1. Pediatricians and other health care professionals

should recommend human milk for all infants in

whom breastfeeding is not specifically contraindicated

and provide parents with complete, current

information on the benefits and techniques

of breastfeeding to ensure that their feeding decision

is a fully informed one.

• When direct breastfeeding is not possible, expressed

human milk should be provided.

If a known contraindication to breastfeeding

is identified, consider whether the

contraindication may be temporary, and if so,

advise pumping to maintain milk production.

Before advising against breastfeeding or recommending

premature weaning, weigh the

benefits of breastfeeding against the risks of

not receiving human milk.

2. Peripartum policies and practices that optimize

breastfeeding initiation and maintenance should

be encouraged.

• Education of both parents before and after

delivery of the infant is an essential component

of successful breastfeeding. Support and

encouragement by the father can greatly assist

the mother during the initiation process and

during subsequent periods when problems

arise. Consistent with appropriate care for the

mother, minimize or modify the course of maternal

medications that have the potential for

altering the infant’s alertness and feeding behavior.

Avoid procedures that may interfere

with breastfeeding or that may traumatize

the infant, including unnecessary, excessive, and

overvigorous suctioning of the oral cavity,

esophagus, and airways to avoid oropharyngeal

mucosal injury that may lead to aversive feeding

behavior.

3. Healthy infants should be placed and remain in

direct skin-to-skin contact with their mothers immediately

after delivery until the first feeding is

accomplished.

• The alert, healthy newborn infant is capable of

latching on to a breast without specific assistance

within the first hour after birth. Dry

the infant, assign Apgar scores, and perform

the initial physical assessment while the infant is with the mother. The mother is an optimal

heat source for the infant. Delay weighing,

measuring, bathing, needle-sticks, and

eye prophylaxis until after the first feeding is

completed. Infants affected by maternal medications

may require assistance for effective

latch-on. Except under unusual circumstances,

the newborn infant should remain

with the mother throughout the recovery period.

4. Supplements (water, glucose water, formula, and

other fluids) should not be given to breastfeeding

newborn infants unless ordered by a physician

when a medical indication exists.

5. Pacifier use is best avoided during the initiation

of breastfeeding and used only after breastfeeding

is well established.

• In some infants early pacifier use may interfere

with establishment of good breastfeeding practices,

whereas in others it may indicate the presence

of a breastfeeding problem that requires

intervention.

• This recommendation does not contraindicate

pacifier use for nonnutritive sucking and oral

training of premature infants and other special

care infants.

6. During the early weeks of breastfeeding, mothers

should be encouraged to have 8 to 12 feedings

at the breast every 24 hours, offering the

breast whenever the infant shows early signs of

hunger such as increased alertness, physical activity,

mouthing, or rooting.

• Crying is a late indicator of hunger. Appropriate

initiation of breastfeeding is facilitated

by continuous rooming-in throughout the day

and night. The mother should offer both

breasts at each feeding for as long a period as

the infant remains at the breast. At each

feed the first breast offered should be alternated

so that both breasts receive equal stimulation

and draining. In the early weeks after

birth, nondemanding infants should be

aroused to feed if 4 hours have elapsed since

the beginning of the last feeding.

• After breastfeeding is well established, the frequency

of feeding may decline to approximately

8 times per 24 hours, but the infant

may increase the frequency again with growth

spurts or when an increase in milk volume is

desired.

7. Formal evaluation of breastfeeding, including

observation of position, latch, and milk transfer,

should be undertaken by trained caregivers at least

twice daily and fully documented in the record

during each day in the hospital after birth.

• Encouraging the mother to record the time

and duration of each breastfeeding, as well as

urine and stool output during the early days

of breastfeeding in the hospital and the first

weeks at home, helps to facilitate the evaluation

process. Problems identified in the hospital

should be addressed at that time, and a

documented plan for management should be

clearly communicated to both parents and to

the medical home.

8. All breastfeeding newborn infants should be

seen by a pediatrician or other knowledgeable and

experienced health care professional at 3 to 5 days

of age as recommended by the AAP.

• This visit should include infant weight; physical

examination, especially for jaundice and

hydration; maternal history of breast problems

(painful feedings, engorgement); infant elimination

patterns (expect 3–5 urines and 3–4

stools per day by 3–5 days of age; 4–6 urines

and 3–6 stools per day by 5–7 days of age);

and a formal, observed evaluation of breastfeeding,

including position, latch, and milk

transfer. Weight loss in the infant of greater

than 7% from birth weight indicates possible

breastfeeding problems and requires more intensive

evaluation of breastfeeding and possible

intervention to correct problems and improve

milk production and transfer.

9. Breastfeeding infants should have a second ambulatory

visit at 2 to 3 weeks of age so that the

health care professional can monitor weight gain

and provide additional support and encouragement

to the mother during this critical period.

10. Pediatricians and parents should be aware that

exclusive breastfeeding is sufficient to support

optimal growth and development for approximately

the first 6 months of life and provides

continuing protection against diarrhea and respiratory

tract infection. Breastfeeding

should be continued for at least the first year of

life and beyond for as long as mutually desired

by mother and child.

• Complementary foods rich in iron should be

introduced gradually beginning around 6

months of age. Preterm and low birth

weight infants and infants with hematologic

disorders or infants who had inadequate iron

stores at birth generally require iron supplementation

before 6 months of age.

Iron may be administered while continuing

exclusive breastfeeding.

• Unique needs or feeding behaviors of individual

infants may indicate a need for introduction

of complementary foods as early as 4

months of age, whereas other infants may not

be ready to accept other foods until approximately

8 months of age.

• Introduction of complementary feedings before

6 months of age generally does not increase

total caloric intake or rate of growth

and only substitutes foods that lack the protective

components of human milk.

• During the first 6 months of age, even in hot

climates, water and juice are unnecessary for

breastfed infants and may introduce contaminants

or allergens.

• Increased duration of breastfeeding confers

significant health and developmental benefits

for the child and the mother, especially in

delaying return of fertility (thereby promoting

optimal intervals between births).

• There is no upper limit to the duration of

breastfeeding and no evidence of psychologic

or developmental harm from breastfeeding

into the third year of life or longer.

• Infants weaned before 12 months of age

should not receive cow’s milk but should receive

iron-fortified infant formula.

11. All breastfed infants should receive 1.0 mg of

vitamin K1 oxide intramuscularly after the first

feeding is completed and within the first 6 hours

of life.

• Oral vitamin K is not recommended. It may

not provide the adequate stores of vitamin K

necessary to prevent hemorrhage later in infancy

in breastfed infants unless repeated

doses are administered during the first 4

months of life.

12. All breastfed infants should receive 200 IU of

oral vitamin D drops daily beginning during the

first 2 months of life and continuing until the

daily consumption of vitamin D-fortified formula

or milk is 500 mL.201

• Although human milk contains small amounts

of vitamin D, it is not enough to prevent rickets.

Exposure of the skin to ultraviolet B wavelengths

from sunlight is the usual mechanism

for production of vitamin D. However, significant

risk of sunburn (short-term) and skin

cancer (long-term) attributable to sunlight exposure,

especially in younger children, makes

it prudent to counsel against exposure to sunlight.

Furthermore, sunscreen decreases vitamin

D production in skin.

13. Supplementary fluoride should not be provided

during the first 6 months of life.

• From 6 months to 3 years of age, the decision

whether to provide fluoride supplementation

should be made on the basis of the fluoride

concentration in the water supply (fluoride

supplementation generally is not needed unless

the concentration in the drinking water is

0.3 ppm) and in other food, fluid sources,

and toothpaste.

14. Mother and infant should sleep in proximity to

each other to facilitate breastfeeding.

15. Should hospitalization of the breastfeeding

mother or infant be necessary, every effort

should be made to maintain breastfeeding, preferably

directly, or pumping the breasts and feeding

expressed milk if necessary.