Please note that some guidelines may be passed their review date. The review process is currently paused. It is recommended that you also refer to more contemporaneous evidence.
The many benefits of breastfeeding and breast milk are well known. Breast milk is a unique 'living' fluid. It contains:
- anti-infective factors
- hormones
- enzymes
- specialised growth factors
- anti-inflammatory mediators
- specific nutrients.
Preterm infants fed with breast milk have significantly reduced rates of sepsis and necrotising enterocolitis compared with infants fed breast milk substitutes. Colostrum is a high density low-volume feed high in immunoglobulins, which evolves into mature milk between three and 14 days postpartum. The Innocenti Declaration (WHO/UNICEF, 1990) recognised that breastfeeding is a unique process that provides ideal nutrition for infants and contributes to their healthy growth and development. The Paediatrics and Child Health Division of the Royal Australasian College of Physicians also encourages and supports the promotion of breastfeeding.
Australia is signatory to the World Health Organization's International code of marketing of breast milk substitutes (1981), which aims to contribute to the provision of safe and adequate nutrition for infants by protecting and promoting breastfeeding and by ensuring the proper use of breast milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.
Some facts about breast milk and neonatal care:
- Breast milk is the milk of first choice in neonates, whether term or preterm.
- There are significant clinical benefits to providing breast milk in the preterm infant.
- Expressed breast milk can be frozen for later use.
- Human milk fortification should be considered in babies with a birth weight of < 2000 g.
- Very few maternal medications contraindicate breastfeeding.
- Maternal hepatitis C does not preclude breastfeeding (unless nipples are cracked).
Initiation and maintenance of breast milk supply
Expressing for a preterm or unwell baby requires commitment by the mother and effective support from staff. Strategies to assist in establishing and maintaining an adequate breast milk supply when the infant cannot breastfeed include the following:
- Commence breast milk expression as soon as possible after birth and at least within the first six hours, followed by frequent, regular and effective breast milk expression to stimulate adequate breast milk production.
- Initially, it is recommended to express at least eight times in 24 hours, with at least one expression overnight.
- Once the supply is well established (usually not for at least two weeks) some women can reduce the frequency of expressing to six to eight times in 24 hours but should continue at least one expression overnight.
- Hand expression is preferable in the first day or two and then the use of a hospital grade electric breastpump is recommended for full-time expressing.
- Simultaneous breast milk expression (double pumping) may enhance milk production and saves time, therefore it should be recommended for any mother who will be expressing for longer than a few days.
- Expressing at the cot side is preferable if this is impractical, a comfortable and private space should be available in the nursery.
- Encourage and facilitate early, frequent and extended skin-to-skin care (also known as 'kangaroo care': the practice of mother holding her baby skin-to-skin between her breasts). Skin-to-skin care promotes the development and maturation of infant feeding behaviours and enhances breast milk production. The close contact also triggers the enteromammary pathway by which a mother produces antibodies in response to antigens in the infant's environment.
If breast milk supply is low, review technique and frequency of expression and assess any other contributing factors before commencing galactagogues.
Storage of breast milk
Guidelines for collecting and storing breast milk are more stringent for sick and preterm babies than for healthy babies at home. Facts to note:
- Use of sterilised containers is recommended.
- Use of freshly expressed breast milk is optimal.
- Refrigeration at 4°C for 48 hours results in minimal loss of nutrients and bacterial count is reduced.
- Freshly expressed breast milk should be chilled in a refrigerator before adding to frozen milk.
- Thaw breast milk by placing in cool or warm water.
- Thawed breast milk should be used within 24 hours.
- Never refreeze or re-warm breast milk.
See: NHMRC Infant Feeding Guidelines for Health workers
How long you can store milk in various conditions
| Breast milk | Room temperature | Refrigerator | Freezer |
|---|---|---|---|
| Freshly expressed into closed container | 6-8 hours (26°C ) If refrigeration is available store milk there. | No more than 72 hours Store in back of refrigerator where it is coldest. | 2 weeks in freezer compartment inside a refrigerator. 3 months in freezer section of refrigerator with separate door. 6-12 months in deep freeze (-18°C). |
| Previously frozen - thawed in refrigerator but not warmed | 4 hours or less i.e. next feeding | Store in refrigerator 24 hours. | Do not refreeze. |
| Thawed outside refrigerator in warm water. | For completion of feeding. | Hold for 4 hours or until next feeding. | Do not refreeze. |
| Infant has begun feeding. | Only for completion of feeding then discard. | Discard. | Do not refreeze. Discard. |
Skin-to-skin contact and transitioning to breastfeeding
Skin-to-skin contact (SSC) has been shown to have statistically significant and positive effects on the initiation, duration and exclusivity of breastfeeding. SSC enhances breast milk production, infant physiological stability, growth, maturation and development. Studies have shown that preterm infants show greater cardiorespiratory stability when breastfeeding than bottle feeding.
Initiation of SSC requires individualised assessment of infant readiness but can be safely initiated for stable infants from 28 weeks' gestation or from birthweight of 600 g. Once infant stability is achieved, SSC can be frequent and prolonged without unjustified restrictions (Nyqvist et al. 2013).
SSC is a good introduction to breastfeeding for the preterm or unwell infant. During SSC, some infants may search for the breast and exhibit nutritive sucking behaviour from as early as 28 weeks' gestation. By 32 weeks there is coordination of sucking and swallowing, but this is often not sustained until closer to term.
There may be wide variation in the attainment of breastfeeding competence in preterm infants that is enhanced by frequent and prolonged SSC, opportunities for breast contact and non-nutritive sucking (Nyqvist 2008). Breast contact and breastfeeding can be initiated without limitations when the infant is medically stable and exhibiting signs of readiness to suck regardless of gestational age and weight (Nyqvist et al. 2013).
Controversy exists over the use of artificial teats and pacifiers and the issue of nipple confusion. Ultrasonography has shown that the sucking action used at the breast is different from that used for an artificial teat. For this reason the use of bottles and teats should be avoided while the infant is learning to breastfeed. Alternative methods of feeding expressed breast milk or supplementary formula include tube feeding, cup feeding, finger feeding and syringe feeding. Each method has advantages and disadvantages and assessment must be made of the capability of each infant and parental wishes when deciding which methods to use (Walker 2014).
Similarly controversy exists between the advantages of indwelling nasogastric feeding tubes and intermittent orogastric tube feeds.
Sandra Lang in her book Breastfeeding special care babies addresses these issues in depth.
Medicines and breastfeeding
The following information is a brief outline only regarding the use of medicines in breastfeeding. Advice regarding specific medicines and breastfeeding may differ if the infant is very preterm or very unwell and it is recommended that clinicians seek further information from a health professional with expertise in this area such as a pharmacist and/or lactation consultant. Drug companies are usually very cautious in their recommendations of safety of medicines for a breastfed infant. Specialist advice about maternal medications including the use of galactagogues can be obtained from
Royal Women’s Hospital Medicines Information Line
Specialist information on the use of medicines during pregnancy and breastfeeding. Ph: 8345 3190 Monday to Friday 0830-1700
Monash Health Drug Information Centre
Specialises in medicines for children, during pregnancy and breastfeeding and for women's health. Ph: 9594 2361 Monday to Friday 0900-1700
Lactmed Online Database for Medicines and Lactation
Royal Women’s Hospital Breastfeeding Service
Ph: 8345 2400 Monday - Friday 0830-1630
Galactagogues
Galactagogues are substances that stimulate the production of breast milk. Galactagogues should only be prescribed after a complete assessment of expressing and breastfeeding and implementation of appropriate management to increase supply. Both pharmacological and herbal preparations are available published evidence supportive of herbal preparations is limited. Fenugreek is the most widely recognised; however, there is no data regarding transmission in breast milk or safety for preterm infants.
Domperidone (Motilium)
Domperidone (Motilium®) is a peripheral dopamine antagonist. It increases prolactin levels, and has been used as a first-line galactagogue. Domperidone does not cross the blood-brain barrier and appears to have fewer side effects in breastfeeding women than Metoclopramide.
Points to note:
- The recommended initial and maintenance dose is 10 mg TDS. If this is not effective, higher doses can be prescribed but specialist advice should be sought first.
- Domperidone is contraindicated with concurrent use of ketaconazole, erythromycin or other CYP3A4 inhibitors which prolong the QT interval such as fluconazole, voriconazole, clarithromycin and amiodarone.
- Domperidone in high doses is known to prolong the QT interval of the heart in some patients, including babies. Doses should be kept to less than 10-20 mg three to four times and day and should not be used in patients with pre-existing prolonged QT interval.
- Domperidone is generally well tolerated by most mothers as a long-term galactogogue.
- Women are usually advised to slowly taper off the medication once an adequate supply has been established to minimise the risk of rebound low supply, although there is little evidence to support this practice.
Metoclopramide (Maxalon)
Metoclopramide (Maxolon®, Pramin®) is a central dopamine antagonist that increases prolactin levels and has been commonly used as a galactagogue. Breastfeeding women taking metoclopramide may experience symptoms such as depression or drowsiness. For this reason, domperidone is the preferred galactogogue. Metoclopramide can be used as an alternative to domperidone when this is contraindicated; for example due to allergic reaction, concurrent use of other medications or prolonged QT interval.
Points to note:
- The recommended initial and maintenance dose is 10 mg TDS.
- Women are usually advised to slowly taper off the medication once an adequate supply has been established to minimise the risk of rebound low supply, although there is little evidence to support this practice.
Maternal medications
Most medications are compatible with breastfeeding with few contraindications.
Absolutely contraindicated:
- chemotherapeutic agents
- radioactive drugs.
Relatively contraindicated:
- lithium
- citalopram
- cyclosporin.
Most psychoactive medications are now generally considered compatible with breastfeeding, although dosage needs to be considered. Infants should always be carefully monitored for effects of sedation when their mother is using psychoactive drugs.
Drugs of addiction
Drug related risks to be aware of:
- Methadone passes in small quantities into breast milk and generally the benefits of breast milk overcome the disadvantages. In situations of very high maternal dosage (for example, 90 mg daily) the infant is at risk of sedation.
- Buprenorphine is a long-acting narcotic agonist and antagonist used to replace methadone in opiate addicts. Little information is available regarding the pharmacology of this drug in lactation. Sedative effects are of concern.
- Marijuana passes into breast milk and the relative dose is concentrated. Infants are at risk of sedation, feeding difficulties and poor weight gain.
Herbal preparations
Scientific data about the effects of herbal preparations on breastfeeding and breast milk is limited. Given the variability in standards of preparation of herbal supplements it is recommended that breastfeeding mothers avoid such products.
Prematurity and breast milk
Preterm breast milk differs from term milk, not only in nutritional composition but also in immuno-protective factors. There are higher levels of proteins, lipids, calories, sodium, chloride, magnesium and iron. These differences persist for at least the first four weeks of lactation. Breast milk may not meet the increased nutritional demands of the preterm infant whose birthweight is below 2000 g. These needs persist to term postmenstrual age. There is considerable variation in the energy content of expressed breast milk largely due to separation of the fat whilst standing. Use of hindmilk, with two to three times greater fat content than foremilk, will provide significantly more energy for growth. The content of protein and sodium declines throughout lactation. Calcium and phosphorous content is also insufficient for the growing preterm infant.
Human milk fortifier
Breast milk can be supplemented by combining it with a commercially prepared fortifier to provide increased protein, energy and minerals. All human milk fortifiers contain similar amounts of protein, energy, calcium and phosphorous. The differences relate to the type of protein and the amounts of lactose, sodium and vitamins. Infants with a birth weight of less than 2,000 g will benefit from addition of a fortifier once tolerating 120 mL/kg/ day. This should continue until the infant is over 2,000 g or at medical staff discretion. Breast milk fortifier is often commenced at half strength for two days and if tolerated full strength fortifier is introduced. However, there are a number of potential complications with fortification. These include:
- an increase in regurgitation
- an increase in feed intolerance
- glycosuria in extremely of preterm infants
- hypercalcemia in extremely preterm infants.
As the fortifier is usually cow's milk-based, there is a theoretical advantage in using a product in which the protein has been hydrolysed. Infants fed fortified human milk receive less volume, but greater intakes of protein and minerals and experience greater weight gain and incremental linear growth than infants fed unfortified milk. In general, fortifier can be discontinued once the infant reaches a corrected age of term and prior to discharge from hospital.
Breast milk substitutes
When there is insufficient breast milk available for infants tolerating enteral feeds, infant formula may be required.
Parents should be informed of the medical need for supplemental formula feeds and should provide either written or verbal consent for its use. Efforts should be made to increase breast milk supply when supplemental formula use is required.
Standard 20 cal newborn formula should be used for infants with a birth weight > 2,000 g. Infants < 2,000 g should have 20 cal formula for the first week of life or until tolerating 120 mL/kg/day, then commenced on preterm formula (24 cal) until the infant is over 2,000 g or at medical staff discretion. The use of partially hydrolysed formula for supplementation of breastfed infants at high risk of allergic disease is controversial and evidence for its routine use is conflicting (Lowe et al. 2011).
Donor breastmilk
Some parents will request the use of donor breast milk for supplementation until the mother's own breast milk supply is adequate.
In Victoria, only the Mercy Hospital for Women has a breast milk bank but it is not able to supply donor breast milk to other hospitals at present.
The use of unpasteurised and unscreened donor breast milk is not recommended due to risk of transmission of infections, particularly viral. Where parents request the use of donor breast milk from a friend or relative for example, screening for infections is recommended before it is used. Purchasing breast milk from the internet from unknown donors should be actively discouraged.
Protocols should exist to guide screening and use of donor breast milk where requested by parents. The Royal Women's Hospital and Ballarat Health Services have protocols for the use of donor human milk.
Infections
Bacterial infections almost never transmit through breast milk. Some points about infection and breast milk:
- Maternal HIV is the only infection in which breastfeeding is contraindicated in the developed world.
- Hepatitis C has been reported to have a 5 per cent risk of transmission. Most probably this occurs at times of active disease (PCR positive women). It is generally advised that HCV positive mothers do not breastfeed when nipples are cracked.
- Hepatitis B is not transmitted through breast milk.
- CMV is transmitted through breast milk. The burden of disease acquired from breast milk is not well established. It is presumed that preterm infants are more vulnerable and likely to exhibit more severe clinical illness, such as pneumonitis, than term infants. However women who are CMV positive are not discouraged from breastfeeding as the other benefits are thought to outweigh the risk.
- Herpes simplexis not transmitted through breast milk. Should there be an active lesion on the breast the mother should be advised to suspend feeding from that breast until the lesion is completely healed. The breast will need to be frequently expressed during this time to maintain lactation and the breast milk discarded.
- Varicella and herpes zoster (shingles) will transmit maternal antibodies through breast milk which will be protective. However in the case of varicella, if the mother develops chicken pox within five days of birth the infant is at risk and should be protected with VZV immunoglobulin. Breastfeeding can then continue, provided there are no lesions on or near the nipple.
Jaundice
Breastfed infants, particularly those who are preterm or unwell may be at increased risk of developing jaundice in the first few days after birth if their intake of breast milk is suboptimal.
In the preterm or unwell infant, ensuring at least eight feeds per 24 hours from birth results in significantly lower serum bilirubin levels on day 3. Increased number of feeds is associated with significantly greater daily milk intake, better elimination of meconium and thereby reduced entero-hepatic circulation of bilirubin.
Commencement of phototherapy is an indication to review breastfeeding frequency and technique. Supplemental formula feeds should only be introduced if there is insufficient breast milk supply or ensure adequate nutrition and hydration during phototherapy.
Preferably mothers will be encouraged to breastfeed more frequently, express after feeding and top up their babies with their own milk rather than formula. Excessive use of formula reduces the infant’s interest in breastfeeding, leading to reduced breast stimulation and drainage and subsequent reduced breast milk production.
See jaundice in newborns.
More information
References
- Lowe AJ et al. (2011)Effect of a partially hydrolyzed whey infant formula at weaning on risk of allergic disease in high-risk children: A randomized controlled trial. Volume 128, Issue 2, August 2011, Pages 360365.e4
- Nyqvist KH (2008) Early attainment of breastfeeding competence in very preterm infants. Acta Paediatrica 2008; 97(6), pp 776-781
- Nyqvist K et al (2013) Expansion of the baby-Friendly Hospital initiative Ten Steps to Successful Breastfeeding into neonatal Intensive Care: Expert Group Recommendations. Journal of Human lactation Volume 23: Number 3: August 2013 pp 300-309
- Walker M (2014) Chapter 4: Influence of Peripartum Factors, Birthing Practices and Early Caretaking Behaviours. Table 4-13 Strengths and Limitations of Selected Alternative Feeding Methods. In: Breastfeeding Management for the Clinician 3rd edition Jones and Bartlett Learning.
Clinical
- NHMRC Infant feeding guidelines for health workers
- Royal Womens Hospital Breastfeeding Service
- ACOG Practice bulletin (2008) - Use of psychiatric medications during pregnancy and lactation.
- WHO International code of marketing of breast-milk substitutes
- Breastfeeding online - Dr Jack Newman
Dr Newman is a Toronto paediatrician who established the first hospital based breastfeeding clinic in Canada. He provides informative parent hand-outs in addition to practical advice for clinicians
Further reading
- Hale T., Medications and Mother's Milk, 15th edition, 2012. Pharmasoft publishing, Texas
- Lawrence R. Breastfeeding: a guide for the medical profession. 7th edition
- Briggs G et al.(2011) Drugs in pregnancy and lactation. 6th edition Lippincott Williams and Wilkins.
- Lang S (2002) Breastfeeding Special Care Babies 2nd edition Bailliere Tindall
Helplines
- Royal Women's Drug Information. Tel. 9344 2000
- Monash Health Drug Information Centre. Tel. 95942361
- Mental Health Research Institute psychotropic drug information service. Phone: 9388 1633
Get in touch
Version history
First published: January 2014
Due for review: January 2017