Guideline sources The following summarized guidelines for the evaluation and management of breastfeeding are prepared by our editorial team based on guidelines from the American Academy of Pediatrics (AAP 2022), the American College of Obstetricians and Gynecologists (ACOG 2019; 2018), the American College of Radiology (ACR 2018), the U.S. Preventive Services Task Force (USPSTF 2016), and the Academy of Breastfeeding Medicine (ABM 2013). 1 3 4 5 6 10 15 15 16 17 Definition Breastfeeding is nursing a child with breast milk, which is recommended as the exclusive source of nutrition for the first six months of infants life. 15 Epidemiology The stages of lactation include mammogenesis (growth of breast tissue) and lactogenesis. 15 Disease course Breast milk contains antibodies, enzymes, and hormones and breastfeeding promote infants growth and neurodevelopment, and maternal health too. Breastfed infants have a decreased incidence of gastrointestinal infection, acute otitis media, hypertension, total cholesterol, pain during procedures, atopic dermatitis, asthma, respiratory tract infections, childhood obesity, type 1 and T2DM, leukemia, necrotizing enterocolitis in premature infants, and sudden infant death syndrome. https://web.pathway.md/diseases/rec3ZX5DH7sabgCR8 1/5 6/29/23, 3:21 AM Breastfeeding Pathway Breastfeeding mothers also have decreased incidence of breast cancer, postnatal depression, ovarian cancer, retained gestational weight, T2DM. 16 Prognosis and risk of recurrence Breastfeeding initiation is associated with a significant reduction in total infant mortality with OR 0.81 (95% CI 0.68-0.97). 17 Guidelines 1. Diagnostic investigations Considerations for diagnostic imaging: do not interrupt breastfeeding after gadolinium administration. D Considerations for cancer screening imaging: obtain digital breast tomosynthesis or mammography with minor modifications to address increased mammographic density, increased breast vascularity, and duration of lactation in lactating females. B 2. Nonpharmacologic interventions Duration of breastfeeding: As per AAP 2022 guidelines, encourage exclusive breastfeeding for about six months with complementary food introduction at about 6 months and continued breastfeeding until 2 years or beyond, as mutually desired by the mother and her child. E As per ACOG 2018 guidelines, encourage exclusive breastfeeding for the first 6 months of life, with continued breastfeeding as complementary foods are introduced during the infant's first year or longer, as mutually desired by the mother and her infant. E As per ABM 2013 guidelines: Encourage exclusive breastfeeding for 6 months with continued breastfeeding with complementary foods until at least 24 months and thereafter as long as mutually desired. B Discuss the introduction of solid food at 6 months of age, emphasizing the need for high-iron solids and advise supplementing vitamins, such as vitamin D, K, or A in accordance with published standards. B 3. Patient education Maternal counseling: As per USPSTF 2016 guidelines, offer interventions during pregnancy and after birth to support breastfeeding. B As per ABM 2013 guidelines, introduce the subject of infant feeding in the first trimester and continue to express support of breastfeeding throughout the course of the pregnancy if providing https://web.pathway.md/diseases/rec3ZX5DH7sabgCR8 2/5 6/29/23, 3:21 AM Breastfeeding Pathway antenatal care for the mother. Consider offering a prenatal visit to become acquainted with the family during which the commitment to breastfeeding can be shown. Use open-ended questions, such as "What have you heard about breastfeeding?," to inquire about a feeding plan for this child. Provide educational material that highlights the many ways in which breastfeeding is superior to formula feeding. Identify patients with lactation risk factors such as flat or inverted nipples, history of breast surgery, no increase in breast size during pregnancy, or previous unsuccessful breastfeeding experience to enable individual breastfeeding care for her particular situation. B 4. Follow-up and surveillance Follow-up assessment: in many areas of the world, the first follow-up visit will be done by non- physician healthcare workers. In most European countries midwives care for the mother and infant in the days and weeks after discharge from the hospital. Mothers contact their pediatrician within the first 3 weeks of delivery for the infant's first check-up, which is covered by insurance. In this system, this is the first opportunity the pediatrician has to support breastfeeding. In other countries, such as Australia and New Zealand, routine medical care of infants is undertaken by general practitioners (family physicians), and infants may never visit a pediatrician. In countries such as the United States, where the postpartum care of the mother and infant is done by physicians or physician extenders (such as physician assistants, nurse practitioners), schedule a first infant follow-up visit 48-72 hours after hospital discharge or earlier if breastfeeding-related problems, such as excessive weight loss of > 7% or jaundice, are present at the time of hospital discharge. 5. Quality improvement Coordinated care: as per ABM 2013 guidelines, establish a written breastfeeding-friendly office. Collaborate with colleagues and office staff during development. Inform all new staff about the policy. Provide copies of your practice's policy to hospitals, physicians, and all healthcare professionals covering your practice for you. B Policies: as per ABM 2013 guidelines, set an example for your patients and community. Consider having a written breastfeeding employee policy and provide a lactation room with supplies for your employees who breastfeed or express milk at work. B Clinician training: as per ABM 2013 guidelines, educate clinicians regarding breastfeeding, beginning in the preclinical years. Areas of suggested education include the risks of artificial feeding, the physiology of lactation, management of common breastfeeding problems, and medical contraindications to breastfeeding. Make educational resources available for quick reference by healthcare professionals. Provide staff education and training to all, including front office staff, nurses, and medical assistants. B References https://web.pathway.md/diseases/rec3ZX5DH7sabgCR8 3/5 6/29/23, 3:21 AM Breastfeeding Pathway 1. No authors listed. ACOG Committee Opinion No. 756 Optimizing Support for Breastfeeding as Part of Obstetric Practice. Obstet Gynecol. 2018 Oct;132 4):e187-e196. Open 2. Lisa E Graves, Magali Robert, Victoria M Allen et al. Guideline No. 425b: Cannabis Use Throughout Women's Lifespans Part 2 Pregnancy, the Postnatal Period, and Breastfeeding. J Obstet Gynaecol Can. 2022 Apr;44 4 436 444.e1. Open 3. Grawey AE, Marinelli KA, Holmes AV et al. ABM Clinical Protocol #14 Breastfeeding-friendly physician's office: optimizing care for infants and children, revised 2013. Breastfeed Med. 2013 Apr;8 237 42. Open 4. Expert Panel on Breast Imaging, Roberta M diFlorio-Alexander, Priscilla J Slanetz et al. ACR Appropriateness Criteria Breast Imaging of Pregnant and Lactating Women. J Am Coll Radiol. 2018 Nov;15 11S S263 S275. Open 5. Joan Younger Meek, Lawrence Noble, Section on Breastfeeding. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics. 2022 Jul 1;150 1):e2022057988. Open 6. Chirag Jain. ACOG Committee Opinion No. 723 Guidelines for Diagnostic Imaging During Pregnancy and Lactation. Obstet Gynecol. 2019 Jan;133 1 186. Open 7. No authors listed. Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services. Geneva: World Health Organization; 2017. Open 8. No authors listed. Breastfeeding Challenges: ACOG Committee Opinion, Number 820. Obstet Gynecol. 2021 Feb 1;137 2):e42-e53. Open 9. No authors listed. Guideline: Counselling of Women to Improve Breastfeeding Practices. Geneva: World Health Organization; 2018. Open 10. US Preventive Services Task Force, Kirsten Bibbins-Domingo, David C Grossman et al. Primary Care Interventions to Support Breastfeeding: US Preventive Services Task Force Recommendation Statement. JAMA. 2016 Oct 25;316 16 1688 1693. Open 11. No authors listed. Committee Opinion No. 722 Marijuana Use During Pregnancy and Lactation. Obstet Gynecol. 2017 Oct;130 4):e205-e209. Open 12. No authors listed. ACOG Committee Opinion No. 776 Immune Modulating Therapies in Pregnancy and Lactation. Obstet Gynecol. 2019 Apr;133 4):e287-e295. Open 13. No authors listed. Barriers to Breastfeeding: Supporting Initiation and Continuation of Breastfeeding: ACOG Committee Opinion Summary, Number 821. Obstet Gynecol. 2021 Feb 1;137 2 396 397. Open 14. J Mitchell, W Jones, E Winkley et al. Guideline on anaesthesia and sedation in breastfeeding women 2020 Guideline from the Association of Anaesthetists. Anaesthesia. 2020 Nov;75 11 1482 1493. Open 15. Christine M Dieterich, Julia P Felice, Elizabeth O'Sullivan et al. Breastfeeding and health outcomes for the mother-infant dyad. 2013 Feb;60 1 31 48.2013 Feb;60 1 31 48. Open 16. Pat Hoddinott, David Tappin, Charlotte Wright. Breast feeding. 2008 Apr 19;336 7649 881 7.2008 Apr 19;336 7649 881 7. Open 17. Julie L Ware, Aimin Chen, Ardythe L Morrow et al. Associations Between Breastfeeding Initiation and Infant Mortality in an Urban Population. 2019 Sep;14 7 465 474.2019 Sep;14 7 465 474. Open https://web.pathway.md/diseases/rec3ZX5DH7sabgCR8 4/5 6/29/23, 3:21 AM Breastfeeding Pathway 18. American Academy of Neurology. Choosing Wisely AAN recommendations. Choosing Wisely. 2016. Open 19. Pat Hoddinott, David Tappin, Charlotte Wright. Breast feeding. BMJ. 2008 Apr 19;336 7649 881 7. Open 20. Julie L Ware, Aimin Chen, Ardythe L Morrow et al. Associations Between Breastfeeding Initiation and Infant Mortality in an Urban Population. Breastfeed Med. 2019 Sep;14 7 465 474. Open 21. Shannon M Bates, Ian A Greer, Saskia Middeldorp et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141 2 Suppl):e691S-e736S. 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