The current paradigm of prenatal care is not effectively preparing families to meet their personal breastfeeding goals. Even today in 2020, we have parents who present for prenatal care or for hospital admission for childbirth and are still asked the question "do you want to breastfeed or bottle feed your child?" People make decisions about infant feeding long before they are even planning a family based on the culture and environment in which they are raised. The current paradigm is neither allowing all families to make an informed feeding decision nor is it effectively preparing families about the physiology of lactation and the science of human milk. A new paradigm is essential.

There are four main components of the essential paradigm shift: 1) how healthcare providers approach breastfeeding and human milk during prenatal care; 2) informed decision-making and the science of human milk; 3) physiology of lactation; and 4) optimizing milk supply during the critical window of opportunity. During prenatal care, breastfeeding should be a point of discussion at every visit so that all families can make an informed decision and be guided to meet their personal breastfeeding goals (Spatz, 2018). At the first point of contact, ask: "What have you heard about human milk and breastfeeding"; "Do you have any personal exposure to breastfeeding, friends, family members?"; "What concerns or questions might you have about breastfeeding?"

Informed decision-making involves teaching the family about how human milk and breastfeeding is critical to improve the health of the mother, child, and family. At Children's Hospital of Philadelphia, when I provide personalized one-to-one prenatal lactation consultations, this is the focus. Families are taught about the science of human milk and how human milk improves health and developmental outcomes of children. Families learn about specific components of human milk and how they work to protect their infants from disease and illness (e.g., osteopontin, white blood cells, stem cells, human milk oligosaccharides, antioxidants, antibodies, lactoferrin).

During prenatal care in the second trimester, healthcare providers should emphasize to the mother that she begins secreting milk at 16 weeks of pregnancy. Teaching families that no matter if they give birth early or at term, the mother will always have the perfect amount of milk and that every drop of colostrum produced at birth is vital for their child's health. Healthcare providers should emphasize during prenatal care that after birth the mother's only job should be to eat, sleep, and make milk for their infant. The family should be empowered to support the mother immediately after birth and the first 2 weeks postpartum to optimize the mother's personal milk-making capacity. It important to teach the family that breastfeeding can be hard work. As nurses, we should help mothers and their families to set goals related to the provision of human milk and breastfeeding (Spatz, 2017).

Optimization of milk supply must be a major discussion point during prenatal care. Many mothers today present with risk factors that could delay onset of lactogenesis II and infants can present risk to the breastfeeding relationship. Families should be taught that there is a critical time frame to effectively convert from lactogenesis I to lactogenesis II. If there is concern about the mother's ability to produce milk or the infant's ability to effectively suckle and remove milk from the breast, the mother should initiate pumping to ensure that she comes to volume. The mother should be encouraged to spend the first 2 weeks holding her infant skin-to-skin and breastfeeding the infant on cue. It is essential to change the current practice paradigm so that more families make the decision to provide milk and breastfeed their child and all families can meet their personal breastfeeding goals.

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