Breastfeeding

compels the milk to flow from the alveoli (lobules), through the ducts (milk canals), into the sacs (milk pools) behind the areola, and then into the baby's mouth. Breast development starts in puberty with the growth of ducts, fat cells, and connective tissue. While prolactin is the predominant hormone in milk production, progesterone, which is at high levels during pregnancy, blocks the prolactin receptors in the breast, thus inhibiting milk from "coming in" during pregnancy. Breast development throughout pregnancy may result in significant Areola and Areolar gland enlargement, erectile nipples or nipple sensitivity. Lactogenesis II continues to be produced for these next few days, as Lactogenesis II occurs. A condition called Mastitis sometimes occurs in this stage, resulting from incomplete milk drainage. The Academy of Breastfeeding Medicine recommends against trying to "empty" the breasts, whether through pushing the baby to feed more or through over use of a breast pump, to prevent causing milk oversupply. == Breast milk ==

The content of breast milk should be discussed in two separate categories: the nutritional content, and the bioactive content, i.e., the enzymes, proteins, antibodies, and signaling molecules that assist the infant in ways outside of nutrition. The pattern of intended nutrient content in breast milk is relatively consistent. Breastmilk is made from nutrients in the mother's bloodstream and bodily stores. It has an optimal balance of fat, sugar, water, and protein that is needed for a baby's age-appropriate growth and development. That being said, a variety of factors can influence the nutritional makeup of breastmilk, including gestational age, age of infant, maternal age, maternal smoking, and nutritional needs of the infant. The first type of milk produced is called colostrum. The volume of colostrum produced during each feeding is appropriate for the size of the newborn's stomach and is sufficient, calorically, for feeding a newborn during the first few days of life. Produced during pregnancy and the first days after childbirth, colostrum is rich in protein and Vitamins A, B12 and K, which support infants' growth, brain development, vision, immune systems, red blood cells, and clotting cascade. The breast milk also has long-chain polyunsaturated fatty acids which help with normal retinal and neural development. The caloric content of colostrum is about 54 Calories/100mL. The second type of milk is transitional milk, which is produced during the transition from colostrum to mature breast milk. As the breast milk matures over several weeks, the protein content decreases on average. If the mother is not deficient in vitamins, breast milk normally supplies the baby's needs, except for Vitamin D. The CDC, National Health Service (UK), Canadian Paediatric Society, the American Academy of Pediatrics, and the American Academy of Family Physicians all agree that breast milk alone does not provide infants with an adequate amount of Vitamin D, thus they advise parents to supplement their infants with 400 IU Vitamin D daily. Providing this quantity of Vitamin D to breastfeeding infants has been shown to reduce rates of Vitamin D insufficiency (defined as 25-OH vitamin D < 50 nmol/L). However, there was insufficient evidence in the most recent Cochrane Review to determine if this quantity reduced rates of Vitamin D deficiency (defined as 25-OH vitamin D < 30 nmol/L) or rickets. Term infants typically do not need iron supplementation. Delaying cord clamping at birth for at least one minute improves the infants' iron status for the first year. When complementary (solid) foods are introduced at about 6 months of age, parents should make sure to choose iron-rich foods to help maintain their children's iron stores. Produced during pregnancy and the first days after childbirth, colostrum is easy to digest and has laxative properties that help the infant to pass early stools. Additionally, colostrum and mature breast milk contain many antioxidant and anti-inflammatory enzymes and proteins that decrease the risk of gastrointestinal allergies to food, respiratory allergies to air particles like pollen, and other atopic diseases, such as asthma and eczema. == Process ==

Commencement It is recommended for mothers to initiate breastfeeding within the first hour after birth. Uninterrupted skin-to-skin contact and breastfeeding can begin immediately after birth, and should continue for at least one hour after birth. Newborns who are immediately placed on their mother's skin have a natural instinct to latch on to the breast and start nursing, typically within one hour of birth. Success with breastfeeding in this "golden hour" increases the likelihood of successful breastfeeding at discharge. The baby is placed on the mother in the operating room or the recovery area. If the mother is unable to immediately hold the baby, a family member can provide skin-to-skin care until the mother is able. Breast crawl According to studies cited by UNICEF, babies naturally follow a process that leads to a first breastfeed. Shortly after birth, the infant relaxes and makes small movements of the arms, shoulders, and head. If placed on the mother's abdomen, the baby gradually inches towards the breast, known as the breast crawl Activities such as weighing, measuring, bathing, needle-sticks, and eye prophylaxis wait until after the first feeding. Preterm or low-tone infants Children who are born preterm (before 37 weeks), children born in the early term period (37 weeks–38 weeks and 6 days), and children born with low muscular tone, such as those with chromosomal abnormalities like Down syndrome or neurological conditions like Cerebral palsy, may have difficulty in initiating breast feeds immediately after birth. These late preterm (34 weeks –36 weeks and 6 days) and early term (37 weeks–38 weeks and 6 days) infants are at increased risk for both breastfeeding cessation and complications of insufficient milk intake (e.g., dehydration, hypoglycemia, jaundice, and excessive weight loss). They are often expected to feed like term babies, but they have less strength and stamina to feed adequately. A newborn has a small stomach capacity, approximately 20 mL. The amount of breast milk that is produced is timed to meet the infant's needs in that the first milk, colostrum, is concentrated but produced in only very small amounts, gradually increasing in volume to meet the expanding size of the infant's stomach capacity. Many newborns typically feed for 10 to 15 minutes on each breast; however, feeds may last up to 45 minutes, depending on the infant's alertness and efficiency. Parents need to recognize the difference between Nutritive and Non-Nutritive Sucking. Nutritive Sucking follows a slow, rhythmic pattern, with one to two sucks per swallow. Non-nutritive sucking is a faster-paced sucking pattern with few swallows. This swallow pattern is often observed at the beginning or the end of a feed. At the beginning of the feed, this pattern triggers milk letdown, while at the end of the feed, this may signal that the infant is tired or becoming relaxed with a slower milk velocity. Exclusive breastfeeding is defined as "an infant's consumption of human milk with no supplementation of any type (no water, no juice, no nonhuman milk and no foods) except for vitamins, minerals and medications." After solids are introduced at around six months of age, continued breastfeeding is recommended. The American Academy of Pediatrics recommends that babies be breastfed at least until 12 months, or longer if both the mother and child wish. Extended breastfeeding means breastfeeding after the age of 12 or 24 months, depending on the source. In Western countries such as the United States, Canada, and Great Britain, extended breastfeeding is relatively uncommon and can provoke criticism. In the United States, 22.4% of babies are breastfed for 12 months, the minimum time advised by the American Academy of Pediatrics. In India, mothers commonly breastfeed for 2 to 3 years. Supplementation Supplementation is defined as the use of additional milk or fluid products to feed an infant, in addition to breastmilk, during the first 6 months of life. The Academy of Breastfeeding Medicine recommends only supplementing when medically indicated, as opposed to mixing use of formula and breastmilk for reasons that are not necessarily medical indications. Some parents may desire to supplement proactively if early signs of insufficient intake, such as decreased urination, dry mucous membranes, or persistent signs of hunger, are noticed. If these signs are noticed, it is important to have the mother-infant dyad evaluated by a breastfeeding specialist or pediatrician to determine the true cause of the symptoms and determine the need for supplementation. Babies can successfully latch on to the breast from multiple positions. Each baby may prefer a particular position. The "football" hold places the baby's legs next to the mother's side with the baby facing the mother. Using the "cradle" or "cross-body" hold, the mother supports the baby's head in the crook of her arm. The "cross-over" hold is similar to the cradle hold, except that the mother supports the baby's head with the opposite hand. The mother may choose a reclining position on her back or side with the baby lying next to her. To help with breastfeeding, some people use a nursing pillow. No matter the position the parent-infant dyad finds most comfortable, there are a few components of every position that will help facilitate a successful latch. One key component is maternal comfort. The mother should be comfortable while breastfeeding, and should have her back, feet, and arms supported with pillows as necessary. Additionally, when starting the latch process, the infant should be aligned with their abdomen facing their mother, which can be remembered as "tummy-to-mummy," and with their hips, shoulders, and head aligned. This alignment helps to facilitate proper, efficient swallowing mechanics. Sebaceous glands called Glands of Montgomery located in the areola secrete an oily fluid that lubricates and protects the nipple during latching. The visible portions of the glands can be seen on the skin's surface as small, round bumps. When preparing to latch, mothers should make use of this reflex by gently stroking the baby's philtrum, the area between the upper lip and the nose, with their nipple to induce the baby to open their mouth with a wide gape. Signs of a good, deep latch In a good latch, a large amount of the areola, in addition to the nipple, is in the baby's mouth. The amount of areola visible on either side of the infant's mouth should be asymmetric, meaning most of the "bottom" of the areola should be in the infant's mouth, and much more of the "top" of the areola should be visible. This position helps point the nipple toward the roof of the infant's mouth, helping the infant recruit more milk. The neck should be extended to facilitate swallowing, and as such, the chin will be close to the breast, and the forehead and nose should be far from the breast. This is a good indicator of effective suck mechanics. Additionally, to achieve a deep latch, the infant's mouth must be open wide, preferably wider than 140 degrees. While the infant is at the breast, the first indicators of a shallow latch are having the areola be largely visible outside the infant's mouth and a narrow infant mouth angle. Problems with breastfeeding Inverted nipples Infants of mothers with inverted nipples can still achieve a good latch with perhaps a little extra effort. For some women, the nipple may easily become erect when stimulated. Other women may require modified breastfeeding techniques, and some may need extra devices, such as nipple shells, modified syringes, or breast pumps to expose the nipple. La Leche League and Toronto Public Health offer several techniques to use during pregnancy or even in the early days following birth that may help to bring a flat or inverted nipple out. Ankyloglossia Ankyloglossia, also called "tongue-tie" may cause shallow latch, poor milk transfer, and other problems with breastfeeding. The Academy of Breastfeeding Medicine and the Australian Dental Association have raised concern over the growing trend of oral tie surgeries, due to evidence for benefit being low-quality, inconsistent, or unsupported. Engorgement Engorgement is the swelling and stretching of the breast tissue due to the accumulation of fluid in the tissue surrounding and supporting the milk-producing cells and ducts. As milk is coming in, several processes occur. At the end of pregnancy, the blood vessels that supply the breast dilate, allowing for leaking into the tissue or interstitial space. Nipple pain Although very common, nipple pain and nipple trauma (cracking, open sores) should not be normalized, as these are often signs of a shallow latch or other underlying problem that can be evaluated and fixed. Pain caused by a problem deep in the breast may also present with nipple pain due to the paths of nerves in the breast. Poor milk intake is signaled by poor infant weight gain, signs of dehydration, and hypoglycemia. There are two types of newborn jaundice related to breastfeeding. Breastfeeding jaundice is quite common and may occur in the first week of life in conjunction with ongoing weight loss. Breast milk jaundice is jaundice that persists despite appropriate weight gain. Unless a medical emergency necessitates abruptly stopping breastfeeding, it is best to gradually increase the period between feedings or eliminate feedings to allow the breasts to adjust to the decreased demands without becoming engorged. La Leche League advises parents to shift their children's focus at bedtime away from breastfeeding, as it is often the most difficult feeding for them to let go. If weaning starts at 12 months or later, it is not necessary to switch to infant formula or "toddler formula" as is sold commercially. At 12 months, it is recommended that the baby be switched to whole cow's milk. Reduced-fat or skim milk generally is not appropriate before age 2 because it lacks sufficient fat or calories to promote early brain development. If the mother was experiencing lactational amenorrhea, periods will begin to return with weaning, along with restored fertility. Extended breastfeeding Extended breastfeeding usually means breastfeeding beyond the age of 12 to 24 months, depending on the culture. The American Academy of Family Physicians states that "health outcomes for mothers and babies are best when breastfeeding continues for at least two years. The American Academy of Pediatrics recommends that mothers nurse for the first 12 months and "thereafter for as long as mother and baby desire." The World Health Organization recommends breastfeeding up to age 2 "or beyond." Professional breastfeeding support Lactation consultants are trained to assist mothers in preventing and solving breastfeeding difficulties such as sore nipples and low milk supply. They commonly work in hospitals, physician or midwife practices, public health programs, and private practice. Lactation consultants earn their credential, International Board Certified Lactation Consultant (IBCLC), through the International Board of Lactation Consultant Examiners. Breastfeeding support from a lactation consultant is associated with higher rates of any breastfeeding at 6 months but not at 1 month or 3 months post pregnancy based on a meta-analysis of studies conducted in the US and Canada. Peer support for breastfeeding is associated with higher rates of any breastfeeding at 1 month and 3 to 6 months and of exclusive breastfeeding at 1 month, but it is unrelated to breastfeeding outcomes past 6 months post-pregnancy. == Contraindications to breastfeeding ==

Maternal contraindications Medical conditions that do not allow breastfeeding are fairly rare. They also recommend that national authorities in each country decide which infant feeding practice should be promoted by their maternal and child health services to avoid transmitting HIV from mother to child. However, the CDC continues to recommend against HIV-positive mothers breastfeeding in the United States. Infant formula should only be given if this can be safely done. The worldwide rate of transmission through breastmilk is estimated to be 3.9–27%, and this risk is increased by high maternal viral load and prolonged periods of breastfeeding. Current data demonstrates that while breastfeeding for less than six months does not, independently, increase risk of HTLV-1 transmission, not breastfeeding during that time does decrease risk of transmission. As such, CDC recommends against breastfeeding when mothers have HTLV Types I or II. Recognizing the importance of breastfeeding in more resource-poor areas of the world, the World Health Organization recommends shortening the duration of breastfeeding, or avoiding breastfeeding where possible. However, these infants may be fed expressed breastmilk from their mother. The CDC advises to continue breastfeeding if there are no open/active lesions on the breast and other lesions covered. The CDC advises that breastfeeding is safe to continue as long as the breasts are clear of lesions, also emphasizing that if pumping or hand expressing milk, proper hand-hygiene should be used to minimize transfer. A study published in 2021 found that, while SARS-CoV-2 RNA may be found in some samples of breastmilk from recently infected mothers, the breastmilk does not contain infectious virus and is not considered a transmission risk factor. Mothers who have suspected or confirmed diagnoses of COVID-19 should thoroughly wash their hands and wear a well-fitting mask before breastfeeding their infant, or express breastmilk and feed the infant by bottle. Substance use Alcohol Moderate alcohol consumption by breastfeeding mothers can significantly affect infants. Even one or two drinks, including beer, may reduce milk intake by 20 to 23%, leading to increased agitation and poor sleep patterns. Regular heavy drinking (more than two drinks daily) can shorten breastfeeding duration and cause issues in infants, such as excessive sedation, fluid retention, and hormonal imbalances. Additionally, higher alcohol consumption may negatively impact children's academic achievement. When breastfeeding, alcohol may be consumed in moderation and does not require "Pumping-and-Dumping" (pumping and discarding breastmilk). Alcohol crosses from the blood to the breastmilk by diffusion. Thus, the concentration of alcohol in the breastmilk is approximately equal to the concentration in the maternal bloodstream at any given time. As the mother's liver processes the alcohol, more and more alcohol is pulled out of the breastmilk and back into the bloodstream. In the case of infrequent binge drinking, it has been shown that infants consume through breastmilk only a fraction of the alcohol their mothers have ingested. While a minute, clinically insignificant amount of alcohol may be absorbed into the infant's bloodstream, it is unlikely that this amount would cause any noticeable cognitive or neuromotor effects. The main active ingredient in marijuana, tetrahydrocannabinol (THC), can be found in breastmilk anywhere from six days to more than six weeks after marijuana use. However, it is important to note that maternal tobacco use may decrease milk supply. • InfantRisk App (InfantRisk Center at Texas Tech University Health Sciences Center) Pumping-and-dumping "Pumping-and-dumping" is the concept of expressing breastmilk and discarding it due to a medication or substance "tainting" the breastmilk. It was once believed that drinking alcohol or taking any medications, even medicines like ibuprofen, required pumping-and-dumping. == Methods ==

and pumped breastmilk side by side. Note that the formula is of uniform consistency and color, while the expressed breast milk exhibits properties of an organic solution by separating into a layer of fat at the top (the "creamline"), followed by the milk, and then a watery blue-colored layer at the bottom. Expressed milk A mother may express milk (remove milk from breasts) for storage and later use. Expression may occur manually with hand expression or by using a breast pump. Mothers express milk for multiple reasons. Expressing breast milk can maintain a mother's milk supply when mother and child are apart. A sick baby who is unable to nurse can take expressed milk through a nasogastric tube. Some babies are unable or unwilling to nurse. Maternal breastmilk is the food of choice for premature babies; these infants may be fed maternal milk through tubes, supplemental nursing systems, bottles, spoons, or cups until they develop satisfactory ability to suck and swallow breast milk. Parents considering directed or informal milk sharing should discuss this option with their doctor, and they should be familiar with the donor's medical history and milk handling practices. Storage of expressed breastmilk Breastmilk may be stored for various amounts of time depending on storage temperature and conditions. The content and quality of expressed milk change over time as it is stored, particularly when frozen. Shared nursing can sometimes provoke negative social reactions in the English-speaking world. Tandem nursing A mother can continue breastfeeding an older sibling while also breastfeeding a new baby; this is called tandem nursing. During the late stages of pregnancy, the milk changes to colostrum. While some children continue to breastfeed even with this change, others may wean. Most mothers can produce enough milk for tandem nursing, but the new baby should be nursed first for at least the first few days after delivery to ensure it receives enough colostrum. Breastfeeding triplets or larger broods is a challenge given babies' varying appetites. Breasts can respond to the demand and produce larger milk quantities; mothers have breastfed triplets successfully. File:Breastfeeding newborn twins.jpg|Newborn twins being breastfed File:Breastfeeding 2 year old twins.jpg|Woman breastfeeds 2-year-old twins whilst reading them a book. File:Tandem breastfeeding toddler and baby.jpg|Woman tandem nurses an infant and a toddler. Re-lactation and induced lactation Re-lactation is the process of restarting breastfeeding. Techniques to promote lactation include frequent attempts to breastfeed, extensive skin-to-skin contact with the baby, and frequent, long pumping sessions. These techniques require the mother's commitment over a period of weeks or months. However, even when lactation is established, the supply may not be large enough to breastfeed exclusively. A supportive social environment improves the likelihood of success. As the mother's milk production increases, other feeding can decrease. Parents and other family members should watch the baby's weight gain and urine output to assess nutritional adequacy. A WHO manual for physicians and senior health workers, citing a 1992 source, states: "If a baby has been breastfeeding sometimes, the breastmilk supply increases in a few days. If a baby has stopped breastfeeding, it may take 1–2 weeks or more before much breastmilk comes." Induced lactation, also called adoptive lactation, is the process of starting breastfeeding in a woman who did not give birth. This usually requires the adoptive mother to take hormones and other drugs to stimulate breast development and promote milk production. In some cultures, breastfeeding an adoptive child creates milk kinship that builds community bonds across class and other hierarchical bonds. == Health effects ==

to support a feeding baby in Rio de Janeiro Breastfeeding support is universal among major health and children's organizations. WHO states, "Breast milk is the ideal food for the healthy growth and development of infants; breastfeeding is also an integral part of the reproductive process with important implications for the health of mothers." Breastfeeding is associated with a lowered risk of several diseases in both mothers and babies. Comparing infants that were exclusively breastfed for at least 3 months with never-breastfed infants, the American Academy of Pediatrics reported that in the first year of life breastfed babies averaged about $400 in savings of health care costs. Baby Infants who are not breastfed are at mildly increased risk of developing lower respiratory infection, ear infections, bacteremia, bacterial meningitis, botulism, urinary tract infection and necrotizing enterocolitis. Breastfeeding may protect against sudden infant death syndrome, insulin-dependent diabetes mellitus, Crohn's disease, ulcerative colitis, childhood lymphoma, allergic diseases, digestive diseases, It is hard however to distinguish the importance of breastfeeding per se and other correlated socioeconomic factors (breastfeeding is more frequent in richer families with higher educations). Comparing breastfed and non-breastfed siblings in a given family drastically decreases the association between breastfeeding and long-term child well-being. The Davis Area Research on Lactation, Infant Nutrition and Growth (DARLING) study reported that breastfed and formula-fed groups had similar weight gain during the first 3 months. Breastfed babies began to drop below the median beginning at 6 to 8 months and were significantly lower in weight than the formula-fed group between 6 and 18 months. Length gain and head circumference values were similar between groups, suggesting that the breastfed babies were leaner. Infections Breast milk contains several anti-infective factors such as bile salt stimulated lipase (protecting against amoebic infections) and lactoferrin (which binds to iron and inhibits the growth of intestinal bacteria). Exclusive breastfeeding until six months of age helps to protect an infant from gastrointestinal infections in both developing and industrialized countries. The risk of death due to diarrhea and other infections increases when babies are either partially breastfed or not breastfed at all. This is one of the important features of colostrum. The main target for these antibodies are probably microorganisms in the baby's intestine. The rest of the body displays some uptake of IgA, but this amount is relatively small. Maternal vaccinations while breastfeeding are safe for almost all vaccines. Additionally, the mother's immunity obtained by vaccination against tetanus, diphtheria, whooping cough, and influenza can protect the baby from these diseases, and breastfeeding can reduce the fever rate after infant immunization. However, smallpox and yellow fever vaccines increase the risk of infants developing vaccinia and encephalitis. Several studies have suggested that breast milk can pass antibodies to the infant for as long as the child continues to nurse. The antibodies may be in the mother's system as a result of being ill, or they may be acquired by drinking milk from a mother who has recently been vaccinated for a particular disease. One small study done on nursing mothers who had received the COVID-19 vaccine found that breastmilk continued to contain antibodies for as long as 80 days after receiving the vaccine. Mortality The World Health Organization reports that babies who receive no breast milk are almost six times more likely to die by the age of one month than those who are partially or fully breastfed. Access to healthcare is the single critical determinant of survival or death for the infant. Childhood obesity The protective effect of breastfeeding against obesity is consistent, though small, across many studies. A 2013 longitudinal study reported less obesity at ages two and four years among infants who were breastfed for at least four months. Allergic diseases In children who are at risk for developing allergic diseases (defined as at least one parent or sibling having atopy), atopic syndrome can be prevented or delayed through 4-month exclusive breastfeeding, though these benefits may not persist. Backwash effect The backwash effect in breastfeeding refers to the process in which an infant's saliva flows back into the mother's breast during nursing. This backward flow may introduce the baby's saliva into the mammary gland, potentially prompting the mother's body to produce tailored immune responses in her breast milk to meet the infant's specific needs. Other health effects Breastfeeding may reduce the risk of necrotizing enterocolitis (NEC) in premature babies. About 14 to 19 percent of leukemia cases may be prevented by breastfeeding for six months or longer. However, breastfeeding is also the primary cause of adult T-cell leukemia/lymphoma, as the HTLV-1 virus is transmitted through breastmilk. Breastfeeding is associated with a lower chance of developing diabetes mellitus type 1 in the offspring. Breastfeeding may decrease the risk of cardiovascular disease in later life, as indicated by lower cholesterol and C-reactive protein levels in breastfed adult women. A 2016 review found that breastfeeding protected against malocclusions. Intelligence It is unclear whether breastfeeding improves intelligence later in life. Several studies found no relationship after controlling for confounding factors like maternal intelligence (smarter mothers were more likely to breastfeed their babies). However, other studies concluded that breastfeeding was associated with increased cognitive development in childhood, although the cause may be increased mother–child interaction rather than nutrition. Mother Maternal bond Oxytocin, a hormone released during breastfeeding, may play a role in maternal-infant attachment and bonding, potentially via decreased anxiety and stress. Fertility Exclusive breastfeeding usually delays the return of fertility through lactational amenorrhea, although it does not provide reliable birth control. Mothers may not ovulate or have regular periods during the entire lactation period. The non-ovulating period varies by individual. This has been used as natural contraception, with greater than 98% effectiveness during the first six months after birth if specific nursing behaviors are followed. Postpartum bleeding During the third stage of labor, the time between the delivery of the baby and the passage of the placenta, and the fourth, the final stage of birth, excessive blood loss can endanger the life of the mother. When the newborn nurses, the mother secretes oxytocin, which causes the uterus to contract and reduce blood loss. Nursing also causes the uterus to cramp for several days postpartum, helping it to return to its pre-pregnancy size. Some women report moderate to severe pain, especially women who have given birth several times, during a nursing session for the first few days following delivery. Weight retention It is unclear whether breastfeeding causes mothers to lose weight after giving birth. The National Institutes of Health states that it may help with weight loss. Chronic conditions Breastfeeding is also associated with a lower risk of type 2 diabetes among mothers who practice it. Longer duration of breastfeeding is associated with reduced risk of hypertension. According to the American Heart Association, breastfeeding also reduces the risk of maternal heart disease and stroke. A 2011 review found it unclear whether breastfeeding affects the risk of postpartum depression. Later reviews have found tentative evidence of a lower risk among mothers who successfully breastfeed, though it is unknown whether breastfeeding decreases depression, or whether depression decreases breastfeeding. Dysphoric milk ejection reflex Dysphoric milk ejection reflex (D-MER) is a condition in which breastfeeding women develop negative emotions that begin just before the milk letdown reflex and last less than a few minutes. It may recur with every letdown, including unexpected letdowns when the baby is not feeding. It presents as an emotional reaction but may also produce physical feelings such as nausea. It is different from postpartum depression and other known psychological conditions. A 2019 study reported a prevalence rate of 9.1%. As of 2021, very little research has been done, and many health care providers and lactation practitioners remain barely able to recognize the syndrome. An October 2021 review of literature published to that date suggested that the lack of up-to-date information "makes it necessary to educate mothers because educated mothers are usually better at handling postpartum situations if they are prepared in advance." There is as yet no medication to treat the symptoms although women have reported that they have found it of benefit to learn that they are not alone and that the symptoms were not "just in their head". == Social factors ==

The majority of mothers intend to breastfeed at birth. Many factors can disrupt this intent. Research done in the US shows that obstetricians rarely provide information about breastfeeding during their prenatal visits, and some health professionals incorrectly believe that commercially prepared formula is nutritionally equivalent to breast milk. Many hospitals have instituted practices that encourage breastfeeding, however a 2012 survey in the US found that 24% of maternity services were still providing supplements of commercial infant formula as a general practice in the first 48 hours after birth. Social support A review found that when effective forms of support are offered to women, exclusive breastfeeding and duration of breastfeeding are increased. Characteristics of effective support include ongoing, face-to-face support tailored to fit their needs. It may be offered by lay/peer supporters, professional supporters, or a combination of both. This review contrasts with another large review that looked at education programs alone, which found no conclusive evidence of initiation of breastfeeding or the proportion of women breastfeeding either exclusively or partially at 3 months and 6 months. Positive social support in essential relationships of new mothers plays a central role in promoting breastfeeding outside of medical centers. Social support can come in many incarnations, including tangible, affectionate, social interactions, and emotional and informational support. An increase in these capacities of support has shown to greatly positively effect breastfeeding rates, especially among women with education below a high school level. Some mothers who have used lactation rooms have taken to leaving sticky notes to not only thank the businesses that have provided them but to support, encourage, and praise the nursing mothers who use them. In the social circles surrounding the mother, support is most crucial from the male partner, the mother's mother, and her family and friends. Research has shown that the closest relationships to the mother have the strongest impact on breastfeeding rates, while negative perspectives on breastfeeding from close relatives hinder its prevalence. Some women fear that breastfeeding will negatively impact the look of their breasts. However, a 2008 study found that breastfeeding did not affect the breasts; other factors did contribute to "drooping" of the breasts, such as advanced age, number of pregnancies, and smoking behavior. • Partner – Partners may lack knowledge of breastfeeding and their role in the practice. • Wet nursing – Social and cultural attitudes towards breastfeeding in the African-American community are also influenced by the legacy of forced wet-nursing during slavery. Maternity leave Work is the most commonly cited reason for not breastfeeding. In 2012, Save the Children examined maternity leave laws, ranking 36 industrialized countries according to their support for breastfeeding. Norway ranked first, while the United States came in last. Maternity leave in the US varies widely, including by state. The United States does not mandate paid maternity leave for any employee; however, the Family Medical Leave Act (FMLA) guarantees qualifying mothers up to 12 weeks of unpaid leave, although most US mothers resume work earlier. A large 2011 study found that women who returned to work at or after 13 weeks after childbirth were more likely to breastfeed beyond three months. Healthcare Caesarean section Women are less likely to start breastfeeding after caesarean delivery compared with vaginal delivery. Breast surgery Breastfeeding can generally be attempted after breast augmentation or reduction surgery; however, prior breast surgery is a risk factor for low milk supply. A 2014 review found that women who have breast implant surgery were less likely to breastfeed exclusively; however, it was based on only three small studies, and the reasons for the correlation were not clear. A large follow-up study done in 2014 found a reduced rate of breastfeeding in women who had undergone breast augmentation surgery; however, again, the reasons were unclear. The authors suggested that women contemplating augmentation should be provided with information related to the rates of successful breastfeeding as part of informed decision-making when contemplating surgery. Prior breast reduction surgery is strongly associated with an increased probability of low milk supply due to disruption to tissues and nerves. Some surgical techniques for breast reduction appear to be more successful than others in preserving the tissues that generate and channel milk to the nipple. A 2017 review found that women were more likely to have success with breastfeeding with these techniques. Medications Breastfeeding mothers should inform their healthcare provider about all of the medications they are taking, including herbal products. Nursing mothers may be immunized and may take most over-the-counter drugs and prescription drugs without risk to the baby but certain drugs, including some painkillers and some psychiatric drugs, may pose a risk. The US National Library of Medicine publishes "LactMed," an up-to-date online database of information on drugs and lactation. Geared to both healthcare practitioners and nursing mothers, LactMed contains over 450 drug records with information such as potential drug effects and alternative drugs to consider. Some substances in the mother's food and drink are passed to the baby through breast milk, including mercury (found in some carnivorous fish), caffeine, and bisphenol A. Medical conditions Undiagnosed maternal celiac disease may cause a short duration of the breastfeeding period. Treatment with the gluten-free diet can increase its duration and restore it to the average value of the healthy women. Mothers with all types of diabetes mellitus normally use insulin to control their blood sugar, as the safety of other antidiabetic drugs while breastfeeding is unknown. Women with polycystic ovary syndrome, which is associated with some hormonal differences and obesity, may have greater difficulty with producing a sufficient supply to support exclusive breastfeeding, especially during the first weeks. Ethnicity and socioeconomic status The rates of breastfeeding in the African-American community remain much lower than those of any other race, for a variety of proposed reasons. These include the legacy of wet nursing during slavery, higher rates of poor perinatal health, higher stress levels, less access to support, and less flexibility in the workplace. While for other races, as socio-economic status increases, rates of breastfeeding also go up, for the African-American community, breastfeeding rates remain consistently low regardless of socio-economic class. There are also racial disparities in access to maternity care practices that support breastfeeding. In the US, primarily African-American neighborhoods are more likely to have facilities (such as hospitals and female healthcare clinics) that do not support breastfeeding, contributing to the low rate of breastfeeding in the African-American community. Comparing facilities in primarily African American neighborhoods to ones in primarily European-American neighborhoods, the rates of practices that support or discourage breastfeeding were: limited use of supplements (13.1% compared with 25.8%) and rooming-in (27.7–39.4%) Low-income mothers are more likely to have unintended pregnancies. Mothers whose pregnancies are unintended are less likely to breastfeed. Especially the combination of powdered formula with unclean water can be very harmful to the health of babies. In the late 1970s, there was a boycott against Nestle due to the large number of baby deaths due to formula. Dr. Michele Barry explains that breastfeeding is most imperative in poverty environments due to the lack of access to clean water for formula. A Lancet study in 2016 found that universal breastfeeding would prevent the deaths of 800,000 children as well as save $300,000,000. Social acceptance Some women feel discomfort when breastfeeding in public. Public breastfeeding may be forbidden in some places, not addressed by law in others, and a legal right in others. Even given a legal right, some mothers are reluctant to breastfeed, while others may object to the practice. It is estimated that around 63% of mothers worldwide have publicly breastfed. The media have reported several incidents in which workers or members of the public have objected to or forbidden women breastfeeding. Some mothers avoid the negative attention and choose to move to another location. But some mothers have protested their treatment and have taken legal action or engaged in protests. Protests have included a public boycott of the offender's business, organizing a "nurse-in" or a breastfeeding flash mob, in which groups of nursing mothers gather at the location where the complaint originated and nursed their babies at the same time. In response, some companies have apologised and instituted reforms. The use of infant formula was thought to be a way for Western culture to adapt to negative perceptions of breastfeeding. The breast pump offered a way for mothers to supply breast milk with most of formula feeding's convenience and without enduring possible disapproval of nursing. Some may object to breastfeeding because of the implicit association between infant feeding and sex. These negative cultural connotations may reduce breastfeeding duration. Maternal guilt and shame are often affected by how a mother feeds an infant. These emotions occur in both bottle- and breast-feeding mothers, although for different reasons. Bottle-feeding mothers may feel they should be breastfeeding. Conversely, breastfeeding mothers may feel forced to feed in uncomfortable circumstances. Some may see breastfeeding as "indecent, disgusting, animalistic, sexual, and even possibly a perverse act." Advocates (known by the neologism "lactivists") use "nurse-ins" to show support for breastfeeding in public. In that country, the Friendly Airports for Mothers (FAM) Act was signed into law in 2019, and the requirements went into effect in 2021. This law requires that all large and medium hub airports in the U.S. provide a private, non-bathroom lactation space in each terminal building. Some commercial establishments in the U.S. provide breastfeeding rooms, although laws generally specify that mothers may breastfeed anywhere without requiring a special area. Despite these laws, many women in the United States continue to be publicly shamed or asked to refrain from breastfeeding in public. In the United Kingdom, the Equality Act 2010 makes the prevention of breastfeeding in any public place discrimination under the law. In Scotland, it is a criminal offense for one to attempt to prevent another from feeding a child under 24 months in public. In 2014, newly elected Pope Francis drew worldwide commentary when he encouraged mothers to breastfeed babies in church. During a papal baptism, he said that mothers "should not stand on ceremony" if their children were hungry. "If they are hungry, mothers, feed them, without thinking twice," he said, smiling. "Because they are the most important people here." == Prevalence ==

In 2012, 37.1% of infants under six months of age were breastfeeding exclusively, which rose to 48% in 2022. The Sustainable Development Goals target is to achieve 70% by 2030. In the United States, the rate of women beginning to breastfeed was 76% in 2009, increasing to 83% in 2015, with 58% still breastfeeding at 6 months, although only 25% were still breastfeeding exclusively. African-American women have persistently low rates of breastfeeding compared to White and Hispanic American women. In 2014, 58.1% of African-American women breastfeed in the early postpartum period, compared to 77.7% of White women and 80.6% of Hispanic women. Breastfeeding rates in different parts of China vary considerably. Rates in the United Kingdom were the lowest in the world in 2015, with only 0.5% of mothers still breastfeeding at a year, while in Germany, 23% are doing so, 56% in Brazil, and 99% in Senegal. In Australia, for children born in 2004, more than 90% were initially breastfed. In Canada, for children born in 2005–06, more than 50% were only breastfed, and more than 15% received both breastmilk and other liquids by the age of 3 months. == History ==

In the Egyptian, Greek and Roman Empires, women usually fed only their own children. However, breastfeeding began to be seen as something too common to be done by royalty. Wet nurses were employed to breastfeed the children of the royal families. This extended over time, particularly in western Europe, where noble women often used wet nurses. Lower-class women breastfed their infants and used a wet nurse only if they were unable to feed their own infant. Attempts were made in 15th-century Europe to use cow or goat milk, but these attempts were unsuccessful. In the 18th century, flour or cereal mixed with broth was introduced as a substitute for breastfeeding, but this provided inadequate nutrition. The appearance of improved infant formulas in the mid-19th century and their increased use caused a decrease in breastfeeding rates, which accelerated after World War II. For some in the US, Canada, and the UK, breastfeeding was seen as uncultured. From the 1960s onwards, breastfeeding experienced a revival that continued into the 2000s, though negative attitudes towards the practice were still entrenched in some countries up to the 1990s. == Society and culture ==

Financial considerations Breastfeeding is less costly than alternatives, but the mother generally must eat more food than would otherwise be necessary. In the US, the extra money spent on food (about US $ each week) is usually about half the cost of infant formula. Breastfeeding reduces health care costs and the cost of caring for sick babies. Parents of breastfed babies are less likely to miss work and lose income because their babies are sick. However, in a study of over 140,000 newborns in the first month of life, exclusively breastfed newborns had higher hospital readmission rates than those exclusively formula fed, and those exclusively breastfed also had more neonatal outpatient visits compared to those exclusively formula fed. Breastfeeding in humanitarian emergencies During humanitarian crises, conflicts, forced displacement, and natural disasters, mothers and caregivers face additional difficulties in maintaining adequate breastfeeding practices. They may experience physical and mental exhaustion, lack safe and private spaces for on-demand breastfeeding, and have limited social support. In many of these situations, unsolicited donations of breast milk substitutes may be distributed through well-intentioned but poorly informed solidarity initiatives. Relying on these products often interrupts breast milk production and creates dependence on formula milk, whose use carries critical health risks in settings where clean water and hygiene materials are not fully accessible. Following a key meeting hosted by the International Baby Food Action Network (IBFAN) in 1995, the Infant Feeding in Emergencies (IFE) Core Group was established in 1999 to address policy guidance and capacity-building on infant and young child feeding in emergencies. Over the years, and in collaboration with many other humanitarian organisations, the IFE Core Group has issued key recommendations aimed at monitoring and controlling unsolicited donations of breast milk substitutes, protecting early initiation of breastfeeding, providing food or financial assistance to caregivers, safeguarding infants who depend exclusively on formula milk, establishing and maintaining community support spaces for infant and young child feeding, and fostering inter-sectoral coordination to promote a positive environment for breastfeeding. Criticism of breastfeeding advocacy dedicated to promoting awareness of breastfeeding in Reykjavík, Iceland, in 2011 There are controversies and ethical considerations surrounding the means used by public campaigns which attempt to increase breastfeeding rates, relating to pressure put on women, and potential feelings of guilt and shame of women who fail to breastfeed; and social condemnation of women who use formula. In addition to this, there is also the moral question as to what degree the state or medical community can interfere with a person's self-determination: for example in the United Arab Emirates the law requires women to breastfeed babies for at least 2 years and allows husbands to sue them if they do not. It is widely assumed that if women's healthcare providers encourage them to breastfeed, those who choose not to will experience more guilt. Evidence does not support this assumption. On the contrary, a study on the effects of prenatal breastfeeding counselling found that those who had received such counselling and chosen to formula-feed denied experiencing feelings of guilt. Women were equally comfortable with their subsequent choices for feeding their infant, regardless of whether they had received encouragement to breastfeed. Preventing a situation where women are denied agency or stigmatized for formula use is also seen as important. In 2018, in the UK, a policy statement from the Royal College of Midwives said that women should be supported and not stigmatized if, after being given advice and information, they choose to formula feed. Social marketing Social marketing is a marketing approach intended to change people's behavior to benefit both individuals and society. When applied to breastfeeding promotion, social marketing works to provide positive messages and images of breastfeeding to increase visibility. Social marketing in the context of breastfeeding has shown efficacy in media campaigns. Some oppose the marketing of infant formula, especially in developing countries. They are concerned that mothers who use formula will stop breastfeeding and become dependent upon substitutes that are unaffordable or less safe. Through efforts including the Nestlé boycott, they have advocated for bans on free samples of infant formula and for the adoption of pro-breastfeeding codes such as the International Code of Marketing of Breast-milk Substitutes by the World Health Assembly in 1981 and the Innocenti Declaration by WHO and UNICEF policy-makers in August 1990. Giving out gift bags that contain infant formula to women as they leave the hospital is also a marketing strategy. The U.S. Government Accountability Office has reported that women who receive formula samples at discharge are associated with lower breastfeeding rates than those who do not receive gift bags. Baby Friendly Hospital Initiative The Baby Friendly Hospital Initiative (BFHI) is a program launched by the World Health Organization (WHO) in conjunction with UNICEF to promote infant feeding and maternal bonding through certified hospitals and birthing centers. BFHI was developed as a response to the influence held by formula companies in private and public maternal health care. The initiative has two core tenets: the Ten Steps to Successful Breastfeeding and the International Code of Marketing of Breast-milk Substitutes. The BFHI has especially targeted hospitals and birthing centers in the developing world, as these facilities are most at risk to the detrimental effects of reduced breastfeeding rates. As of 2018, 530 hospitals in the United States hold the "Baby-Friendly" title in all 50 states. Globally, there are more than 20,000 "Baby-Friendly" hospitals worldwide in over 150 countries. Representation on television The first depiction of breastfeeding on television was in the children's program Sesame Street, in 1977. With few exceptions since that time, breastfeeding on television has either been portrayed as strange, disgusting, or a source of comedy, or it has been omitted entirely in favor of bottle feeding. Islam has a complex system of rules regarding this, known as Rada (fiqh). Like the Christian practice of godparenting, milk kinship established a second family that could take responsibility for a child whose biological parents came to harm. "Milk kinship in Islam thus appears to be a culturally distinctive, but by no means unique, institutional form of adoptive kinship." In Western countries, differences in breastfeeding practices have also been observed according to the affiliation or practice of Christian religions; unaffiliated and Protestant women exhibit higher rates of breastfeeding. Transgender women Milk production can be induced in transgender women by the use of hormone medication. In one case report, a transgender woman was able to produce 7 mL of milk per day with hormone treatment. A different transgender woman was able to produce 8 oz of milk per day achieving "sufficient breast milk volume to be the sole source of nourishment for her child for six weeks." == Workplace ==

Many mothers have to return to work a short time after their babies have been born. In the U.S., about 70% of mothers with children younger than three years old work full-time, with 1/3 of the mothers returning to work within 3 months and 2/3 returning within 6 months. Working outside of the home and full-time work are significantly associated with lower rates of breastfeeding and breastfeeding for a shorter duration of time. According to the Centers for Disease Control and Prevention, support for breastfeeding in the workplace includes several types of employee benefits and services, including writing corporate policies to support breastfeeding women; teaching employees about breastfeeding; providing designated private space for breastfeeding or expressing milk; allowing flextime to support milk expression during work; giving mothers options for returning to work, such as remote work, part-time jobs, and extended maternity leave; providing on-site or near-site child care; providing high-quality breast pumps; and offering professional lactation consultants. In the United States the CDC reports on a study that "examined the effect of corporate lactation programs on breastfeeding behavior among employed women in California [which] included prenatal classes, perinatal counseling, and lactation management after the return to work". They found that "about 75% of mothers in the lactation programs continued breastfeeding at least 6 months, although nationally only 10% of mothers employed full-time who initiated breastfeeding were still breastfeeding at 6 months." The employee must be allowed to breastfeed in a private place, other than a bathroom. The employer is not required to pay the employee during the break time. A 2016 study found that federal policy does not address lactation space functionality and accessibility, policy only protects a subset of employees, and that the enforcement of the policy requires women to file a complaint with the United States Department of Labor. To address each of these issues, the report recommends additional requirements surrounding lactation space and functionality, mandated coverage of exempt employees, and a requirement that employers develop company-specific lactation policies. In 2022, the Providing Urgent Maternal Protections for Nursing Mothers Act, also known as the PUMP Act, became law in the United States. It mandates that salaried workers who are breastfeeding must have break time and a private space that is not a bathroom. However, employers who do not have 50 or more employees do not have to follow this law if following it would create an undue hardship because of expense or difficulty. In British Columbia, employers are required to provide accommodation to employees who breastfeed or express breast milk. Although no specific requirements are mandated, under the Human Rights Code, accommodations suggested include paid breaks (not including meal breaks), private facilities that include clean running water, comfortable seating areas, and refrigeration equipment, as well as flexibility in terms of work-related conflicts. == Research ==

Breastfeeding research continues to assess prevalence, HIV transmission, pharmacology, costs, benefits, immunology, contraindications, and comparisons to synthetic breast milk substitutes. Factors related to the mental health of the nursing mother in the perinatal period have been studied. While cognitive behavior therapy may be the treatment of choice, medications are sometimes used. The use of therapy rather than medication reduces the infant's exposure to medication that may be transmitted through the milk. In coordination with institutional organisms, researchers are also studying the social impact of breastfeeding throughout history. Accordingly, strategies have been developed to foster the increase of the breastfeeding rates in the different countries. == See also ==