Breastfeeding

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Breastfeeding an infant

Symbol for breastfeeding (Matt Daigle, Mothering magazine contest winner 2006)

Breastfeeding is the process of a woman feeding an infant or young child with milk from her breasts. Babies have a sucking reflex that enables them to suck and swallow milk. Also important in the process is a successful latch^[1], a normal frenulum^[2], and a milk supply.

Experimental evidence suggests that except for a few important exceptions(see exceptions below) human breast milk provides the optimal nutrition source for human infants, but disagreement remains between experts regarding the optimal duration of breastfeeding to realize the benefits^[3] or the harm in using substitutes. Breastfeeding may occur between the infant and its own mother, or another lactating female. Breastmilk substitutes are available for mothers or families who cannot or prefer not to breastfeed their children. Examples of accepted alternatives to breastfeeding include feeding the infant expressed breast milk from its own mother, from another lactating female, pasteurized donor human milk, or commercially available infant formulas. There are conflicting studies concerning the equivalence between available breastmilk substitutes. In both term and preterm infants, the use of commercial brestmilk substitutes have been proven safe and effective as a nutrition source but inferior to breastfeeding. Donor breastmilk handling processes have been suspected in the proven reduction of effectiveness in pasteurized donor human milk^[4].

Many governmental strategies and international initiatives have promoted breastfeeding as the best method of feeding a child in his or her first year and beyond, as does the World Health Organization (WHO),^[5] the American Academy of Pediatrics (AAP),^[6] and many others.

Beginning lactation

When the baby sucks, a hormone called oxytocin starts the milk flowing from the alveoli, through the ducts (milk canals) into the sacs (milk pools) behind the areola and then into the baby's mouth

Main article: Breast milk

Throughout the last two trimesters of pregnancy a woman's body produces hormones which stimulate the growth of the milk duct system in the breasts:

• Progesterone -- influences the growth in size of alveoli and lobes. Progesterone levels drop along with oestrogen levels after birth, triggering the onset of copious milk secretion ^[7]
• Estrogen -- stimulates the ductule system to grow and become specific. Estrogen levels drop at delivery and remain low for the first several months of breastfeeding. ^[7] (This is also why it is recommended that breastfeeding mothers avoid oestrogen-based birth control methods while they are planning to breastfeed. A spike in estrogen levels compromises a mother's milk supply level)
• Follicle stimulating hormone (FSH)
• Luteinizing hormone (LH)
• Prolactin -- contributes to the accelerated growth of the alveoli during pregnancy ^[8]
• Oxytocin -- contracts the smooth muscle of the uterus during birth, after birth, and during orgasm. After birth, oxytocin contracts the smooth muscle layer of band-like cells surrounding the alveoli to squeeze the newly-produced milk into the duct system. Oxytocin is necessary for a let-down, or milk ejection reflex, to occur ^[8]
• Human placental lactogen (HPL) -- released in large amounts by the placenta during pregnancy (beginning in the second month); appears to be instrumental in breast, nipple, and areola growth before birth ^[8]

By the fifth or sixth month of pregnancy, the breasts are sufficiently developed to produce milk (although it is also possible to induce lactation as described in a later section).

During the latter part of pregnancy, the woman's breasts enter into the Lactogenesis I stage, where the breasts are making colostrum (a thick, sometimes yellowish fluid), but high levels of progesterone inhibit most milk secretion and keep the volume “turned down”. It is considered medically normal for a pregnant woman to leak colostrum before her baby's birth, and also normal not to leak at all. Neither situation is an indicator of future milk production levels in the mother.

At birth, the delivery of the placenta results in a sudden drop in progesterone/oestrogen/HPL levels. This abrupt withdrawal of progesterone in the presence of high prolactin levels cues Lactogenesis II (copious milk production).

Prolactin blood levels rise when the breast is stimulated, and peak around 45 minutes later. They return to pre-breastfeeding levels about three hours afterwards. The release of prolactin triggers the cells in the alveoli to create milk. Some research ^[9] indicates that prolactin in milk is higher at times of higher milk production, and that the highest levels tend to occur between 2 a.m. and 6 a.m.

Other hormones (insulin, thyroxine, cortisol) are also involved, but their roles are not yet well understood. Although biochemical markers indicate that Lactogenesis II commences approximately 30-40 hours after birth, mothers do not typically begin feeling increased breast fullness (the sensation of milk "coming in") until 50-73 hours (2-3 days) after birth.

The colostrum is the first milk the baby receives; it contains higher amounts of white blood cells and antibodies than mature milk, and is especially high in immunoglobulin A (IgA), which coats the lining of babies' immature intestines, helping to prevent germs from invading baby's system. Secretory IgA also works to help prevent food allergies. ^[10]

After a baby has been nursing for 3-4 days, the colostrum in the breast slowly begins the process of changing into mature breast milk over the next two weeks. ^[7]

During pregnancy and the first few days postpartum, milk supply is hormonally driven. This is the endocrine control system. After milk supply has been more firmly established, Lactogenesis III begins - the autocrine (or local) control system.

At this stage, milk production follows the law of supply and demand: the more milk removed from the breast, the more milk the breast will produce. Thus milk supply is strongly influenced by how often the baby feeds and how well it is able to transfer milk out of the breast. Low supply can often be traced to:

• not feeding or pumping often enough
• inability of the infant to transfer milk effectively caused by, among other things:
  • jaw or mouth structure deficits
  • poor latching technique
• rare maternal endocrine disorders
• hypoplastic breast tissue
• a metabolic or digestive inability in the infant, rendering it unable to utilise the milk it receives
• inadequate calorie intake or malnutrition of the mother

Research on mothers who express their milk ^{[11] [12]} indicates that for most women the more times per day a mother expresses her milk, the more milk she produces. Ongoing research ^[13] shows that more fully draining the breasts also increases the rate of milk production.

The production, secretion and ejection of milk is called lactation. Feeding at least once every two to three hours helps to maintain the milk supply. For most women, a target of eight nursing sessions/pumping sessions per 24 hours seems to keep a milk supply high not only during the early months of lactation, but especially past the fourth month. ^[14] It is not at all uncommon for newborn infants to nurse far in excess of this amount: 10 to 12 nursing sessions per 24 hours is the comparative norm, while some may even nurse 18 times in the same time frame.^{[citation needed]} Feeding a baby on demand, which may mean nursing many times more than the recommended minimum, is the best way to maintain milk production and ensure the baby's needs for milk and comfort are being met satisfactorily.^[5]

The exact properties of breast milk are not entirely understood, but the nutrient content of mature milk is relatively consistent and draws its ingredients from the mother's food supply and the nutrients in her bloodstream at the time of feeding. If that supply is inadequate, content is obtained from the mother's bodily stores. (Some studies estimate that a woman uses an extra 500 calories per day simply producing milk for her offspring.) The exact composition of breast milk varies from day to day, and even hour to hour, depending on both the manner in which the baby nurses and the mother's food consumption and environment, so the ratio of water to fat fluctuates. Foremilk, the milk released at the beginning of a feed, is watery, low in fat and high in carbohydrates compared with the creamier hindmilk which is increasingly released as the feed progresses. There is no sharp distinction between foremilk and hindmilk – the change is very gradual. Research from Peter Hartmann's group tells us that fat content of the milk is primarily determined by the emptiness of the breast -- the less milk in the breast, the higher the fat content. The breast can never be truly "emptied" since milk production is continuous.

The let-down reflex

The let-down reflex, also known as the milk ejection reflex, is caused by the release of the hormone, oxytocin. Oxytocin stimulates the muscles of the breast to squeeze out the milk. Breastfeeding mothers describe the sensation differently, with some feeling a slight tingling, some feeling immense amounts of pressure, some feeling slight pain/discomfort, and still others not feeling anything different.

The reflex is not always consistent, especially at first. The thought of nursing or the sound of any baby can stimulate the let-down reflex, causing unwanted leakage, or both breasts giving out milk when one infant is feeding. However, this and other problems often settle after two weeks of feeding. If the mother is in a stressed or anxious state of mind this can cause difficulties with breastfeeding.

Causes of a poor let-down reflex:

• Sore or cracked nipples
• Separation from the infant
• A history of breast surgery

If a mother has trouble breastfeeding she can try different methods of assisting the let-down reflex. These include:

• Feeding in a familiar and comfortable location
• Massage of the breast or back
• Warming the breast with a cloth or shower

Afterpains

The surge of oxytocin for triggering milk let-down also causes the uterus to subinvolute (contract down). Subsequently, during breastfeeding mothers can feel uterine contractions (pain ranging from period-like cramps to strong labour-like contractions). Afterpains can be more severe with second and subsequent babies. ^[15]

Benefits

The benefits of breastfeeding are both physical and psychological for both mother and child. Nutrients and antibodies are passed to the baby while hormones are released into the mother's system.^[16] The bond between baby and mother can also be strengthened during breastfeeding. ^[17]

Benefits for the infant

Breast milk, when fed directly from the breast, is immediately available with no wait and is at body temperature.

Breast-fed babies have a decreased risk for several infant conditions including sudden infant death syndrome (SIDS). The sucking technique required of the infant encourages the proper development of both the teeth and other speech organs. Sucking also has a beneficial role in the prevention of obstructive sleep apnea.

The many health benefits of breastfeeding have been well documented. According to the American Academy of Pediatrics policy statement, "Extensive research, especially in recent years, documents diverse and compelling advantages to infants, mothers, families, and society from breastfeeding and the use of human milk for infant feeding. These include health, nutritional, immunologic, developmental, psychological, social, economic, and environmental benefits."^[6]

Breast milk may help to lower the risk of or protect against:

1. Allergies^[18]
2. Asthma^[6][17]
3. Autoimmune thyroid diseases^{[citation needed]}
4. Bacterial meningitis^[6]
5. Breast cancer^[16]
6. Crohn's disease^[19]
7. Diabetes^[6][17]
8. Diarrhea^[6][17]
9. Eczema^[20]
10. Gastroenteritis^[21]
11. Hodgkin's lymphoma^[6][17]
12. Necrotizing enterocolitis^[6]
13. Multiple sclerosis^{[citation needed]}
14. Obesity^[6][17]
15. Otitis media (ear infection)^[6][17]
16. Respiratory infection and wheezing^[6][17]
17. Rheumatoid arthritis^{[citation needed]}
18. Urinary tract infection^[6]

Breast milk also has various anti-infective factors. These include the anti malarial factor para amino benzoic acid (PABA), the anti amoebic factor BSSL, and lactoferrin (which binds to iron, inhibiting the growth of intestinal bacteria like E. Coli).^{[citation needed]} Unlike human milk, the predominant protein in cow's milk is lactoglobulin. This is an important factor in allergy to cow's milk. ^{[citation needed]}

Breast milk also has, in adequate amounts, various factors for neuronal development like cystine, methionine and taurine.^{[citation needed]}

Benefits for the mother

Breastfeeding also benefits the mother. It releases hormones that have been found to relax the mother and cause her to experience nurturing feelings toward her infant.^{[citation needed]} Breastfeeding as soon as possible after giving birth increases levels of oxytocin which encourages the uterus to contract more quickly. This helps to decrease bleeding after the birth.^{[citation needed]}

Mothers can find breastfeeding helps them return to their previous weights as the fat accumulated during pregnancy is used in milk production.^{[citation needed]} Frequent and exclusive breastfeeding delays the return of menstruation and fertility known as lactational amenorrhoea. This allows for improved iron stores and the possibility of natural child spacing.^{[citation needed]}

Breastfeeding mothers may enjoy many health benefits:

1. Reduced risk of breast cancer^[6][17]
2. Reduced risk of ovarian cancer^[6][17]
3. Decreased insulin requirements in diabetic Mothers^{[citation needed]}
4. Stabilization of maternal endometriosis^[6]
5. Reduced risk of post-partum hemorrhage^{[citation needed]}
6. Reduced risk of endometrial cancer^{[citation needed]}
7. Reduced risk of osteoporosis^[6][17]
8. Beneficial effects on insulin levels of mothers with PCOS^{[citation needed]}

Mothers who breastfeed experience improved bone re-mineralisation after the birth,^{[citation needed]} and a reduced risk for both ovarian and breast cancer both before and after menopause.

Bonding

The maternal bond may be strengthened through breastfeeding, with the hormonal releases strengthening the mother's nurturing feelings towards the child. Strengthening the maternal bond is very important; up to 80% of mothers suffer from some form of postpartum depression, though most cases are very mild. A secondary parent can support the mother in a variety of ways and is an important factor in successful breastfeeding.^{[citation needed]}

Breastfeeding can also greatly affect the personal relationship between the partner and the child. While some partners may feel left out when the mother is feeding the baby, others may see the whole process as a chance to bond as a family. Breastfeeding, possibly alongside birth-related health problems, takes a lot of time. This may add pressure to the partner and the family, because the partner has to care for the mother and also perform tasks she would otherwise do. However, as partners are often very willing to give this support, this pressure can help to strengthen family bonds.^{[citation needed]}

When looking after the child while the mother is away, an alternative caregiver may feed the child using expressed breast milk (EBM). Sometimes this may be impractical as the mother must produce and store enough milk to feed the child for the duration of her absence. If the two caregivers are separated, feeding the breast milk may also be awkward. These two situations may prompt the caregivers to use an alternative feeding method for the child either temporarily or permanently. However, a variety of breast pumps now on the market, both for sale and for rent, make it possible for working mothers to exclusively breastfeed their babies for as long as they wish.

Recommendations and research

The World Health Organization advises: "A vast majority of mothers can and should breastfeed, just as vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother's milk be considered as unsuitable for her infant. For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed milk from the infant's own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast milk substitute fed with a cup, which is a safer method than a feeding bottle or a teat – depends on individual circumstances. Infants who are not breastfed, for whatever reason, should receive special attention from the health and social welfare system since they constitute a risk group." ^[22]

Conditions that interfere with breastfeeding

It is not uncommon for conditions affecting mother, child or both to result in difficulties with breastfeeding. Many common issues can be resolved with the help of well trained hospital staff, nurses and lactation consultants. To establish breastfeeding it is important for the baby to be put to the breast soon after birth.

The AAP policy on breastfeeding says: Delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed.

Several common factors that interfere with successful breastfeeding:

• Formula feeding
• Artificial teats (nipples) or dummies(pacifiers)
• Thrush [1] [2]
• Distractions or interruptions during feeds^{[citation needed]}
• Long separations from the mother^{[citation needed]}
• Tachypnea (rapid breathing) such as in transient tachypnea of the newborn, surfactant deficiency, respiratory distress syndrome or other infant medical conditions
• Swallowing difficulties such as with prematurity and coordination of sucking, swallowing and breathing, or GI tract abnormalities like tracheo-oesophageal fistula.
• Pain as may resuls from surgical procedures like circumcision, blood tests, or vaccinations.

[3] [4]

• Difficulties latching onto the breast^{[citation needed]}
• Poor sucking reflex^{[citation needed]}
• Poor stamina^{[citation needed]}
• Cleft palate^{[citation needed]}
• Ankyloglossia (tongue tie)^{[citation needed]}
• Hypoglycemia or hyperglycemia^{[citation needed]}
• Hypotonia, or "low-tone" infant disorder^{[citation needed]}Premature babies can have difficulties coordinating their sucking reflex with breathing. They may also tire during feeds.^{[citation needed]}.

Premature infants unable to take sufficient calories by mouth may require enteral support using gavage feeding - insertion of a feeding tube into the stomach to provide a sufficient volume of breastmilk or a substitute. This is often done in conjunction with Kangaroo Care to facilitate later exclusive breastfeeding. For some sucking related feeding difficulties, such as may occur with cleft lip/palate, the infant can receive supplementation with a Haberman Feeder

Breast pain

Breast pain when breastfeeding is another common issue that interferes with successful breastfeeding. It is cited as the second most common leading to abandonment of exclusive breastfeeding. ^[23] Some of the most commonly encountered sources for pain (and their treatments) are discussed here.

Engorgement

Engorgement is the sense of breast fullness experienced by most post partum women within 36 hours of delivery. Normally, this is a painless sensation of "heaviness". Painful or pathologic engorgement is the firm, painful overfilling with milk that accompanies infrequent or ineffective breastfeeding. When it occurs, engorgement happens around days 3 to 7 after delivery and happens more frequently in first time mothers. Contrimutions to engorgement include congestion and increased vascularity, accumulation of milk and edema. ^[24] It may affect the areola, the periphery of the breast or the entire breast, and may lead to interference with breastfeeding not only because of pain but by distortion of the normal shape of the areola/nipple making it difficult for the infant to effectively latch for feeding. Latching may occur over only a portion of the areola which can further irritate the nipple, and may lead to ineffective drainage of breastmilk and pain. Engorgement may begin as a result of several factors such as nipple pain, improper feeding technique, infrequent feeding or infant-mother separation. Primary prevention can be accomplished with breastfeeding "on demand".

Treatment involves prevention through removal of milk either through nursing, expressing or pumping. Pressure relief can be accomplished with gentle massage to help initiate milk flow - which softens the areola perhaps even allowing infant nursing. Warm water or warm compresses along with expressing some milk prior to feeding may also aid in effective nursing. Some researchers have suggested that following feeding mothers should pump and/or apply cold compresses to further reduce swelling pain and vascularity. One published study even suggested the use of "chilled cabbage leaves" applied to the breasts - but attempts to reproduce this technique met with mixed results. ^{[25] [26]} Pain relievers like anti-inflammatories or paracetamol(acetominophen)may improve the pain.

Nipple pain

Sore nipples are likely the most frequently noted post-partum complaint. This is generally reported by the second post delivery day and improves within 5 days.^{[27] [28]} Pain beyond the first week, severe pain, cracking, fissures or localized swelling is not normal and should prompt referral to a physician for further evaluation. One common cause of pain is trauma - often resulting from improper positioning of the infant for breastfeeding. Excessive pressure applied to the nipple when insufficient amount opf areola is included during a latch, or improper release of suction at the end of a feeding can contribute to this injury. Other possible causes of injury include improper use of a breast pump or the use of topical remedies or creams/hygiene rituals that lead to irritation. Treatment of trauma involves correcting the inciting factors, protection of the nipple through the use of hydorgel or lanolin creams ^[29]

Candidiasis

The symptoms of candidal breast infections include pain, pruritus (itching), burning and redness or a shiny or white patchy appearance. These infections are not uncommon and may be associated with infant thrush. Both mother and infant must be treated to eradicate this infection and first-line therapies include nystatin, ketaconacole or miconazole applied to the nipple and given orally to the infant. Strict cleaning of clothing and breast pumping/nipple shield supplies is also required to eradicate the infection.^[30]

Milk stasis

A localized plugging or blocking to the drainage from a milk duct. It may affect a single portion of the breast and is not associated with any infection. It can be treated with variation of the infant's nursing position, application of heat before feeding and if recurrent should be further evaluated for a physical blockage to the underlying ducts.

Mastitis

This is a bacterial infection involving one breast, and results in the classic signs of infection - pain, redness, swelling and warmth (dolor, rubor, turgor, calor). It most often occurs 2-3 weeks after delivery but can occur at any time.^[31] The usual causal organisms are Staphylococcus, Streptococcus and E. Coli. Prompt treatment can reduce further complications like abscess formation. Antibiotics and continued breastfeeding are the treatments of choice. Severe cases may require intravenous antibiotics.^[32]

When breastfeeding may be harmful to the infant

True contraindications to breastfeeding rare. The vast majority of mothers will not encounter a situation that makes breastfeeding unsafe - but breastfeeding may be harmful to the infant if the mother:

• has HIV ^[33]
• has untreated pulmonary tuberculosis (see paragraph below)
• is taking certain medications that suppress the immune system^{[citation needed]}
• is taking certain medications which may be passed onto the child through the milk. The vast majority of medications are compatible with breastfeeding^{[citation needed]}
• has had unusually excessive exposure to heavy metals such as mercury^{[citation needed]}
• uses potentially harmful substances such as cocaine, heroin and amphetamines.^[6] (Substances such as caffeine, tobacco, and alcohol, while possibly harmful to the nursling if consumed in large quantities, are safe to use in moderation while breastfeeding -- see below)

Determining the infant's risk from exposure to an unsafe substance in breastmilk depends on the total quantity of the exposure which in turn depends on both a) the concentration of the substance secreted in breastmilk and b) the total volume of breast milk consumed.

Women with tuberculosis who have been treated appropriately for 2 or more weeks and who are not considered contagious may breastfeed. Women with tuberculosis disease suspected of being contagious should refrain from breastfeeding or any other close contact with the infant because of potential transmission through respiratory tract droplets (see Tuberculosis, p 678). Mycobacterium tuberculosis rarely causes mastitis or a breast abscess, but if a breast abscess caused by M tuberculosis is present, breastfeeding should be discontinued until the mother no longer is contagious.^[34]

In many areas of the world, interrupting breastfeeding presents an even greater risk to the infant (e.g. from unsafe drinking water used to mix breastmilk substitutes). In such cases continued breastfeeding is the safer alternative.

In areas where BCG vaccination is the standard of care, The WHO provides treatment recommendations and advises mothers to continue breastfeeding. ^[35]. TB may be congenitally acquired^[36], or perinatally acquired through airborne droplet spread.

Infants with classic galactosemia cannot consume lactose and therefore cannot consme breastmilk. [5]

Health, diet and substance abuse

Since the nutritional requirements of the baby must be satisfied solely by the breast milk when exclusively breastfeeding it is important for the mother to maintain a healthy lifestyle, especially a good diet.^{[citation needed]} Consumption of 1,500-1,800 calories per day could coincide with a weight loss of 0.45kg (one pound) per week. ^[37] While mothers in famine conditions can produce milk with highly nutritional content, a malnourished mother may produce milk with decreased levels of vitamins A, D, B₆ and B₁₂. ^[38] She may also have a lower supply than well-fed mothers.

There are no foods which are absolutely contraindicated during lactation, although a baby may show sensitivity to particular foods in the mother's diet. Some breastfeeding advisers suggest mothers avoid certain gas producing food, such as beans, if the baby starts to develop colic or gas.^{[citation needed]}

Breastfeeding mothers must use caution if they smoke and therefore consume nicotine. Heavy use of cigarettes by the mother (more than 20 per day) has been shown to reduce the mother's milk supply and cause vomiting, diarrhoea, rapid heart rate, and restlessness in breastfeeding infants. Research is ongoing to determine whether the benefits of breastfeeding out-weigh the potential harm of nicotine in breast milk. Sudden Infant Death Syndrome (SIDS) is more common in babies exposed to a smoky environment. ^[39] Breastfeeding mothers who smoke are counselled not to do so during or immediately before feeding their child. They are encouraged to seek advice to help them reduce their nicotine intake or quit.^{[citation needed]}

Heavy alcohol consumption harms the infant, causing problems with the development of motor skills and decreasing the speed of weight gain. There is no consensus on how much alcohol may be consumed safely, but it is generally agreed that small amounts of alcohol may be occasionally consumed by a breastfeeding mother.^{[citation needed]} Considering the known dangers of alcohol exposure to the developing fetus, those mothers wishing to err on the side of caution should restrict or eliminate their alcoholic intake.^{[citation needed]}

Excessive caffeine consumption by the mother can cause irritability, sleeplessness, nervousness and increased feeding in the breastfed infant. Moderate use (one to two cups per day) usually produces no effect. Breastfeeding mothers are advised to avoid or restrict caffeine intake.^{[citation needed]}Cannabis is listed by the American Association of Pediatrics as a compound that transfers into human breast milk. Research demonstrated that certain compounds in marijuana have a very long half-life. ^[40] Cannabis exposure via the mother's milk during the first month postpartum appears to be associated with a decrease in infant motor development at one year of age.^{[citation needed]}

Baby's age average weight gain

0-4 months: 170 grams per week †
4-6 months: 113-142 grams per week
6-12 months: ‡ 57-113 grams per week

† It is acceptable for some babies to gain 113-142 grammes (4-5 ounces) per week.

‡ The average breastfed baby doubles birth weight in 5-6 months. By one year, the typical breastfed baby will weigh about 2½ times birth weight. By two years, differences in weight gain and growth between breastfed and formula-fed babies are no longer evident.

Source: Mohrbacher N and Stock J. The Breastfeeding Answer Book, Third Revised ed. Schaumburg, Illinois: La Leche League International, 2003, pp. 148-149.

Feeding options and requirements

Exclusive breastfeeding means feeding a baby nothing but breast milk. Predominant or mixed breastfeeding means feeding breast milk along with some form of substitute – infant formula or baby food and even water, depending upon the age of the child. Babies feed differently with artificial teats than from a breast. When feeding from the breast, the tongue massages the milk out rather than sucking, and the nipple does not go as far into the mouth; when feeding from a bottle, an infant will suck harder. Therefore the advice is not to mix breastfeeding and bottle-feeding (or the use of a pacifier) until the baby is used to feeding from its mother. Orthodontic teats, which are generally slightly longer, can be used to better replicate the breast.

Exclusively breastfed infants feed, on average, 6-14 times a day. The requirement varies greatly among children. Newborns consume about 30 to 90 ml (1 to 3 US fluid ounces), and after the age of four weeks, babies consume about 120ml (4 US fluid ounces) per feed. Each baby is different, and as it grows the amount will increase. It is important to recognise the signs of a baby's hunger and it is advised that the baby should dictate the number, frequency, and length of each feed, based on the assumption that it knows how much milk it needs. The supply of milk in the breast is determined by the frequency and length of these feeds or the amount of milk expressed. The birth weight of the baby may affect its feeding habits, and mothers may be influenced by what they perceive its requirements to be. For example, a baby born small for gestational age may lead a mother to believe that her child needs to feed more than if it larger; they should, however, go by the demands of the baby rather than what they feel is necessary.

One limitation of breastfeeding is that it is harder to accurately measure the amount of food the baby consumes. Since a baby will normally feed to meet its own requirements, this is rarely a problem except when attempting to determine a cause for undernutrition. It is possible to guess output from wet and soiled nappies: 8 wet cloth or 5-6 wet disposable, and 2-5 soiled per 24 hours) suggests an acceptable amount of input for newborns older than 5-6 days old. After 2-3 months, stool frequency is a less accurate measure of adequate input as some normal infants may go up to 10 days between stools.

Expression

Manual breast pump

When direct breastfeeding is not possible a baby may still be fed breast milk. By expressing (artificially removing and storing) her milk, a mother can enable her child to be fed while she is away from the child. With expression through manual massage or the use of a breast pump the woman can draw out her milk and keep it in supplemental nursing system or a bottle ready for use. This bottle may be kept on the counter for up to seven hours, refrigerated for up to eight days or frozen for up to four months. Research suggests that antioxidant activity in expressed breast milk decreases over time [6] but it still remains in higher levels than in infant formula.

Expression can be used to maintain lactation, such as when the mother and child are separated for an extended period. If the baby is unable to feed, expressed milk can be fed through a nasogastric tube.

Expressed milk can also be used to help a mother who is having difficulty breastfeeding, such as when a newborn causes grazing and bruising or when an older baby grows teeth and bites the nipple (though the reaction of the mother to a bite - a jump and a cry of pain - is usually enough to discourage the child from biting again).

Some women donate their expressed breast milk (EBM) to others, either directly or through a hospital. Though some dislike the idea of feeding their own child with another person's milk, others appreciate the ability to give their baby the benefits of breast milk. Feeding an infant breast milk is more important in some situations than in others, such as for a premature baby. ^{[citation needed]}

Infant formula

Expressed breast milk (EBM) or infant formula can be fed to an infant by bottle

The World Health Organization recommends that all mothers be encouraged to breastfeed.^[5] Hospitals that are accredited by the World Health Organization are tolerant of formula feeding but do not offer it to infants who can be breastfed as feeding a new baby with formula undermines the establishment of breastfeeding.

If the decision is made not to feed the child breast milk, or if breastfeeding is not possible, then infant formula can be given to the infant, usually using a baby bottle. According to the WHO, infant formula is the last option for infant feeding as breastfeeding, expressed milk of the baby's own mother and the expressed milk of another lactating mother (donor) should all be tried before resorting to infant formula. Infant formula may also be introduced as a supplemental liquid drink to weaned babies. Because it is proportioned for human babies it is healthier than simply drinking the milk from another mammal. Dry-nursing or drinking the milk of another mammal has been associated with high infant mortality.

While it is inferior to breastfeeding, infant formula has been effectively marketed and promoted to new mothers as a modern, easy or convenient option to feeding a baby. A 2004 UK Department of Health survey showed that 34% of women incorrectly believe infant formula to be very similar to or the same as breast milk. [7] In 1979 the International Baby Food Action Network (IBFAN) was formed to help raise awareness of such practices as supplementary feeding of new babies with formula, inappropriate promotion of baby formula and to help change attitudes that discourage or inhibit mothers from breastfeeding their babies.

Tandem, extended, and shared breastfeeding

Feeding two infants simultaneously is called tandem breastfeeding. The most common need for this is after the birth of twins whereby both babies are fed at the same time. It is not necessarily the case, however, that the appetite and feeding habits of both babies are the same. This leads to the complication of trying to feed each baby according to its own individual requirements while also trying to breastfeed them both at the same time.

In cases of multiple births with three or more children it is extremely difficult for the mother to organise feeding around the appetites of all of the babies. The breasts can produce a high quantity of milk, according to the demand placed upon them, and many mothers have been able to feed their infants successfully [8]. It is common, however, for the woman to use other alternatives.

Tandem breastfeeding is also convenient if a woman gives birth to a newborn while still feeding an older baby or child. Under these circumstances during the late stages of pregnancy the milk will change to colostrum for the benefit of the newborn. Some older nurslings will continue to feed even with this change while others may wean due to the change in taste.

Although some may find it controversial, some women breastfeed their offspring for as many as 3 to (rarely) 7 years from birth. This is referred to as extended breastfeeding. Supporters of extended breastfeeding believe that all the benefits of human milk, both nutritional and emotional, continue for as long as a child nurses. Detractors believe that prolonging breastfeeding for several years can result in the child developing emotional or psycho-sexual problems.

In developing nations within Africa and elsewhere, it is sometimes common for more than one woman to feed a child. This shared breastfeeding has been highlighted as a source of HIV infection amongst infants born HIV-negative [9].

See also: wet nurse

Breastfeeding method

There are many texts and videos available to new mothers to assist in the establishment of breastfeeding. The baby will usually indicate hunger by crying or moaning and fussing. When the baby's cheek is stroked, the baby will move his or her face towards the stroking and open his or her mouth, demonstrating the rooting instinct. Breastfeeding can make the mother thirsty and can last for up to an hour (usually in the early days, when both mother and baby are inexperienced) – it is therefore common for the mother to replace lost water by drinking during the process.

Feeding and positioning

It is essential for the infant to feed in the correct position and with an adequate latch.

While for some people the process of breastfeeding seems natural there is a level of skill required for successful feeding and a correct technique to use. Incorrect positioning is one of the main reasons for unsuccessful feeding and can easily cause pain in the nipple or breast. By stroking the baby's cheek with the nipple the baby will open its mouth and turn toward the nipple, which should then be pushed in so that the baby has a mouthful of nipple and areola; the nipple should be at the back of the baby's throat. Achievement of this position is referred to as latching on. Inverted or flat nipples can be massaged to give extra area for the baby to latch onto. Many women choose to wear a nursing bra to allow easier access to the breast than normal bras.

The baby may pull away from the nipple after a few minutes or after a much longer period of time. Sometimes the baby will re-latch on the same breast or mother may offer the other side.

The length of feeding is quite variable. Regardless of the duration, it is important for the breastfeeding woman to be comfortable.

• Upright: The sitting position with the back straight
• Mobile: The mother carries her nursling in a sling or other baby carrier while breastfeeding. Doing so permits the mother to incorporate breastfeeding into the varied work of daily life
• Lying down: Good for night feeds or for those who have had a caesarean section
  • On her back: Mother is usually sitting slightly upright; particularly useful for tandem breastfeeding
  • On her side: The mother and baby lie on their sides
• Hands and knees: The mother is on all fours with the baby underneath her (not usually recommended)

There are many positions and ways in which the feeding infant can be held. This depends upon the comfort of the mother and child and the feeding preference of the baby – some babies tend to prefer one breast to another. Most women breastfeed their child in the cradling position.

• Cradling positions:
  • Cradle hold: The baby is held with its head in the woman's elbow horizontally across the abdomen, "tummy to tummy", with the woman in an upright and supported position [10]
  • Cross-cradle hold: As above but the baby is held with its head in the woman's hand
• Football hold: The woman is upright and the baby is held securely under the mother's arm with the head cradled in her hands.This position is especially useful for feeding twins simultaneously [11]
• Feeding up hill: The baby lies stomach to stomach with the mother who is lying on her back; this is helpful for babies finding it difficult to feed
• Lying down:
  • On its side: The mother and baby lie on their sides
  • On its back: The baby is lying on its back (cushioned by something soft) with the mother on her hands and knees above the child (not usually recommended)

When tandem breastfeeding the mother is unable to move the baby from one breast to another and comfort can be more of an issue. This brings extra strain to the arms, especially as the babies grow, and many mothers of twins recommend the use of more supporting pillows. Favoured positions include:

• Double cradle hold
• Double clutch hold [12]
• One clutched baby and one cradled baby
• Lying down

Breast and nipple pain

Breastfeeding may hurt some women. Sometimes this is related to an incorrect technique, but it usually eases over time. Milk ducts can block up on occasion, leading to breast engorgement or mastitis, and should be addressed with massage and by encouraging the baby to suck from that side to keep it as empty as possible until the problem goes away. The presence of thrush in the nipples can also be painful. Limiting feeding time does not prevent soreness.

Cracked nipples can happen to anyone whose baby is not positioned correctly. The baby's rough tongue can also cause grazes and the suction can cause bruising if the mother and baby have not learned to latch and unlatch. To break the suction, mothers should wait for the baby to come off the breast, insert a finger just inside the baby's mouth, or press down gently on the breast. The use of nursing pads or tight bras can lead to breast and nipple pain, as can hair dryers, sun lamps, soap, alcohol, perfume, deodorant, hair spray, body powder and incorrect use of breast pumps. Bottles and nipple shields may change the way the baby sucks, as well.

Some mothers apply medical grade lanolin to sooth nipples; La Leche League International has endorsed Lansinoh, an ultra pure medical grade lanolin cream designed for breastfeeding mothers. Mothers can also express milk and rub it on the nipples.[13] After six weeks of breastfeeding, the process usually becomes easier, as both mother and baby learn the best technique. Mothers can also buy or rent breast pumps to extract the milk, if nipple pain becomes unbearable. It should be noted, however, that pumping breast milk can also be associated with nipple pain, and is best used only as a temporary solution while the most common culprit, a poor latch, is improved.

Nipple damage due to breastfeeding can increase the likelihood of a Candidiasis infection. If a baby develops symptoms of oral thrush, both the mother and the child must be treated at the same time.[14] Proper antifungal treatment will help neutralise the infection and aid in the nipple healing process.

Exclusive breastfeeding

International guidelines recommend that all infants be breastfed exclusively for the first six months of life. Each country has its own policy regarding infant feeding, but it is universally accepted that newborns should be exclusively breastfed for around 4–6 months. The practice of exclusive breastfeeding has dramatically reduced infant mortality in developing countries due to a reduction in diarrhea and infectious diseases.

Weaning

Weaning is the process of gradually introducing the infant to what will be its adult diet and withdrawing the supply of milk. The infant is considered to be fully weaned once it no longer receives any breast milk and begins to rely on solid foods for all its nutrition. Most mammals cease the production of the enzyme lactase at the end of weaning, becoming lactose intolerant. Many humans have a mutation that allows the production of lactase throughout life and can drink milk well beyond the age of weaning. ^[15] Typically, this milk comes from domesticated animals.

In the past, bromocriptine was sometimes used to reduce the engorgement experienced by many women during weaning. However, it was discovered that when used for this purpose, this medication posed serious health risks to women, such as stroke, and the U.S. FDA withdrew this indication for the drug. ^[16]

History of breastfeeding

An early 20^th century Korean woman wearing traditional breastfeeding clothing.

Two early 20^th century Korean women feeding their babies while working.

In the early years of the human species, breastfeeding was as common as it was for other mammals feeding their young. There were no alternative foods for the infants, and the mother, along with other lactating females, would have no choice but to breastfeed the children. This process is still seen in many developing countries and is known as shared breastfeeding.

The Egyptian, Greek and Roman empires saw women only feeding their own children. However, breastfeeding began to be seen as something too common to be done by royalty, and wet nurses were employed to breastfeed the children of the royal families. This was extended over the ages, particularly in western Europe, and saw women of noble birth (or who married into nobility) making use of wet nurses.

According to some Brahminical literature, breastfeeding in 2^nd century India was commonly practised but not until the fifth day, allowing the colostrum to be discarded and the true breast milk to flow.

Developing alternatives

Alternatives first became popular in the late 15^th century with many parents substituting cow or goat's milk for their own breast milk. This was particularly necessary for those families working the land whereby time could not easily be taken out to regularly breastfeed the child. Such trends soon faded when the problems associated with these milks started to show, and by the mid to late 16^th century breastfeeding once again became the preferred feeding method for most families.^{[citation needed]} The Italian Hieronymus Mercurialis wrote in 1583 that women generally finished breastfeeding an infant exclusively after the third month and entirely after around 13 months.

The feeding of flour or cereal mixed with broth or water, became the next alternative in the 19^th century but once again quickly faded. Around this time there became an obvious disparity in the feeding habits of those living in rural areas and those in urban areas. Most likely due to the availability of alternative foods, babies in urban areas were breastfed for a much shorter length of time, supplementing the feeds earlier than those in rural areas.

Though first developed by Henri Nestlé in the 1860s, infant formula received a huge boost during the post World War II "Baby Boom". The aggressive marketing campaigns when business and births decreased saw Nestlé and other such companies focus on non-industrialised countries, while government strategies in industrialised countries attempted to highlight the benefits of breastfeeding.

Breastfeeding in Japan

Traditionally, Japanese babies were born at home and breastfed with the help of breast massage. Weaning was often late, with breastfeeding in rare cases continuing until early adolescence. After World War II Western medicine was taken to Japan and the women began giving birth in hospitals, where the baby was usually taken to the nursery and fed formula. In 1974 a new breastfeeding promotion by the government helped to boost the awareness of its benefits and the uptake has sharply increased. Japan became the first developed country to have a Baby-friendly hospital (and as of 2006 has another 24 such facilities). ^{[citation needed]}

Breastfeeding in Canada

A 1994 Canadian government health survey found that 73% of Canadian mothers initiated breastfeeding, up from 38% in 1963. It has been speculated that the gap between breastfeeding generations in Canada contributes to lack of success of those who do attempt it: new parents cannot look to older family members for help with breastfeeding since they are also ignorant on the topic. [17] Western Canadians are more likely to breastfeed; just 53% of Atlantic province mothers breastfeed, compared to 87% in British Columbia. More than 90% of women surveyed said they breastfeed because it provides more benefits for the baby than does formula. Of women who did not breastfeed, 40% said formula feeding was easier (the most prevalent answer). Women who were older, more educated, had higher income, and were married were the most likely to breastfeed. Immigrant women were also more likely to breastfeed. About 40% of mothers who breastfeed do so for less than three months. Women were most likely to discontinue breastfeeding if they perceived themselves to have insufficient milk. However, among women who breastfed for more than three months, returning to work or a previous decision to stop at that time were the top reasons.

A 2003 La Leche League International study found that 72% of Canadian mothers initiate breastfeeding and that 31% continue to do so past four to five months. [18]

A 1996 article in the Canadian Journal of Public Health found that, in Vancouver, 82.9% of mothers initiated breastfeeding, but that this differed by Caucasian (91.6%) and non-Caucasian (56.8%) women. [19] The article reported that just 18.2% of mothers breastfeed at nine months, and that breastfeeding practices were significantly associated with the mothers' marital status, education and family income.

Typically, if a baby is born in a hospital in Canada, the mother will be given coupons for free formula "just in case" she has any problems breastfeeding.^{[citation needed]}

Breastfeeding in Cuba

Since 1940, Cuba's constitution has contained a provision officially recognising and supporting breastfeeding. Article 68 of the 1975 constitution reads, in part:During the six weeks immediately preceding childbirth and the six weeks following, a woman shall enjoy obligatory vacation from work on pay at the same rate, retaining her employment and all the rights pertaining to such employment and to her labour contract. During the nursing period, two extraordinary daily rest periods of a half hour each shall be allowed her to feed her child.

Publicity, promotion and law

Actress Lucy Lawless in a promotional poster for World Breastfeeding Week.

In response to public pressure, the health departments of various governments have recognised the importance of encouraging women to breastfeed. The required provision of baby changing facilities was a large step towards making places more accessible for parents and in many countries there are now laws in place to protect the rights of a breastfeeding mother when feeding her child in public.

The World Health Organization (WHO), along with grassroots non-governmental organisations like the International Baby Food Action Network (IBFAN) have played a large role in encouraging these governmental departments to promote breastfeeding. Under this advice they have developed national breastfeeding strategies, including the promotion of its benefits and attempts to encourage mothers, particularly those under the age of 25, to choose to feed their child with breast milk.

Government campaigns and strategies around the world include:

• National Breastfeeding Week in the UK
• The Department of Health and Ageing Breastfeeding Strategy in Australia
• The National Women's Health Information Center in the U.S.
• La Leche League International, a volunteer mother-to-mother international group
• World Breastfeeding Week

However, there has been a long, ongoing struggle between corporations promoting artificial substitutes and grassroots organisations and WHO promoting breastfeeding. The International Code of Marketing of Breast-milk Substitutes was developed in 1981 by WHO, but violations have been reported by organisations, including those networked in IBFAN. In particular, Nestlé took three years before it initially implemented the code, and in the late 1990s and early 2000s was again found in violation. Nestlé had previously faced a boycott, beginning in the U.S. but soon spreading through the rest of the world, for marketing practices in the third world (see Nestlé boycott).

Developing nations

In many countries, particularly those with a generally poor level of health, malnutrition is the majority cause of death in children under 5, with 60% of all those cases being within the first year of life [20]. International organisations such as Plan International and La Leche League have helped to promote breastfeeding around the world, educating new mothers and helping the governments to develop strategies to increase the number of women exclusively breastfeeding.

Traditional beliefs in many developing countries give different advice to women raising their newborn child. In Ghana babies are still frequently fed with tea alongside breastfeeding [21]. This reduces the benefits of exclusive breastfeeding and the drink can inhibit the absorption of iron, important in the prevention of anaemia.

Breastfeeding in public

When in public with a breastfed baby it is often difficult to avoid the need to feed the infant. Therefore legal and social rules regarding indecent exposure and dress code, as well as inhibitions of the woman, tend to be relaxed for this situation. There are numerous laws around the world that have made public breastfeeding legal and disallow companies from prohibiting it in the workplace. Yet, the public reaction at the sight of breastfeeding can make the situation uncomfortable for those involved.

USA

In the U.S. an appropriations bill (H.R.2490) with a breastfeeding amendment (H.AMDT.295 to H.R.2490) was signed into law on September 29, 1999 affirming the right of a woman to breastfeed her child anywhere on federal property. However, not all state laws have affirmed the same right in their respective public places. Recent attempts to codify a child's right to nurse found success in Ohio, but failed in West Virginia and some other states. By June 2005, 35 states had enacted legislation to protect breastfeeding mothers and their children. Laws protecting the right to nurse aim to change attitudes and promote increased incidence and duration of breastfeeding. Nowhere is breastfeeding in public illegal.

In November 2006, Emily Gillette, a 27-year-old from Santa Fe, N.M. was forced off a Freedom Airlines flight by a flight attendant who said she was offended by the breastfeeding mother.

UK

A survey reported by the UK Department of Health stated that most people (84%) find breastfeeding in public acceptable as long as it is done discreetly [22]. Contrastingly, 67% of mothers are worried about general opinion being against public breastfeeding. To combat these fears in Scotland, a bill [23] (pdf) safeguarding the freedom of women to breastfeed in public has been passed [24] in the Scottish Parliament [25]. The legislation sets up a fine of up to £2500 for preventing breastfeeding in legally permitted places.

Canada

In Canada, the Canadian Charter of Rights and Freedoms affords some protection under sex equality. Although Canadian human rights protection does not explicitly include breastfeeding, a 1989 Supreme Court of Canada decision (Brooks v. Canadian Safeway Ltd.) set the precedent for pregnancy as a condition unique to women and that thus discrimination on the basis of pregnancy is a form of sex discrimination. Canadian legal precedent also allows women the right to bare their breasts, just as men may. In British Columbia, the British Columbia Human Rights Commission Policy and Procedures Manual protects the rights of female workers who wish to breastfeed.

Cultural conflicts

When a Peruvian immigrant in the USA exposed her breast to feed her baby, and a photo was taken of the act, American police forces briefly considered it to be sexual abuse and production of child pornography, resulting in the mother's arrest and the seizure of her children:

Victor Jaeger...says he was prepared to testify on the couple's behalf and explain what appears to him to have been a cultural misunderstanding. Jaeger, who grew up in Peru, says breast-feeding is culturally important in his native country and considered acceptable to do in public, particularly in the country's jungle regions. "My cousin sent me a picture of her newborn, and it was of the baby being breast-fed," he says. "As someone who has lived here for 20 years, I asked myself, 'Why did she send me that picture?' To her, it was nothing."

1-Hour Arrest, Thomas Korosec, Dallas Observer, Apr 17, 2003

Recent global uptake

The following table shows the uptake of exclusive breastfeeding. Sources: WHO Global Data Bank on Breastfeeding and UNICEF Global Database Breastfeeding Indicators

Lactation without pregnancy

Although it is not widely known in developed countries, women who have never been pregnant are sometimes able to stimulate lactation sufficient to breastfeed. This is called "induced lactation", while a woman who has lactated before and re-starts is said to "relactate". If the nipples are stimulated as in breastfeeding for a while (such as by a breast pump or actual suckling), eventually the breasts will begin to produce milk which can be used to feed a baby. Once established, lactation adjusts to demand. For this reason, adoptive mothers, usually initially in conjunction with some form of supplementation, such as a supplemental nursing system, are able to breastfeed their infants and young children [27]. There is thought to be little or no difference in milk composition whether lactation is induced or a result of pregnancy. Rare accounts of male lactation (as distinct from galactorrhea) exist in the medical literature.

Some couples may choose to induce lactation as a sexual practice.

Additionally, some drugs, primarily atypical antipsychotics such as Risperdal, may cause lactation in both women and men.

See also

• Attachment parenting
• Baby-friendly hospital
• Continuum concept
• Lactation
• List of child related articles
• Erotic lactation
• Parenting
• Roman Charity
• Topfree equality
• Breast milk
• Breast pump
• Baby-led weaning

References

Numbered references

Unnumbered references

Other well-known authors on breastfeeding

• Arlene Eisenberg
• Hale Thomas (Medications in Mothers Milk)
• Sheila Kitzinger
• Doula
• La Leche League International
• Ruth A. Lawrence, M.D.
• Francesca Naish & Janette Roberts
• Miriam Stoppard
• Kathy Dettwyler
• Dr Jack Newman

Website references

• American Academy of Pediatrics Policy Statement on Breastfeeding
• 4woman.gov – US Department of Health & Human Services Breastfeeding resource page
• Breastfeeding NHS – UK NHS Breastfeeding strategy
• Royal Australasian College of Physicians Paediatric Policy: Brreastfeeding
• ADC Online journals
• American Family Physician Initial Management of Breastfeeding by Keith Sinusas and Amy Galgliardi
• Linkages Project Benefits of Breastfeeding USAID Program
• Benefits of breastfeeding United States Breastfeeding Committee
• Breastfeeding is Priceless No Substitute for Human Milk Coalition for Improving Maternity Services
• Breastfeed-essentials.com
• Plan International
• La Leche League International – An international organisation whose mission is to help mothers worldwide to breastfeed through mother-to-mother support, encouragement, information, and education and to promote a better understanding of breastfeeding as an important element in the healthy development of the baby and mother
• WhyQuit.com – Anti-smoking site with numerous links in the "Known Breastfeeding Risk Factors" section
• Mama's Baby: Happy, Healthy and Breastfed Black Women's health Imperative
• The Adoptive Breastfeeding Resource Website
• Weaning Diary

Infant pain and breastfeeding

• American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health; Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001 Sep;108(3):793-7.
• Howard CR, Howard FM, Weitzman ML. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics. 1994;93(4):641-6.
• The Womanly Art of Breastfeeding, Third Edition, July 1981. Pages 92-93 Elective Surgery for you or baby
• See also the section on circumcision and breastfeeding in Medical analysis of circumcision

Health risks of formula feeding

• Health risks of not breastfeeding US Department of Health & Human Services
• The Risks of Infant Formula Feeding breastfeeding task force of greater Los Angeles
• Breastfeeding and the Risk of Postneonatal Death in the United States Pediatrics, Vol. 113 No. 5 May 2004 & resulting correspondence
• Supplementation of the Breastfed Baby "Just One Bottle Won't Hurt" ...or Will It? by Marsha Walker RN IBCLC (National Alliance for Breastfeeding Advocacy)
• Salon.com Formula for disaster by Katie Allison Granju
• What should I know about infant formula? Kellymom.com (contains links to other websites)
• National Alliance for Breastfeeding Advocacy contains links to other articles including:
• Contaminents in Infant Formula
• Recalls of Infant Feeding Products
• Antidepressants, Antipsychotics, Benzodiazepines, and the Breastfeeding Dyad Perspectives in Psychiatric Care, Apr-Jun 2004, by Kirsten J. Malone This article discusses the risks to both mother and child of formula feeding and attempts to weigh them against the risk to infants of absorbing psychotropic druge through breastmilk.

External links

• Breastfeeding: A Guide for the Medical Profession by Ruth A. Lawrence and Robert Lawrence - The most up-to-date (6th edition, 2005) , authoritative, evidence-based reference book on breastfeeding
• Australian Breastfeeding Association — Informative website and forum
• Baby Milk Action — Supports mothers' rights to breastfeed