BREASTFEEDING 2001, PART II:

THE MANAGEMENT OF BREASTFEEDING 0031-3955/01 $15.00 + .00

PREVENTION OF
BREASTFEEDING TRAGEDIES
Marianne R. Neifert, MD

Although successful breastfeeding conveys compelling advantages to in-

fants and mothers, inadequate breastfeeding may result in critical infant failure
to thrive and hypernatremic dehydration. A stark contrast exists between the
optimal health and developmental outcomes observed in thriving, breastfed
infants and the devastating morbidity that has been documented in cases of
breastfeeding failure. The consequences of inadequate intake of breast milk
range from hyperbilirubinemia, infant hunger, and slow weight gain to life-
threatening, and even fatal, dehydration and starvation.
Unfortunately, breastfeeding tragedies tend to be viewed as exceptionally
rare, isolated events rather than as the extreme spectrum of a clinical continuum
of suboptimal nutrition in breastfed infants. IS Tragic outcomes often involve
underlying maternal and infant breastfeeding risk factors, made deadly by
parental and professional misbeliefs and knowledge deficits or health care sys-
tem failures. A breastfeeding catastrophe is not only devastating for the individ-
ual infant, but such incidents generate negative publicity that makes breastfeed-
ing advocates reluctant to expose tragic cases. The fear that saying anything
negative about breastfeeding will have an adverse effect on promotion efforts
contributes to a conspiracy of silence about breastfeeding failures that impedes
an understanding of the problem. Clinicians must overcome the tendency to
view the complications of mismanaged breastfeeding as an indictment of the
process." Instead, pediatric practitioners are obligated to confront the reality of
breastfeeding failure, identify associated risk factors, and implement intervention
strategies to prevent infant morbidity.

From the HealthONE Alliance Lactation Program, Rose Medical Center; and the Depart-
ment of Pediatrics, University of Colorado Health Sciences Center, Denver, Colorado

PEDIATRIC CLINICS OF NORTH AMERICA

VOLUME 48 • NUMBER 2 • APRIL 2001 273

274 NEIFERT

HISTORICAL REPORTS OF MALNUTRITION AND

HYPERNATREMIC DEHYDRATION IN BREASTFED INFANTS

Sporadic case reports of hypernatremic dehydration in breastfed infants

have appeared in the medical literature for at least 3 decades.* See Table 1 for
selective clinical features of reported cases. Most often, the mothers of affected
infants have been primiparous, well educated, motivated to breastfeed, and
unaware of their infants' progressive malnutrition and dehydration. Affected
infants have lost as much as one third of their birth weight in the first 2 weeks
of life. Yet often the infant is brought to the physician for a problem other than
excessive weight loss and only then is discovered to be severely dehydrated and
undernourished." Breastfeeding risk factors that have been identified in reported
cases include infant prematurity;" 24, 71 infrequent feeding,": 24, 60 failure of the
infant to demand ("happy to starve")." poor infant suck," 60, 62 neonatal jaun-
dice," 11, 24, 58, 71 infant lethargy/,ll, 60, 62 partial cleft palate,60 excessive infant weight
loss before discharge," decreased infant elimination," 10,11,23,24,46,60,71 maternal
inverted nipples,": 68 use of a nipple shield, and maternal reluctance to offer
supplements. Major complications of hypernatremic dehydration in breastfed
infants include seizures, disseminated intravascular coagulopathy, vascular com-
plications, renal failure, dural thromboses, massive intraventricular hemorrhage,
brain damage, and death.': 11, 23, 36, 46, 60, 62
The prevalence of infant morbidity caused by inadequate breastfeeding
seems to be on the increase''- 36, 46, 58, 69, 77 as US breastfeeding initiation rates reach
their highest level in a half-century (Abbott Laboratories, Mothers' Survey,
Ross Products Division, personal communication, 2000). Factors proposed to
contribute to the problem include shorter postpartum hospital stays that do not
allow sufficient time for new mothers to become adept at breastfeeding; inconsis-
tent follow-up of breastfeeding dyads after discharge because of health care cost
restraints; increased breastfeeding promotion, with more mothers breastfeeding
exclusively; and decreased social, cultural, and health care support systems that
traditionally provide a safety net for breastfeeding couples.v"
In July 1994, catastrophic outcomes in breastfed infants received national
media attention when several mothers whose infants had been harmed by
inadequate breastfeeding decided to go public with their stories. One profoundly
damaged infant was profiled on the front page of The Wall Street Iournal?"
Similar cases were described in other national print media, including Time
magazine," and the topic was featured on national television, including ABC's
Prime Time Live and 20/20.
After this national publicity about breastfeeding tragedies, Cooper et aP1
reported a cluster of five breastfed newborn infants with hypernatremic dehy-
dration who were admitted to a tertiary children's hospital from a tristate region
over a 5-month period. This occurrence represented a significant increase in
observed cases between 1990 and 1994, whereas the annual birth rate in the
region remained unchanged. During this same period, the average age at postna-
tal discharge for all newborn infants in the region decreased from 2.4 days in
1990 to 1.7 days in 1994. In the series described by Cooper et al, infant age at
presentation was 5 to 14 days, and the percentage of weight loss from birth
weight at time of hospital admission ranged from 14% to 32%. The mothers
were 28 to 38 years of age and were well prepared for breastfeeding prenatally.
Three mothers had inverted nipples, and one infant was born at 36 weeks. Three

"References 3, 4, 9-11, 15, 19, 23, 24, 35, 36, 40, 46, 56, 58, 60, 62, 63, 68, 71, and 77.
 PREVENTION OF BREASTFEEDING TRAGEDIES 275

of the five families reported contact with a health care provider, including a visit
by a home health nurse, calls to a pediatrician, and contact with a lactation
consultant. No infant, however, had been weighed or seen by a physician before
readmission, despite the presence in each case of multiple breastfeeding risk
factors, such as infant latch-on problems, decreased infant voiding and stooling,
infrequent feedings, and infant lethargy or irritability.
For several decades, US breastfeeding rates have been highest among older,
better-educated, married women in higher-income groupS.64 The subtitle of the
1994 The Wall Street Journal article "Yuppie Syndrome Among Well-Meaning
Parents Stems from Bad Advice'?" reflected the observation that many reported
cases of breastfeeding failure to thrive occurred in infants of well-to-do, profes-
sional parents. The US Department of Agriculture has launched a national media
campaign to aggressively promote breastfeeding to disadvantaged women who
traditionally have been least likely to nurse their infants. As a result of wide-
spread promotion efforts, breastfeeding rates have increased most rapidly among
mothers who are young, have less education, and are enrolled in the Special
Supplemental Nutrition Program for Women, Infants, and Children (WIC).64
The breastfeeding morbidities that first were described among infants of more
privileged women who were strongly motivated to breastfeed also have ap-
peared in the offspring of disadvantaged mothers, who have fewer resources,
less support and information, and daunting obstacles in accessing health care.
In 1999, The New York Times ran a series of articles chronicling the criminal
trial of a teenaged welfare recipient who was prosecuted for the 1997 starvation
death of her 8-week-old, breastfed son." 8, 17 The full-term infant, whose birth
weight was 3.6 kg, weighed barely 2.25 kg at his death. Contributing to the
tragedy were medical risk factors that went unrecognized by health care profes-
sionals, maternal youth and inexperience, and obstacles to accessing health care,
The mother previously had undergone breast reduction surgery that jeopardized
her ability to fully breastfeed, and a bureaucratic snafu in issuing the infant's
Medicaid card foiled the mother's attempts to obtain medical follow-up for him
after hospital discharge. The young woman ultimately was convicted of crimi-
nally negligent homicide and sentenced to 5 years' probation rather than a jail
term-partly because of the mitigating circumstances and also as a result of
nearly 900 letters received by the presiding judge urging him to exercise leniency.
Among the letters in support of the defendant were numerous testimonials from
other parents whose breastfed infants lost an alarming amount of weight."
This highly publicized case received national media coverage before and
after the trial and seems to have inspired the story line for at least two television
drama shows, An October 1998 episode of ABC's Chicago Hope dealt with the
starvation death of a 6-week-old breastfed infant, and a February 2000 episode
of NBC's Lawand Order had a similar story line. In conjunction with the publicity
surrounding the New York trial, a Colorado mother recounted on 20/20 the story
of her infant son's ultimately fatal hypernatremic dehydration at 10 days of age
that left him severely brain damaged until he succumbed to related complica-
tions at 9 months.v" This woman, a registered nurse with previous breastfeed-
ing experience, spoke eloquently in defense of the disadvantaged teen mother
who was being prosecuted for her son's starvation death.

INSUFFICIENT MILK SYNDROME

Lack of milk is the most common reason women cite for discontinuation of
breastfeeding, yet this complex complaint is poorly understood. 30, 32, 57, 67 The
N
'I
0'>

Table 1. SELECTIVE CLINICAL FEATURES IN REPORTED CASES OF HYPERNATREMIC DEHYDRATION AND

MALNUTRITION IN BREASTFED INFANTS

Infant Age at Infant WI. Maternal Sodium BUN

Study Presentation (d) Loss (%) Age (y) Parity Red Flags (mmoI/L) (mg/dL) Complications and Outcome

Kaplan et al" 9 >10at4d 36 1 Breastfeeding ineffectively 191 177 IVH, dural thromboses, death
(1998) at 12 d
13 28 29 1 Fussy, slept >8 h. pale 180 107 IVH, seizures, death at 16 d
Cooper et al" 9 26 31 1 [de, inv. nipples, latch diff, 186 35.0 Nl at follow-up
(1995) ! elim, 36 wk
14 32 28 1 Inv. nipples, latch diff, 188 79.5 CVA, ! facial movement
! elim
8 14 36 1 Infrequent feeds, ! elim, 176 46.5 Left leg amputated, Nl at
sleepy/irritable, blue leg follow-up
12 27 38 1 ! feeding, ! elim, sleepy/ 214 62.0 CVAs, seizures, EEG slowing
irritable
5 16 32 1 Inv. nipples, latch diff, 161 16.0 Coagulopathy, Nl at follow-up
! elim
Chilton (1995)9 7 24 23 1 10% ! b. wt. at 4 d, fever 182 205 Nl at 3 y
! urine, lethargic, jdc
Moltini (1994)46 15 32 1 No breast engorge, ! stools, 208 298 Seizures, hypotonia, gross
"good" baby, poor feeding motor delay at 8 mo
9 28 1 Latch diff, ! elim, fussy 198 203 Renal failure, Nl at 18 mo
Marino et al 40 10 33 28 1 LBW, supplemented in 168 116 Sodium Nl at 48 h
(1989) hospital, sleepy, quiet
Thullen 71 14 29 26 1 36 wk, LBW, jaundice, 189 55 Mother relactated successfully
(1988) ! urine Nl at 2 mo
Ghishan & 17 31 21 1 Feeds took 1 h, ! elim, 189 150 Seizures, EEG grossly
Roloff 23 slept 20 h PTA abnormal
(1983) 14 35 1 Nursed ineffectively, 192 135 Staph aureus, me, Nl EEG
! urine, pustules, listless
Rushton et al 63
6 14 35 1 Urate crystals in diaper 155 27 Nl at discharge
(1982)
 Rowland et a162 10 25 2 Poor suck, weak cry x 24 h 174 47 Nl at 6 d
(1982) 15 37 1 Poor suck-5 min/breast q 4 208 232 Ole, hyperglycemia, seizures
h, lethargy
Roddey et al 60 30 30 29 1 Nursing q 3-4 h, became 135 73 Perforated duodenal ulcer, Nl
(1981) lethargic at 3 y
10 27 35 1 15% wt. loss in hospital, 175 115 Nl at 2 y
t suck, t sleep
10 27 26 1 Partial cleft palate, slow 173 118 Nl at 9 rna
feeder, t urine, lethargic
14 35 28 1 t urine, listless 190 282 Renal failure, seizures, Nl at
lOrna
Jaffe et al 35 20 32 1 Sleepy, sucked 5 min, cried 182 94 Nl after discharge
(1981) little, 26% wt. loss at 14 d
Arboit & 15 31 Minimal feeding history 180 286 Ole, seizure, Nl at 5 wk
Cildengers' elicited
(1980)
Anand et a1' 15 36 24 1 37 wk, sleepy, [de, sucked 192 101 Nl at 30 d
(1980) 5minq4h
Clarke et a1'0 14 27 28 1 Fed poorly, sleepy, nursed 178 104 Nl at 6 wk
(1979) t.i.d., t stools
Gilmore & 30 18 1 t Suck, t crying, lethargy, 136 78 Nl at 8 rna
Rowland" poor feeding
(1978) 27 13 28 1 Phototherapy at 2 d, sleepy, 134 51 Nl at 10.5 rna
infrequent feeds, cold
13 25 29 1 36 wk, breasts not full, 148 35 Nl at 6 rna
t bowel movements
BUN = blood urea nitrogen; jdc = jaundice; inv. = inverted; diff = difficulty; elim = elimination; LBW = low birth weight; PTA = prior to admission; IVH =
intraventricular hemorrhage; NI = normal; CVA = cerebral vascular accident; EEG = electroencephalogram; Ole = disseminated intravascular coagulation.

!'oJ
::j
278 NEIFERT

phenomenon, dubbed the insufficient milk syndrome (IMS), has been used to refer
to real and perceived inadequate breast milk. Various explanations have been
proposed for IMS, ranging from lack of close contact between mothers and
infants as a result of modern, urban lifestyles" and overuse of supplemental
feedings" to a rationalization by women who decline to breastfeed. In recent
years, the label has appeared in the media and medical literature to describe
infant failure to thrive caused by insufficient daily intake of breast milk." This
imprecise term, however, does not clarify whether the mother fails to produce
adequate milk or the infant is unable to extract available milk by breastfeeding.
Nor does it distinguish the mother who never had enough milk from the woman
whose once abundant supply has subsequently decreased.
Some mothers, such as those with anatomic breast abnormalities or hor-
monal aberrations, have a primary inability to fully lactate, even with optimal
breastfeeding management. Fortunately, most mothers experience normal post-
partum lactogenesis and initially have the potential to produce an abundant
milk supply, but breastfeeding difficulties that interfere with regular and efficient
milk removal can soon lead to diminished milk production that is secondary to
problems in breastfeeding management. This phenomenon is related to the
well-described autocrine control of lactation, whereby a chemical inhibitor that
accumulates in residual milk acts to decrease further milk production." In a
prospective study of lactation outcome measured by weight gain in infants
exclusively fed breast milk, 15% of healthy primiparous women were deemed
to have insufficient lactation at 2 to 3 weeks postpartum." At least two
thirds of cases were judged to be secondary breastfeeding problems rather
than primary.

Primary Insufficient Lactation

Renewed enthusiasm about the marvels of human milk, combined with the
unwavering conviction that "every woman can breastfeed," may contribute to
breastfeeding tragedies by encouraging health care professionals to overlook
risk factors that may preclude full lactation, The bold claims made about the
infallibility of lactation are not cited about any other physiologic processes, A
health care professional would never tell a diabetic woman that "every pancreas
can make insulin" or insist to a devastated infertility patient that "every woman
can get pregnant." The fact is that lactation, like all physiologic functions,
sometimes fails because of various medical causes.
Although most mothers are capable of breastfeeding successfully, as many
as 5% of women may have primary insufficient lactation because of anatomic
breast variations or medical illness that make them unable to produce a full
milk supply despite heroic efforts. Identification of such women is essential to
ensure that their breastfed infants receive adequate supplementation to meet
their nutritional requirements.
Examples of primary lactation insufficiency have been well documented,
including case reports of failure of lactogenesis associated with retained pla-
centa'" and insufficient milk production among women with inadequate mam-
mary glandular tissue." Periareolar breast incisions have been linked with insuf-
ficient lactation, presumably because of the severing of milk ducts that precludes
drainage of milk from affected lobes." Reduction breast surgery is well accepted
to pose a risk for compromised lactation.": 47 and augmentation mammoplasty
has been shown to be associated with an increased prevalence of lactation
insufficiency, most significantly when a periareolar incision is used." Numerous
 PREVENTION OF BREASTFEEDING TRAGEDIES 279

case reports confirm that breast radiation adversely affects subsequent lactation
function.": 61. 73 In addition to breast mammoplasty, excisional biopsies involving
periareolar incisions, previous drainage of a breast abscess, and other breast
surgeries may place a woman at risk for insufficient lactation.
Several historical and objective factors are linked with primary insufficient
lactation caused by abnormalities in breast development. Typically, a mother's
breasts undergo remarkable glandular and ductal development in preparation
for lactation under the influence of pregnancy hormones." Women who report
only minimal or no breast enlargement during pregnancy have been shown to
be more likely to have insufficient lactation." Many mothers report that they
experienced only minimal breast engorgement after delivery, explaining that
their milk did not "come in" abundantly. The breasts may be hypoplastic,
tubular, markedly asymmetric, or have a wide intramammary space."
Huggins et aP3 reported on the breastfeeding outcomes among 34 women
with various degrees of breast hypoplasia. Most reported little or no breast
growth during pregnancy and little or no postpartum breast engorgement. Sixty-
one percent of those followed-up were unable to produce a full milk supply
within the first month after delivery.
Unfortunately, many women with breast hypoplasia or other primary causes
of insufficient lactation are improperly advised by health care professionals
and breastfeeding counselors that they may increase their poor production by
improving their breastfeeding technique or working harder to stimulate their
breasts. Such oversimplistic counseling not only creates feelings of maternal
guilt and inadequacy when the mother's milk supply remains insufficient but
also places her breastfed infant in jeopardy. The highly publicized New York
criminal case provided a tragic example in which the mother's breast-reduction
surgery was not recognized as a lactation risk factor that contributed to the
infant's starvation death?' 8. 17
Additional causes of primary lactation insufficiency include severe maternal
illness, such as postpartum hemorrhage with Sheehan's syndrome," infection,
or hypertension. Some lactation specialists have observed an apparent increased
prevalence of unexplained insufficient lactation among mothers in their late 30s
or 40s, some of whom breastfed successfully at a younger age. Fortunately, in
most cases of primary insufficient lactation, women and their health care provid-
ers quickly discern that the infants are obtaining inadequate milk and conse-
quently supplement breastfeeding with appropriate volumes of formula to per-
mit adequate infant growth.

Secondary Insufficient Lactation

Secondary insufficient lactation is far more prevalent than is primary lacta-

tion failure and refers to an inadequate milk supply that results from-or is
secondary to-one or more breastfeeding difficulties. The well-known endocrine
control of lactation does not explain fully how milk production is regulated in
lactating women. l2 • 13 After abundant milk production begins after birth, the rate
of milk secretion is regulated by the frequency and completeness of milk re-
moval."- 76 An initially normal supply may diminish rapidly in the face of
maternal or infant breastfeeding difficulties that interfere with regular, effective
removal of milk. Simply put, the failure of an infant to take adequate milk soon
leads to failure of the mother to make adequate milk. Secondary insufficient milk
is not only more common than primary causes but is also potentially preventable
and remediable if recognized early and effective breast stimulation and drainage
280 NEIFERT

are promptly initiated. Practitioners should screen at each pediatric visit for
maternal or infant risk factors that may contribute to secondary insufficient milk
production.

Common Maternal Causes of Secondary

Insufficient Lactation

More than 50 years ago, British physician Waller 75 attributed early failure of
lactation to unrelieved postpartum breast engorgement, or the inability to estab-
lish a free flow of milk after lactogenesis occurs. He estimated that approxi-
mately 20% of primiparous mothers experience extreme postpartum breast en-
gorgement, with high milk tension and obstructed milk flow that, if not relieved
promptly, results in the rapid cessation of lactation. A bottle-feeding mother
provides a readily observable example of how quickly milk-laden breasts un-
dergo involution if not suckled. After abundant milk production begins a few
days post partum, the frequency and efficacy of milk removal seems to be the
most powerful determinant of the milk volume produced in each breast.": 13, 16, 76
When accumulated milk is not removed from the breasts, a chemical inhibitor
in residual milk and pressure atrophy of milk-producing alveolar glands result
in diminished milk production. Even if maternal production initially is adequate,
the breasts soon begin producing less milk if an infant does not extract it
effectively.
Thus, inappropriate infant feeding routines that result in ineffective or
incomplete removal of milk soon lead to diminished production. Sore nipples
may contribute to a low milk supply by several mechanisms. First, sore nipples
usually result when an infant is latched on incorrectly to nurse, and improper
latch-on interferes with milk transfer during breastfeeding. Mothers experiencing
nipple discomfort may feed less frequently or have pain-related inhibition of
their milk-ejection reflex. The resulting incomplete milk removal further limits
milk production and leaves an infant at risk for being underfed.
Secondary insufficient milk frequently results when breastfeeding mothers
are separated from their infants because of maternal employment or schooling,
hospitalization of mother or infant, or maternal travel that results in infrequent
or incomplete breast emptying. An initially normal supply also may decrease
when a nursing mother takes estrogen-containing oral contraceptives. Milk pro-
duction declines dramatically in breastfeeding women who conceive while lac-
tating, as a result of the inhibitory effect of pregnancy hormones. A localized
breast infection also may result in a diminished milk supply in the affected
breast. Although women may breastfeed successfully while consuming a wide
range of diets, severe caloric restriction places a woman at risk for decreased
milk production.

Common Infant Causes of Secondary Insufficient Lactation

The popular belief exists that a small infant needs no special help with
breastfeeding-that the breasts produce just what the infant needs. Small or
borderline (born at 36-37 weeks' gestational age) premature infants seldom
nurse as well as do larger, full-term infants. In follow-up studies of readmission
rates after hospital discharge, infants born at less than 37 weeks' gestational age
are Significantly more likely to be readmitted for morbidities related to poor
feeding compared with infants born at term. 1B, 69 Preterm and low birth weight
 PREVENTION OF BREASTFEEDING TRAGEDIES 281

infants may have trouble grasping the breast well and tire easily during feeding.
Many of these infants seem to breastfeed satisfactorily in the first 2 days of life,
when the scant volume of colostrum makes it difficult to assess the effectiveness
of milk transfer, but after abundant milk production begins, these "imposter"
infants often are unable to extract appreciable milk, and the mother's supply
quickly decreases. Waller75 recognized that these at-risk infants pose a risk to
the maintenance of lactation, explaining that "the phrase 'wholly breastfed' on
leaving hospital...may denote no more than that the child is still being put to
breasts which are rapidly reverting to the resting stage." Pediatric practitioners
need to identify such high-risk infants in the low-risk nursery and be prepared
to prescribe the use of an electric breast pump to augment the ineffective breast
stimulation and emptying provided by the infant.
Unconjugated hyperbilirubinemia in breastfed infants is a common marker
for poor breastfeeding and inadequate intake of milk, a phenomenon known as
breastfeeding jaundice?' An infant's initial poor breastfeeding that contributes to
exaggerated hyperbilirubinemia is further exacerbated by the lethargy of jaun-
dice. The evaluation of neonatal jaundice always should include an assessment
of the infant's nutritional status.": 72 Several reported cases of critical weight loss
in breastfed infants came to medical attention because parents sought help for
infant jaundice. no 58
Twins also represent a significant risk for secondary insufficient lactation
because they are often premature and have low birth weights, both of which
predispose to poor feeding. Many other infants are at increased risk for ineffec-
tive breastfeeding, including infants with hypotonia or hypertonia, birth as-
phyxia, or Down syndrome. Infants with significant cardiac lesions, respiratory
problems, or infections may be expected to nurse less effectively than healthy
infants. Any abnormality of the oral structures, especially cleft palate, places
infants at perilous risk for ineffective breastfeeding. Although these infants may
seem to nurse satisfactorily, objective measures of intake often show that they
obtain little or no milk. Even minor variations in the oral structures that are
easily overlooked, such as moderate micrognathia or ankyloglossia, may cause
an infant to have difficulty extracting milk.
Other newborn infants who are at risk for obtaining inadequate milk from
a mother's diminishing supply include infants having difficulty latching on to
one or both breasts; infants who nurse infrequently, need to be awakened for
feedings, or suckle for only a short duration; and infants who use a pacifier
excessively" or receive regular supplements. Because round-the-clock feedings
are important for stimulating generous milk production, a mother's milk supply
may decrease if her newborn sleeps more than 5 to 6 hours at night without feed-
ing.

PARENTAL ATTITUDES AND MISBELIEFS THAT

CONTRIBUTE TO BREASTFEEDING TRAGEDIES

Intense Commitment to Breastfeed

Ironically, the mothers whose infants are most likely to suffer breastfeeding
morbidity often are those who are the most highly motivated to breastfeed to
give their infants the best. Their strong commitment to the nutritional superiority
and health benefits of human milk makes them willing to persevere in the
face of lactation difficulties. Although less-motivated women may lose their
282 NEIFERT

determination when early problems arise, often the mother whose infant gets
into trouble is unwavering in her dedication to breastfeed.

Reluctance to Use Infant Formula

Although many breastfeeding women experience insufficient milk produc-

tion, associated infant morbidity is rare because mothers who perceive their
breastfed infants to be hungry usually start supplementing with formula or
switch to formula-feeding, but parents who are intensely motivated to breastfeed
often are keenly aware that formula supplements may jeopardize breastfeeding
success. Well-meaning admonitions to avoid supplementation abound in lay
breastfeeding publications and may be interpreted out of context by parents.
Such cautions are coupled with reassuring promises that a mother will produce
all of the milk her infant needs and that more frequent nursing will readily
increase a low milk supply:
• "Not Enough Milk ... Think carefully before giving supplements to your
baby at this time. It is a difficult decision to make, because your baby is
hungry; but supplements do make it harder to produce milk"5Ba
• "Ways to Build Up Your Milk Production ... Do not offer your baby
formula. A few ounces soon turn into a full bottle, which soon turns into
several bottles, until you find that you're producing even less milk"IBa
• "A baby's need for milk and his mother's ability to produce it in just the
right quantity have been said to be one of nature's most perfect examples
of the law of supply and demand."37a
• "The more often your baby takes milk, the more milk you will have.... If
it drops too low to suit his needs, he will want to nurse more often. With
added nursings, your breasts will respond by making more milk.">"
The campaign among many lactation consultants to publicize the health
hazards of infant formula" and the insistence on referring to formula as "artifi-
cial baby milk" and emphasizing its inferiority to human milk" may inadver-
tently contribute to breastfeeding tragedies by magnifying parental resistance to
its use, even when medically indicated. Some parents conclude that it is better
for their infants to be underfed and receive breast milk only than to consume
adequate quantities of nutrients, some of which are contributed by infant for-
mula. They do not appreciate that ideal infant nutrition refers to the quality and
quantity of the milk being fed.

Exaggerated Fear of Nipple Confusion

Much has been written about the popular belief that early bottle-feeding of
infants will result in nipple confusion/" Anecdotal reports exist of infants who
were exposed to bottle-feeding before breastfeeding and who then displayed a
preference for bottle-feeding over breastfeeding. Cautions appearing in popular
breastfeeding publications often exaggerate the risks of nipple confusion and
fuel parental fears about giving medically indicated supplemental milk by bottle:
• "Just one bottle is enough to confuse some babies, especially in the early
weeks ... You'll want to be wary of bottles or pacifiers if your baby is
gaining slowly as nipple confusion can add to rather than solve the
problem."37a
 PREVENTION OF BREASTFEEDING TRAGEDIES 283

• " ... estimates that 95% of all babies will become confused if given an
artificial nipple during the first three to four weeks after birth. For some
babies it may take a week or two of bottles before they become nipple-
confused; for other babies, only one or two bottles or other artificial
nipples will cause it."4Sa
• " ... about one baby in four becomes temporarily confused when asked to
alternate between suckling at the breast and sucking on a rubber nipple
or pacifier. And you don't know ahead of time which category your baby
will fall intO."IBa

Inability to Recognize Their Infant's Malnourished Condition

Probably what has been least understood about breastfeeding tragedies is

how a parent could fail to see that his or her infant was severely underweight
when an objective observer immediately recognizes the problem; however, lack
of parental awareness is a common characteristic in reported cases of critical
weight loss in breastfed infants. The explanation is that the parent who is with
the infant continually may not notice progressive wasting because the infant's
gradual weight loss seems subtle when measured day to day. The apparently
contented, but wasted, infant is especially difficult for parents to recognize as
being underfed.IS. 19 Also, anxious new parents have a natural tendency to deny
that anything is wrong with their infant, and this overriding desire to believe
that their infant is healthy easily is reinforced by reassurances from books,
family members, and self-explanations (e.g., "I was a thin baby," "Babies come
in all sizes," "All babies lose some weight after birth," "He must be getting
enough because he nurses so often," or "He must be getting enough because he
sleeps so long."). Overt signs of hunger, such as excessive crying after feedings,
have been misinterpreted as colic, intestinal gas, a "high-needs" infant, or a
reaction to maternal allergens in milk. Progressive lethargy has been mistaken
for contentment and satiety (e.g., "Things must be going better because he
finally seems satisfied.").
Many mothers of malnourished infants become so physically depleted from
marathon breastfeeding that sheer exhaustion clouds their judgment about their
infants' welfare. Parents often do not know that their infant is in danger until
the infant is placed on the scale at a routine check-up after birth." Severe
malnutrition and dehydration have occurred among infants of medical profes-
sionals who did not recognize the magnitude of their own infants' weight loss.

HEALTH CARE PROFESSIONAL MISBELIEFS AND

PRACTICES THAT CONTRIBUTE TO BREASTFEEDING
TRAGEDIES

Lack of Timely Follow-Up

Most reported cases of hypernatremic dehydration in breastfed infants have

occurred within the first 2 weeks of life, and in some instances, unsuspecting
mothers bring moribund infants for routine 2-week visits. The American Acad-
emy of Pediatrics now recommends that infants discharged less than 48 hours
after delivery be seen by a pediatrician or other knowledgeable health care
practitioner at 2 to 4 days of age. I. 2 Maisels and Kring" evaluated the effect of
postnatal age at hospital discharge on the risk for readmission within the first
284 NEIFERT

14 days. Of 29,934 infants discharged, 247 (0.8%) were readmitted by 14 days of

age. The investigators found that discharge at less than 72 hours after delivery
significantly increases the risk for hospital readmission, and particularly read-
mission for jaundice, compared with discharge at more than 72 hours after
delivery. This study and other results" suggest that the recommendation for
early follow-up should be extended to infants discharged less than 72 hours
after birth, but practices vary widely, and an early visit within a few days of
discharge is far from universal practice."
Many lactation problems go unrecognized in the hospital and do not become
evident until milk starts being produced in abundance and the effectiveness of
milk transfer during feedings may be evaluated. An early follow-up visit a few
days after hospital discharge allows at-risk infants to be identified before they
lose excessive weight and at a time when intervention may easily correct most
breastfeeding problems before they become complicated by insufficient milk
production. Many clinicians assume that only primiparous mothers require
an early visit, but past experience provides no guarantee that the currently
breastfeeding infant will nurse effectively. One multiparous mother of a critically
underweight infant explained to this author, "I may have breastfed before, but
I've never breastfed this baby before."

Failure to Recognize Breastfeeding Red Flags

Although many breastfeeding tragedies result from delayed follow-up after

hospital discharge, even infants undergoing medical care have experienced life-
threatening complications because health care professionals have not recognized
the signs of inadequate breastfeeding. Popular dogma has it that breastfeeding
takes many weeks to become well established and that most early problems
self-resolve with time and perseverance alone. This false belief promotes a risky
"wait-and-see" approach that contributes to inappropriate delays in intervening
for early difficulties. The hallmarks of successful breastfeeding usually are evi-
dent within the first week postpartum.w " When warning signs are present at
the early follow-up visit, further investigation is warranted and appropriate
modifications in breastfeeding technique or routines should be made. Failure to
intervene in a timely manner may lead to diminished milk supply and worsen-
ing of an infant's status. Infants may become dangerously dehydrated in a
matter of days.v "
Kaplan et a136 reported on a case of fatal hypernatremic dehydration in a
term, exclusively breastfed newborn infant whose primiparous mother first
sought medical care when the infant was 4 days of age because of her concern
that the infant was not breastfeeding effectively. See Table 1 for clinical features.
Although the infant was more than 10% below his birth weight at this visit, no
specific intervention was initiated, but the combination of a dwindling milk
supply and a dehydrated infant, with increasing lethargy and a diminished
ability to suck, made it progressively more difficult for the infant to extract milk.
Five days later, the mother returned with the infant, who was now lethargic,
had positive tenting, had not urinated in 24 hours, and was severely hyperna-
tremic. The infant suffered massive intraventricular hemorrhage in association
with multiple dural thromboses and was pronounced brain dead.
The use of specific criteria may help practitioners evaluate the success of
breastfeeding a few days after hospital discharge when abundant milk produc-
tion has begun. 48• 49 In addition to weighing the infant and assessing the infant's
general health, breastfeeding should be observed directly. The clinician should
 PREVENTION OF BREASTFEEDING TRAGEDIES 285

elicit the infant's frequency and duration of feedings, stooling and voiding
patterns, pacifier use," infant hydration, and evidence of jaundice." Maternal
reports of postpartum breast engorgement, difficulties with milk flow, and com-
plaints of sore nipples also should be sought.
Infant weight parameters provide highly reliable criteria for assessing the
effectiveness of breastfeeding. Weight loss of 8% or more from birth weight,
failure to surpass birth weight by 2 weeks of age, or failure to commence weight
gain of approximately 28 g per day by 5 days of age always warrants further
investigation.v- 49, 66 In Willis and Livingstone's report" of 10 cases of insufficient
milk after severe postpartum hemorrhage, hypernatremic dehydration occurred
in two infants whose weight loss from birth weight was only 6% and 9%,
respectively, within the first week of life. They recommend that a weight loss of
more than 7% of birth weight warrants further investigation. In the series of
cases reported by Cooper et al," one patient with severe hypernatremia had lost
14% from birth weight at 8 days of age.
Physicians caring for neonates must be aware of the association between
breastfeeding, dehydration, and hypernatremia and maintain a high level of
suspicion. Because intravascular volume is preserved in hypernatremia, observ-
able signs of dehydration may not be present until water loss is severe (>15%).40
Clinicians should consider performing appropriate laboratory analysis whenever
an infant's weight loss from birth weight exceeds 12%.
Although insufficient milk intake is the most common reason why breastfed
infants fail to gain adequate weight, clinicians must consider and rule out the
presence of underlying organic illness causing poor feeding, an increased meta-
bolic requirement, or malabsorption of nutrients. Tragic outcomes have occurred
when poor breastfeeding caused by, for example, unrecognized congestive heart
failure or sepsis, has been misinterpreted as a latch-on or sucking problem.
Maternal lactation risk factors include:
Previous insufficient milk or underweight, breastfed infant
Flat or inverted nipples affecting infant latch-on or milk removal
Significant variation in breast appearance (e.g., markedly asymmetric, tubular,
or hypoplastic)
Excessive or unrelieved postpartum breast engorgement
Previous breast surgery, especially periareolar incisions or breast abscess
Cracked or bleeding nipples or severe or persistent nipple pain
Perinatal complications, such as hemorrhage, hypertension, and infection
Systemic illness, such as cystic fibrosis, diabetes, and heart disease
Failure of milk to "come in" by 4 days postpartum
Lack of previous breastfeeding experience
Maternal age older than 37 years
Infant early breastfeeding risk factors include:
Prematurity, including borderline premature infants (born at 36-37 weeks'
gestation)
Small-for-gestational age, intrauterine growth retardation, birth weight of less
than 2.7 kg
Neonatal separation from mother for more than 24 hours
Oral defects (e.g., cleft lip, cleft palate, micrognathia, macroglossia, or ankylo-
glossia)
Neuromotor problems (Le., Down syndrome, dysfunctional sucking)
Hyperbilirubinemia, especially jaundice requiring phototherapy
Multiple births, including term twins and triplets
286 NEIFERT

Systemic illness (e.g., oxygen requirement, cardiac defect, or infection)

Difficulty latching on correctly to one or both breasts
Sleepy, nondemanding behavior, the need to be awakened for feedings
Weak or unsustained suck
Irritablity, fretfulness, apparent hunger after feeds
Excessive use of a pacifier
Weight loss of more than 7% of birth weight
Not passing yellow, seedy "milk" stools by 4 days of age
Having fewer than four sizeable stools per day between 4 days and 4 weeks
of age
Having fewer than six clear voids per day by 4 days of age
Appearance of urate crystals in the diaper after 3 days of age
Failure to surpass birth weight by 10 to 14 days of age
Failure to commence weight gain of approximately 28 g per day after 4 or 5
days of age
Breast surgery and anatomic variations, such as inverted nipples or hypo-
plastic breasts, unrelieved postpartum engorgement, and severely sore nipples,
are significant maternal risk factors that predispose to insufficient milk supply.
In addition to infant weight criteria, major breastfeeding red flags in infants that
warrant further investigation and closer monitoring include prematurity or low
birth weight, latch-on problems or oral anatomic variations, infrequent stooling
and voiding, sleepiness, infrequent feedings, and nonsustained suckling.

Prevention Pumping
When maternal or infant breastfeeding risk factors are detected in the
hospital or at the early follow-up visit, prompt intervention to maximize mater-
nal milk supply and improve infant milk intake may avert continued infant
weight loss. Whenever doubt exists about the infant's ability to extract milk
efficiently, the mother should be instructed to use a fully automatic electric
breast pump to express any residual milk remaining after feedings. Beginning
in the early postpartum period to drain her breasts well will help to ensure that
a mother establishes and maintains a generous milk supply even though her
infant may not nurse effectively. If the supply is superabundant, an infant who
does not breastfeed vigorously still may be able to obtain sufficient milk by
"drinking from a fire hydrant." Without the pumping regimen described, a
mother's milk production may decrease rapidly if her infant nurses ineffectively
and removes little milk. If required, the milk obtained with the pump may be
used to supplement the infant until the infant is able to obtain sufficient milk
by breastfeeding. Obviously, close follow-up after discharge is necessary until
exclusive breastfeeding is achieved.

Failure to Use Objective Measures of Infant Milk Intake

A breastfeeding tragedy may occur when faulty assumptions are made

about the amount of milk an infant obtains during a breastfeeding session.
Standard advice to improve infant latch-on and breastfeed more often does not
necessarily deliver more milk to an infant if a mother's supply is profoundly
low or the infant is unable to extract available milk. The common practice of
relying on clinical cues to estimate milk consumption during breastfeeding may
be highly inaccurate. Although some mothers and health care professionals
 PREVENTION OF BREASTFEEDING TRAGEDIES 287

insist that they can estimate how much milk an infant takes with breastfeeding,
these "guesstimates" often are inaccurate. Two convenient techniques are avail-
able to estimate more precisely the amount of milk a mother produces and how
much an infant ingests at a breastfeeding. An accurate estimate of infant milk
consumption allows clinicians to tailor a rational feeding plan to ensure that
underweight infants receive adequate supplement.

Infant Feeding Test Weights

An infant feeding test weighing procedure is a noninvasive, accurate

method of measuring infant milk consumption during a breastfeeding session."
The identically clothed infant is weighed before and after breastfeeding with an
electronic infant scale accurate to at least 2 g.44, 45 (For more information, see the
article by Meier later in this issue.)
Many clinicians who evaluate breastfeeding problems rely on test-weight
data from a representative breastfeeding, together with other measures of
breastfeeding adequacy, to assess lactation performance and tailor a suitable
feeding plan.v 55, 77 Intake of breast milk measured by office test weights using
a highly accurate integrating balance has been found to be associated with rate
of infant weight gain. 54 Daily milk intakes for breastfed infants measured by 3-
day test weighing have been shown to average 600 to 690 mL in 24 hours
between 2 weeks and 3 months of age." A helpful rule of thumb for adequate
milk intake in young breastfed infants is approximately 30 mL per hour of milk.
The firmly held belief that more frequent nursing automatically increases a
mother's milk production and an infant's milk intake causes inappropriate
delays in providing adequate nutrition to underfed infants and increasing a
mother's low milk supply. Test weighing of infants shows that some infants take
negligible milk during a representative breastfeeding session, and others lose
weight because of insensible water loss and failure to extract any milk. 54 In such
cases, breastfeeding more often only stresses a compromised infant without
improving the infant's milk intake. The use of test weights to estimate a breastfed
infant's milk intake allows practitioners to realistically calculate the quantity of
formula (or expressed milk) supplement that is required to meet an underweight
infant's nutritional needs.

Pumped Milk Volumes

Most lactating women respond well to hospital-grade, fully automatic elec-
tric breast pumps and are able to express milk with relative ease. The volume
of milk that a mother obtains with one of these pumps at a usual feeding time
provides a useful estimate of the quantity of milk that would have been available
to her nursing infant. The pump usually empties the breasts more completely
than does an infant who nurses ineffectively. Pumping immediately after a test-
weighing procedure may provide a more realistic picture of the mother's total
milk yield and helpful information about an infant's effectiveness in draining
the breasts. One drawback to pumping is that the expressed milk must be fed
to the infant by an alternative method.

Delay in Instituting Medically Necessary Supplement

A rigid approach on the part of parents and health care providers to

avoiding supplementation in attempts to establish breastfeeding is believed to
288 NEIFERT

contribute to some cases of hypernatremic dehydration." Strong evidence shows

that early introduction of supplemental formula has a negative impact on
breastfeeding duration/- 20, 31 and physician-prescribed supplementation of
breastfeeding commonly is blamed for sabotaging long-term success. Clinicians
who are strong advocates of breastfeeding and are faced with underweight,
breastfed infants may fear that recommending supplementation will be per-
ceived as unsupportive of breastfeeding.
The fact that supplementary feeds are linked with early termination of
breastfeeding, however, does not justify the withholding of medically indicated
supplements for underweight infants. Because so many breastfeeding parents
are well versed in the perils of formula, health care professionals must bring a
voice of reason and help parents to distinguish between the inappropriate use
of convenience bottles and the legitimate use of essential, medically indicated
supplements. Formula and bottles are not anathema when they are used to
restore an infant to good health.
Although supplementing an infant without providing additional breast stim-
ulation and draining invariably causes a mother's milk supply to decrease, the
availability of fully automatic electric breast pumps now makes it possible to
give required supplements without dealing a blow to breastfeeding. Instead,
giving supplement and using an efficient breast pump to express residual milk
from the breasts after the infant nurses allows an infant to obtain adequate
nutrition while providing an effective stimulus to increase the mother's milk
supply. The mother should pump for 10 to 15 minutes using a dual collection
system to drain both breasts simultaneously. The high-fat, calorie-dense hind-
milk obtained with the breast pump may be used to supplement the infant, with
additional formula as required. This triple-feeding regimen-breastfeeding for
approximately 10 minutes per breast, supplementing the infant to satiety, and
pumping for approximately 10 minutes-should not exceed 1 hour.
Counseling the parents of underweight, breastfed infants who are opposed
to feeding supplemental milk may be challenging. Instead of criticizing the
mother's intense desire to breastfeed exclusively, the clinician should acknowl-
edge her good intentions and establish rapport by giving her a sincere affirma-
tion, such as, "Sounds like you are a mother who wants what's best for her
baby." Clinicians should explain that three problems have been detected: (1) the
infant's underweight condition, (2) the mother's low milk production, and (3)
the ineffectiveness of direct breastfeeding. In prioritizing these problems, the
infant's welfare must be paramount. Providing appropriate supplemental milk
to an underweight infant is necessary to prevent malnutrition, dehydration,
electrolyte imbalance, cerebral infarcts, and other complications of inadequate
breastfeeding. The next priority is to increase the mother's milk supply without
further delay because the longer low milk has been present, the more difficult it
is to increase production. Also, the more abundant her supply, the more readily
her infant will learn to breastfeed effectively. The third priority of achieving
exclusive, direct breastfeeding is best facilitated if the infant is healthy and
thriving and the milk supply is generous. Therefore, addressing the first two
priorities improves the likelihood of succeeding with the third.

Insufficient Quantity and Duration of Supplement

When supplementing an underweight, breastfed infant, many clinicians

make the mistake of giving arbitrary or token volumes of formula. Often, the
supplements are limited to once or twice a day or given with every other
 PREVENTION OF BREASTFEEDING TRAGEDIES 289

feeding, out of fear that the infant will be satisfied too easily or come to expect
the supplement after every breastfeeding." Many breastfeeding advocates accept
minimal weight gain in an underweight infant as evidence that the nutritional
problem is being adequately addressed: "It may help the mother to know that
babies seldom go from losing weight one week to gaining rapidly the next. They
usually stabilize for one or two weeks and then begin to gain slowly (perhaps
only 11/2 oz or 42 grams [per week] initially)."45a
An otherwise healthy infant who is underweight because of caloric depriva-
tion should commence immediate weight gain as soon as adequate calories are
provided. Significantly underweight infants who are given appropriate volumes
of supplemental milk should be expected to have initial catch-up weight gain of
at least 56 g per day for the first several days, followed by maintenance weight
gain of approximately 28 g per day. Unless the infant has an underlying medical
problem, failure to begin catch-up weight gain means insufficient supplement is
being given.
One reason that insufficient supplement may be given is that many prac-
titioners fear causing nipple confusion if they supplement by bottle-usually the
most efficient and least stressful method. With a compromised infant, alternative
methods of supplementing, such as finger-feeding, using a supplemental nursing
system (SNS), or cup-feeding, may be too slow and deliver insufficient calories
while stressing the infant unnecessarily. A more prudent approach is to use the
bottle to supplement breastfeeding until catch-up infant weight gain has been
accomplished. After the infant is well nourished, the mother may choose to use
an alternative device, such as the SNS, to provide the supplement if she desires.
Another common error in the use of supplement is to withdraw it abruptly
after the infant begins to gain weight, only to have the weight falter again.
Medically indicated supplements should be tapered only when objective mea-
sures confirm that the infant is obtaining more milk from breastfeeding. The
mother usually needs to continue pumping after feedings to maintain an abun-
dant supply until the infant has weaned from all supplements and is gaining
adequate weight with exclusive breastfeeding. At this point, she may gradually
taper the pumping sessions.

STRATEGIES TO PROMOTE BREASTFEEDING SUCCESS

Although it may not be possible to prevent every case of insufficient milk

supply, breastfeeding tragedies are preventable by appropriate education of
parents and professionals, vigilant screening for lactation risk factors, early
follow-up after hospital discharge, appropriate anticipatory guidance for
breastfeeding mothers, and timely intervention when ineffective breastfeeding
is detected. The following practice strategies will help to ensure optimal out-
comes in breastfed infants.
• Encourage expectant parents to attend a prenatal breastfeeding class and
to become as knowledgeable as possible about breastfeeding before deliv-
ery.
• Ensure that pregnant women undergo a prenatal breast examination to
screen for anatomic variations that could impact lactation performance.
• Help mothers to get the best possible start with breastfeeding in the
hospital setting, including hands-on assistance with correct breastfeeding
technique. See Figure 1 and accompanying description. Encourage early
initiation of breastfeeding; frequent, cue-based feedings; continuous room-
290 NEIFERT

Correct Breastfeeding Technique

To nurse using the traditional cradle hold, the baby is well

supported on the mother's ipsilateral arm, with the infant's
head, shoulders, back, and hips in alignment. The baby's head
rests at or below the mother's elbow, so that the infant's mouth
is aligned with the mother's nipple. Using her contralateral
hand, the mother supports her breast by cupping it with four
fingers underneath and her thumb on top. The mother's fingers
are parallel to the baby's jaws and placed well behind the
areola, so that they do not get in the way of the infant's mouth.
The mother rotates her forearm so that the baby's body is
turned to face her breast. Next, the mother lightly touches her
nipple against the midpoint of her baby's lips to stimulate the
infant to open the mouth wide, as with a yawn. The mother
waits patiently until the infant's mouth gapes open wide, then
quickly pulls the baby to her breast. The Infant should grasp
the entire nipple, plus at least 1 in of surrounding areola and
breast. A baby must grasp sufficient breast to allow the jaws to
be positioned over the dilated milk ducts situated beneath the
areola to properly compress these sinuses and readily obtain
milk.
The baby should grasp a larger portion of the inferior areola
to assure sufficient breast tissue is drawn into the mouth by the
stroking action of the tongue. Grasping ample surrounding
areola also ensures that the nipple is far back In the baby's
mouth to avoid damaging friction and soreness. When an
infant is attached correctly, the mouth is open wide with lips
flanged out, nose resting against the upper breast, and chin
pressed against the underside of the breast. The baby is
observed to suck deeply and rhythmically, with several sucking
bursts separated by pauses and frequent audible swallowing.

Figure 1. A and B, Correct breastfeeding technique. (From Neifert M: Dr' Mom's Guide to
Breastfeeding. New York, Plume Publishing, 1998, pp 96,98; illustration by Tim Burkhardt,
Crystal Lake, IL; with permission.)

ing-in; and avoidance of pacifiers and supplemental feedings unless a

valid medical indication exists.
• Screen mothers and newborn infants for breastfeeding risk factors and,
when potential problems are detected, arrange for early intervention to
maximize maternal milk production and infant milk intake. See Appendix
1 of this article, the Early Breastfeeding Screening Form.
 PREVENTION OF BREASTFEEDING TRAGEDIES 291

• Whenever a breastfed infant is unable to extract milk regularly and effec-

tively, advise mothers to begin using a fully automatic electric breast
pump to express residual milk after nursings. Establishing and main-
taining a generous milk supply improves a woman's chances of overcom-
ing early breastfeeding difficulties and also ensures that her infant will be
adequately nourished.
• Encourage new, breastfeeding mothers to remain in close contact with
their infants and to nurse their infants whenever they display hunger
cues, at least eight to twelve times in 24 hours for approximately 10 to 15
minutes per breast. Teach mothers the infant behavioral and elimination
signs of a well-nourished, breastfed infant. See Appendix 2 of this article,
How Do I Know My Baby is Getting Enough Milk? Urge parents to seek
medical advice for poor infant feeding, jaundice, or infrequent elimination.
• Schedule follow-up visits for breastfed newborn infants within 48 hours
after hospital discharge. Evaluate the infant's percentage of weight loss
from birth weight and assess the frequency and duration of feedings,
elimination patterns, evidence of jaundice, and maternal reports of
breastfeeding difficulties.
• Provide encouragement for breastfeeding women and refer them to peer
support groups, where successful breastfeeding mothers may serve as
influential role models.

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62. Rowland TW, Zori RT, Lafleur WR, et al: Malnutrition and hypernatremic dehydration
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63. Rushton AR, Lambert GP, Katcher AL, et al: Dehydration in a breast-fed infant.
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64. Ryan A: The resurgence of breastfeeding in the United States. Pediatrics 99:E12, 1997
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Address reprint requests to

Marianne R. Neifert, MD
HealthONE Alliance Lactation Program
4500 E 9th Avenue
Suite 320 South
Denver, CO 80220

e-mail: DrNeifert@aol.com
APPENDIX 1
Early Breastfeeding Screening Form

Please complete this screening form when your baby is four to six days old.
If you circle any answers in the right-hand column, call your baby's doctor to
arrange for further evaluation. The earlier problems are identified, the easier
they are to correct. Your doctor may refer you to a lactation consultant who can
observe your breastfeeding technique and provide assistance.
1. Do you feel breastfeeding is going well for you so far? Yes No
2. Has your milk come in yet? (That is, did your breasts get firm Yes No
and full between the second and fourth postpartum days?)
3. Is your baby able to latch on to both breasts without difficulty? Yes No
4. Is your baby able to sustain rhythmic sucking for at least ten Yes No
minutes total per feeding?
5. Does your baby usually demand to feed? (Answer "No" if Yes No
you have a sleepy baby who needs to be awakened for most
feedings.)
6. Does your baby usually nurse at both breasts at each feeding? Yes No
7. Does your baby nurse approximately every two to three hours, Yes No
with no more than one longer interval of up to five hours at
night? (At least eight nursings each twenty-four hours?)
8. Do your breasts feel full before feedings? Yes No
9. Do your breasts feel softer after feedings? Yes No
10. Are your nipples extremely sore? (for example, causing you to No Yes
dread feedings?)
11. Is your baby having yellow, seedy bowel movements that look Yes No
like cottage cheese and mustard?
12. Is your baby having at least four good-size bowel movements Yes No
each day? (That is, more than a stain on the diaper?)
13. Is your baby wetting his/her diaper at least six times each day? Yes No
14. Does your baby appear hungry after most feedings? No Yes
15. Do you hear rhythmic suckling and swallowing while your Yes No
baby nurses?

Copyright ©The HealthONE Alliance Lactation Program, Denver, CO. Used with
permission.

295
296 NEIFERT

APPENDIX 2
How Do I Know My Baby is Getting Enough Milk?

Even though a breastfeeding mother can't see exactly how much milk her
baby takes while nursing, observant parents can tell whether breastfeeding is
off to a good start, provided they know what to look for. Once a mother's milk
comes in, the following patterns are typical of well-nourished, breastfed infants.
1. Your milk should "come in" abundantly approximately 2-4 days after
delivery. With this surge in milk production, your breasts become larger,
firmer, heavier, and warmer, and may spontaneously leak milk. If your
baby seems hungry after most nursings and you do not think your milk
has "come in" by 4 days postpartum, you should consult your baby's
doctor and have your baby weighed to find out if he or she is getting
enough milk.
2. Your baby should latch on correctly to each breast and suck rhythmi-
cally for at least 10 minutes per side. He or she may pause periodically,
but should nurse vigorously throughout most of the feeding. You should
hear your baby swallow often while breastfeeding. A baby usually takes
more milk by nursing from both breasts than from just one side. Allow
ample time at the first breast to help assure your baby gets the rich,
high-fat hindmilk before switching sides. Since the first breast nursed
gets better drained, it is best to alternate the side on which you start
feedings, so both breasts receive comparable stimulation and emptying.
3. Your newborn baby should breastfeed 8 to 12 times each 24 hours.
This will be accomplished if you nurse every 1.5-3 hours, with a single
longer stretch at night, not exceeding 5 hours. Time the feedings from
the beginning of one nursing to the beginning of the next. Very few
breastfed babies will gain adequate weight if nursed at 4 hour intervals
(or only 6 times each 24 hours). It is not uncommon to need to awaken
your baby to feed. Some babies just don't demand as often as they
should and they need to be coaxed to breastfeed.
4. Your baby should appear satisfied after nursings and probably will
fall asleep at the second breast. Breastfed infants who appear hungry
after most feedings-who cry, suck their hands, make mouthing move-
ments, or often require a pacifier after nursing-may not be getting
enough milk. If your baby acts hungry after most feedings, contact your
baby's doctor and have your infant weighed. It is best to avoid giving
your baby a pacifier until breastfeeding is well established and your
baby is gaining weight well.
5. Your breasts should feel full before feedings and softer after your
baby has nursed. You should hear your baby swallow regularly while
breastfeeding. One breast may drip milk while your baby nurses on the
other side. After your longest night interval, your breasts should feel
particularly full. The side on which you last finished nursing should
feel fuller at the next feeding.
6. Your baby's bowel movements should look yellow-somewhat like a
mixture of cottage cheese and mustard-by the 4th or 5th day of life.
These loose, yellow, seedy movements are called "milk stools." If your
baby is still having dark meconium or greenish brown "transition"
stools by 5 days of age, he or she may not be getting enough milk.

Copyright © The HealthONE Alliance Lactation Program. Used With Permission.

 PREVENTION OF BREASTFEEDING TRAGEDIES 297

7. Your baby should have 4 or more bowel movements each day. Many
breastfed infants pass a stool with every nursing during the first month
of life. If your newborn baby is having fewer than four stools each day,
it might mean he or she is not getting enough milk. The volume of stool
passed should be sizeable, not just a spot on the diaper.
8. Your baby should urinate 6 or more times a day. Most breastfed
newborns wet their diapers after every feeding. The urine should be
colorless, not yellow. A red or pink "brick dust" appearance on the
diaper after the 4th day (due to urinary crystals) suggests that your
baby may not be getting enough milk. Contact your baby's doctor for
infrequent urine or stool.
9. Your nipples might be mildly tender for the first several days of
nursing. Tenderness usually is present only at the beginning of the
feedings, and discomfort is typically gone by the end of the first week.
Severe nipple pain, cracks or other breaks in the nipple skin, pain that
lasts throughout a feeding, or pain persisting beyond 5-7 days suggests
that your baby is not nursing correctly. If your baby is incorrectly
latched on to nurse, not only will your nipples hurt, your baby may not
obtain enough milk. If you have severe sore nipples, ask your baby's
doctor to check your infant's weight and refer you to a breastfeeding
specialist who can evaluate your nursing technique. Damaged nipple
skin can become infected with bacteria or yeast, causing increased pain
and delayed healing.
10. After 2 or 3 weeks, you should notice the sensations associated with
your milk ejection, or milk let-down, reflex. You may feel a tingling,
"pins-and-needles," or tightening sensation in your breasts as milk
begins to flow. When your milk ejection reflex is triggered, your baby
may start to gulp milk, and milk may drip or spray from the other
breast. Just hearing your baby cry can cause your milk to "let-down,"
even before your baby latches on. Failure to perceive any signs of milk
let-down could suggest that your milk supply is low.
Once your milk has come in abundantly, your breastfed baby should gain
about one ounce each day for the first couple months of life. The only way to
be absolutely certain that your baby is getting enough milk is to have him or
her weighed regularly. If your baby is not gaining weight appropriately, it is
possible that your milk supply is low or that your baby is not nursing effectively.
Such breastfeeding difficulties are easier to remedy if they are recognized and
treated early. Your baby's doctor can work with a breastfeeding specialist to
develop a feeding plan tailored for you and your baby.