least 12 months, and thereafter for as long as mutually desired.

In the first 6 months, water, juice, and other foods are generally unnecessary for breast-fed infants. Vitamin D and iron may need to be given before 6 months of age in selected groups of infants (vitamin D for infants whose mothers are vitamin D-deficient or those infants not exposed to adequate sunlight; iron for those who have low iron stores or anemia). Fluoride should not be administered to infants during the first 6 months after birth, whether they are breast- or formula-fed. During the period from 6 months to 3 years of age, breast-fed infants (and formula-fed infants) require fluoride supplementation only if the water supply is severely deficient in fluoride (<0.3 ppm).

Should hospitalization of the breastfeeding mother or infant be necessary, every effort should be made to maintain breastfeeding, preferably directly, or by pumping the breasts and feeding expressed breast milk, if necessary.

Role of pediatricians in promoting and protecting breastfeeding

To provide an optimal environment for breastfeeding, pediatricians should follow these recommendations:

Promote and support breastfeeding enthusiastically. In consideration of the extensive published evidence for improved outcomes in breast-fed infants and their mothers, a strong position on behalf of breastfeeding is justified.

Become knowledgeable and skilled in both the physiology and the clinical management of breastfeeding.

Work collaboratively with the obstetric community to ensure that women receive adequate information throughout the perinatal period to make a fully informed decision about infant feeding. Pediatricians should also use opportunities to provide age-appropriate breastfeeding education to children and adults.

Promote hospital policies and procedures that facilitate breastfeeding. Electric breast pumps and private lactation areas should be available to all breastfeeding mothers in the hospital, both on ambulatory and inpatient services. Pediatricians are encouraged to work actively toward eliminating hospital practices that discourage breastfeeding (eg, infant formula discharge packs and separation of mother and infant).

Become familiar with local breastfeeding resources (eg, Special Supplemental Nutrition Program for Women, Infants, and Children clinics, lactation educators and consultants, lay support groups, and breast pump rental stations) so that patients can be referred appropriately. When specialized breastfeeding services are used, pediatricians need to clarify for patients their essential role as the infant's primary medical caretaker. Effective communication among the various counselors who advise breastfeeding women is essential.

Encourage routine insurance coverage for necessary breastfeeding services and supplies, including breast pump rental and the time required by pediatricians and other licensed health care professionals to assess and manage breastfeeding.

Promote breastfeeding as a normal part of daily life, and encourage family and societal support for breastfeeding.

Develop and maintain effective communications and collaboration with other health care providers to ensure optimal breastfeeding education, support, and counsel for mother and infant.

Advise mothers to return to their physician for a thorough breast examination when breastfeeding is terminated.

Promote breastfeeding education as a routine component of medical school and residency education.

Encourage the media to portray breastfeeding as positive and the norm.

Encourage employers to provide appropriate facilities and adequate time in the workplace for breast pumping.

Conclusion

Although economic, cultural, and political pressures often confound decisions about infant feeding, the AAP firmly adheres to the position that breastfeeding ensures the best possible health as well as the best developmental and psychosocial outcomes for the infant. Enthusiastic support and involvement of pediatricians in the promotion and practice of breastfeeding is essential to the achievement of optimal infant and child health, growth, and development.

CLINICAL ALGORITHM(S):
None provided

DEVELOPER(S):
American Academy of Pediatrics (AAP) - Medical Specialty Society

COMMITTEE:
Work Group on Breastfeeding

GROUP COMPOSITION:
Names of the Work Group on Breastfeeding Members, 1996 to 1997: Lawrence M. Gartner, MD, Chairperson; Linda Sue Black, MD; Antoinette P. Eaton, MD; Ruth A. Lawrence, MD; Audrey J. Naylor, MD, DrPH; Marianne E. Neifert, MD; Donna O'Hare, MD; Richard J. Schanler, MD.

Liaison Representatives: Michael Georgieff, MD, AAP Committee on Nutrition; Yvette Piovanetti, MD, AAP Committee on Community Health Services; John Queenan, MD, American College of Obstetricians and Gynecologists.

ENDORSER(S):
Not stated

GUIDELINE STATUS:
This is the current release of the guideline. It is intended to replace the previously issued policy statement of the American Academy of Pediatrics (AAP).

The current position statement reflects the considerable advances that have occurred in recent years in the scientific knowledge of the benefits of breastfeeding, in the mechanisms underlying these benefits, and in the practice of breastfeeding.

AAP Policies are reviewed every 3 years by the authoring body, at which time a recommendation is made that the policy be retired, revised, or reaffirmed without change. Until the Board of Directors approves a revision or reaffirmation, or retires a statement, the current policy remains in effect.

GUIDELINE AVAILABILITY:
Electronic copies: Available from the American Academy of Pediatrics (AAP) Web site:

Print copies: Available from the American Academy of Pediatrics, 141 NW Point Blvd, PO Box 927, Elk Grove Village, IL 60009-0927; Web site, http://www.aap.org/

COMPANION DOCUMENTS:
None available

PATIENT RESOURCES:
The following is available:

A woman's guide to breastfeeding. Elk Grove Village, IL; AAP, 1999. Available from the AAP Web site.

Print copies: Available from AAP, PO Box 747, Elk Grove Village, IL 60009-0747.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC STATUS:
This summary was completed by ECRI on April 27, 1999. The information was verified by the guideline developer on July 13, 1999.

COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest Point Blvd, Elk Grove Village, IL 60007.