breastfeeding and human lactation

Breastfeeding and
Human Lactation,
Third Edition
Jan Riordan, EdD, RN, IBCLC, FAAN
JONES AND BARTLETT PUBLISHERS
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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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Copyright © 2005 by Jones and Bartlett Publishers, Inc.
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All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any
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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
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SECTION 1
H
ISTORICAL AND
WORK PERSPECTIVES
TABLE OF CONTENTS
Preface xxi Chapter Authors xxiv
Acknowledgements xxiii
CHAPTER 1
Tides in Breastfeeding Practice 3
Evidence About Breastfeeding Practices 3
Large-Scale Surveys 3
Other Evidence 4
The Biological Norm in Infant Feeding 5
Early Human Evolution 5
Early Breastfeeding Practices 5
The Replacement of Maternal Breastfeeding 5
Wet-Nursing 5
Hand-Fed Foods 6
Timing of the Introduction of Hand-Feeding 7
Technological Innovations in
Infant Feeding 8
The Social Context 8
The Technological Context 9
The Role of the Medical Community 9

The Prevalence of Breastfeeding 12
United States, England, and Europe 12
Developing Regions 13
The Cost of Not Breastfeeding 15
Health Risks of Using Manufactured
Infant Milks 16
Economic Costs of Using Manufactured
Infant Milks 16
The Promotion of Breastfeeding 18
Breastfeeding Promotion in the
United States 19
International Breastfeeding Promotion 20
Private Support Movements 23
Summary 24
Key Concepts 25
Internet Resources 26
References 27
CHAPTER 2
Work Strategies and the
Lactation Consultant 31
History 31
Do Lactation Consultants Make a
Difference? 32
Certification 32
Getting a Job as a Lactation Consultant 35
Interviewing for a Job 36
Gaining Clinical Experience 36
LC Education 37
Lactation Programs 38
Workload Issues 41

Developing a Lactation Program 41
Marketing 44
The Unique Characteristics of Counseling
Breastfeeding Women 44
Roles and Responsibilities 45
Stages of Role Development 46
Lactation Consultants in the
Community Setting 47
Medical Office 47
Lactation Consultants and
Volunteer Counselors 48
Networking 48
Reporting and Charting 49
Clinical Care Plans 50
Legal and Ethical Considerations 51
vii
viii Breastfeeding and Human Lactation
Reimbursement 53
Insurance and Third-Party Payment 53
Coding 56
Private Practice 57
The Business of Doing Business 57
Payment and Fees 58
Partnerships 59
Summary 60
Key Concepts 61
Internet Resources 62
References 62
SECTION 2 ANATOMICAL AND
BIOLOGICAL IMPERATIVES

CHAPTER 3
Anatomy and Physiology
of Lactation 67
Mammogenesis 67
Breast Structure 69
Variations 72
Pregnancy 72
Lactogenesis 73
Delay in Lactogenesis 74
Hormonal Influences 74
Progesterone 75
Prolactin 75
Cortisol 77
Thyroid-Stimulating Hormone 77
Prolactin-Inhibiting Factor 77
Oxytocin 78
Milk Production 79
Autocrine Versus Endocrine 79
Galactopoiesis 80
Galactorrhea 80
Clinical Implications: Mother 80
Breast Assessment 80
Classification of Nipple Function 82
Concepts to Practice 82
Newborn Oral Development 83
Suckling 85
Breathing and Suckling 87
Frequency of Feedings 89
Summary 90
Key Concepts 90

References 92
CHAPTER 4
The Biological Specificity
of Breastmilk 97
Milk Synthesis and Maturational Changes 98
Energy, Volume, and Growth 98
Caloric Density 99
Milk Volume and Storage Capacity 100
Differences in Milk Volume
Between Breasts 102
Infant Growth 103
Nutritional Values 103
Fat 103
Lactose 105
Protein 106
Vitamins and Micronutrients 106
Minerals 108
Preterm Milk 110
Anti-infective Properties 111
Gastroenteritis and Diarrheal Disease 111
Respiratory Illness 112
Otitis Media 114
Controversies and Claims 115
Contents ix
Chronic Disease Protection 115
Childhood Cancer 116
Allergies and Atopic Disease 116
Asthma 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
Bioactive Components 122
Enzymes 122
Growth Factors and Hormones 123
Taurine 124
Implications for Clinical Practice 124
Summary 126
Key Concepts 126
Internet Resources 127
References 128
Appendix 4-A: Composition of Human
Colostrum and Mature Breastmilk 136
CHAPTER 5
Drug Therapy
and Breastfeeding 137
The Alveolar Subunit 138
Drug Transfer into Human Milk 139
Passive Diffusion of Drugs into Milk 140
Ion Trapping 141
Molecular Weight 141
Lipophilicity 142
Milk/Plasma Ratio 142
Maternal Plasma Levels 142
Bioavailability 143
Drug Metabolites 143
Calculating Infant Exposure 143

Unique Infant Factors 144
Maternal Factors 146
Minimizing the Risk 146
Effect of Medications on Milk Production 146
Drugs That May Inhibit Milk Production 146
Drugs That May Stimulate
Milk Production 148
Herbs 149
Review of Selected Drug Classes 149
Analgesics 149
Antibiotics 150
Antihypertensives 153
Psychotherapeutic Agents 153
Corticosteroids 157
Thyroid and Antithyroid Medications 157
Drugs of Abuse 158
Radioisotopes 159
Radiocontrast Agents 159
Summary 161
Key Concepts 162
Internet Resources 162
References 162
CHAPTER 6
Viruses and Breastfeeding 167
HIV and Infant Feeding 167
Exclusive Breastfeeding 168
What We Know 168
Treatment and Prevention 170
Health-Care Practitioners 171
Counseling 171

Herpes Simplex Virus 172
Chickenpox/Varicella 173
Cytomegalovirus 175
x Breastfeeding and Human Lactation
Rubella 176
Hepatitis B 176
Hepatitis C 176
Human Lymphotropic Virus 177
West Nile Virus 177
Implications for Practice 178
Summary 179
Key Concepts 179
Internet Resources 180
References 181
SECTION 3 PR ENATAL, PERI NATAL, AND
POSTNATAL PERIODS
CHAPTER 7
Perinatal and
Intrapartum Care 185
Breastfeeding Preparation 185
Early Feedings 186
Feeding Positions 191
Latch-on and Positioning Techniques 191
The Infant Who Has Not Latched-On 192
Plan for the Baby Who Has Not
Latched-On Yet 194
Establishing the Milk Supply 194
Assessment of the Mother’s
Nipples and Breasts 196
Baby Problems That May Cause

Difficulty with Latch-on 196
The 34 to 38 “Weeker” 197
Feeding Methods 198
Cup-Feeding 198
Finger-Feeding 199
Nipple Shields 200
Hypoglycemia 201
Cesarean Births 204
Breast Engorgement 205
Breast Edema 206
Hand Expression 207
Clinical Implications 209
Breastfeeding Assessment 209
Discharge Planning 210
Basic Feeding Techniques 210
Signs That Intervention Is Needed 211
Discharge 211
Summary 212
Key Concepts 212
Internet Resources 214
References 214
CHAPTER 8
Postpartum Care 217
Hydration and Nutrition in the Neonate 217
Signs of Adequate Milk Intake 218
Milk Supply––Too Much or Too Little 218
Temporary Low Milk Supply or
Delayed Lactogenesis 220
Effect of Pharmaceutical Agents on
Milk Supply 220

Too Much Milk 221
Nipple Pain 221
Treatments for Painful Nipples 225
Nipple Creams and Gels 225
Engorgement + Milk Stasis = Involution 228
Breast Massage 228
Clothing, Leaking, Bras, and
Breast Pads 228
Contents xi
Infant Concerns 230
Pacifiers 230
Stooling Patterns 231
Jaundice in the Newborn 232
Breast Refusal and Latching Problems 232
Later Breast Refusal 234
Crying and Colic 234
Multiple Infants 236
Full-Term Twins or Triplets 237
Preterm or Ill Multiples 237
Putting It All Together 238
Partial Breastfeeding and Human
Milk Feeding 239
Breastfeeding During Pregnancy 240
Clinical Implications 241
Summary 242
Key Concepts 242
Internet Resources 242
References 243
CHAPTER 9
Breast-Related Problems 247

Nipple Variations 247
Inverted or Flat Nipples 247
Absence of Nipple Pore Openings 248
Large or Elongated Nipples 248
Plugged Ducts 248
Mastitis 250
Treatment for Mastitis 251
Types of Mastitis 252
Breast Abscess 254
Breast and Nipple Rashes, Lesions, and
Eczema 254
Candidiasis (Thrush) 255
Treatment 256
Breast Pain 260
Vasospasm 260
Milk Blister 261
Mammoplasty 261
Breast Reduction 261
Mastopexy 263
Breast Augmentation 263
Breast Lumps and Surgery 265
Galactoceles 266
Fibrocystic Disease 267
Bleeding from the Breast 267
Breast Cancer 268
Lactation Following Breast Cancer 269
Clinical Implications 270
Summary 271
Key Concepts 271
Internet Resources 273

References 273
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 280
Current Growth Curves Still
Underrepresent Breastfeeding 280
Low Intake and Low Milk Supply: Definit-
ions 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
xii Breastfeeding and Human Lactation
Oral-Motor Dysfunction
(Ineffective Suckling) 286
Gastroesophageal Reflux/Cow Milk
Allergy/Oversupply 290
Nonspecific Neurological Problems 291
Ankyloglossia (Tight Frenulum,
Tongue-Tie) 291

Abnormal Patterns of Growth:
The Baby with Obvious Illness 292
Maternal Considerations:
The Mother Who Appears Healthy 293
Delayed Lactogenesis 293
Stress 293
Inverted Nipples 294
Nipple Shields 294
Medications and Substances 294
Hormonal Alterations 294
Breast Surgery 295
Insufficient Glandular Development
of the Breast 295
Psychosocial Factors 296
Maternal Nutrition 296
Maternal Considerations:
Obvious Illness 296
History, Physical Exam, and
Differential Diagnosis 296
History 296
Physical Examination 296
Differential Diagnosis 297
Clinical Management 297
Determining the Need
for Supplementation 297
Intervention 297
Reducing the Amount
of Supplementation 300
Family and Peer Support 300
When Maternal Milk Supply Does

Not Increase 300
Special Techniques for Management of
Low Intake or Low Supply 300
Breast Massage 300
Switch Nursing 300
Feeding-Tube Device 301
Test Weighing 303
Galactagogues 303
Hindmilk 304
Summary 305
Key Concepts 306
Internet Resources 307
References 307
CHAPTER 11
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 316
Diagnostic Assessment 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 328
Prolactin 328
Clinical Implications 329
Oxytocin 330
Pumps 330
Mechanical Milk Removal 330
Contents xiii
Compression 331
The Evolution of Pumps 331
A Comparison of Pumps 332
Manual Hand Pumps 333
Battery-Operated Pumps 335
Electric Pumps 336
Simultaneous and/or
Sequential Pumping 338
Flanges 338
Miscellaneous Pumps 342
Pedal Pumps 342
Clinical Implications Regarding
Breast Pumps 342
When Pumps Cause Problems 345
Sample Guidelines for Pumping 345
Common Pumping Problems 347
Nipple Shields 349
Review of Literature 350
Types of Shields 351
Shield Selection and Instructions 351

Weaning from the Shield 352
Responsibilities 352
Breast Shells 354
Feeding-Tube Devices 355
Situations for Use 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 367
Suitability of Human Milk for Preterm
Infants 367
Mothers of Preterm Infants 368
Rates of Breastfeeding Initiation and
Duration 370
Research-Based Lactation Support
Services 370
The Decision to Breastfeed 370
Facilitating an Informed Decision 370
Alternatives to Exclusive, Long-Term
Breastfeeding 370
Models for Hospital-Based Lactation
Support Services 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 376
Expressed Milk Volume Guidelines 376
Preventing Low Milk Volume 376
Skin-to-Skin (Kangaroo) Care 377
Evidence-Based Guidelines for Milk
Collection, Storage, and Feeding 378
Guidelines for Collection and Storage
of Expressed Mother’s Milk (EMM) 378
Preparing Expressed Mother’s Milk
for Infant Feeding 379
Special Issues Regarding the Feeding
of EMM 380
Volume Restriction Status 382
Commercial Nutritional Additives 382
Hindmilk Feeding 382
Methods of Milk Delivery 383
Maternal Medication Use 383
Feeding at Breast in the NICU 384
Suckling at the Emptied Breast 384
The Science of Early Breastfeeding 385
Progression of In-Hospital Breastfeeding 390
Milk Transfer During Breastfeeding 390
Discharge Planning for
Postdischarge Breastfeeding 396
Getting Enough: Determining the Need
for Extra Milk Feedings 397
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
CHAPTER 14
Donor Human Milk Banking 409
Defining Donor Milk Banking 409
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
Donor Human Milk Banking Beyond
North America 412
The Impact of Culture on Donor
Milk Banking 413
The Benefits of Banked Donor
Human Milk 413
Species Specificity 413
Ease of Digestion 413
Promotion of Growth, Maturation,
and Development of Organ Systems 414
Immunological Benefits 414

Clinical Uses 414
Distribution of Banked Donor Milk:
Setting Priorities 414
Classifying Clinical Uses: Is Donor
Milk Food or Medicine? 415
Current Practice 420
Donor Selection and Screening 420
Collection 422
Pasteurization 422
Packaging and Transport 425
Costs of Banked Donor Milk 425
Policy Statements Supporting the
Use of Banked Donor Human Milk 425
Summary 426
Key Concepts 427
Internet Resources 427
References 427
Appendix 14-A: Storage and Handling
of Expressed Human Milk 432
SECTION 4 BEYOND
POSTPARTUM
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 443
Caffeine 443
Food Flavorings 443
Allergens in Breastmilk 443
The Goal of the Maternal Diet
During Lactation 444
Contents xv
Nutrition Basics 446
Energy 446
Macronutrients 447
Carbohydrates 447
Protein 447
Fat 448
Micronutrients 448
Vitamins 448
Minerals 449
Clinical Implications 449
Summary 453
Key Concepts 453
Internet Resources 454
References 454
CHAPTER 16
Women’s Health
and Breastfeeding 459
Alterations in Endocrine and
Metabolic Functioning 459
Diabetes 459
Thyroid Disease 461
Pituitary Dysfunction 462

Polycystic Ovarian Syndrome 462
Theca Lutein Cysts 462
Cystic Fibrosis 463
Acute Illness and Infections 463
Tuberculosis 464
Group B Streptococcus 464
Dysfunctional Uterine Bleeding 465
Maternal Immunizations 465
Surgery 465
Donating Blood 466
Relactation 467
Induced Lactation 467
Domperidone, Metoclopramide,
and Sulpride 468
Autoimmune Diseases 470
Systemic Lupus Erythematosus 470
Multiple Sclerosis 471
Rheumatoid Arthritis 471
Physically Challenged Mothers 472
Seizure Disorders 473
Headaches 475
Postpartum Depression 476
Clinical Implications 477
Medications and Herbal Therapy
for Depression 478
Support for the Mother with
Postpartum Depression 480
Asthma 480
Smoking 480
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
CHAPTER 17
Maternal Employment
and Breastfeeding 487
Why Women Work 487
Historical Perspective 488
The Effect of Work on Breastfeeding 488
Strategies to Manage Breastfeeding
and Work 489
Prenatal Planning and Preparation 489
Return to Work 491
Hand Expression and Pumping 492
Human Milk Storage 493
Fatigue and Loss of Sleep 496
Maintaining an Adequate Milk Supply 496
The Day-Care Dilemma 497
xvi Breastfeeding and Human Lactation
Workplace Strategies 497
Lactation Programs in Work Sites 498
The Employer’s Perspective 500
Community Strategies 501
Health-Care Providers and
Lactation Consultants 501
Breastfeeding Support Groups 501

National and International Strategies 501
Legislative Support and
Public Advocacy 501
International Labour Organization 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 511
Physical Growth 511
Weight and Length 512
Senses 513
Reflexes 514
Levels of Arousal 514
Theories of Development 514
Nature Versus Nurture 514
Social Development 517
Language and Communication 517
Attachment and Bonding 520
Temperament 523
Stranger Distress 523
Separation Anxiety 523
Clinical Implications 525
Immunizations 525

Vitamin D and Rickets 527
Dental Health and Orofacial
Development 527
Solid Foods 528
Introducing Solid Foods 528
Choosing the Diet 529
Choosing Feeding Location 531
Delaying Solid Foods 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 541
Team Care for the Child with
Feeding Difficulties 541
Feeding Behaviors of the Ill Infant/Child 541
What to Do If Weight Gain
Is Inadequate 544
What to Do When Direct Breastfeeding
Is Not Sufficient 544
Alternative Feeding Methods 546
Care of the Hospitalized Breastfeeding
Infant/Child 548

Home from the Hospital:
The Rebound Effect 550
Perioperative Care of the Breastfeeding
Infant/Child 551
Emergency Room 552
Contents xvii
Care of Children with
Selected Conditions 552
Infection 552
Gastroenteritis 552
Respiratory Infections 554
Pneumonia 555
Bronchiolitis 555
Respiratory Syncytial Virus 556
Otitis Media 556
Meningitis 556
Alterations in Neurological Functioning 557
Down Syndrome or Trisomy 21 560
Neural Tube Defects 560
Hydrocephalus 561
Congenital Heart Disease 561
Oral/Facial Anomalies 563
Cleft Lip and Palate 563
Pierre Robin Sequence 566
Choanal Atresia 568
Gastrointestinal Anomalies
and Disorders 568
Esophageal Atresia/Tracheoesophageal
Fistula 568
Gastroesophageal Reflux 569

Pyloric Stenosis 571
Imperforate Anus 571
Metabolic Dysfunction 571
Phenylketonuria 572
Galactosemia 572
Congenital Hypothyroidism 574
Type I Diabetes 575
Celiac Disease 575
Cystic Fibrosis 575
Allergies 576
Food Intolerance 579
Lactose Intolerance 579
Psychosocial Concerns 579
Family Stress 579
Coping with Siblings 581
Chronic Grief and Loss 581
The Magic-Milk Syndrome 581
The Empty Cradle When a Child Dies 582
Caring for Bereaved Families 582
Summary 583
Key Concepts 583
Internet Resources 584
References 585
CHAPTER 20
Infant Assessment 591
Perinatal History 591
Gestational Age Assessment 591
The New Ballard Score 594
Indicators of Effective Breastfeeding
and Assessment Scales 598

Breastfeeding Behaviors
and Indicators 598
Breastfeeding Scales and Tools 598
Summary of Breastfeeding
Assessment Scales 600
Physical Assessment 600
Transitional Assessment 600
Skin 604
Birthmarks 605
Head 606
Ears/Eyes 606
Nose 607
Mouth 607
Neck 608
Chest 608
Abdomen 609
Genitalia 609
Back and Spine 609
Extremities 609
Elimination 610
Behavioral Assessment 611
Sleep-Wake States 614
Neurobehavioral Cues and Reflexes 614
Summary 616
Key Concepts 616
References 616
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
Appendix 20-D: Via Christi Breastfeeding
Assessment Tool 620
CHAPTER 21
Fertility, Sexuality,
and Contraception
During Lactation 621
Fertility 621
The Demographic Impact
of Breastfeeding 621
Mechanisms of Action 622
Lactational Amenorrhea 623
The Suckling Stimulus 624
The Repetitive Nature of the Recovery
of Fertility 628
The Bellagio Consensus 630
Sexuality 632
Libido 632
Sexual Behavior During Lactation 637
Contraception 639
The Contraceptive Methods 639
Clinical Implications 645
Summary 647
Key Concepts 647
References 648
SECTION 5 SOCIOCULTURAL AND
RESEARCH ISSUES
CHAPTER 22

Research, Theory,
and Lactation 655
Theories Related to Lactation Practice 655
Maternal Role Attainment Theory 656
Parent-Child Interaction Model 656
Bonding and Attachment Theory 657
Theory of Darwinian and
Evolutionary Medicine 657
Self-Care Theory 658
Self-Efficacy Theory 658
Theory of Planned Behavior and
Theory of Reasoned Action 658
Types of Research Methods 659
Qualitative Methods 659
Quantitative Methods 660
Additional Methods and Approaches
for Breastfeeding Research 662
Elements of Research 663
Research Problem and Purpose 663
Variables, Hypotheses, and
Operational Definitions 665
Review of Literature 667
Protection of the Rights of Human
Subjects 667
Method 668
Data Analysis 669
Application of Methods to
Qualitative Approaches 669
Sampling 669
Data Collection 670

Data Analysis 670
Trustworthiness of Qualitative Research 671
Application of Methods to
Quantitative Approaches 671
Sampling and Sample Size 671
Data Collection 672
Reliability and Validity 672
Data Analysis 674
Results, Discussion, Conclusions,
and Dissemination 677
Evaluating Research for Use in Practice 678
Contents xix
Using Research in Clinical Practice 680
Perspectives of Research Methodologies 680
Positivist and Postpositive Perspective 681
Naturalistic, Humanistic, or
Interpretive Perspective 681
Critical or Emancipatory Perspective 681
Summary 682
Key Concepts 683
Internet Resources 684
References 684
Appendix 22-A: Research Terms 687
CHAPTER 23
Breastfeeding Education 689
Educational Programs 689
Distance Learning and Web Courses 690
Learning Principles 690
Adult Education 691
Curriculum Development 692

Parent Education 692
Prenatal Education 694
Early Breastfeeding Education 694
Continuing Support for
Breastfeeding Families 697
How Effective Is
Breastfeeding Education? 697
Teaching Strategies 698
Small Group Dynamics 700
Multimedia Presentations 700
Slides 701
Transparencies 701
Television, Videotapes, and DVDs 701
Compact Discs 702
Educational Materials 702
Education for At-Risk Populations 703
Adolescents 704
Older Parents 705
Educational Needs and Early Discharge 706
Continuing Education 706
Objectives and Outcomes 707
The Team Approach 708
Childbirth Educators 708
Nurses 708
Lactation Consultants 709
Physicians 709
Dietitians 709
Community Support Groups 709
Summary 709
Key Concepts 710

Internet Resources 711
References 711
CHAPTER 24
The Cultural Context
of Breastfeeding 713
The Dominant Culture 714
Ethnocentrism Versus Relativism 714
Assessing Cultural Practices 715
Language Barriers 715
The Effects of Culture on Breastfeeding 716
Rituals and Meaning 719
Colostrum 719
Sexual Relations 719
Wet-Nursing 720
Other Practices 720
Contraception 720
Infant Care 721
Maternal Foods 722
“Hot” and “Cold” Foods 722
Herbs and Galactogogues 723
Weaning 723
Types of Weaning 724
Implications for Practice 725
Summary 726
Key Concepts 727
xx Breastfeeding and Human Lactation
Internet Resources 727
References 727
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 737
Lack of Information 737
Hospital Practices 738
The Importance of Peer Counselors 739
The Downside of Family Experience 739
Violence 740
Childhood Sexual Abuse 741
Summary 742
Key Concepts 742
Internet Resources 743
References 743
APPENDIXES 747
A. Clinical Competencies for
IBCLC Practice 749
B. Code of Ethics 754
C. Summary of Eligibility Pathway
Requirements to Become Certified
by IBLCE 756
D. Prototype Lactation Consultant
Job Description 758
E. Tables of Equivalencies and Methods
of Conversion 761
F. Infant Weight Conversion Table 762
G. Breastfeeding Weight Loss Table 763

H.Patient History 764
Glossary 773
Index 785
Figure, Table, and Box Credits 817
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 breast-
feeding mother get her baby onto the breast.
New knowledge has changed the field. Re-
search 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 lacta-
tion 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 ser-
vices of some type and employ lactation consul-
tants. 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 consul-
tants medicalizing infant feeding.
Other changes affect lactation practice. The in-
surance industry now drives the health care system,
reversing the reward system in favor of short hospi-
tal 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 al-
most no opportunity to ensure that the baby is
breastfeeding effectively. Mothers still needing care
themselves return home to assume full-time child-
care before they feel physically able to do so. Fol-
low-up care of a new family at home should be
universal, yet many mothers of preterm and “near-
term” breastfed infants who are developmentally
immature leave the hospital without any plan for as-
sistance.
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 breastfeed-
ing 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 possi-
ble 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 in-
fant assessment reflects current expectations that
the health care worker working with the breastfeed-
ing dyad can perform a total assessment of the
baby. Nearly every chapter contains a clinical im-
plications section. Important concepts discussed
in chapters are summarized at the end of each
chapter––a new feature that will make studying eas-
ier. Throughout the book are new references
deemed by the authors to be the most important
from the vastly expanded research and clinical lit-
erature. 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. Chap-
ter 1 presents the history of breastfeeding by plac-
ing 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 re-
ality of work-related issues of lactation consulting.
Section 2 focuses on basic anatomic and bio-
logic imperatives of lactation. Clinical application of
PREFACE
xxi
xxii Breastfeeding and Human Lactation
techniques must be based on a clear understanding
of the relationships between form, function, and bio-
logical constructs. Thus this section, too, provides
the background upon which to understand other as-
pects 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 pe-
riod 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 appro-
priately used. It concludes with a review of the de-
velopment 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 chap-
ter. 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 cor-
nerstone 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, mean-
ing 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, lac-
tation consultants, and other health care workers
are referred to by feminine pronouns, although we
recognize here that males serve in all health care
professions.
I gratefully acknowledge the contributions to this
book made by the following individuals:
Judy Angeron BA, RN, IBCLC, Coordinator, Lac-
tation Services, Via Christi Regional Medical Cen-
ter, Wichita, Kansas

Kathleen G. Auerbach PhD, IBCLC, Ferndale,
Washington
Suzanne Bentley MSN, CNM, IBCLC, Clinical
Nurse Specialist, University of Kansas, Clinical In-
structor, University of Kansas, School of Nursing,
Kansas City, Kansas
Belinda Childs MN, ARNP, CDE, Clinic/Re-
search Coordinator, Mid-America Diabetes Associ-
ates, Wichita, Kansas
Mary Margaret Coates MS, IBCLC, TechEdit,
Wheat Ridge, Colorado
Amy Ellington RN, BSN, Lactation Consultant,
Via Christi Regional Medical Center, Wichita,
Kansas
Barbara Gabbert-Bacon, La Leche League, Wi-
chita, Kansas
Lenore Goldfarb, B.Comm, B.Sc, IBCLC, Herzl
Family Practice Centre, Sir Mortimer B. Davis-
Jewish 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 Uni-
versity, School of Nursing, Wichita, Kansas
Kerstin Hedberg-Nyqvist PhD, RN, IBCLC, Assis-
tant Professor in Pediatric Nursing, Department of
Women’s and Children’s Health, Uppsala Univer-
sity,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
Amal Omer-Salim, MSc, Nutritionist, International
Maternal and Child Health, Department of
Women’s and Children’s Health, Uppsala Univer-
sity, Uppsala, Sweden
Virginia Phillips, IBCLC, Brisbane, Queensland,
Australia
Christina M Smillie MD, FAAP, IBCLC, Breast-
feeding Resources, Stratford, Connecticut
I am especially grateful to La Leche League Inter-
national for providing the foundation for my breast-
feeding 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) grand-
children.
ACKNOWLEDGEMENTS
xxiii