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Prenatal preparations: During the last trimester of pregnancy, techniques that increase the potential for successful breast-feeding are discussed with women who have selected that infant-feeding option. Very little preparation is required for the breast and nipples. During pregnancy, the nipple and aerola thicken, and glands on the aerola, which contain a lubricant to keep the nipple from drying, enlarge. Toughening nipples by vigorous rubbing with a towel or nipple-rolling are no longer recommended. Nipple shells or shields may be recommended for women whose nipples are flat or inverted.
Postpartum breast-feeding: A successful breast-feeding experience is potentiated by assisting the woman to develop confidence, comfort, and skill in using techniques for appropriate infant latch-on, feeding, and disengagement. Basic breast care is described, discussed, and demonstrated to minimize the potential for discomforts that interfere with successful breast-feeding, such as nipple soreness. Washing the breasts and nipples with clear water and avoiding the use of soap, which removes the natural breast lubricants that protect the nipples against drying and cracking, are recommended. Drying the nipples thoroughly by exposing them to air, sunlight, or a hair dryer set on low heat prevents excoriation. Allowing colostrum or milk to dry on the nipple helps heal small cracks. Sparing use of 100% lanolin creams is also helpful. The woman should be encouraged to wear a nursing bra that effectively supports her breasts 24 hr a day. Soft disposable fabric pads may be inserted to absorb any milk leakage; however, plastic liners should be avoided because they retain moisture and body heat, which softens and macerates the nipple. Skin-to-skin contact is encouraged and is associated with longer periods of breast-feeding, better temperature regulation, less crying, enhanced maternal responsiveness, and skill competence.
Positioning: Positioning is a fundamental component of successful breast-feeding and the greatest deterrent to sore nipples. Both mother and infant should be positioned for comfort and convenience of nursing. Mother and infant should face each other in the chest-to-chest position, and the mother's nipple should be at the level of the infant's nose. Positions include cross cradle, football hold, and side-lying.
Latching-on: To elicit nipple erection and to facilitate latch-on, the mother cups her hand under her breast and either places her thumb (C-hold) or her index finger (scissors-hold) above the areola with the other three fingers below the areola, supporting the weight of the breast. The infant should grasp the whole nipple with its gums on the areola. Suckling then compresses the milk ducts and effectively ejects milk. Preventing the infant from suckling only on the end of the nipple reduces potential for nipple soreness, erosion, and cracking.
Feeding: Infants should be allowed to feed until they exhibit signs of satisfaction. Feeding from a single breast is allowable as long as the infant nurses approximately every 2 hr and feeds until satisfied; this encourages the intake of the higher-calorie, high-fat hind milk.
Disengaging: The mother should gently insert her fingers between the infant's gums to break the suction and withdraw the breast from the baby's mouth.
Engorgement: Feeding the newborn on demand usually prevents the development of engorgement. Should it occur, the mother either may apply warm wet compresses or stand beneath a shower of warm water to stimulate the let-down reflex and initiate milk flow. The mother also should be taught how to manually express enough milk to relieve the pressure and soften the areola to encourage latch-on when feeding.
Nipple soreness: Some discomfort is common during the first few breast-feeding days. The mother's first actions should be to check the infant's feeding position and grasp of the nipple. Altering her position for feeding also alters the stress points on the nipple as the infant suckles and enhances breast emptying. If soreness is related to the newborn's vigorous sucking because of hunger, the mother may elect to nurse more frequently. The mother is encouraged to continue with breast-feeding; however, if the suggested measures prove ineffective and discomfort persists throughout the feeding interval or does not subside by the end of the first postpartum week, the mother should be assisted to seek consultation with a lactation specialist.
Breast reduction: Successful breast-feeding after breast reduction is decreased due to a greater risk of insufficient milk supply, esp. if the nerves to the nipple have been compromised. Some milk ducts are lost, which decreases the potential to produce milk. It is important to support a woman's decision to breast-feed and assist her with supplemental systems if needed.
Breast augmentation: There is increased success with breast-feeding with augmentation as long as the nipple has not been surgically altered. Compression of glandular tissue can increase the risk of decreased milk supply. Support and use of supplemental systems, if needed, are helpful.
CAUTION!Women who are infected with the human immunodeficiency virus (HIV) may transmit it to their children by breast-feeding.
In most instances, however, maternal illness does not contraindicate breast-feeding, or does so only for a short time until treatment is initiated. If maternal surgery is anticipated, the mother can be encouraged to pump and store milk in advance, then assisted to pump or breast-feed directly as soon as possible after surgery. Many medications required by mothers are safe for their infants either because drug concentration in breast milk will be insignificant or because the infant’s gut will absorb only a minimal amount of the drug. Resources containing information on breast-feeding and breast-feeding/medications include: the AAP’s “Transfer of Drugs & Other Chemicals into Human Milk” (170 usually compatible drugs, effects on milk production, minor adverse effects on mother or infant, drugs requiring temporary cessation of breast-feeding, “caution” drugs) (http://aappolicy.aappublications.org/cgi/content/full/pesiatrics:108/3/776); International Lactation Consultant Association (www.ilca.org); National Center for Chronic Disease Prevention and Health Promotion: Breastfeeding (www.cdc.gov/breastfeeding); La Leche League International (www.llli.org).
Health care professionals should carefully examine and question policies that limit women’s rights, abilities, or opportunities to breast-feed.