After birth hospital discharge, amount, quality, and type of lactation interventions that breastfeeding families receive can be quite variable. Even before the COVID-19 pandemic, many families had challenges accessing appropriate evidence-based lactation support and care. Since the pandemic, inpatient length of stay has been reduced and lactation evaluation or education prior to discharge may be minimal. Thus, there is an increasing need for primary care providers to enhance their role in technical breastfeeding assistance so the family can reach their personal breastfeeding goals. Given the critical window of opportunity to effectively establish milk supply, it is essential that all nurses who work in primary care settings know about science of human milk and physiology of lactation.

Both the American Academy of Pediatrics (Meek et al., 2017) and the Academy of Breastfeeding Medicine (Grawey et al., 2013) recommend establishing a breastfeeding supportive primary care practice. Nurses in primary care must own the practice of breastfeeding evaluation, care, and interventions. In primary care, physicians and advanced practice nurses have limited time to spend with families because of the fee-for-service nature of reimbursement. Pediatric practices must embrace the role of the nurse in providing this care and support. At the first newborn visit, the nurse should establish the breastfeeding family's goals in terms of exclusivity and duration while reinforcing the recommendations for exclusive human milk for 6 months and continued breastfeeding for a year or more (Meek et al.). At this first visit, it is also essential to assess for risk factors for delay in lactogenesis II (secretory activation) or coming to full volume (Spatz, 2020). If risk factors are identified, or the infant has not been breastfeeding effectively and has not transitioned to yellow seedy stools by day 5, the main priority should be protection of milk supply (Spatz). If there are recommendations for supplementation, pumping must be the first priority to ensure milk supply is protected (Spatz).

At all subsequent visits, breastfeeding should be assessed in detail including: 1) times per day the infant breastfeeds and from one or both breasts; 2) infant's feeding patterns over the course of the day and night (24 recall); 3) does the lactating parent have to go back to work or school; 4) is the lactating parent currently expressing milk? If so, type of pump and amount expressed per breast per session; 5) introduction of solids (at 6 months) while maintaining continued breastfeeding; 6) presence of supportive family members or community supports; and 7) concerns of the lactating parent or any changes in their health status. We recently reported a case where growth failure of the infant was noted and formula feeding was recommended (Spatz & Conover, 2021). However, by applying these detailed assessment questions, it was discovered that the infant was sleeping for a very long period over night and the mother was not expressing. The mother's goal was to maintain exclusive breastfeeding and with thorough assessment and intervention, the infant never required formula, got back on the growth curve and the mother met her goal of breastfeeding for over a year (Spatz & Conover). Nurses in primary care should make it a priority to get the knowledge to provide effective evidence-based lactation care, interventions, and support so they can help breastfeeding families reach their personal breastfeeding goals.

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