Jones.and.Bartlett.Publishers.Breastfeeding.and.Human.Lactation
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Breastfeeding and
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Human Lactation,
Third Edition
Jan Riordan, EdD, RN, IBCLC, FAAN
JONES AND BARTLETT PUBLISHERS
Breastfeeding and Human Lactation
Jones and Bartlett Series in Breastfeeding/Human Lactation
Case Studies in Breastfeeding: Problem-Solving Skills and Strategies, Cadwell/Turner-Maffei
Clinical Lactation: A Visual Guide, Auerbach
Coach’s Notebook: Games and Strategies for Lactation Education, Smith
Comprehensive Lactation Consultant Exam Review, Smith
Core Curriculum for Lactation Consultant Practice, Walker, editor
Counseling the Nursing Mother: A Lactation Consultant’s Guide, Third Edition, Lauwers/Shinskie
Impact of Birthing Practices on Breastfeeding: Protecting the Mother and Baby Continuum, Kroeger with Smith
The Lactation Consultant in Private Practice: The ABCs of Getting Started, Smith
Reclaiming Breastfeeding for the United States: Protection, Promotion and Support, Cadwell
Ten Steps to Successful Breastfeeding: An 18 Hour Interdisciplinary Breastfeeding Management Course for the United
States, Cadwell/Turner-Maffei
Varney’s Midwifery, Fourth Edition, Varney/Kriebs/Gegor
Breastfeeding and Human
Lactation
Third Edition
Jan Riordan, EdD, RN, IBCLC, FAAN
Professor
School of Nursing
Wichita State University
Wichita, Kansas
Lactation Consultant
Via Christi Regional Medical Center
St. Joseph Campus
Wichita, Kansas
World Headquarters
Jones and Bartlett Publishers
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Sudbury, MA 01776
978-443-5000
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Jones and Bartlett Publishers Canada
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Mississauga, ON L5C 2W6
CANADA
Jones and Bartlett Publishers
International
Barb House, Barb Mews
London W6 7PA
UK
Copyright © 2005 by Jones and Bartlett Publishers, Inc.
Cover image © InJoy Productions, Inc.
All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any
form, electronic or mechanical, including photocopying, recording, or by any information storage and
retrieval system, without written permission from the copyright owner.
Library of Congress Cataloging-in-Publication Data
Breastfeeding and human lactation / [edited by] Jan Riordan.— 3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-7637-4585-5 (hardcover)
1. Breast feeding. 2. Lactation.
[DNLM: 1. Breast Feeding. 2. Infant Nutrition. 3. Lactation. 4.
Milk, Human. WS 125 B8293 2004] I. Riordan, Jan.
RJ216.B775 2004
649'.33—dc22
2003022400
Chief Executive Officer: Clayton Jones
Chief Operating Officer: Don W. Jones, Jr.
President of Jones and Bartlett Higher Education and
Professional Publishing: Robert W. Holland, Jr.
V.P., Design and Production: Anne Spencer
V.P., Manufacturing and Inventory Control: Therese
Bräuer
V.P. of Sales and Marketing: William Kane
Acquisitions Editor: Penny M. Glynn
Production Manager: Amy Rose
Editorial Assistant: Amy Sibley
Associate Production Editor: Jenny L. McIsaac
Director of Marketing: Alisha Weisman
Marketing Manager: Edward McKenna
Manufacturing Buyer: Amy Bacus
Cover Design: Anne Spencer
Composition: Modern Graphics Incorporated
Printing and Binding: Malloy Inc.
Cover Printing: Malloy Inc.
Printed in the United States of America
08 07 06 05 04
10 9 8 7 6 5 4 3 2 1
This book is dedicated to breastfeeding women
and their babies around the globe.
This page intentionally left blank
TA B L E
Preface
Acknowledgements
xxi
xxiii
O F
CO N T E N T S
Chapter Authors
SECTION 1
xxiv
H I STOR ICAL AN D
WOR K P E R S P ECTIVE S
CHAPTER 1
Internet Resources
26
References
27
Tides in Breastfeeding Practice
3
Evidence About Breastfeeding Practices
Large-Scale Surveys
Other Evidence
3
3
4
The Biological Norm in Infant Feeding
Early Human Evolution
Early Breastfeeding Practices
5
5
5
The Replacement of Maternal Breastfeeding
Wet-Nursing
Hand-Fed Foods
Timing of the Introduction of Hand-Feeding
5
5
6
7
Technological Innovations in
Infant Feeding
The Social Context
The Technological Context
The Role of the Medical Community
8
8
9
9
The Prevalence of Breastfeeding
United States, England, and Europe
Developing Regions
12
12
13
The Cost of Not Breastfeeding
Health Risks of Using Manufactured
Infant Milks
Economic Costs of Using Manufactured
Infant Milks
15
The Unique Characteristics of Counseling
Breastfeeding Women
44
16
48
48
49
50
51
CHAPTER 2
Work Strategies and the
Lactation Consultant
History
31
Do Lactation Consultants Make a
Difference?
32
Certification
32
Getting a Job as a Lactation Consultant
Interviewing for a Job
Gaining Clinical Experience
35
36
36
LC Education
37
Lactation Programs
Workload Issues
38
41
Developing a Lactation Program
Marketing
41
44
The Promotion of Breastfeeding
Breastfeeding Promotion in the
United States
International Breastfeeding Promotion
Private Support Movements
19
20
23
Summary
24
Roles and Responsibilities
Stages of Role Development
Lactation Consultants in the
Community Setting
Medical Office
Lactation Consultants and
Volunteer Counselors
Networking
Reporting and Charting
Clinical Care Plans
Key Concepts
25
Legal and Ethical Considerations
16
18
31
45
46
47
47
vii
viii
Breastfeeding and Human Lactation
Reimbursement
Insurance and Third-Party Payment
Coding
53
53
56
Private Practice
The Business of Doing Business
Payment and Fees
57
57
58
Partnerships
59
Summary
60
Key Concepts
61
Internet Resources
62
References
62
SECTION 2
A NATOM ICAL AN D
B IOLOG ICAL I M P E RATIVE S
CHAPTER 3
Breathing and Suckling
87
Frequency of Feedings
89
Summary
90
Key Concepts
90
References
92
Anatomy and Physiology
of Lactation
67
Mammogenesis
67
Breast Structure
69
Variations
72
Pregnancy
72
Lactogenesis
Delay in Lactogenesis
73
74
The Biological Specificity
of Breastmilk
Hormonal Influences
Progesterone
Prolactin
Cortisol
Thyroid-Stimulating Hormone
Prolactin-Inhibiting Factor
Oxytocin
74
75
75
77
77
77
78
Milk Synthesis and Maturational Changes 98
Milk Production
79
Autocrine Versus Endocrine
79
Galactopoiesis
80
Galactorrhea
80
Clinical Implications: Mother
Breast Assessment
Classification of Nipple Function
Concepts to Practice
80
80
82
82
Newborn Oral Development
83
Suckling
85
CHAPTER 4
97
Energy, Volume, and Growth
Caloric Density
Milk Volume and Storage Capacity
Differences in Milk Volume
Between Breasts
Infant Growth
98
99
100
102
103
Nutritional Values
Fat
Lactose
Protein
Vitamins and Micronutrients
Minerals
Preterm Milk
103
103
105
106
106
108
110
Anti-infective Properties
Gastroenteritis and Diarrheal Disease
Respiratory Illness
Otitis Media
Controversies and Claims
111
111
112
114
115
Contents
Chronic Disease Protection
Childhood Cancer
Allergies and Atopic Disease
Asthma
115
116
116
117
The Immune System
117
Active Versus Passive Immunity
117
Cells
118
Antibodies/Immunoglobulins
119
Nonantibody Antibacterial Protection
120
Anti-inflammatory and Immunomodulating
Components
121
Calculating Infant Exposure
Unique Infant Factors
Maternal Factors
143
144
146
Minimizing the Risk
146
Effect of Medications on Milk Production
Drugs That May Inhibit Milk Production
Drugs That May Stimulate
Milk Production
Herbs
146
146
148
149
Review of Selected Drug Classes
Analgesics
Antibiotics
Antihypertensives
Psychotherapeutic Agents
Corticosteroids
Thyroid and Antithyroid Medications
149
149
150
153
153
157
157
Bioactive Components
Enzymes
Growth Factors and Hormones
Taurine
122
122
123
124
Implications for Clinical Practice
124
Drugs of Abuse
158
Summary
126
Radioisotopes
159
Key Concepts
126
Radiocontrast Agents
159
Internet Resources
127
Summary
161
Key Concepts
162
References
128
Internet Resources
162
Appendix 4-A: Composition of Human
Colostrum and Mature Breastmilk
136
References
162
CHAPTER 6
CHAPTER 5
Drug Therapy
and Breastfeeding
Viruses and Breastfeeding
137
The Alveolar Subunit
138
Drug Transfer into Human Milk
Passive Diffusion of Drugs into Milk
Ion Trapping
Molecular Weight
Lipophilicity
Milk/Plasma Ratio
Maternal Plasma Levels
Bioavailability
Drug Metabolites
139
140
141
141
142
142
142
143
143
167
HIV and Infant Feeding
167
Exclusive Breastfeeding
168
What We Know
Treatment and Prevention
168
170
Health-Care Practitioners
Counseling
171
171
Herpes Simplex Virus
172
Chickenpox/Varicella
173
Cytomegalovirus
175
ix
x
Breastfeeding and Human Lactation
Rubella
176
Implications for Practice
178
Hepatitis B
176
Summary
179
Hepatitis C
176
Key Concepts
179
Human Lymphotropic Virus
177
Internet Resources
180
West Nile Virus
177
References
181
P R E NATAL , P E R I NATAL , AN D
P OSTNATAL P E R IODS
SECTION 3
Breastfeeding Preparation
185
Clinical Implications
Breastfeeding Assessment
Discharge Planning
Basic Feeding Techniques
Signs That Intervention Is Needed
Discharge
Early Feedings
186
Summary
212
Feeding Positions
Latch-on and Positioning Techniques
191
191
Key Concepts
212
Internet Resources
214
The Infant Who Has Not Latched-On
Plan for the Baby Who Has Not
Latched-On Yet
Establishing the Milk Supply
Assessment of the Mother’s
Nipples and Breasts
Baby Problems That May Cause
Difficulty with Latch-on
192
References
214
CHAPTER 7
Perinatal and
Intrapartum Care
185
194
194
196
196
The 34 to 38 “Weeker”
197
Feeding Methods
Cup-Feeding
Finger-Feeding
198
198
199
Nipple Shields
200
Hypoglycemia
201
Cesarean Births
204
Breast Engorgement
205
Breast Edema
206
Hand Expression
207
209
209
210
210
211
211
CHAPTER 8
Postpartum Care
217
Hydration and Nutrition in the Neonate
Signs of Adequate Milk Intake
Milk Supply––Too Much or Too Little
Temporary Low Milk Supply or
Delayed Lactogenesis
Effect of Pharmaceutical Agents on
Milk Supply
Too Much Milk
217
218
218
220
221
Nipple Pain
Treatments for Painful Nipples
Nipple Creams and Gels
221
225
225
Engorgement + Milk Stasis = Involution
228
Breast Massage
228
Clothing, Leaking, Bras, and
Breast Pads
228
220
Contents
Infant Concerns
Pacifiers
Stooling Patterns
Jaundice in the Newborn
Breast Refusal and Latching Problems
Later Breast Refusal
Crying and Colic
230
230
231
232
232
234
234
Multiple Infants
Full-Term Twins or Triplets
Preterm or Ill Multiples
Putting It All Together
Partial Breastfeeding and Human
Milk Feeding
236
237
237
238
Mammoplasty
Breast Reduction
Mastopexy
Breast Augmentation
261
261
263
263
Breast Lumps and Surgery
Galactoceles
Fibrocystic Disease
265
266
267
Bleeding from the Breast
267
Breast Cancer
Lactation Following Breast Cancer
268
269
239
Clinical Implications
270
Breastfeeding During Pregnancy
240
Summary
271
Clinical Implications
241
Key Concepts
271
Summary
242
Internet Resources
273
Key Concepts
242
References
273
Internet Resources
242
References
243
CHAPTER 9
Breast-Related Problems
247
Nipple Variations
Inverted or Flat Nipples
Absence of Nipple Pore Openings
Large or Elongated Nipples
247
247
248
248
Plugged Ducts
248
Mastitis
Treatment for Mastitis
Types of Mastitis
250
251
252
Breast Abscess
254
Breast and Nipple Rashes, Lesions, and
Eczema
254
Candidiasis (Thrush)
Treatment
255
256
Breast Pain
260
Vasospasm
260
Milk Blister
261
CHAPTER 10
Low Intake in the Breastfed
Infant: Maternal and
Infant Considerations
277
Factors That Influence Maternal
Milk Production
277
Normal Milk Intake and Rate of Gain
279
US Growth Curves
Current Growth Curves Still
Underrepresent Breastfeeding
280
280
Low Intake and Low Milk Supply: Definitions and Incidence of Occurrence
282
Confusing Terminology and
Nonstandardized Research
282
The Infant’s Presentation
283
The Mother’s Presentation
285
Abnormal Patterns of Growth: The Baby
Who Appears Healthy
286
Inadequate Weight Gain in the
First Month
286
The Near-Term Infant
286
xi
xii
Breastfeeding and Human Lactation
Oral-Motor Dysfunction
(Ineffective Suckling)
Gastroesophageal Reflux/Cow Milk
Allergy/Oversupply
Nonspecific Neurological Problems
Ankyloglossia (Tight Frenulum,
Tongue-Tie)
Abnormal Patterns of Growth:
The Baby with Obvious Illness
Maternal Considerations:
The Mother Who Appears Healthy
Delayed Lactogenesis
Stress
Inverted Nipples
Nipple Shields
Medications and Substances
Hormonal Alterations
Breast Surgery
Insufficient Glandular Development
of the Breast
Psychosocial Factors
Maternal Nutrition
286
290
291
291
303
304
Summary
305
Key Concepts
306
Internet Resources
307
References
307
292
CHAPTER 11
293
293
293
294
294
294
294
295
295
296
296
Maternal Considerations:
Obvious Illness
296
History, Physical Exam, and
Differential Diagnosis
History
Physical Examination
Differential Diagnosis
296
296
296
297
Clinical Management
Determining the Need
for Supplementation
Galactagogues
Hindmilk
297
297
Intervention
Reducing the Amount
of Supplementation
Family and Peer Support
When Maternal Milk Supply Does
Not Increase
297
300
Special Techniques for Management of
Low Intake or Low Supply
Breast Massage
Switch Nursing
Feeding-Tube Device
Test Weighing
300
300
300
301
303
300
300
Jaundice and the
Breastfed Baby
311
Neonatal Jaundice
312
Assessment of Jaundice
313
Postnatal Pattern of Jaundice
314
Breastmilk Jaundice
314
Breast-Nonfeeding Jaundice
314
Bilirubin Encephalopathy
316
Evaluation of Jaundice
Diagnostic Assessment
316
317
Management of Jaundice
318
Key Concepts
319
Internet Resources
320
References
320
CHAPTER 12
Breast Pumps and
Other Technologies
323
Concerns of Mothers
323
Stimulating the Milk-Ejection Reflex
324
Hormonal Considerations
Prolactin
Clinical Implications
Oxytocin
328
328
329
330
Pumps
Mechanical Milk Removal
330
330
Contents
Compression
The Evolution of Pumps
331
331
A Comparison of Pumps
Manual Hand Pumps
Battery-Operated Pumps
Electric Pumps
332
333
335
336
Simultaneous and/or
Sequential Pumping
338
Flanges
338
Miscellaneous Pumps
Pedal Pumps
342
342
Clinical Implications Regarding
Breast Pumps
342
When Pumps Cause Problems
345
Sample Guidelines for Pumping
345
Common Pumping Problems
347
Nipple Shields
Review of Literature
Types of Shields
Shield Selection and Instructions
Weaning from the Shield
Responsibilities
349
350
351
351
352
352
Breast Shells
354
Feeding-Tube Devices
Situations for Use
355
355
Summary
357
Key Concepts
358
Internet Resources
361
References
361
Appendix 12-A: Manufacturers/
Distributors of Breast Pumps
365
CHAPTER 13
Breastfeeding the
Preterm Infant
Suitability of Human Milk for Preterm
Infants
367
367
Mothers of Preterm Infants
368
Rates of Breastfeeding Initiation and
Duration
370
Research-Based Lactation Support
Services
The Decision to Breastfeed
Facilitating an Informed Decision
Alternatives to Exclusive, Long-Term
Breastfeeding
Models for Hospital-Based Lactation
Support Services
370
370
370
370
371
Initiation of Mechanical Milk Expression 372
Principles of Milk Expression
372
Selecting a Breast Pump
372
Milk-Expression Technique
373
Milk Expression Schedule
374
Written Pumping Records
374
Maintaining Maternal Milk Volume
Expressed Milk Volume Guidelines
Preventing Low Milk Volume
Skin-to-Skin (Kangaroo) Care
376
376
376
377
Evidence-Based Guidelines for Milk
Collection, Storage, and Feeding
Guidelines for Collection and Storage
of Expressed Mother’s Milk (EMM)
Preparing Expressed Mother’s Milk
for Infant Feeding
379
Special Issues Regarding the Feeding
of EMM
Volume Restriction Status
Commercial Nutritional Additives
Hindmilk Feeding
Methods of Milk Delivery
Maternal Medication Use
380
382
382
382
383
383
Feeding at Breast in the NICU
Suckling at the Emptied Breast
The Science of Early Breastfeeding
Progression of In-Hospital Breastfeeding
Milk Transfer During Breastfeeding
384
384
385
390
390
Discharge Planning for
Postdischarge Breastfeeding
Getting Enough: Determining the Need
for Extra Milk Feedings
378
378
396
397
xiii
xiv
Breastfeeding and Human Lactation
Methods to Deliver Extra Milk Feedings
Away from the Breast
398
Postdischarge Breastfeeding Management 398
Summary
399
Key Concepts
399
Internet Resources
400
References
401
Appendix 13-A: The Preterm Infant
Breastfeeding Behavior Scale (PIBBS)
407
The Benefits of Banked Donor
Human Milk
Species Specificity
Ease of Digestion
Promotion of Growth, Maturation,
and Development of Organ Systems
Immunological Benefits
413
413
413
414
414
Clinical Uses
Distribution of Banked Donor Milk:
Setting Priorities
Classifying Clinical Uses: Is Donor
Milk Food or Medicine?
414
Current Practice
Donor Selection and Screening
Collection
Pasteurization
Packaging and Transport
Costs of Banked Donor Milk
420
420
422
422
425
425
A Brief History of Human Milk Banking 409
Foundations of Donor Human Milk
Banking: Pre-1975
409
Donor Human Milk Banking in the
United States: Post-1975
410
Potential Hazards of Informal Sharing of
Human Milk
411
Policy Statements Supporting the
Use of Banked Donor Human Milk
425
Summary
426
Key Concepts
427
Internet Resources
427
Donor Human Milk Banking Beyond
North America
The Impact of Culture on Donor
Milk Banking
References
427
Appendix 14-A: Storage and Handling
of Expressed Human Milk
432
CHAPTER 14
Donor Human Milk Banking
Defining Donor Milk Banking
409
409
412
413
414
415
B EYON D
SECTION 4
P OSTPARTU M
CHAPTER 15
Maternal Nutrition
During Lactation
437
Maternal Caloric Needs
438
Maternal Fluid Needs
439
Weight Loss
439
Exercise
440
Calcium Needs and Bone Loss
441
Vegetarian Diets
442
Dietary Supplements
442
Foods That Pass Into Milk
Caffeine
Food Flavorings
443
443
443
Allergens in Breastmilk
443
The Goal of the Maternal Diet
During Lactation
444
Contents
Systemic Lupus Erythematosus
Multiple Sclerosis
Rheumatoid Arthritis
470
471
471
Physically Challenged Mothers
Seizure Disorders
472
473
Headaches
475
476
477
453
Postpartum Depression
Clinical Implications
Medications and Herbal Therapy
for Depression
Support for the Mother with
Postpartum Depression
480
Key Concepts
453
Asthma
480
Internet Resources
454
Smoking
480
References
454
Poison Ivy Dermatitis
481
Diagnostic Studies Using Radioisotopes
481
The Impact of Maternal Illness
and Hospitalization
482
Summary
482
Key Concepts
483
Internet Resources
484
References
484
Nutrition Basics
Energy
446
446
Macronutrients
Carbohydrates
Protein
Fat
447
447
447
448
Micronutrients
Vitamins
Minerals
448
448
449
Clinical Implications
449
Summary
CHAPTER 16
Women’s Health
and Breastfeeding
459
Alterations in Endocrine and
Metabolic Functioning
Diabetes
Thyroid Disease
Pituitary Dysfunction
Polycystic Ovarian Syndrome
Theca Lutein Cysts
Cystic Fibrosis
459
459
461
462
462
462
463
Acute Illness and Infections
Tuberculosis
Group B Streptococcus
Dysfunctional Uterine Bleeding
463
464
464
465
Maternal Immunizations
478
CHAPTER 17
Maternal Employment
and Breastfeeding
487
Why Women Work
487
Historical Perspective
488
465
The Effect of Work on Breastfeeding
488
Surgery
465
Donating Blood
466
Relactation
467
Induced Lactation
Domperidone, Metoclopramide,
and Sulpride
467
468
Autoimmune Diseases
470
Strategies to Manage Breastfeeding
and Work
Prenatal Planning and Preparation
Return to Work
Hand Expression and Pumping
Human Milk Storage
Fatigue and Loss of Sleep
Maintaining an Adequate Milk Supply
The Day-Care Dilemma
489
489
491
492
493
496
496
497
xv
xvi
Breastfeeding and Human Lactation
Workplace Strategies
Lactation Programs in Work Sites
The Employer’s Perspective
Community Strategies
Health-Care Providers and
Lactation Consultants
Breastfeeding Support Groups
497
498
500
501
501
501
National and International Strategies
Legislative Support and
Public Advocacy
International Labour Organization
501
501
503
Clinical Implications
503
Summary
505
Key Concepts
506
Internet Resources
507
Other Resources
507
References
507
CHAPTER 18
Child Health
509
Developmental Outcomes and Infant
Feeding
509
Growth and Development
Physical Growth
Weight and Length
Senses
Reflexes
Levels of Arousal
511
511
512
513
514
514
Theories of Development
Nature Versus Nurture
514
514
Social Development
Language and Communication
Attachment and Bonding
Temperament
Stranger Distress
Separation Anxiety
517
517
520
523
523
523
Clinical Implications
Immunizations
Vitamin D and Rickets
527
Dental Health and Orofacial
Development
527
Solid Foods
Introducing Solid Foods
Choosing the Diet
Choosing Feeding Location
Delaying Solid Foods
528
528
529
531
531
Obesity
532
Co-Sleeping
532
Long-Term Breastfeeding
533
Weaning
533
Implications for Practice
534
Summary
535
Key Concepts
535
Internet Resources
536
References
536
CHAPTER 19
The Ill Child:
Breastfeeding Implications
Team Care for the Child with
Feeding Difficulties
541
541
Feeding Behaviors of the Ill Infant/Child 541
What to Do If Weight Gain
Is Inadequate
What to Do When Direct Breastfeeding
Is Not Sufficient
Alternative Feeding Methods
544
544
546
Care of the Hospitalized Breastfeeding
Infant/Child
Home from the Hospital:
The Rebound Effect
550
525
Perioperative Care of the Breastfeeding
Infant/Child
551
525
Emergency Room
552
548
Contents
Care of Children with
Selected Conditions
Infection
Gastroenteritis
Respiratory Infections
Pneumonia
Bronchiolitis
Respiratory Syncytial Virus
Otitis Media
Meningitis
552
552
552
554
555
555
556
556
556
Alterations in Neurological Functioning
Down Syndrome or Trisomy 21
Neural Tube Defects
Hydrocephalus
557
560
560
561
Congenital Heart Disease
561
Oral/Facial Anomalies
Cleft Lip and Palate
Pierre Robin Sequence
Choanal Atresia
563
563
566
568
Gastrointestinal Anomalies
and Disorders
Esophageal Atresia/Tracheoesophageal
Fistula
Gastroesophageal Reflux
Pyloric Stenosis
Imperforate Anus
568
569
571
571
Metabolic Dysfunction
Phenylketonuria
Galactosemia
Congenital Hypothyroidism
Type I Diabetes
Celiac Disease
Cystic Fibrosis
571
572
572
574
575
575
575
Allergies
576
Food Intolerance
Lactose Intolerance
579
579
Psychosocial Concerns
Family Stress
Coping with Siblings
Chronic Grief and Loss
The Magic-Milk Syndrome
579
579
581
581
581
568
The Empty Cradle...When a Child Dies
Caring for Bereaved Families
582
582
Summary
583
Key Concepts
583
Internet Resources
584
References
585
CHAPTER 20
Infant Assessment
591
Perinatal History
591
Gestational Age Assessment
The New Ballard Score
591
594
Indicators of Effective Breastfeeding
and Assessment Scales
Breastfeeding Behaviors
and Indicators
Breastfeeding Scales and Tools
Summary of Breastfeeding
Assessment Scales
598
598
598
600
Physical Assessment
Transitional Assessment
Skin
Birthmarks
Head
Ears/Eyes
Nose
Mouth
Neck
Chest
Abdomen
Genitalia
Back and Spine
Extremities
Elimination
600
600
604
605
606
606
607
607
608
608
609
609
609
609
610
Behavioral Assessment
Sleep-Wake States
Neurobehavioral Cues and Reflexes
611
614
614
Summary
616
Key Concepts
616
References
616
xvii
xviii
Breastfeeding and Human Lactation
Appendix 20-A: Infant Breastfeeding
Assessment Tool (IBFAT)
618
Appendix 20-B: LATCH
Assessment Tool
618
Appendix 20-C: Mother-Baby
Assessment Scale
619
Contraception
The Contraceptive Methods
639
639
Clinical Implications
645
Summary
647
621
Key Concepts
647
621
References
648
621
S OCIOCU LTU RAL AN D
R E S EARCH I SS U E S
SECTION 5
CHAPTER 22
Research, Theory,
and Lactation
Theories Related to Lactation Practice
Maternal Role Attainment Theory
Parent-Child Interaction Model
Bonding and Attachment Theory
Theory of Darwinian and
Evolutionary Medicine
Self-Care Theory
Self-Efficacy Theory
Theory of Planned Behavior and
Theory of Reasoned Action
628
630
632
632
637
CHAPTER 21
Fertility
The Demographic Impact
of Breastfeeding
622
623
624
Sexuality
Libido
Sexual Behavior During Lactation
Appendix 20-D: Via Christi Breastfeeding
Assessment Tool
620
Fertility, Sexuality,
and Contraception
During Lactation
Mechanisms of Action
Lactational Amenorrhea
The Suckling Stimulus
The Repetitive Nature of the Recovery
of Fertility
The Bellagio Consensus
655
655
656
656
657
657
658
658
658
Types of Research Methods
Qualitative Methods
Quantitative Methods
Additional Methods and Approaches
for Breastfeeding Research
659
659
660
662
Elements of Research
Research Problem and Purpose
663
663
Variables, Hypotheses, and
Operational Definitions
Review of Literature
Protection of the Rights of Human
Subjects
Method
Data Analysis
Application of Methods to
Qualitative Approaches
Sampling
Data Collection
Data Analysis
Trustworthiness of Qualitative Research
Application of Methods to
Quantitative Approaches
Sampling and Sample Size
Data Collection
Reliability and Validity
Data Analysis
Results, Discussion, Conclusions,
and Dissemination
Evaluating Research for Use in Practice
665
667
667
668
669
669
669
670
670
671
671
671
672
672
674
677
678
Contents
Using Research in Clinical Practice
680
Educational Needs and Early Discharge
706
Perspectives of Research Methodologies
Positivist and Postpositive Perspective
Naturalistic, Humanistic, or
Interpretive Perspective
Critical or Emancipatory Perspective
680
681
Continuing Education
Objectives and Outcomes
706
707
681
681
Summary
682
Key Concepts
683
Internet Resources
684
The Team Approach
Childbirth Educators
Nurses
Lactation Consultants
Physicians
Dietitians
Community Support Groups
708
708
708
709
709
709
709
References
684
Summary
709
Appendix 22-A: Research Terms
687
Key Concepts
710
Internet Resources
711
References
711
CHAPTER 23
Breastfeeding Education
689
CHAPTER 24
Educational Programs
Distance Learning and Web Courses
689
690
Learning Principles
690
The Cultural Context
of Breastfeeding
Adult Education
691
The Dominant Culture
714
Curriculum Development
692
Ethnocentrism Versus Relativism
714
Parent Education
692
Assessing Cultural Practices
715
Prenatal Education
694
Language Barriers
715
Early Breastfeeding Education
Continuing Support for
Breastfeeding Families
694
The Effects of Culture on Breastfeeding
Rituals and Meaning
Colostrum
Sexual Relations
Wet-Nursing
Other Practices
Contraception
Infant Care
716
719
719
719
720
720
720
721
Maternal Foods
“Hot” and “Cold” Foods
Herbs and Galactogogues
722
722
723
Weaning
Types of Weaning
723
724
Implications for Practice
725
Summary
726
Key Concepts
727
697
How Effective Is
Breastfeeding Education?
697
Teaching Strategies
698
Small Group Dynamics
700
Multimedia Presentations
Slides
Transparencies
Television, Videotapes, and DVDs
Compact Discs
700
701
701
701
702
Educational Materials
Education for At-Risk Populations
Adolescents
Older Parents
702
703
704
705
713
xix
xx
Breastfeeding and Human Lactation
Internet Resources
727
Key Concepts
742
References
727
Internet Resources
743
References
743
APPENDIXES
A. Clinical Competencies for
IBCLC Practice
B. Code of Ethics
C. Summary of Eligibility Pathway
Requirements to Become Certified
by IBLCE
D. Prototype Lactation Consultant
Job Description
E. Tables of Equivalencies and Methods
of Conversion
F. Infant Weight Conversion Table
G. Breastfeeding Weight Loss Table
H. Patient History
747
CHAPTER 25
Families
729
Family Forms and Functions
729
Family Theory
730
Social Factors that Influence
Breastfeeding
731
Fathers
733
The Adolescent Mother
736
The Low-Income Family
Lack of Information
Hospital Practices
The Importance of Peer Counselors
737
737
738
739
The Downside of Family Experience
Violence
Childhood Sexual Abuse
739
740
741
Summary
742
749
754
756
758
761
762
763
764
Glossary
773
Index
785
Figure, Table, and Box Credits
817
P R E FA C E
I have worked in the field of lactation since the
early 1960s, first as a La Leche Leader and later as
a lactation consultant when it became a professional
practice discipline in 1985. As I look back over
those years I am struck both by how different things
are now and by how much things have stayed the
same. Although the breastfeeding initiation rate in
the United States has risen to almost 70 percent––a
vast improvement from 20 percent in the 1960s!––it
still takes time and patience to help a new breastfeeding mother get her baby onto the breast.
New knowledge has changed the field. Research studies now verify that breastfed children are
more intelligent and that not breastfeeding costs the
U.S. health care system billions of dollars annually.
Because of the new awareness of the importance of
breastfeeding, the number and influence of lactation consultants has expanded. The International
Board of Lactation Consultants has certified more
than 10,000 health care workers in 36 countries.
Most hospitals, large and small, offer lactation services of some type and employ lactation consultants. Lest anyone question the powerful, positive
influence of interventions by health care workers on
breastfeeding, they only need to review the table of
intervention studies in Chapter 2. At the same time,
lest we follow that conflicted path that led to the
medicalization of childbirth, we must listen to
voices that warn of the danger of lactation consultants medicalizing infant feeding.
Other changes affect lactation practice. The insurance industry now drives the health care system,
reversing the reward system in favor of short hospital stays, which are now two days or less in the U.S.
for vaginal births. While these short stays mean that
breastfeeding mothers and babies return home less
likely to be exposed to hospital infections and to
supplementary feedings, this brief time allows almost no opportunity to ensure that the baby is
breastfeeding effectively. Mothers still needing care
themselves return home to assume full-time childcare before they feel physically able to do so. Follow-up care of a new family at home should be
universal, yet many mothers of preterm and “nearterm” breastfed infants who are developmentally
immature leave the hospital without any plan for assistance.
This text brings together in a single volume the
latest clinical techniques and research findings that
direct evidence-based clinical practice. I have been
fortunate in being able to enlist a dozen breastfeeding experts recognized around the world to help with
the writing of this extensive volume. Dr. Kathleen
Auerbach, the much-missed former co-author of this
book, remains as co-author of two chapters.
Over 1,000 research studies support the clinical
recommendations in this book. The Internet and
MEDLINE made the literature searches so much
easier for this edition––a sea of change from writing
the first two editions. The Internet also made possible quick correspondence with colleagues and
chapter authors as this book progressed. Addresses
of helpful resources on the Internet have been
added to each chapter.
Like the earlier editions, the third edition of this
text has a clear clinical focus. A new chapter on infant assessment reflects current expectations that
the health care worker working with the breastfeeding dyad can perform a total assessment of the
baby. Nearly every chapter contains a clinical implications section. Important concepts discussed
in chapters are summarized at the end of each
chapter––a new feature that will make studying easier. Throughout the book are new references
deemed by the authors to be the most important
from the vastly expanded research and clinical literature. Some older references that introduced new
ideas that are now accepted common knowledge
have been regretfully removed to make room for
new research. The glossary of key terms relating to
lactation has been expanded in this edition.
Section 1 contrasts the past and present. Chapter 1 presents the history of breastfeeding by placing lactation and breastfeeding in its historical
context. Chapter 2 fast-forwards to the work of the
present-day health care worker who specializes in
lactation and breastfeeding, and it addresses the reality of work-related issues of lactation consulting.
Section 2 focuses on basic anatomic and biologic imperatives of lactation. Clinical application of
xxi
xxii
Breastfeeding and Human Lactation
techniques must be based on a clear understanding
of the relationships between form, function, and biological constructs. Thus this section, too, provides
the background upon which to understand other aspects of lactation and breastfeeding behavior.
Section 3 is the clinical “heart” of the book that
describes the basics of what to do, when to do it, and
how to do it when one assists the lactating mother.
Section 3 thus concerns itself with the perinatal period in the birth setting and concerns during the
postpartum period following the family’s return
home—notably breast problems, neonatal jaundice,
and infant weight gain. This section also addresses
special needs of preterm babies and their mothers,
and it critically evaluates breastfeeding devices and
recommends how and when they are most appropriately used. It concludes with a review of the development and current activities of human milk
banking.
The first part of Section 4 focuses on the
mother: maternal nutrition, the mother’s health,
and returning to work. The topics then turn to the
infant and child’s health and special health needs.
The techniques of infant assessment are explained
and demonstrated with photographs in a new chapter. The section ends with a discussion of maternal
sexuality and fertility.
Section 5 begins with a careful look at research––
how it is conducted, why ongoing research is
needed, and how research findings can be applied in
clinical settings. The principles of education, the cornerstone of clinical practice, are explored next. The
book concludes with the socio-cultural context of the
breastfeeding family and explores the different ways
in which the breastfeeding family functions within
that context.
To avoid linguistic confusion, the book uses the
following conventions. The word nursing (in italics)
in the text refers to the profession. Nursing, meaning breastfeeding, is always shown in ordinary
Roman type. The masculine pronoun has been
used to denote the infant or child throughout the
text as a matter of convenience to distinguish the
child from the breastfeeding mother. Nurses, lactation consultants, and other health care workers
are referred to by feminine pronouns, although we
recognize here that males serve in all health care
professions.
ACKNOWLEDGEMENTS
I gratefully acknowledge the contributions to this
book made by the following individuals:
Judy Angeron BA, RN, IBCLC, Coordinator, Lactation Services, Via Christi Regional Medical Center, Wichita, Kansas
Kathleen G. Auerbach PhD, IBCLC, Ferndale,
Washington
Suzanne Bentley MSN, CNM, IBCLC, Clinical
Nurse Specialist, University of Kansas, Clinical Instructor, University of Kansas, School of Nursing,
Kansas City, Kansas
Kerstin Hedberg-Nyqvist PhD, RN, IBCLC, Assistant Professor in Pediatric Nursing, Department of
Women’s and Children’s Health, Uppsala University,Uppsala, Sweden
Heather Hull MSN, PNP, Instructor, Wichita State
University, Wichita, Kansas
Voni Miller RN, IBCLC, Lactation Consultant,
Phoenix Children’s Hospital, Phoenix, Arizona
Gerald Nelson MD, The University of Kansas
School of Medicine, Wichita, Kansas
Belinda Childs MN, ARNP, CDE, Clinic/Research Coordinator, Mid-America Diabetes Associates, Wichita, Kansas
Amal Omer-Salim, MSc, Nutritionist, International
Maternal and Child Health, Department of
Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
Mary Margaret Coates MS, IBCLC, TechEdit,
Wheat Ridge, Colorado
Virginia Phillips, IBCLC, Brisbane, Queensland,
Australia
Amy Ellington RN, BSN, Lactation Consultant,
Via Christi Regional Medical Center, Wichita,
Kansas
Christina M Smillie MD, FAAP, IBCLC, Breastfeeding Resources, Stratford, Connecticut
Barbara Gabbert-Bacon, La Leche League, Wichita, Kansas
Lenore Goldfarb, B.Comm, B.Sc, IBCLC, Herzl
Family Practice Centre, Sir Mortimer B. DavisJewish General Hospital, Montreal, Quebec,
Canada
Robert T. Hall MD, Professor, Children’s Mercy
Hospital and Clinics, Kansas City, Missouri
Eileen Hawkins MSN, ARNP, Wichita State University, School of Nursing, Wichita, Kansas
I am especially grateful to La Leche League International for providing the foundation for my breastfeeding education and to those institutions which
encouraged and supported me in writing the book:
the School of Nursing, Wichita State University,
and Via Christi Regional Medical Center, both of
Wichita, Kansas.
Finally, thanks to my family: Hugh, Michael,
Neil and Shirley, Brian, Quinn and Rika Riordan,
Teresa Riordan and Richard Chenoweth, Renee
and Don Olmstead and our 11 (breastfed) grandchildren.
xxiii
CHAPTER AUTHORS
Kathleen G. Auerbach, PhD, IBCLC
Ferndale, Washington
Lois D. W. Arnold, PhD (C.), MPH, IBCLC
National Commission on Donor Milk Banking
East Sandwich, Massachusetts
Debi Leslie Bocar, PhD, RN, IBCLC
Perinatal Educator, Mercy Health Center
Director, Lactation Consultant Services
Oklahoma City, Oklahoma
Yvonne Bronner, ScD, RD, LD
Professor and Director, Public Health Program
Morgan State University
Baltimore, Maryland
Mary Margaret Coates, MS, IBCLC
TechEdit
Wheat Ridge, Colorado
Lawrence M. Gartner, MD
Professor Emeritus
Departments of Pediatrics and Obstetrics/
Gynecology
The University of Chicago
Chicago, Illinois
Kathy Gill-Hopple, MSN, RN
Instructor
Wichita State University, School of Nursing
Wichita, Kansas
Thomas W. Hale, PhD, RPH
Professor of Pediatrics
Texas Tech University, School of Medicine
Amarillo, Texas
Marguerite Herschel, MD
Associate Professor of Pediatrics
Medical Director, General Care Nursery
The University of Chicago
Chicago, Illinois
Roberta J. Hewat, PhD, RN, IBCLC
Associate Professor
University of British Columbia,
School of Nursing,
Vancouver, British Columbia, Canada
xxiv
Kay Hoover, MEd, IBCLC
Philadelphia Department of Public Health
Philadelphia, Pennsylvania
Nancy Hurst, RN, MSN, IBCLC
Director, Lactation Program and Mother’s Own
Milk Bank
Texas Children’s Hospital
Assistant Professor of Pediatrics
Baylor College of Medicine
Houston, Texas
Kathy I. Kennedy, MA, Dr.PH
Director, Regional Institute for Health and Environmental Leadership,
University of Denver Associate Clinical Professor
of Preventive Medicine,
University of Colorado Health Sciences
Denver, Colorado
Mary Koehn, PhD, RN, MSN
Assistant Professor
Wichita State University, School of Nursing
Wichita, Kansas
Paula Meier, DNSc, RN, FAAN
NICU Lactation Program Director, Department of
Maternal-Child Nursing,
Associate Director for Clinical Research,
Section of Neonatology,
Rush-Presbyterian-St Luke’s Medical Center
Chicago, Illinois
Sallie Page-Goertz, MN, CPNP, IBCLC
Assistant Clinical Professor,
KU Children’s Center/Kansas University School
of Medicine
Overland Park, Kansas
Nancy Powers, MD
Medical Director, Lactation Services
Pediatrix Medical Group
Wesley Medical Center
Wichita, Kansas
Chapter Authors
Wailaiporn Rojjanasrirat, PhD, MSN
Research Assistant Professor
University of Kansas, School of Nursing
Kansas City, Kansas
Linda J. Smith, BSE, FACCE, IBCLC
Bright Future Lactation Resource Centre Ltd.
Dayton, Ohio
Marsha Walker, RN, IBCLC
Lactation Associates
Executive Director, National Alliance for Breastfeeding Advocacy
Research, Education, and Legal Branch
Weston, Massachusetts
Karen Wambach, PhD, RN, IBCLC
Assistant Professor
University of Kansas, School of Nursing
Kansas City, Kansas
xxv
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S E C T I O N
1
Historical and Work Perspectives
Just as the breastfeeding course flows and ebbs in
a woman’s life, so breastfeeding has experienced
flows and ebbs through the centuries. It takes a village to return to breastfeeding, and community-based
programs that promote breastfeeding are successfully
and steadily increasing the rate of breastfeeding
around the world.
As more mothers choose to breastfeed, the need for
specialized help increases also. The visibility and acceptance of lactation consulting as an allied health
profession offers opportunities for practice in hospitals, the community, and in private practice. Randomized clinical trials consistently demonstrate that
lactation consultant services lengthen a mother’s
breastfeeding course and save money through healthier mothers and babies.
1
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C
H
A
P
T
E
R
1
Tides in Breastfeeding Practice
Mary Margaret Coates and Jan Riordan
Throughout the world today, an infant is apt to receive less breastmilk than at any time in the past.
Until the 1940s, the prevalence of breastfeeding
was high in nearly all societies. Although the feeding of manufactured milks and baby milks had
begun before the turn of the century in parts of Europe and North America, the practice spread slowly
during the next decades. It was still generally limited to segments of population elites, and it involved only a small percentage of the world’s
people. During the post–World War II era, however, the way in which most mothers in industrialized regions fed their infants began to change, and
the export of these new practices to developing nations was underway.
Evidence About Breastfeeding
Practices
How do we know what we “know” about the prevalence of breastfeeding? (The word prevalence is used
here to mean the combined effect of breastfeeding
initiation rates and breastfeeding continuance rates.)
Before attempting to trace trends in infant feeding
practices, let us consider the nature of the evidence.
Large-Scale Surveys
National surveys that produce the kind of representative data that allow statistical evaluation have been
available only since 1955. These surveys consist primarily of national fertility or natality surveys and of
marketing surveys conducted by manufacturers of
artificial baby milk. For most, exclusive breastfeeding is not a separate statistic. However, the percentage of exclusive breastmilk feedings at hospital
discharge can be found in state birth certificate databases (Feldman-Winter et al., 2002). A brief description of national surveys conducted in the United
States follows (Grummer-Strawn & Li, 2000):
●
●
●
National Health Interview Survey: A personal interview is conducted in 43,000 households.
Questions about incidence and duration of
breastfeeding are asked.
National Health and Nutrition Examination Survey
(NHANES): Breastfeeding data are periodically
collected from personal interviews in the home.
National Survey of Family Growth (NSFG): Personal interviews are conducted every 6 years.
Standard questions on incidence, duration, and
exclusivity are included.
3
4
Historical and Work Perspectives
●
●
●
●
Pediatric Nutrition Surveillance System (PedNSS):
Statistics of breastfeeding incidence and duration
in low-income populations are collected in public health clinics and reported annually. National,
state, county, and clinic data are analyzed.
WIC Participant Characteristics Study: Data on
breastfeeding are collected each even-numbered year by the Department of Agriculture.
Ross Laboratories Mothers Survey: Questionnaires
are mailed to new mothers whose names are
obtained from a national sample of hospitals
and physicians. For marketing purposes, data
on type of milk fed is collected for up to 12
months for a given cohort. Data are published
on an ad hoc basis. The survey currently functions as a baseline and monitoring data source
for breastfeeding goals in Healthy People 2010.
Mead-Johnson Longitudinal Study of Infant Feeding
Practices: For marketing purposes, a panel of infants is followed for 12 months. Data is collected on incidence of, duration of, and
changes in breastfeeding frequencies.
Outside the United States, representative data
for countries in Latin America, Asia, Africa, and the
Middle East are derived from three sources. World
Fertility Surveys are sponsored by the Office of
Population within the United States Agency for International Development (USAID), the United Nations Fund for Population Activities, and the United
Kingdom Office of Development Assistance (Lightbourne, Singh, & Green, 1982). The World Health
Organization began ongoing surveys on infant
feeding in the mid-1970s. Its Global Data Bank on
Breast-Feeding pools information garnered from
well-designed nutrition and breastfeeding surveys
around the world; on the basis of these data, breastfeeding practices are periodically summarized. The
most recent summary appeared in 2000 (WHO,
2000). Finally, demographic and health surveys
were initiated in 1984; these ongoing surveys are
sponsored jointly by USAID and governments of
host countries in which the surveys are made.
Other Evidence
Until the last several decades, breastfeeding was the
unremarkable norm. Thus what we “know” about
breastfeeding from much earlier times often must be
inferred from evidence of other methods of feeding
infants. Most historical material available in Englishlanguage literature derives from a rather limited geographic area: Western Europe, Asia Minor, the
Middle East, and North Africa. Written materials,
which include verses, legal statutes, religious tracts,
personal correspondence, inscriptions, and medical
literature, extend back to before 2000 BC.
Some of the earliest existing medical literature
deals at least in passing with infant feeding. An
Egyptian medical encyclopedia, the Papyrus Ebers
(c. 1500 BC), contains recommendations for increasing a mother’s milk supply (Fildes, 1986). The first
writings to discuss infant feeding in detail are those
of the physician Soranus, who practiced in Rome
around AD 100; his views were widely repeated by
other writers until the mid-1700s. It is not immediately apparent to what degree these early exhortations either reflected or influenced actual practices.
Many writings before AD 1800 deal primarily with
wet nurses or how to hand-feed infants.
Archeological evidence provides some information about infant feeding prior to 2000 BC. Some of
the earliest artifacts are Middle Eastern pottery figurines that depict lactating goddesses, such as Ishtar
of Babylon and Isis of Egypt. The abundance of this
evidence suggests that lactation was held in high regard (Fildes, 1986). Such artifacts first appear in sites
about 3000 BC, when pottery making first became
widespread in that region. Information about infant
feeding may also be derived from paintings, inscriptions, and infant feeding implements.
Modern ethnography has a place of special importance. By documenting the infant feeding practices of present-day nontechnological hunter-gatherer, herding, and farming societies, ethnographers
expand our knowledge of the range of normal breastfeeding practices. At the same time, they provide a
richer appreciation of cultural practices that enhance
the prevalence of breastfeeding. Such studies are also
our best window into breastfeeding practices that
may be the biological norm for Homo sapiens sapiens.
In summary, the historical aspect of this chapter
deals with limited data from a limited social stratum in
a limited geographic region. However, the common
threads of these data provide a useful context within
which we may better understand modern breastfeeding practices, especially in Western cultures.
Tides in Breastfeeding Practice
The Biological Norm in Infant Feeding
Early Human Evolution
The class Mammalia is characterized principally by
the presence of breasts (mammae), which secrete
and release a fluid that for a time is the sole nourishment of the young. This manner of sustaining
newborns is extremely ancient; it dates back to the
late Mesozoic era, some 100 million years ago. (See
Figure 1–1.) Hominid precursors first appeared
about 4 million years ago; the genus Homo has existed for about 2 million years. The currently dominant human species, Homo sapiens sapiens, has
existed for perhaps 40,000 years. Information about
breastfeeding practices among our earliest ancestors is uncertain, although other information about
Paleolithic societies that existed 10,000 or more
years ago sheds light on this subject.
Early Breastfeeding Practices
Diets reconstructed by archeological methods reveal that the Late Paleolithic era, roughly 40,000 to
10,000 years ago, was populated by pre-agricultural
peoples who ate a wide variety of fruits, nuts, vegetables, meat (commonly small game), fish, and
shellfish. This diet closely resembles that of twentieth-century hunter-gatherer societies. Therefore,
the infant-feeding practices of societies today may
reflect breastfeeding practices of much earlier (prehistoric) times. Consider the breastfeeding practices
of the ¡Kung of the Kalahari Desert in southern
Africa (Konner & Worthman, 1980) as well as
hunter-gatherer societies of Papua New Guinea and
elsewhere (Short, 1984). Among these people,
breastfeeding of young infants is frequent (averaging four feeds per hour) and short (about 2 minutes
per feed). It is equally distributed over a 24-hour
period and continues, tapering off gradually, for
two to six years. These breastfeeding patterns are
considered a direct inheritance of practices that prevailed at the end of a long, and dietetically stable,
evolutionary period that ended about 10,000 BC.
This assumption is supported by observations of the
human’s closest primate relative, the chimpanzee,
which secretes a milk quite similar to that of humans, suckles several times per hour, and sleeps
with and nurses its young at night (Short, 1984).
The Replacement of Maternal
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Human Lactation,
Third Edition
Jan Riordan, EdD, RN, IBCLC, FAAN
JONES AND BARTLETT PUBLISHERS
Breastfeeding and Human Lactation
Jones and Bartlett Series in Breastfeeding/Human Lactation
Case Studies in Breastfeeding: Problem-Solving Skills and Strategies, Cadwell/Turner-Maffei
Clinical Lactation: A Visual Guide, Auerbach
Coach’s Notebook: Games and Strategies for Lactation Education, Smith
Comprehensive Lactation Consultant Exam Review, Smith
Core Curriculum for Lactation Consultant Practice, Walker, editor
Counseling the Nursing Mother: A Lactation Consultant’s Guide, Third Edition, Lauwers/Shinskie
Impact of Birthing Practices on Breastfeeding: Protecting the Mother and Baby Continuum, Kroeger with Smith
The Lactation Consultant in Private Practice: The ABCs of Getting Started, Smith
Reclaiming Breastfeeding for the United States: Protection, Promotion and Support, Cadwell
Ten Steps to Successful Breastfeeding: An 18 Hour Interdisciplinary Breastfeeding Management Course for the United
States, Cadwell/Turner-Maffei
Varney’s Midwifery, Fourth Edition, Varney/Kriebs/Gegor
Breastfeeding and Human
Lactation
Third Edition
Jan Riordan, EdD, RN, IBCLC, FAAN
Professor
School of Nursing
Wichita State University
Wichita, Kansas
Lactation Consultant
Via Christi Regional Medical Center
St. Joseph Campus
Wichita, Kansas
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ISBN 0-7637-4585-5 (hardcover)
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Acquisitions Editor: Penny M. Glynn
Production Manager: Amy Rose
Editorial Assistant: Amy Sibley
Associate Production Editor: Jenny L. McIsaac
Director of Marketing: Alisha Weisman
Marketing Manager: Edward McKenna
Manufacturing Buyer: Amy Bacus
Cover Design: Anne Spencer
Composition: Modern Graphics Incorporated
Printing and Binding: Malloy Inc.
Cover Printing: Malloy Inc.
Printed in the United States of America
08 07 06 05 04
10 9 8 7 6 5 4 3 2 1
This book is dedicated to breastfeeding women
and their babies around the globe.
This page intentionally left blank
TA B L E
Preface
Acknowledgements
xxi
xxiii
O F
CO N T E N T S
Chapter Authors
SECTION 1
xxiv
H I STOR ICAL AN D
WOR K P E R S P ECTIVE S
CHAPTER 1
Internet Resources
26
References
27
Tides in Breastfeeding Practice
3
Evidence About Breastfeeding Practices
Large-Scale Surveys
Other Evidence
3
3
4
The Biological Norm in Infant Feeding
Early Human Evolution
Early Breastfeeding Practices
5
5
5
The Replacement of Maternal Breastfeeding
Wet-Nursing
Hand-Fed Foods
Timing of the Introduction of Hand-Feeding
5
5
6
7
Technological Innovations in
Infant Feeding
The Social Context
The Technological Context
The Role of the Medical Community
8
8
9
9
The Prevalence of Breastfeeding
United States, England, and Europe
Developing Regions
12
12
13
The Cost of Not Breastfeeding
Health Risks of Using Manufactured
Infant Milks
Economic Costs of Using Manufactured
Infant Milks
15
The Unique Characteristics of Counseling
Breastfeeding Women
44
16
48
48
49
50
51
CHAPTER 2
Work Strategies and the
Lactation Consultant
History
31
Do Lactation Consultants Make a
Difference?
32
Certification
32
Getting a Job as a Lactation Consultant
Interviewing for a Job
Gaining Clinical Experience
35
36
36
LC Education
37
Lactation Programs
Workload Issues
38
41
Developing a Lactation Program
Marketing
41
44
The Promotion of Breastfeeding
Breastfeeding Promotion in the
United States
International Breastfeeding Promotion
Private Support Movements
19
20
23
Summary
24
Roles and Responsibilities
Stages of Role Development
Lactation Consultants in the
Community Setting
Medical Office
Lactation Consultants and
Volunteer Counselors
Networking
Reporting and Charting
Clinical Care Plans
Key Concepts
25
Legal and Ethical Considerations
16
18
31
45
46
47
47
vii
viii
Breastfeeding and Human Lactation
Reimbursement
Insurance and Third-Party Payment
Coding
53
53
56
Private Practice
The Business of Doing Business
Payment and Fees
57
57
58
Partnerships
59
Summary
60
Key Concepts
61
Internet Resources
62
References
62
SECTION 2
A NATOM ICAL AN D
B IOLOG ICAL I M P E RATIVE S
CHAPTER 3
Breathing and Suckling
87
Frequency of Feedings
89
Summary
90
Key Concepts
90
References
92
Anatomy and Physiology
of Lactation
67
Mammogenesis
67
Breast Structure
69
Variations
72
Pregnancy
72
Lactogenesis
Delay in Lactogenesis
73
74
The Biological Specificity
of Breastmilk
Hormonal Influences
Progesterone
Prolactin
Cortisol
Thyroid-Stimulating Hormone
Prolactin-Inhibiting Factor
Oxytocin
74
75
75
77
77
77
78
Milk Synthesis and Maturational Changes 98
Milk Production
79
Autocrine Versus Endocrine
79
Galactopoiesis
80
Galactorrhea
80
Clinical Implications: Mother
Breast Assessment
Classification of Nipple Function
Concepts to Practice
80
80
82
82
Newborn Oral Development
83
Suckling
85
CHAPTER 4
97
Energy, Volume, and Growth
Caloric Density
Milk Volume and Storage Capacity
Differences in Milk Volume
Between Breasts
Infant Growth
98
99
100
102
103
Nutritional Values
Fat
Lactose
Protein
Vitamins and Micronutrients
Minerals
Preterm Milk
103
103
105
106
106
108
110
Anti-infective Properties
Gastroenteritis and Diarrheal Disease
Respiratory Illness
Otitis Media
Controversies and Claims
111
111
112
114
115
Contents
Chronic Disease Protection
Childhood Cancer
Allergies and Atopic Disease
Asthma
115
116
116
117
The Immune System
117
Active Versus Passive Immunity
117
Cells
118
Antibodies/Immunoglobulins
119
Nonantibody Antibacterial Protection
120
Anti-inflammatory and Immunomodulating
Components
121
Calculating Infant Exposure
Unique Infant Factors
Maternal Factors
143
144
146
Minimizing the Risk
146
Effect of Medications on Milk Production
Drugs That May Inhibit Milk Production
Drugs That May Stimulate
Milk Production
Herbs
146
146
148
149
Review of Selected Drug Classes
Analgesics
Antibiotics
Antihypertensives
Psychotherapeutic Agents
Corticosteroids
Thyroid and Antithyroid Medications
149
149
150
153
153
157
157
Bioactive Components
Enzymes
Growth Factors and Hormones
Taurine
122
122
123
124
Implications for Clinical Practice
124
Drugs of Abuse
158
Summary
126
Radioisotopes
159
Key Concepts
126
Radiocontrast Agents
159
Internet Resources
127
Summary
161
Key Concepts
162
References
128
Internet Resources
162
Appendix 4-A: Composition of Human
Colostrum and Mature Breastmilk
136
References
162
CHAPTER 6
CHAPTER 5
Drug Therapy
and Breastfeeding
Viruses and Breastfeeding
137
The Alveolar Subunit
138
Drug Transfer into Human Milk
Passive Diffusion of Drugs into Milk
Ion Trapping
Molecular Weight
Lipophilicity
Milk/Plasma Ratio
Maternal Plasma Levels
Bioavailability
Drug Metabolites
139
140
141
141
142
142
142
143
143
167
HIV and Infant Feeding
167
Exclusive Breastfeeding
168
What We Know
Treatment and Prevention
168
170
Health-Care Practitioners
Counseling
171
171
Herpes Simplex Virus
172
Chickenpox/Varicella
173
Cytomegalovirus
175
ix
x
Breastfeeding and Human Lactation
Rubella
176
Implications for Practice
178
Hepatitis B
176
Summary
179
Hepatitis C
176
Key Concepts
179
Human Lymphotropic Virus
177
Internet Resources
180
West Nile Virus
177
References
181
P R E NATAL , P E R I NATAL , AN D
P OSTNATAL P E R IODS
SECTION 3
Breastfeeding Preparation
185
Clinical Implications
Breastfeeding Assessment
Discharge Planning
Basic Feeding Techniques
Signs That Intervention Is Needed
Discharge
Early Feedings
186
Summary
212
Feeding Positions
Latch-on and Positioning Techniques
191
191
Key Concepts
212
Internet Resources
214
The Infant Who Has Not Latched-On
Plan for the Baby Who Has Not
Latched-On Yet
Establishing the Milk Supply
Assessment of the Mother’s
Nipples and Breasts
Baby Problems That May Cause
Difficulty with Latch-on
192
References
214
CHAPTER 7
Perinatal and
Intrapartum Care
185
194
194
196
196
The 34 to 38 “Weeker”
197
Feeding Methods
Cup-Feeding
Finger-Feeding
198
198
199
Nipple Shields
200
Hypoglycemia
201
Cesarean Births
204
Breast Engorgement
205
Breast Edema
206
Hand Expression
207
209
209
210
210
211
211
CHAPTER 8
Postpartum Care
217
Hydration and Nutrition in the Neonate
Signs of Adequate Milk Intake
Milk Supply––Too Much or Too Little
Temporary Low Milk Supply or
Delayed Lactogenesis
Effect of Pharmaceutical Agents on
Milk Supply
Too Much Milk
217
218
218
220
221
Nipple Pain
Treatments for Painful Nipples
Nipple Creams and Gels
221
225
225
Engorgement + Milk Stasis = Involution
228
Breast Massage
228
Clothing, Leaking, Bras, and
Breast Pads
228
220
Contents
Infant Concerns
Pacifiers
Stooling Patterns
Jaundice in the Newborn
Breast Refusal and Latching Problems
Later Breast Refusal
Crying and Colic
230
230
231
232
232
234
234
Multiple Infants
Full-Term Twins or Triplets
Preterm or Ill Multiples
Putting It All Together
Partial Breastfeeding and Human
Milk Feeding
236
237
237
238
Mammoplasty
Breast Reduction
Mastopexy
Breast Augmentation
261
261
263
263
Breast Lumps and Surgery
Galactoceles
Fibrocystic Disease
265
266
267
Bleeding from the Breast
267
Breast Cancer
Lactation Following Breast Cancer
268
269
239
Clinical Implications
270
Breastfeeding During Pregnancy
240
Summary
271
Clinical Implications
241
Key Concepts
271
Summary
242
Internet Resources
273
Key Concepts
242
References
273
Internet Resources
242
References
243
CHAPTER 9
Breast-Related Problems
247
Nipple Variations
Inverted or Flat Nipples
Absence of Nipple Pore Openings
Large or Elongated Nipples
247
247
248
248
Plugged Ducts
248
Mastitis
Treatment for Mastitis
Types of Mastitis
250
251
252
Breast Abscess
254
Breast and Nipple Rashes, Lesions, and
Eczema
254
Candidiasis (Thrush)
Treatment
255
256
Breast Pain
260
Vasospasm
260
Milk Blister
261
CHAPTER 10
Low Intake in the Breastfed
Infant: Maternal and
Infant Considerations
277
Factors That Influence Maternal
Milk Production
277
Normal Milk Intake and Rate of Gain
279
US Growth Curves
Current Growth Curves Still
Underrepresent Breastfeeding
280
280
Low Intake and Low Milk Supply: Definitions and Incidence of Occurrence
282
Confusing Terminology and
Nonstandardized Research
282
The Infant’s Presentation
283
The Mother’s Presentation
285
Abnormal Patterns of Growth: The Baby
Who Appears Healthy
286
Inadequate Weight Gain in the
First Month
286
The Near-Term Infant
286
xi
xii
Breastfeeding and Human Lactation
Oral-Motor Dysfunction
(Ineffective Suckling)
Gastroesophageal Reflux/Cow Milk
Allergy/Oversupply
Nonspecific Neurological Problems
Ankyloglossia (Tight Frenulum,
Tongue-Tie)
Abnormal Patterns of Growth:
The Baby with Obvious Illness
Maternal Considerations:
The Mother Who Appears Healthy
Delayed Lactogenesis
Stress
Inverted Nipples
Nipple Shields
Medications and Substances
Hormonal Alterations
Breast Surgery
Insufficient Glandular Development
of the Breast
Psychosocial Factors
Maternal Nutrition
286
290
291
291
303
304
Summary
305
Key Concepts
306
Internet Resources
307
References
307
292
CHAPTER 11
293
293
293
294
294
294
294
295
295
296
296
Maternal Considerations:
Obvious Illness
296
History, Physical Exam, and
Differential Diagnosis
History
Physical Examination
Differential Diagnosis
296
296
296
297
Clinical Management
Determining the Need
for Supplementation
Galactagogues
Hindmilk
297
297
Intervention
Reducing the Amount
of Supplementation
Family and Peer Support
When Maternal Milk Supply Does
Not Increase
297
300
Special Techniques for Management of
Low Intake or Low Supply
Breast Massage
Switch Nursing
Feeding-Tube Device
Test Weighing
300
300
300
301
303
300
300
Jaundice and the
Breastfed Baby
311
Neonatal Jaundice
312
Assessment of Jaundice
313
Postnatal Pattern of Jaundice
314
Breastmilk Jaundice
314
Breast-Nonfeeding Jaundice
314
Bilirubin Encephalopathy
316
Evaluation of Jaundice
Diagnostic Assessment
316
317
Management of Jaundice
318
Key Concepts
319
Internet Resources
320
References
320
CHAPTER 12
Breast Pumps and
Other Technologies
323
Concerns of Mothers
323
Stimulating the Milk-Ejection Reflex
324
Hormonal Considerations
Prolactin
Clinical Implications
Oxytocin
328
328
329
330
Pumps
Mechanical Milk Removal
330
330
Contents
Compression
The Evolution of Pumps
331
331
A Comparison of Pumps
Manual Hand Pumps
Battery-Operated Pumps
Electric Pumps
332
333
335
336
Simultaneous and/or
Sequential Pumping
338
Flanges
338
Miscellaneous Pumps
Pedal Pumps
342
342
Clinical Implications Regarding
Breast Pumps
342
When Pumps Cause Problems
345
Sample Guidelines for Pumping
345
Common Pumping Problems
347
Nipple Shields
Review of Literature
Types of Shields
Shield Selection and Instructions
Weaning from the Shield
Responsibilities
349
350
351
351
352
352
Breast Shells
354
Feeding-Tube Devices
Situations for Use
355
355
Summary
357
Key Concepts
358
Internet Resources
361
References
361
Appendix 12-A: Manufacturers/
Distributors of Breast Pumps
365
CHAPTER 13
Breastfeeding the
Preterm Infant
Suitability of Human Milk for Preterm
Infants
367
367
Mothers of Preterm Infants
368
Rates of Breastfeeding Initiation and
Duration
370
Research-Based Lactation Support
Services
The Decision to Breastfeed
Facilitating an Informed Decision
Alternatives to Exclusive, Long-Term
Breastfeeding
Models for Hospital-Based Lactation
Support Services
370
370
370
370
371
Initiation of Mechanical Milk Expression 372
Principles of Milk Expression
372
Selecting a Breast Pump
372
Milk-Expression Technique
373
Milk Expression Schedule
374
Written Pumping Records
374
Maintaining Maternal Milk Volume
Expressed Milk Volume Guidelines
Preventing Low Milk Volume
Skin-to-Skin (Kangaroo) Care
376
376
376
377
Evidence-Based Guidelines for Milk
Collection, Storage, and Feeding
Guidelines for Collection and Storage
of Expressed Mother’s Milk (EMM)
Preparing Expressed Mother’s Milk
for Infant Feeding
379
Special Issues Regarding the Feeding
of EMM
Volume Restriction Status
Commercial Nutritional Additives
Hindmilk Feeding
Methods of Milk Delivery
Maternal Medication Use
380
382
382
382
383
383
Feeding at Breast in the NICU
Suckling at the Emptied Breast
The Science of Early Breastfeeding
Progression of In-Hospital Breastfeeding
Milk Transfer During Breastfeeding
384
384
385
390
390
Discharge Planning for
Postdischarge Breastfeeding
Getting Enough: Determining the Need
for Extra Milk Feedings
378
378
396
397
xiii
xiv
Breastfeeding and Human Lactation
Methods to Deliver Extra Milk Feedings
Away from the Breast
398
Postdischarge Breastfeeding Management 398
Summary
399
Key Concepts
399
Internet Resources
400
References
401
Appendix 13-A: The Preterm Infant
Breastfeeding Behavior Scale (PIBBS)
407
The Benefits of Banked Donor
Human Milk
Species Specificity
Ease of Digestion
Promotion of Growth, Maturation,
and Development of Organ Systems
Immunological Benefits
413
413
413
414
414
Clinical Uses
Distribution of Banked Donor Milk:
Setting Priorities
Classifying Clinical Uses: Is Donor
Milk Food or Medicine?
414
Current Practice
Donor Selection and Screening
Collection
Pasteurization
Packaging and Transport
Costs of Banked Donor Milk
420
420
422
422
425
425
A Brief History of Human Milk Banking 409
Foundations of Donor Human Milk
Banking: Pre-1975
409
Donor Human Milk Banking in the
United States: Post-1975
410
Potential Hazards of Informal Sharing of
Human Milk
411
Policy Statements Supporting the
Use of Banked Donor Human Milk
425
Summary
426
Key Concepts
427
Internet Resources
427
Donor Human Milk Banking Beyond
North America
The Impact of Culture on Donor
Milk Banking
References
427
Appendix 14-A: Storage and Handling
of Expressed Human Milk
432
CHAPTER 14
Donor Human Milk Banking
Defining Donor Milk Banking
409
409
412
413
414
415
B EYON D
SECTION 4
P OSTPARTU M
CHAPTER 15
Maternal Nutrition
During Lactation
437
Maternal Caloric Needs
438
Maternal Fluid Needs
439
Weight Loss
439
Exercise
440
Calcium Needs and Bone Loss
441
Vegetarian Diets
442
Dietary Supplements
442
Foods That Pass Into Milk
Caffeine
Food Flavorings
443
443
443
Allergens in Breastmilk
443
The Goal of the Maternal Diet
During Lactation
444
Contents
Systemic Lupus Erythematosus
Multiple Sclerosis
Rheumatoid Arthritis
470
471
471
Physically Challenged Mothers
Seizure Disorders
472
473
Headaches
475
476
477
453
Postpartum Depression
Clinical Implications
Medications and Herbal Therapy
for Depression
Support for the Mother with
Postpartum Depression
480
Key Concepts
453
Asthma
480
Internet Resources
454
Smoking
480
References
454
Poison Ivy Dermatitis
481
Diagnostic Studies Using Radioisotopes
481
The Impact of Maternal Illness
and Hospitalization
482
Summary
482
Key Concepts
483
Internet Resources
484
References
484
Nutrition Basics
Energy
446
446
Macronutrients
Carbohydrates
Protein
Fat
447
447
447
448
Micronutrients
Vitamins
Minerals
448
448
449
Clinical Implications
449
Summary
CHAPTER 16
Women’s Health
and Breastfeeding
459
Alterations in Endocrine and
Metabolic Functioning
Diabetes
Thyroid Disease
Pituitary Dysfunction
Polycystic Ovarian Syndrome
Theca Lutein Cysts
Cystic Fibrosis
459
459
461
462
462
462
463
Acute Illness and Infections
Tuberculosis
Group B Streptococcus
Dysfunctional Uterine Bleeding
463
464
464
465
Maternal Immunizations
478
CHAPTER 17
Maternal Employment
and Breastfeeding
487
Why Women Work
487
Historical Perspective
488
465
The Effect of Work on Breastfeeding
488
Surgery
465
Donating Blood
466
Relactation
467
Induced Lactation
Domperidone, Metoclopramide,
and Sulpride
467
468
Autoimmune Diseases
470
Strategies to Manage Breastfeeding
and Work
Prenatal Planning and Preparation
Return to Work
Hand Expression and Pumping
Human Milk Storage
Fatigue and Loss of Sleep
Maintaining an Adequate Milk Supply
The Day-Care Dilemma
489
489
491
492
493
496
496
497
xv
xvi
Breastfeeding and Human Lactation
Workplace Strategies
Lactation Programs in Work Sites
The Employer’s Perspective
Community Strategies
Health-Care Providers and
Lactation Consultants
Breastfeeding Support Groups
497
498
500
501
501
501
National and International Strategies
Legislative Support and
Public Advocacy
International Labour Organization
501
501
503
Clinical Implications
503
Summary
505
Key Concepts
506
Internet Resources
507
Other Resources
507
References
507
CHAPTER 18
Child Health
509
Developmental Outcomes and Infant
Feeding
509
Growth and Development
Physical Growth
Weight and Length
Senses
Reflexes
Levels of Arousal
511
511
512
513
514
514
Theories of Development
Nature Versus Nurture
514
514
Social Development
Language and Communication
Attachment and Bonding
Temperament
Stranger Distress
Separation Anxiety
517
517
520
523
523
523
Clinical Implications
Immunizations
Vitamin D and Rickets
527
Dental Health and Orofacial
Development
527
Solid Foods
Introducing Solid Foods
Choosing the Diet
Choosing Feeding Location
Delaying Solid Foods
528
528
529
531
531
Obesity
532
Co-Sleeping
532
Long-Term Breastfeeding
533
Weaning
533
Implications for Practice
534
Summary
535
Key Concepts
535
Internet Resources
536
References
536
CHAPTER 19
The Ill Child:
Breastfeeding Implications
Team Care for the Child with
Feeding Difficulties
541
541
Feeding Behaviors of the Ill Infant/Child 541
What to Do If Weight Gain
Is Inadequate
What to Do When Direct Breastfeeding
Is Not Sufficient
Alternative Feeding Methods
544
544
546
Care of the Hospitalized Breastfeeding
Infant/Child
Home from the Hospital:
The Rebound Effect
550
525
Perioperative Care of the Breastfeeding
Infant/Child
551
525
Emergency Room
552
548
Contents
Care of Children with
Selected Conditions
Infection
Gastroenteritis
Respiratory Infections
Pneumonia
Bronchiolitis
Respiratory Syncytial Virus
Otitis Media
Meningitis
552
552
552
554
555
555
556
556
556
Alterations in Neurological Functioning
Down Syndrome or Trisomy 21
Neural Tube Defects
Hydrocephalus
557
560
560
561
Congenital Heart Disease
561
Oral/Facial Anomalies
Cleft Lip and Palate
Pierre Robin Sequence
Choanal Atresia
563
563
566
568
Gastrointestinal Anomalies
and Disorders
Esophageal Atresia/Tracheoesophageal
Fistula
Gastroesophageal Reflux
Pyloric Stenosis
Imperforate Anus
568
569
571
571
Metabolic Dysfunction
Phenylketonuria
Galactosemia
Congenital Hypothyroidism
Type I Diabetes
Celiac Disease
Cystic Fibrosis
571
572
572
574
575
575
575
Allergies
576
Food Intolerance
Lactose Intolerance
579
579
Psychosocial Concerns
Family Stress
Coping with Siblings
Chronic Grief and Loss
The Magic-Milk Syndrome
579
579
581
581
581
568
The Empty Cradle...When a Child Dies
Caring for Bereaved Families
582
582
Summary
583
Key Concepts
583
Internet Resources
584
References
585
CHAPTER 20
Infant Assessment
591
Perinatal History
591
Gestational Age Assessment
The New Ballard Score
591
594
Indicators of Effective Breastfeeding
and Assessment Scales
Breastfeeding Behaviors
and Indicators
Breastfeeding Scales and Tools
Summary of Breastfeeding
Assessment Scales
598
598
598
600
Physical Assessment
Transitional Assessment
Skin
Birthmarks
Head
Ears/Eyes
Nose
Mouth
Neck
Chest
Abdomen
Genitalia
Back and Spine
Extremities
Elimination
600
600
604
605
606
606
607
607
608
608
609
609
609
609
610
Behavioral Assessment
Sleep-Wake States
Neurobehavioral Cues and Reflexes
611
614
614
Summary
616
Key Concepts
616
References
616
xvii
xviii
Breastfeeding and Human Lactation
Appendix 20-A: Infant Breastfeeding
Assessment Tool (IBFAT)
618
Appendix 20-B: LATCH
Assessment Tool
618
Appendix 20-C: Mother-Baby
Assessment Scale
619
Contraception
The Contraceptive Methods
639
639
Clinical Implications
645
Summary
647
621
Key Concepts
647
621
References
648
621
S OCIOCU LTU RAL AN D
R E S EARCH I SS U E S
SECTION 5
CHAPTER 22
Research, Theory,
and Lactation
Theories Related to Lactation Practice
Maternal Role Attainment Theory
Parent-Child Interaction Model
Bonding and Attachment Theory
Theory of Darwinian and
Evolutionary Medicine
Self-Care Theory
Self-Efficacy Theory
Theory of Planned Behavior and
Theory of Reasoned Action
628
630
632
632
637
CHAPTER 21
Fertility
The Demographic Impact
of Breastfeeding
622
623
624
Sexuality
Libido
Sexual Behavior During Lactation
Appendix 20-D: Via Christi Breastfeeding
Assessment Tool
620
Fertility, Sexuality,
and Contraception
During Lactation
Mechanisms of Action
Lactational Amenorrhea
The Suckling Stimulus
The Repetitive Nature of the Recovery
of Fertility
The Bellagio Consensus
655
655
656
656
657
657
658
658
658
Types of Research Methods
Qualitative Methods
Quantitative Methods
Additional Methods and Approaches
for Breastfeeding Research
659
659
660
662
Elements of Research
Research Problem and Purpose
663
663
Variables, Hypotheses, and
Operational Definitions
Review of Literature
Protection of the Rights of Human
Subjects
Method
Data Analysis
Application of Methods to
Qualitative Approaches
Sampling
Data Collection
Data Analysis
Trustworthiness of Qualitative Research
Application of Methods to
Quantitative Approaches
Sampling and Sample Size
Data Collection
Reliability and Validity
Data Analysis
Results, Discussion, Conclusions,
and Dissemination
Evaluating Research for Use in Practice
665
667
667
668
669
669
669
670
670
671
671
671
672
672
674
677
678
Contents
Using Research in Clinical Practice
680
Educational Needs and Early Discharge
706
Perspectives of Research Methodologies
Positivist and Postpositive Perspective
Naturalistic, Humanistic, or
Interpretive Perspective
Critical or Emancipatory Perspective
680
681
Continuing Education
Objectives and Outcomes
706
707
681
681
Summary
682
Key Concepts
683
Internet Resources
684
The Team Approach
Childbirth Educators
Nurses
Lactation Consultants
Physicians
Dietitians
Community Support Groups
708
708
708
709
709
709
709
References
684
Summary
709
Appendix 22-A: Research Terms
687
Key Concepts
710
Internet Resources
711
References
711
CHAPTER 23
Breastfeeding Education
689
CHAPTER 24
Educational Programs
Distance Learning and Web Courses
689
690
Learning Principles
690
The Cultural Context
of Breastfeeding
Adult Education
691
The Dominant Culture
714
Curriculum Development
692
Ethnocentrism Versus Relativism
714
Parent Education
692
Assessing Cultural Practices
715
Prenatal Education
694
Language Barriers
715
Early Breastfeeding Education
Continuing Support for
Breastfeeding Families
694
The Effects of Culture on Breastfeeding
Rituals and Meaning
Colostrum
Sexual Relations
Wet-Nursing
Other Practices
Contraception
Infant Care
716
719
719
719
720
720
720
721
Maternal Foods
“Hot” and “Cold” Foods
Herbs and Galactogogues
722
722
723
Weaning
Types of Weaning
723
724
Implications for Practice
725
Summary
726
Key Concepts
727
697
How Effective Is
Breastfeeding Education?
697
Teaching Strategies
698
Small Group Dynamics
700
Multimedia Presentations
Slides
Transparencies
Television, Videotapes, and DVDs
Compact Discs
700
701
701
701
702
Educational Materials
Education for At-Risk Populations
Adolescents
Older Parents
702
703
704
705
713
xix
xx
Breastfeeding and Human Lactation
Internet Resources
727
Key Concepts
742
References
727
Internet Resources
743
References
743
APPENDIXES
A. Clinical Competencies for
IBCLC Practice
B. Code of Ethics
C. Summary of Eligibility Pathway
Requirements to Become Certified
by IBLCE
D. Prototype Lactation Consultant
Job Description
E. Tables of Equivalencies and Methods
of Conversion
F. Infant Weight Conversion Table
G. Breastfeeding Weight Loss Table
H. Patient History
747
CHAPTER 25
Families
729
Family Forms and Functions
729
Family Theory
730
Social Factors that Influence
Breastfeeding
731
Fathers
733
The Adolescent Mother
736
The Low-Income Family
Lack of Information
Hospital Practices
The Importance of Peer Counselors
737
737
738
739
The Downside of Family Experience
Violence
Childhood Sexual Abuse
739
740
741
Summary
742
749
754
756
758
761
762
763
764
Glossary
773
Index
785
Figure, Table, and Box Credits
817
P R E FA C E
I have worked in the field of lactation since the
early 1960s, first as a La Leche Leader and later as
a lactation consultant when it became a professional
practice discipline in 1985. As I look back over
those years I am struck both by how different things
are now and by how much things have stayed the
same. Although the breastfeeding initiation rate in
the United States has risen to almost 70 percent––a
vast improvement from 20 percent in the 1960s!––it
still takes time and patience to help a new breastfeeding mother get her baby onto the breast.
New knowledge has changed the field. Research studies now verify that breastfed children are
more intelligent and that not breastfeeding costs the
U.S. health care system billions of dollars annually.
Because of the new awareness of the importance of
breastfeeding, the number and influence of lactation consultants has expanded. The International
Board of Lactation Consultants has certified more
than 10,000 health care workers in 36 countries.
Most hospitals, large and small, offer lactation services of some type and employ lactation consultants. Lest anyone question the powerful, positive
influence of interventions by health care workers on
breastfeeding, they only need to review the table of
intervention studies in Chapter 2. At the same time,
lest we follow that conflicted path that led to the
medicalization of childbirth, we must listen to
voices that warn of the danger of lactation consultants medicalizing infant feeding.
Other changes affect lactation practice. The insurance industry now drives the health care system,
reversing the reward system in favor of short hospital stays, which are now two days or less in the U.S.
for vaginal births. While these short stays mean that
breastfeeding mothers and babies return home less
likely to be exposed to hospital infections and to
supplementary feedings, this brief time allows almost no opportunity to ensure that the baby is
breastfeeding effectively. Mothers still needing care
themselves return home to assume full-time childcare before they feel physically able to do so. Follow-up care of a new family at home should be
universal, yet many mothers of preterm and “nearterm” breastfed infants who are developmentally
immature leave the hospital without any plan for assistance.
This text brings together in a single volume the
latest clinical techniques and research findings that
direct evidence-based clinical practice. I have been
fortunate in being able to enlist a dozen breastfeeding experts recognized around the world to help with
the writing of this extensive volume. Dr. Kathleen
Auerbach, the much-missed former co-author of this
book, remains as co-author of two chapters.
Over 1,000 research studies support the clinical
recommendations in this book. The Internet and
MEDLINE made the literature searches so much
easier for this edition––a sea of change from writing
the first two editions. The Internet also made possible quick correspondence with colleagues and
chapter authors as this book progressed. Addresses
of helpful resources on the Internet have been
added to each chapter.
Like the earlier editions, the third edition of this
text has a clear clinical focus. A new chapter on infant assessment reflects current expectations that
the health care worker working with the breastfeeding dyad can perform a total assessment of the
baby. Nearly every chapter contains a clinical implications section. Important concepts discussed
in chapters are summarized at the end of each
chapter––a new feature that will make studying easier. Throughout the book are new references
deemed by the authors to be the most important
from the vastly expanded research and clinical literature. Some older references that introduced new
ideas that are now accepted common knowledge
have been regretfully removed to make room for
new research. The glossary of key terms relating to
lactation has been expanded in this edition.
Section 1 contrasts the past and present. Chapter 1 presents the history of breastfeeding by placing lactation and breastfeeding in its historical
context. Chapter 2 fast-forwards to the work of the
present-day health care worker who specializes in
lactation and breastfeeding, and it addresses the reality of work-related issues of lactation consulting.
Section 2 focuses on basic anatomic and biologic imperatives of lactation. Clinical application of
xxi
xxii
Breastfeeding and Human Lactation
techniques must be based on a clear understanding
of the relationships between form, function, and biological constructs. Thus this section, too, provides
the background upon which to understand other aspects of lactation and breastfeeding behavior.
Section 3 is the clinical “heart” of the book that
describes the basics of what to do, when to do it, and
how to do it when one assists the lactating mother.
Section 3 thus concerns itself with the perinatal period in the birth setting and concerns during the
postpartum period following the family’s return
home—notably breast problems, neonatal jaundice,
and infant weight gain. This section also addresses
special needs of preterm babies and their mothers,
and it critically evaluates breastfeeding devices and
recommends how and when they are most appropriately used. It concludes with a review of the development and current activities of human milk
banking.
The first part of Section 4 focuses on the
mother: maternal nutrition, the mother’s health,
and returning to work. The topics then turn to the
infant and child’s health and special health needs.
The techniques of infant assessment are explained
and demonstrated with photographs in a new chapter. The section ends with a discussion of maternal
sexuality and fertility.
Section 5 begins with a careful look at research––
how it is conducted, why ongoing research is
needed, and how research findings can be applied in
clinical settings. The principles of education, the cornerstone of clinical practice, are explored next. The
book concludes with the socio-cultural context of the
breastfeeding family and explores the different ways
in which the breastfeeding family functions within
that context.
To avoid linguistic confusion, the book uses the
following conventions. The word nursing (in italics)
in the text refers to the profession. Nursing, meaning breastfeeding, is always shown in ordinary
Roman type. The masculine pronoun has been
used to denote the infant or child throughout the
text as a matter of convenience to distinguish the
child from the breastfeeding mother. Nurses, lactation consultants, and other health care workers
are referred to by feminine pronouns, although we
recognize here that males serve in all health care
professions.
ACKNOWLEDGEMENTS
I gratefully acknowledge the contributions to this
book made by the following individuals:
Judy Angeron BA, RN, IBCLC, Coordinator, Lactation Services, Via Christi Regional Medical Center, Wichita, Kansas
Kathleen G. Auerbach PhD, IBCLC, Ferndale,
Washington
Suzanne Bentley MSN, CNM, IBCLC, Clinical
Nurse Specialist, University of Kansas, Clinical Instructor, University of Kansas, School of Nursing,
Kansas City, Kansas
Kerstin Hedberg-Nyqvist PhD, RN, IBCLC, Assistant Professor in Pediatric Nursing, Department of
Women’s and Children’s Health, Uppsala University,Uppsala, Sweden
Heather Hull MSN, PNP, Instructor, Wichita State
University, Wichita, Kansas
Voni Miller RN, IBCLC, Lactation Consultant,
Phoenix Children’s Hospital, Phoenix, Arizona
Gerald Nelson MD, The University of Kansas
School of Medicine, Wichita, Kansas
Belinda Childs MN, ARNP, CDE, Clinic/Research Coordinator, Mid-America Diabetes Associates, Wichita, Kansas
Amal Omer-Salim, MSc, Nutritionist, International
Maternal and Child Health, Department of
Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
Mary Margaret Coates MS, IBCLC, TechEdit,
Wheat Ridge, Colorado
Virginia Phillips, IBCLC, Brisbane, Queensland,
Australia
Amy Ellington RN, BSN, Lactation Consultant,
Via Christi Regional Medical Center, Wichita,
Kansas
Christina M Smillie MD, FAAP, IBCLC, Breastfeeding Resources, Stratford, Connecticut
Barbara Gabbert-Bacon, La Leche League, Wichita, Kansas
Lenore Goldfarb, B.Comm, B.Sc, IBCLC, Herzl
Family Practice Centre, Sir Mortimer B. DavisJewish General Hospital, Montreal, Quebec,
Canada
Robert T. Hall MD, Professor, Children’s Mercy
Hospital and Clinics, Kansas City, Missouri
Eileen Hawkins MSN, ARNP, Wichita State University, School of Nursing, Wichita, Kansas
I am especially grateful to La Leche League International for providing the foundation for my breastfeeding education and to those institutions which
encouraged and supported me in writing the book:
the School of Nursing, Wichita State University,
and Via Christi Regional Medical Center, both of
Wichita, Kansas.
Finally, thanks to my family: Hugh, Michael,
Neil and Shirley, Brian, Quinn and Rika Riordan,
Teresa Riordan and Richard Chenoweth, Renee
and Don Olmstead and our 11 (breastfed) grandchildren.
xxiii
CHAPTER AUTHORS
Kathleen G. Auerbach, PhD, IBCLC
Ferndale, Washington
Lois D. W. Arnold, PhD (C.), MPH, IBCLC
National Commission on Donor Milk Banking
East Sandwich, Massachusetts
Debi Leslie Bocar, PhD, RN, IBCLC
Perinatal Educator, Mercy Health Center
Director, Lactation Consultant Services
Oklahoma City, Oklahoma
Yvonne Bronner, ScD, RD, LD
Professor and Director, Public Health Program
Morgan State University
Baltimore, Maryland
Mary Margaret Coates, MS, IBCLC
TechEdit
Wheat Ridge, Colorado
Lawrence M. Gartner, MD
Professor Emeritus
Departments of Pediatrics and Obstetrics/
Gynecology
The University of Chicago
Chicago, Illinois
Kathy Gill-Hopple, MSN, RN
Instructor
Wichita State University, School of Nursing
Wichita, Kansas
Thomas W. Hale, PhD, RPH
Professor of Pediatrics
Texas Tech University, School of Medicine
Amarillo, Texas
Marguerite Herschel, MD
Associate Professor of Pediatrics
Medical Director, General Care Nursery
The University of Chicago
Chicago, Illinois
Roberta J. Hewat, PhD, RN, IBCLC
Associate Professor
University of British Columbia,
School of Nursing,
Vancouver, British Columbia, Canada
xxiv
Kay Hoover, MEd, IBCLC
Philadelphia Department of Public Health
Philadelphia, Pennsylvania
Nancy Hurst, RN, MSN, IBCLC
Director, Lactation Program and Mother’s Own
Milk Bank
Texas Children’s Hospital
Assistant Professor of Pediatrics
Baylor College of Medicine
Houston, Texas
Kathy I. Kennedy, MA, Dr.PH
Director, Regional Institute for Health and Environmental Leadership,
University of Denver Associate Clinical Professor
of Preventive Medicine,
University of Colorado Health Sciences
Denver, Colorado
Mary Koehn, PhD, RN, MSN
Assistant Professor
Wichita State University, School of Nursing
Wichita, Kansas
Paula Meier, DNSc, RN, FAAN
NICU Lactation Program Director, Department of
Maternal-Child Nursing,
Associate Director for Clinical Research,
Section of Neonatology,
Rush-Presbyterian-St Luke’s Medical Center
Chicago, Illinois
Sallie Page-Goertz, MN, CPNP, IBCLC
Assistant Clinical Professor,
KU Children’s Center/Kansas University School
of Medicine
Overland Park, Kansas
Nancy Powers, MD
Medical Director, Lactation Services
Pediatrix Medical Group
Wesley Medical Center
Wichita, Kansas
Chapter Authors
Wailaiporn Rojjanasrirat, PhD, MSN
Research Assistant Professor
University of Kansas, School of Nursing
Kansas City, Kansas
Linda J. Smith, BSE, FACCE, IBCLC
Bright Future Lactation Resource Centre Ltd.
Dayton, Ohio
Marsha Walker, RN, IBCLC
Lactation Associates
Executive Director, National Alliance for Breastfeeding Advocacy
Research, Education, and Legal Branch
Weston, Massachusetts
Karen Wambach, PhD, RN, IBCLC
Assistant Professor
University of Kansas, School of Nursing
Kansas City, Kansas
xxv
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S E C T I O N
1
Historical and Work Perspectives
Just as the breastfeeding course flows and ebbs in
a woman’s life, so breastfeeding has experienced
flows and ebbs through the centuries. It takes a village to return to breastfeeding, and community-based
programs that promote breastfeeding are successfully
and steadily increasing the rate of breastfeeding
around the world.
As more mothers choose to breastfeed, the need for
specialized help increases also. The visibility and acceptance of lactation consulting as an allied health
profession offers opportunities for practice in hospitals, the community, and in private practice. Randomized clinical trials consistently demonstrate that
lactation consultant services lengthen a mother’s
breastfeeding course and save money through healthier mothers and babies.
1
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C
H
A
P
T
E
R
1
Tides in Breastfeeding Practice
Mary Margaret Coates and Jan Riordan
Throughout the world today, an infant is apt to receive less breastmilk than at any time in the past.
Until the 1940s, the prevalence of breastfeeding
was high in nearly all societies. Although the feeding of manufactured milks and baby milks had
begun before the turn of the century in parts of Europe and North America, the practice spread slowly
during the next decades. It was still generally limited to segments of population elites, and it involved only a small percentage of the world’s
people. During the post–World War II era, however, the way in which most mothers in industrialized regions fed their infants began to change, and
the export of these new practices to developing nations was underway.
Evidence About Breastfeeding
Practices
How do we know what we “know” about the prevalence of breastfeeding? (The word prevalence is used
here to mean the combined effect of breastfeeding
initiation rates and breastfeeding continuance rates.)
Before attempting to trace trends in infant feeding
practices, let us consider the nature of the evidence.
Large-Scale Surveys
National surveys that produce the kind of representative data that allow statistical evaluation have been
available only since 1955. These surveys consist primarily of national fertility or natality surveys and of
marketing surveys conducted by manufacturers of
artificial baby milk. For most, exclusive breastfeeding is not a separate statistic. However, the percentage of exclusive breastmilk feedings at hospital
discharge can be found in state birth certificate databases (Feldman-Winter et al., 2002). A brief description of national surveys conducted in the United
States follows (Grummer-Strawn & Li, 2000):
●
●
●
National Health Interview Survey: A personal interview is conducted in 43,000 households.
Questions about incidence and duration of
breastfeeding are asked.
National Health and Nutrition Examination Survey
(NHANES): Breastfeeding data are periodically
collected from personal interviews in the home.
National Survey of Family Growth (NSFG): Personal interviews are conducted every 6 years.
Standard questions on incidence, duration, and
exclusivity are included.
3
4
Historical and Work Perspectives
●
●
●
●
Pediatric Nutrition Surveillance System (PedNSS):
Statistics of breastfeeding incidence and duration
in low-income populations are collected in public health clinics and reported annually. National,
state, county, and clinic data are analyzed.
WIC Participant Characteristics Study: Data on
breastfeeding are collected each even-numbered year by the Department of Agriculture.
Ross Laboratories Mothers Survey: Questionnaires
are mailed to new mothers whose names are
obtained from a national sample of hospitals
and physicians. For marketing purposes, data
on type of milk fed is collected for up to 12
months for a given cohort. Data are published
on an ad hoc basis. The survey currently functions as a baseline and monitoring data source
for breastfeeding goals in Healthy People 2010.
Mead-Johnson Longitudinal Study of Infant Feeding
Practices: For marketing purposes, a panel of infants is followed for 12 months. Data is collected on incidence of, duration of, and
changes in breastfeeding frequencies.
Outside the United States, representative data
for countries in Latin America, Asia, Africa, and the
Middle East are derived from three sources. World
Fertility Surveys are sponsored by the Office of
Population within the United States Agency for International Development (USAID), the United Nations Fund for Population Activities, and the United
Kingdom Office of Development Assistance (Lightbourne, Singh, & Green, 1982). The World Health
Organization began ongoing surveys on infant
feeding in the mid-1970s. Its Global Data Bank on
Breast-Feeding pools information garnered from
well-designed nutrition and breastfeeding surveys
around the world; on the basis of these data, breastfeeding practices are periodically summarized. The
most recent summary appeared in 2000 (WHO,
2000). Finally, demographic and health surveys
were initiated in 1984; these ongoing surveys are
sponsored jointly by USAID and governments of
host countries in which the surveys are made.
Other Evidence
Until the last several decades, breastfeeding was the
unremarkable norm. Thus what we “know” about
breastfeeding from much earlier times often must be
inferred from evidence of other methods of feeding
infants. Most historical material available in Englishlanguage literature derives from a rather limited geographic area: Western Europe, Asia Minor, the
Middle East, and North Africa. Written materials,
which include verses, legal statutes, religious tracts,
personal correspondence, inscriptions, and medical
literature, extend back to before 2000 BC.
Some of the earliest existing medical literature
deals at least in passing with infant feeding. An
Egyptian medical encyclopedia, the Papyrus Ebers
(c. 1500 BC), contains recommendations for increasing a mother’s milk supply (Fildes, 1986). The first
writings to discuss infant feeding in detail are those
of the physician Soranus, who practiced in Rome
around AD 100; his views were widely repeated by
other writers until the mid-1700s. It is not immediately apparent to what degree these early exhortations either reflected or influenced actual practices.
Many writings before AD 1800 deal primarily with
wet nurses or how to hand-feed infants.
Archeological evidence provides some information about infant feeding prior to 2000 BC. Some of
the earliest artifacts are Middle Eastern pottery figurines that depict lactating goddesses, such as Ishtar
of Babylon and Isis of Egypt. The abundance of this
evidence suggests that lactation was held in high regard (Fildes, 1986). Such artifacts first appear in sites
about 3000 BC, when pottery making first became
widespread in that region. Information about infant
feeding may also be derived from paintings, inscriptions, and infant feeding implements.
Modern ethnography has a place of special importance. By documenting the infant feeding practices of present-day nontechnological hunter-gatherer, herding, and farming societies, ethnographers
expand our knowledge of the range of normal breastfeeding practices. At the same time, they provide a
richer appreciation of cultural practices that enhance
the prevalence of breastfeeding. Such studies are also
our best window into breastfeeding practices that
may be the biological norm for Homo sapiens sapiens.
In summary, the historical aspect of this chapter
deals with limited data from a limited social stratum in
a limited geographic region. However, the common
threads of these data provide a useful context within
which we may better understand modern breastfeeding practices, especially in Western cultures.
Tides in Breastfeeding Practice
The Biological Norm in Infant Feeding
Early Human Evolution
The class Mammalia is characterized principally by
the presence of breasts (mammae), which secrete
and release a fluid that for a time is the sole nourishment of the young. This manner of sustaining
newborns is extremely ancient; it dates back to the
late Mesozoic era, some 100 million years ago. (See
Figure 1–1.) Hominid precursors first appeared
about 4 million years ago; the genus Homo has existed for about 2 million years. The currently dominant human species, Homo sapiens sapiens, has
existed for perhaps 40,000 years. Information about
breastfeeding practices among our earliest ancestors is uncertain, although other information about
Paleolithic societies that existed 10,000 or more
years ago sheds light on this subject.
Early Breastfeeding Practices
Diets reconstructed by archeological methods reveal that the Late Paleolithic era, roughly 40,000 to
10,000 years ago, was populated by pre-agricultural
peoples who ate a wide variety of fruits, nuts, vegetables, meat (commonly small game), fish, and
shellfish. This diet closely resembles that of twentieth-century hunter-gatherer societies. Therefore,
the infant-feeding practices of societies today may
reflect breastfeeding practices of much earlier (prehistoric) times. Consider the breastfeeding practices
of the ¡Kung of the Kalahari Desert in southern
Africa (Konner & Worthman, 1980) as well as
hunter-gatherer societies of Papua New Guinea and
elsewhere (Short, 1984). Among these people,
breastfeeding of young infants is frequent (averaging four feeds per hour) and short (about 2 minutes
per feed). It is equally distributed over a 24-hour
period and continues, tapering off gradually, for
two to six years. These breastfeeding patterns are
considered a direct inheritance of practices that prevailed at the end of a long, and dietetically stable,
evolutionary period that ended about 10,000 BC.
This assumption is supported by observations of the
human’s closest primate relative, the chimpanzee,
which secretes a milk quite similar to that of humans, suckles several times per hour, and sleeps
with and nurses its young at night (Short, 1984).
The Replacement of Maternal