Literature Review:

Definitions of

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A mainstream amount studies did not discriminate between limited
and partially breastfed infants, or explain the difference between
“breastfeeding” and “feeding of expressed breast milk.” The term
“breastfeeding” is applied for studies in full-term infants and the term “human
milk feeding” is applicable for studies in preterm infants

Exclusive breastfeeding is defined as an infant’s
consumption of human milk with no supplementation of any type (no water, no
juice, no nonhuman milk, and no foods) except for vitamins, minerals, and

Breastfeeding the baby can bring many welfares and help
create a bond with the baby. Extensive research using improved epidemiologic
methods and modern laboratory techniques documents varied and convincing
advantages for infants, mothers, families, and society from breastfeeding and
use of human milk for infant feeding (Kramer
et al., 2001). These advantages include health, nutritional, immunologic,
developmental, psychologic, social, economic, and environmental benefits. In
1997, the American Academy of Pediatrics (AAP) published the policy
statement Breastfeeding and the Use of Human Milk (American Academy of Pediatrics, 1997). Since
then, significant advances in science and clinical medicine have occurred. This
revision cites substantial new research on the importance of breastfeeding and
sets forth principles to guide pediatricians and other health care
professionals in assisting women and children in the commencement and
maintenance of breastfeeding. The ways pediatricians can protect, promote, and
support breastfeeding in their individual practices, hospitals, medical
schools, and communities are delineated, and the central role of the
pediatrician in coordinating breastfeeding management and providing a medical
home for the child is emphasized as stated by the American Academy of
Pediatrics (2002).


Child Health Benefits

Human milk is species-specific, and all substitute feeding
preparations differ markedly from it, making human milk exceptionally superior
for infant feeding (Hambreaus et al.,
1975) Exclusive breastfeeding is the reference or normative model against
which all alternative feeding methods must be measured with regard to growth,
health, development, and all other short- and long-term outcomes. In addition,
human milk-fed premature infants receive significant benefits with respect to
host protection and improved developmental outcomes compared with formula-fed
premature infants (Lucas et al.,1998). From
studies in preterm and term infants, the following outcomes have been

Infectious Diseases

Research in developed and emergent countries of the world,
including middle-class populations in developed countries, provides strong
evidence that human milk feeding decreases the incidence and/or severity of a
wide range of infectious diseases (Heinig et al., 2001) including bacterial, (Hopkins et
al., 1986) meningitis. bacteremia, diarrhea, respiratory tract
infection, (Howie et al., 1990), urinary
tract infection. In addition, post neonatal infant mortality rates in the
United States are reduced by 21% in breastfed infants (Rogan et al., 2004).

Other Health Outcomes

Some studies suggest decreased rates of sudden infant death
syndrome in the first year of life (McVea et al., 2000) and reduction in
incidence of insulin-dependent (type 1) and non–insulin-dependent (type 2)
diabetes mellitus, (Mosko et al.,
1997) lymphoma, leukemia, and overweight and obesity, (Benner
& Armstrong et al., 2002) hypercholesterolemia, and
asthma in older children and adults who were breastfed, compared with
individuals who were not breastfed. Additional research in this area is defensible.


Breastfeeding has been associated with slightly enhanced
performance on tests of cognitive development (Horwood et al., 1998). Breastfeeding during a painful
procedure such as a heel-stick for newborn screening provides analgesia to

Maternal Health

Important health benefits of breastfeeding and lactation are
also described for mother (Labbok, 2001). The benefits include decreased
postpartum bleeding and more rapid uterine involution attributable to increased
concentrations of oxytocin, (Ratnam
et al., 1994) decreased menstrual blood loss and increased child
spacing attributable to lactational amenorrhea, earlier return to
prepregnancy weight, (Kennedy et al.,
1996), decreased risk of breast cancer, (Newcomb & Tim at al., 2003) decreased
risk of ovarian cancer, and possibly decreased risk of hip fractures and
osteoporosis in the postmenopausal period (Jernstorm
et al., 2004).

Community Benefits

In addition to specific health advantages for infants and
mothers, economic, family, and environmental benefits have been described.
decreased costs for public health programs, decreased parental employee malingering
and associated loss of family income; more time for attention to siblings and
other family matters as a result of reduced infant illness; decreased
environmental burden for removal of formula cans and bottles; and decreased
energy demands for production and transport of artificial feeding products (Cohen & Levine at al., 1992) These
savings for the country and for families would be offset to some unknown extent
by increased costs for physician and lactation discussions, increased
office-visit time, and cost of breast pumps and other equipment, all of which
should be covered by insurance payments to providers and families.


Although breastfeeding is optimal for infants, there are a
few conditions under which breastfeeding may not be in the best interest of the
infant (Chen et al., 2000); mothers who have active untreated
tuberculosis disease or are human T-cell lymphotropic virus type I–or
II–positive (Ando and Nakano et al.,
1989); mothers who are receiving diagnostic or therapeutic radioactive isotopes
or have had exposure to radioactive materials (for as long as there is
radioactivity in the milk) (Robinson et al., 1994); mothers who are receiving
antimetabolites or chemotherapeutic agents or a small number of other medications
until they clear the milk (Bakheer & Egan et al., 1998); mothers who are using drugs of abuse (“street drugs”); and
mothers who have herpes simplex grazes on a breast (infant may feed from other
breast if clear of lesions). Appropriate information about infection-control
measures should be provided to mothers with infectious diseases.

Mothers who are infected with human immunodeficiency virus
(HIV) have been advised not to breastfeed their infants (Read et al., 2004). In developing areas of the
world with populations at increased risk of other infectious diseases and
nutritional deficiencies resulting in increased infant death rates, the
mortality risks associated with false feeding may outweigh the possible risks
of acquiring HIV infection (Kourtis et al., 2003). One study in Africa
detailed in 2 reports (Lawrence et
al., 1999) found that exclusive breastfeeding for the first 3 to 6 months
after birth by HIV-infected mothers did not increase the risk of HIV
transmission to the infant, whereas infants who received mixed feedings
(breastfeeding with other foods or milks) had a higher rate of HIV infection
compared with infants who were exclusively formula-fed.


Certain conditions have been shown to be compatible with
breastfeeding. Breastfeeding is not contraindicated for infants born to mothers
who are hepatitis B surface antigen–positive, (Berlin et al., 2002) mothers who are infected with
hepatitis C virus (persons with hepatitis C virus antibody or hepatitis C
virus-RNA–positive blood), (American Academy of Pediatrics, 2003) mothers
who are febrile (unless cause is a contraindication outlined in the previous
section), (Coutsoudis et al., 2003).

Tobacco smoking by mothers is not a contraindication to
breastfeeding, but health care professionals should advise all tobacco-using
mothers to avoid smoking within the home and to make every effort to wean
themselves from tobacco as rapidly as possible (Spooner and Kuhn et al., 2003).

Breastfeeding mothers should avoid the use of alcoholic
beverages, because alcohol is concentrated in breast milk and its use can
inhibit milk production. An occasional celebratory single, small alcoholic
drink is acceptable, but breastfeeding should be avoided for 2 hours after the
drink (Andersen et al., 1982).

For the great majority of newborns with jaundice and
hyperbilirubinemia, breastfeeding can and should be continued without
interruption. In rare instances of severe hyperbilirubinemia, breastfeeding may
need to be interrupted temporarily for a brief period (American Academy of
Pediatrics, 2004).


Many of the mothers counted as breastfeeding were accompanying
their infants with formula during the first 6 months of the infant’s
life. Although breastfeeding instigation rates have increased steadily
since 1990, exclusive breastfeeding initiation rates have shown little or no
increase over that same period of time. Similarly, 6 months after birth, the
proportion of infants who are exclusively breastfed has increased at a much
slower rate than that of infants who receive mixed feedings Exclusive
breastfeeding has been shown to provide better-quality protection against many
diseases and to increase the probability of continued breastfeeding for at
least the first year of life.

Hindrances to commencement and extension of breastfeeding
include inadequate prenatal education about breastfeeding, troublesome hospital
policies and practices, unsuitable disruption of breastfeeding,
early hospital discharge in some populations, lack of timely routine
follow-up care and postnatal home health visits, maternal employment, (especially
in the absence of workplace facilities and support for breastfeeding), lack of
family and broad societal support, media depiction of bottle feeding as
normative, profitable promotion of infant formula through distribution
of hospital discharge packs, vouchers for free or discounted formula, and some
television and general magazine promotion, misinformation; and lack of guidance
and encouragement from health care professionals.


Pediatricians and other health care professionals should
recommend human milk for all infants in whom breastfeeding is not specifically
contraindicated and provide parents with complete, current information on the
benefits and techniques of breastfeeding to ensure that their feeding decision
is a fully informed one (Gartner et al., 2001).

When direct breastfeeding is not possible, expressed human
milk should be provided. If a known contraindication to breastfeeding is
identified, consider whether the contraindication may be provisional, and if
so, advise impelling to maintain milk production.

Peri partum policies and practices that optimize
breastfeeding initiation and maintenance should be encouraged. Education of
both parents before and after delivery of the infant is an essential component
of successful breastfeeding. Support and encouragement by the father can
greatly assist the mother during the initiation process and during subsequent
periods when problems arise. Consistent with appropriate care for the mother,
minimize or modify the course of maternal medications that have the potential
for altering the infant’s alertness and feeding behavior (Widstrom et al.,

Healthy infants should be placed and remain in direct
skin-to-skin contact with their mothers immediately after delivery until the
first feeding is accomplished. The alert, healthy newborn infant is
capable of latching on to a breast without specific assistance within the first
hour after birth (Righard et al., 1990)
Supplements (water, glucose water, formula, and other fluids) should not be
given to breastfeeding newborn infants unless ordered by a physician when a
medical indication exists. (Ven
Den Bosch et al., 1990).

During the early weeks of breastfeeding, mothers should be
encouraged to have 8 to 12 feedings at the breast every 24 hours, offering the
breast whenever the infant shows early signs of hunger such as increased
alertness, physical activity, mouthing, or rooting (Gunther et al., 1995).

Crying is a late indicator of hunger (Klaus et al., 1987). Appropriate
initiation of breastfeeding is facilitated by continuous rooming-in throughout
the day and night. At each feed the first breast offered are alternated so that
both breasts receive equal stimulation and draining. After breastfeeding is
well established, the frequency of feeding may decline to approximately 8 times
per 24 hours, but the infant may increase the frequency again with growth
spurts or when an increase in milk volume is desired.

Formal evaluation of breastfeeding, including observation of
position, latch, and milk transfer, should be undertaken by trained caregivers
at least twice daily and fully documented in the record during each day in the
hospital after birth.

Pediatricians and parents should be aware that exclusive
breastfeeding is sufficient to support optimal growth and development for
approximately the first 6 months of life‡ and provides continuing protection
against diarrhea and respiratory tract infection. Breastfeeding should be
continued for at least the first year of life and beyond for as long as mutually
desired by mother and child (Kramer et al., 2002).

Complementary foods rich in iron should be introduced
gradually beginning around 6 months of age (Butte
et al., 2004). Preterm and low birth weight infants and infants with
hematologic disorders or infants who had inadequate iron stores at birth
generally require iron supplementation before 6 months of age. Iron may be
administered while continuing exclusive breastfeeding.

Introduction of complementary feedings before 6 months of
age generally does not increase total caloric intake or rate of growth and only
substitutes foods that lack the protective components of human milk. During the
first 6 months of age, even in hot climates, water and juice are unnecessary
for breastfed infants and may introduce contaminants or allergens (Ashraf et al.,
1993). Increased duration of breastfeeding confers significant health and
developmental benefits for the child and the mother, especially in delaying
return of fertility (thereby promoting optimal intervals between births) (Huffman
et al., 1987). There is no upper limit to the duration of breastfeeding and no
evidence of psychologic or developmental harm from breastfeeding into the third
year of life or longer (Detwyler et al., 1995).


Hospitals and physicians should recommend human
milk for premature and other high-risk infants either by direct breastfeeding
and/or using the mother’s own articulated milk. Maternal support and
education on breastfeeding and milk countenance should be provided from the
earliest possible time. Mother-infant skin-to-skin contact and direct
breastfeeding should be encouraged as early as possible. Fortification of
expressed human milk is indicated for many very low birth weight infants. Massed
human milk may be a suitable feeding alternative for infants whose mothers are
unable or unwilling to provide their own milk. Human milk banks in North
America adhere to national guidelines for quality control of screening and
testing of donors and pasteurize all milk before distribution. (Hughes et al., 1990) Fresh human
milk from unscreened donors is not recommended because of the risk of transmission
of infectious agents (Kaplan et al., 1998).