Breastfeeding Management for theClinician: Using the Evidence

Marsha WalkerJones & Bartlett, 2006

Sudbury, Massachusetts, USA496 pp, $46.95, pb

Over the last two decades an explosion in research onlactation has occurred. In parallel, breastfeeding man-agement and counseling have changed radically andmore and more clinicians have identified their practiceas ‘‘evidence-based.’’ It seems like a real victory forscience, for practitioners, and above all, for mothersand infants—and to some extent it is, but as MarshaWalker tells us, there are ‘‘large gaps existing between

common practices and what the research actuallysays’’ (p 137). Breastfeeding Management for the Clini-cian aims to fill the gap.

Taking the glossy strands of research in one handand the more mundane practice strand in the other,Walker weaves the two together into an elegant,coherent whole that is both solidly science basedand exciting in its implications for practice. Usinganatomy, physiology, and the bio-specificity ofhuman milk, she lays a solid foundation for assessingbreastfeeding and the context in which it is being prac-ticed, recognizing issues that may influence it andmaking recommendations for solutions and interven-tions to most effectively help mothers and infantsbreastfeed.

Her basic assumptions are straightforward (p 130):

d The human infant. . .is uniquely adapted to securefood and nurturance from the maternal breast rightfrom the start

d Prompt recognition of deviations and appropriatereferrals and follow-up often permit breastfeedingor the provision of breast milk in even the mostextreme situations

d All babies benefit from human milk

Building systematically on her model of howbreastfeeding is meant to work, Walker explores thereasons why actually getting it to work is sometimesa challenge. Chapters on infant issues for breastfeed-ing (Part II) provide the tools for practitioners toidentify and manage everything from hypoglycemiato hypernatremic dehydration to the long-term issuesrelated to congenital anomalies, both the familiar(cleft lip/palate, Down syndrome) and those seenonly seldom (esophageal atresia, Rubenstein-Taybisyndrome). Research and practice speak with onevoice here: the vast majority of infants—even thosecompromised by birth defects or illness—can learnto suckle at the breast, and for those few who cannot,mother’s milk feeding is almost always an option.

Maternal issues may also pose a challenge tobreastfeeding. In the final two chapters, Walkerexplores both the classic breast-related difficulties(sore nipples, engorgement, mastitis, abscess, priorsurgery) and medical, emotional, and environmentalfactors (spinal cord injury, maternal metabolic condi-tions, mood disorders, and maternal employment).Here, too, her view that there is nearly always a wayto make breastfeeding possible is backed up withrecent research and developments in practice. Twominor points mar the perfection of this chapter: anold (1977) citation from Lozoff et al to the effect that‘‘perinatal medical management practices. . .approachthe limits beyond which breastfeeding may fail ‘thelimits of adaptability’’’ is presented without commen-tary, although experience with nonpuerperal lactationhas demonstrated that ‘‘the limits of adaptability’’ arebroader than generally believed. The brief section on

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induced lactation and relactation could have beenmore useful had it drawn on the World Health Orga-nization relactation review and on recently publishedinternational literature to provide more concretedetails.

Of particular interest to Birth readers will be thesection on the influence of peripartum factors onbreastfeeding (Chapter 4). Here the author has care-fully assembled the research to document what manyclinicians observe in their practice: medications inlabor, instrument deliveries, and other interventionscan ‘‘disturb the behavioral sequence of pre-feedingbehaviors immediately after delivery, such as hand-to-mouth movements, touching of the areola, sucklingmovements, and the sucking pattern itself’’ (pp 142–143). Add early separation and the acceptance ofextended crying as ‘‘normal’’ to the mix and the stagehas been set for interventions, among them supple-mentation and pacifier use, that can undermine boththe establishment of lactation and the mother’s confi-dence in her ability to feed her infant at the breast.Particularly noteworthy with respect to supplementa-tion is research indicating that ‘‘breastfed infants sup-

plemented with formula lost significantly more weightthan exclusively breastfed infants or exclusively bot-tle-fed infants’’ (p 153). The second half of this chapteris an extensive, differentiated analysis of the indica-tions for, and the management of, supplementationwith a breastfed baby, which clearly defines when sup-plementation is therapeutic and supportive of breast-feeding and when it reflects a lack of knowledge of thephysiology of lactation. It should be required readingfor every pediatrician, midwife, and nurse practi-tioner.

For more than a quarter of a century, MarshaWalker has worked methodically to ensure that infor-mation about lactation—both for professionals andfor parents—is rooted in science. In the process shehas launched some far-reaching action and madesignificant contributions to the literature. This bookmay be her best effort yet.

Elizabeth Hormann, EdM, IBCLCNeusser Str. 866

50737 Cologne, Germany

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