Guideline 4

Guideline 4: Perinatal Breastfeeding* Promotion and Support

Purpose 

Breastfeeding* is the biological norm for infant nutrition and the ideal method for feeding infants. Breast milk not only meets the specific nutritional needs of human babies, it also provides enzymes, growth factors, antibodies, and hormones not found in formula. It is easy for babies to digest, supports optimal growth, and development as well as immune function. Breasfeeding also provides significant health benefits for parent, including lower risk of high blood pressure, diabetes Type II, ovarian cancer, and breast cancer. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for the first six months, and then continued breastfeeding for two years and beyond, even as solid foods are introduced. 
*The term breastfeeding is used throughout this document.  Chestfeeding may also be used  
to describe an infant feeding from a lactating person's chest.   

Process 

All home visitors should: 

• Be knowledgeable of inclusive and affirming lactation terminology.  Be able to adjust language to a client's preferred terms. 
• Academy of Breastfeeding Medicine Position Statement and Guideline: Infant Feeding and Lactation-Related Language and Gender 
• ILCA Style Guidelines for Written Professional Resources 
•  Understand a family's motivations and barriers to breastfeeding. During pregnancy, use open-ended questions to assess the client's breast health history (breast surgery may impact breastfeeding), desires around breastfeeding and plan for feeding their infant, and impact of previous experience and preconceptions about breastfeeding 
• Be able to list local public health challenges impacting breastfeeding in their community (e.g. COVID19, lack of breastfeeding protection laws) 
• Provide accurate and reliable breastfeeding education and resources (WIC, La Leche League, health care providers and lactation specialists.)   
• Safe breastmilk donating (https://www.donatemilk.org/for-healthcare-providers)
• Advocate for breastfeeding families (key resources linked on the OHA website) 
• Breastfeeding laws 
• Be able to list local breastfeeding resources and the strengths/limitations of each role:  
• Lactation Support Providers Descriptor Table (US Breastfeeding Committee) 
• The Landscape of Breastfeeding Support (Massachusetts Breastfeeding Coalition) 
• Make referrals to the appropriate resources based on level of lactation care neeeded 
• Postpartum, continue to monitor and support breastfeeding, ensuring client has access to lactation consultation, as needed. Reinforce that breastfeeding may require practice, and that solutions are available for problems or concerns that arise. 

Home visitors with training and competency* should 

• Perform a physical assessment of breastfeeding client and infant (including oral assessment of infant) 
• Observe an infant feeding (latch and positioning) 
• Provide guidance and support to increase milk supply and discuss and support pumping 
• Discuss signs and symptoms of common problems, including mastitis, clogged ducts 
• Monitor infant weight gain using calibrated infant scales and CDC/WHO growth charts 
• Support parents in development of a breastfeeding plan which may include pumping and/or supplementation 
• Communicate and collaborate with other lactation support professionals 

Resources for home visitors providing support 

• Academy of Breastfeeding Medicine:  https://www.bfmed.org/protocols 
• Medications and Breastmilk: LactMed: https://www.ncbi.nlm.nih.gov/books/NBK501922/ 
• Dr. Hale's Infant Risk Center at Texas Tech University www.infantrisk.com 
• CDC contraindications to breastfeeding: https://www.cdc.gov/breastfeeding/ breastfeeding-special-circumstances/contraindications-to-breastfeeding.html 
• WIC: https://www.oregon.gov/oha/ph/healthypeoplefamilies/wic/Pages/index.aspx 
• La Leche: https://www.llli.org/ 

*Training and competency may vary depending on implementing agency and International Board Certified Lactation Consultant, Certified Lactation Counselor (IBCLC, CLC) certification. 

Breastfeeding and Special Circumstances

There are very few contraindications to breastfeeding. Contraindications and special circumstances are summarized below. 
Contraindications to breastfeeding or expressed breast milk feeding:  The American Academy of Pediatrics and the Centers for Disease Control provide slightly different information regarding breastfeeding contraindications. The role of the home visitor is to provide: 

1. Reliable sources of information (such as the American Academy of Pediatrics, the Centers for Disease Control (CDC, and the National Perinatal HIV/AIDS hotline (1-888-448-8764) 
2. Referral back to the lactating parent and/or infant's medical home 
3. Referral to lactation professionals as appropriate 
   

Special Circumstances 

As detailed in the recent AAP Clinical Report (2024), Infant Feeding for Persons Living with and at Risk for HIV in the United States, people living with HIV who are receiving antiretroviral treatment and maintain their viral load under 50 copies/mL should be supported to choose the infant feeding option that best suits their needs, whether that means providing their own human milk, formula, or certified banked donor milk.
According to the Centers for Disease Control, special circumstances that require a temporary pause in breastfeeding and a pause in feeding expressed breast milk to an infant include the when the lactating parent: 

1. Has untreated brucellosis 
2. Is taking certain medications (consult medical provider and LactMed) 
3. Is undergoing diagnostic imaging with radiopharmaceuticals 
4. Has mpox virus infection 

Clients may consider a pause or breastfeeding modification in circumstances when the lactating person: 

1. Has active herpes simplex virus (HSV) lesion on the breast.  They may feed from unaffected breast if lesions are completely covered on affected breast. 
2. Has Hepatitis B and/or C and an open sore on the breast.  In general, clients with Hepatitis B or C may breastfeed. If a client has an open sore on their breast, or a cracked and bleeding nipple, they may breastfeed from the side that is not affected, and express and discard any milk they collect from the affected side until the sore heals. Ensure the lesion is covered carefully so the infant has lower risk of contact. 

Breastfeeding should be temporarily paused in the following situations.  However, feeding expressed breast milk is acceptable: 

1. Untreated, active tuberculosis
2. Active varicella (chicken pox) infection that developed between 5 days before delivery and 2 days following delivery

Alcohol and Substance Use  

• Alcohol: Not drinking alcohol is the safest option for a breastfeeding client. Generally, moderate alcohol consumption by a breastfeeding client (up to 1 standard drink per day) is not known to be harmful to the infant, especially if the client waits at least 2 hours after a single drink before nursing. However, exposure to alcohol above moderate levels through breast milk could be damaging to an infant's development, growth, and sleep patterns. Alcohol consumption above moderate levels may also impair a parent's judgment and ability to safely care for her child. For parents with a family history of alcoholism, milk ejection reflex may be impaired and overall milk production may decrease from the dehydrating effects of alcohol.  

• Cannabis: While data on cannabis's possible detrimental effects on infants exposed through breastmilk is limited, tetrahydrocannabinol (THC) can pass from the breast milk to the infant. Potential also exists for impairment in the parent's ability to care for the infant. Counsel parents about not smoking in the home with the infant and having sober adults to care for the infant when using cannabis.  

• Tobacco or e-cigarettes: It is always best for a client to NOT smoke or vape. However, for clients who are not prepared to quit, breastfeeding will decrease the baby's risk for respiratory problems, allergies, and Sudden Infant Death Syndrome. Clients who smoke are encouraged to breastfeed, and to keep secondhand smoke (or vaping cartridges or liquid nicotine) away from the infant– not smoking near infant, in the house or car, to change the client's shirt after smoking, etc. Clients who smoke may also have lower milk production. 

• Vaccines: It is safe breastfeed after almost all vaccines. According to the ACIP's General Best Practice Guidelines for Immunization in Special Situations, except for smallpox and yellow fever vaccines, neither inactivated nor live-virus vaccines administered to a lactating person affect the safety of breastfeeding for the breastfeeding person or their infants. 

References 

1. Breastfeeding and the Use of Human Milk. SECTION ON BREASTFEEDING. Pediatrics Mar 2012, 129 (3) e827-e841. 
2. Centers for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. Atlanta: U.S. Department of Health and Human Services; 2013. 
3. Jolley, Sandra. Breastfeeding Triage Tool. Public Health Seattle and King County. 2005, 5th ed