J Pediatr Adolesc Gynecol (2006) 19:419e421
Management Quandary
Section Editors: Lesley Breech, MD
University of Cincinnati College of Medicine, Cincinnati, Ohio
Elisabeth H. Quint, MD
University of Michigan Health Systems, Ann Arbor, Michigan
Case 2005: Management of an Adolescent Mother and
Breastfeeding
Discussant: Claire Westdahl, CNM
Emory University School of Medicine, Atlanta, Georgia
Case Presentation
A 15-yr-old G1P0 female (SC) is 38 weeks pregnant
and presents to see her nurse midwife for continuing
prenatal care. During her visit, she and her provider
begin discussing post delivery plans, including pediat-
ric care, infant feeding, and contraception. She says
that she would like to bottle-feed her baby using for-
mula. She describes that she is afraid breastfeeding
will be painful. She also admits to being embarrassed
to feed around others.
Ms. Westdahls comments:
A teens decision to breastfeed has far-reaching ben-
efits that include the infants and her own health as
well as benefits to society. To reach the Healthy Peo-
ple 2010 goals of 75% breastfeeding initiation we
need to do more than reiterate the benefits of breast-
feeding. It is surprising how knowledgeable women
are about the benefits of breastfeeding, even teen-
agers. However, the decision to breastfeed is made
after weighing the pros and cons within the context
of the womans own beliefs, knowledge, confidence,
and support systems. One study reported that 78% of
adult women made their feeding decision before
pregnancy or during the first trimester. To improve
efficacy in promoting the decision to breastfeed, the
breastfeeding conversation should be initiated at
the first contact with the young woman and repeated
at each encounter.
An effective approach to promote the decision to
breastfeed includes three easy steps: First: Ask the
woman an open-ended question to elicit her feelings,
worries and thoughts about breastfeeding. What are
you thinking about breastfeeding? This open-ended
approach does not ask for a feeding decision. This
approach recognizes that most women would like
2006 North American Society for Pediatric and Adolescent Gynecology
Published by Elsevier Inc.
more information and help overcoming their barriers
to breastfeeding. When a woman is asked for a feed-
ing decision, How do you plan to feed your baby?
the default decision is often formula feeding. Once
a feeding decision has been expressed, it is difficult
to provide more information and to recommend
breastfeeding without being perceived as overbearing
and guilt producing. When women are asked an
open-ended question they will be more likely to share
their thoughts and fears about this complex decision.
The most common worries teens share when asked
about breast feeding include time constraints like go-
ing back to school, fear of pain, embarrassment, lack
of social support, and the all-pervasive feeling of lack
of confidence.
After asking an open-ended question and listening to
the answer, the second step is to affirm what tis heard.
Affirmation statements let the woman know that she has
been heard, that you accept her statement and that she
was safe when she shared a little piece of her private
thoughts and fears. An example would be, I have
heard that from many of my patients. The woman will
relax and be open to your next statement. This second
step is important, yet it is most likely to be omitted by
a busy practitioner. It just takes a few seconds and reaps
untold rewards by increasing confidence and im-
proving relationships with your teen patients.
The third step of this counseling strategy is to provide
targeted education to address the specific fear or con-
cern the adolescent shared with you. If she mentions
embarrassment, you will give her information
about covering up or give her permission to give
a bottle in public. If she mentions lack of confi-
dence, you can assure her that her breasts will make
milk just as well as her body is growing the baby.
You can include additional education about how the
breast works and where to get more information. If
she mentions pain, you can assure her that breast-
feeding is not supposed to hurt and that we now know
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420 Breech and Qunit: Management Quandary
better how to teach the baby to attach to minimize
discomfort to the mother. As well as reducing the
barriers to breastfeeding, you can highlight the
unique benefits of breastfeeding. For teens, the
unique benefits of breastfeeding compared to formula
feeding include having a relationship with the baby
that others cannot usurp, fewer infant sick days,
and getting her figure back faster.
If this 3-step strategy is repeated at every encounter
you will uncover the complex thinking and weighing
of pros and cons that goes into the decision to breast-
feed. You will have taken advantage of the many op-
portunities to provide education, advice, support, and
referrals which specifically address the unique needs
of your patients. This 3-step strategy was designed to
fit into the time constraints of busy practitioners.
More information about the 3-Step Counseling Strat-
egy as well as materials, such as Physician/Health
Provider Breastfeeding Support kits and Your New
Life MagazineAn Informative Guide to Breast-
feeding for Teens and Teen Mothers, is available
from Best Start, Inc.2
At delivery, SC has a prolonged labor with a poorly
functioning epidural and a difficult second stage of la-
bor. She has a vacuum-assisted vaginal delivery of an
8-lb male infant. She suffers a third-degree perineal
laceration, which is repaired after delivery. She is
exhausted and declines an offer to breastfeed the baby
in the delivery room.
Ms. Westdahls comments:
Immediate mother-baby contact after birth has been
firmly established as evidence-based practice that
supports breastfeeding.3 Early initiation of breast-
feeding within the first hour after birth should be en-
couraged. Early nursing is associated with an
increase in the percentage of couples still nursing at
2e4 months post partum. In contemporary hospital
practice there are many routines that interrupt
initiation of early and uninterrupted maternal infant
contact. Many of those procedures can be accom-
plished with the infant on the mothers abdomen. If
the teen is unwilling to put the baby to breast, she
should be encouraged to accept the infant on his/
her abdomen for uninterrupted skin-to-skin contact.
Often, the infant will find the nipple and areola on
his/her own during the alert first hour after birth.
The teens feeling of competence as a mother will
be enhanced if you point out to her how her baby
is looking for her and calms when they are together.
Even after long and difficult childbirth a woman will
cuddle and gaze at her baby. This teen should be pro-
tected and supported to do just that.3
At her postpartum visit, 6 weeks after delivery, she
says that she is still trying to breastfeed the baby, but
has found it difficult to manage feedings alone. Her
friends have told her that using formula would be eas-
ier for her. She complains of fatigue and is worried
about how much help she will have as she returns to
school and a part-time job.
Ms. Westdahls comments:
The Healthy People 2010 goal aims for 75% of women
to initiate breastfeeding. Currently only 45% of teens
ever breastfeed and only 17% are exclusively breast-
feeding at 3 months.4 Praise her success and take the
time to explore her concerns. Fatigue and stress can af-
fect the milk supply. This teen needs help in order to
rest and assure adequate nutrition including sleeping
near her infant to minimize nighttime sleep distur-
bance. Be sure to screen this young mother for signs
and symptoms of post-partum depression.
Every nursing mother needs help, support, and encour-
agement. Support systems for breastfeeding are ideally
set up before they are needed. Adolescent mothers
have unique needs for support during breastfeeding.
Including the babys father and the teens mother in
the breastfeeding conversations offers an opportu-
nity to address their specific worries and fears that
might prevent them from supporting the breastfeeding
teen mother. Peer support counselors, young women
who have met the unique challenges of breastfeeding
while returning to school and work, are particularly
effective with teen mothers and have been shown to
improve initiation and duration of breastfeeding.5
The teen will need to make plans for feeding her infant
while they are separated. Expressing/pumping breast
milk and having the child care provider feed breast
milk from the bottle is a good plan. A good quality
electric pump will make it easier to efficiently express
adequate amounts of milk. Milk expression and stor-
age should begin before the planned separation so that
there is an adequate supply of milk stored before she
returns to work or school. Teens often work in environ-
ments without access to privacy and milk storage facil-
ities. The teen should explore her work and school
environment to assess on-site childcare services and/
or to plan where to pump and to store breast milk.
You can reassure her that after separation, breastfeed-
ing will be a good way to re-establish the close connec-
tion between her and her baby. Specific strategies for
the mother who is returning to work or school are listed
in the Breastfeeding Handbook for Physicians.1 Com-
munity resources which can be very helpful include:
Peer counseling services through some WIC Pro-
grams, the La Leche League, support groups through
pediatric offices, telephone support lines, and private
lactation consultants.
As a physician/health care provider caring for adoles-
cent mothers you will have many opportunities to
promote, support and protect breastfeeding and to
help young women achieve a satisfying and success-
ful breastfeeding experience.
References
1. Schanler R, Dooley S. (eds): Breastfeeding Handbook for
Physicians. Elk Grove Village, American Academy of
Pediatrics, and the American College of Obstetricians
and Gynecologists, 2006
 Breech and Qunit: Management Quandary
2. Best Start, Inc. Your New Life MagazineAn Informative
Guide to Breastfeeding for Teens and Teen Mothers.
Available: www.beststartinc.org. Accessed November 6,
2006.
3. Kroeger M, with Smith L: Impact of Birthing Practices on
Breastfeeding: Protecting the Mother and Baby Continuum.
Sudbury, MA, Jones and Bartlett Publishers, 2004
4. Breastfeeding: Data and Statistics: Breastfeeding Prac-
tices Results from the 2004 National Immunization
421
Survey. Atlanta, US Department of Health and Human
Services, Centers for Disease Control and Preven-
tion, 2005. Available: www.cdc.gov/breasttfeeding./data.
Accessed November 6, 2006.
5. Shealy KR, Li R, Benton-Davis S, Grummer-Strawn LM:
The CDC Guide To Breastfeeding Interventions. Atlanta,
US Department of Health and Human Services, Centers
for Disease Control and Prevention, 2005. Available:
www.cdc.gov/breastfeeding.