A-Z Breast Feeding Guide For
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| When the baby sucks, a hormone called oxytocin starts the milk flowing from the alveoli, through the ducts (milk canals) into the sacs (milk pools) behind the areola and finally into the baby's mouth |
The breast can never be truly "emptied" since milk production
is a continuous biologic process
The let-down reflex
The let-down reflex, also known as the milk ejection reflex, is the stimulation of the muscles of the breast to squeeze out the milk by the release of the hormone oxytocin.
Breastfeeding mothers describe the sensation differently, with some feeling slight tingling and others not feeling anything different.
The reflex is not always consistent, especially at the start of the breastfeeding process.
The thought of nursing or the sound of any baby can stimulate the process, causing unexpected leakage.
Commonly both breasts can give out milk when one infant is feeding, but this and other problems often settle after two weeks of feeding.
One major cause of difficulties during breastfeeding is when the mother is in a stressed or anxious state of mind.
Causes of a poor let-down reflex:
- Sore or cracked nipples
- Separation from the infant
- History of breast surgery
When a mother has difficulties breastfeeding she may try different methods of assisting the let-down reflex, including:
- Feeding in a familiar and comfortable location
- Massage of the breast or back
- Warming the breast with a cloth or shower
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Benefits
The benefits of breastfeeding are both physical and psychological.
Nutrients and antibodies are passed through to the baby and the process of breastfeeding releases hormones into the woman's system.
The bond between the baby and its mother is also strengthened during breastfeeding.
Benefits for the infant
Breast milk consumption has been linked to a decreased risk for several infant conditions including Sudden Infant Death Syndrome (SIDS). The sucking technique required of the infant encourages the proper development of both the teeth and other speech organs.
Numerous health benefits of breastfeeding have been medically documented.
According to the American Academy of Pediatrics' policy statement on breastfeeding and the use of human milk, "Extensive research, especially in recent years, documents diverse and compelling advantages to infants, mothers, families, and society from breastfeeding and the use of human milk for infant feeding [1].
These include:
- Health
- Nutritional
- Immunologic
- Developmental
- Psychological
- Social
- Economic
- Environmental benefits
Breast milk helps to lower the risk of or protect against:
- Diabetes
- Gastroenteritis
- Diarrhea
- Eczema
- Allergies
- Urinary tract infections
- Chest infections and wheezing
- Ear infections
- Obesity
- Attention-deficit hyperactivity disorder
- Recent studies show that children who have been breastfed on
average score
- igher on IQ tests than those babies who have not been breastfed.
Benefits for the mother
Breastfeeding has also been shown to be beneficial to the mother.
BONDING: The act of breast feeding releases hormones which have been found to both relax the mother and cause her to experience nurturing feelings toward her infant.
RECOVERY: Breastfeeding as soon as possible after giving birth increases levels of oxytocin which encourages a more rapid contraction of the uterus and in turn decreases postpartum bleeding.
Breastfeeding can also allow the mother to return to her pre-pregnant weight as the fat stores accumulated during pregnancy are utilized in milk production.
Frequent and exclusive breastfeeding delays the return of menstruation and fertility (known as lactational amenorrhea) allowing for improved iron stores and the possibility of natural child spacing.
Breastfeeding mothers experience improved bone re-mineralization postpartum, and a reduced risk for both ovarian and pre/post-menopausal breast cancer.
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Bonding
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Madonna Litta, a circa 1490 painting by Leonardo da Vinci |
The maternal bond is strengthened through breastfeeding, with the hormonal releases giving the mother positive feelings of nurture towards the child.
Building upon this bond is very important as studies show that up to 80% of mothers suffer from some form of postpartum depression, though most cases are very mild.
The partner can support the mother in a variety of ways and is seen as an important factor in successful breastfeeding.
This can also help to establish the paternal bond in fathers.
The relationship between the partner and the child can also be greatly affected by the act of breastfeeding.
While some partners may feel left out when the mother is feeding the baby, others may see the whole process as a chance to bond as a family.
Breastfeeding, possibly alongside birth-related health problems, takes a lot of time. This may add pressure to the partner and the family, with them having to work harder, caring for the mother and performing tasks she would otherwise do.
However, as they are often very willing to show their supportiveness, this pressure can help to strengthen the family bonds.
If looking after the child while the mother is away, the father may find it impractical or inappropriate to feed expressed breast milk to the infant. This may remove the choice of the mother of whether to breastfeed her child or not.
Family support in breast feeding is a important part of successful breastfeeding!
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Recommendations and research
"Pediatricians and parents should be aware that exclusive breastfeeding is sufficient to support optimal growth and development for approximately the first 6 months of life......Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child."
– The American Academy of Pediatrics (AAP) [2]
"A vast majority of mothers can and should breastfeed, just as vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother's milk be considered as unsuitable for her infant. For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed milk from the infant's own mother, breastmilk from a healthy wet-nurse or a human-milk bank, or a breastmilk substitute fed with a cup, which is a safer method than a feeding bottle or a teat – depends on individual circumstances"
"If we allow the 'breast versus bottle' argument to be reduced to a simple issue of nutrition, we ignore the much greater potential breastfeeding has to enhance the lives of parents and children."
– Gill
Rapley, deputy programme director of the UNICEF UK Baby Friendly
Initiative [4]
Difficulties and Complications
It is not uncommon for a mother and child to have difficulties breast feeding, with some women unable to feed their child at all.
Others find it too problematic or choose not to attempt or continue breastfeeding for personal reasons.
Breast refusal
When first born the child must learn how to feed.
Though babies have a natural sucking reflex they may occasionally resist feeding from the breast, often due to external factors.
It is important for the baby to be fed soon after birth in order to quickly establish the routine and to become accustomed to feeding from the breast.
Other causes of breast refusal include:
- Overhandling after birth
- Formula feeding, sometimes without the knowledge of the mother
- Poor feeding technique
- The use of artificial teats leading to "nipple confusion"
- The presence of thrush in the mouth of the baby
- Distractions or interruptions during feeds
- Long separations from the mother
- Breathing difficulties, often caused by a common cold
- Pain or discomfort; for example, due to recent surgery or medical procedures (such as circumcision [6] [7]
In later stages teething is a significant hindrance to breastfeeding and is seen by many as the ideal time to wean the infant.
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Medical conditions of the infant
Reasons for the inability of an infant to feed include:- Difficulties latching onto the breast
- Poor sucking reflex
- Poor stamina
- Medical conditions such as cleft palate
- Hypoglycemia or Hyperglycemia
- Premature babies have difficulties because their sucking reflex is still underdeveloped and because they tire during feeds.
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Medical conditions of the mother
Damage to the breast tissue can cause problems or totally prevent
manageable breastfeeding, especially women with history of breast
surgery or infection.
Cancer (particularly breast cancer) and chemotherapy treatments have also been shown to cause difficulties.
However, many women with previous surgeries, abscesses and cancer can breastfeed successfully.
Infectious diseases such as HIV, AIDS, or active, untreated tuberculosis can be passed onto the infant.
A HIV-positive mother breastfeeding an infant can, in some countries, be investigated for child abuse – a 1998 case in the U.S. resulted in the HIV-positive mother being reported to social services for her continued breastfeeding and non-treatment of the child for HIV [8].
The presence of herpes lesions on the breast is also contraindicative to breastfeeding.
Mastitis, the inflammation of the mammary glands caused by the blocking of the milk ducts, can cause painful areas on the breasts or nipples and may lead to a fever or flu-like symptoms.
It is not necessary to wean a nursling simply because of mastitis; in fact, nursing is the most effective way to remove the blockage and alleviate the symptoms, and is not harmful to the baby.
Sudden weaning can cause or exacerbate mastitis symptoms.
Negative effects upon the infant
Breastfeeding can be harmful to the infant if the mother:
- Is taking certain medications that suppress the immune system
- Is taking certain medications which may be passed onto the child
through the milk and are found to be harmful. However, the vast
majority of medications are compatible with breastfeeding.
- Has had excessive exposure to heavy metals such as mercury
- Uses potentially harmful substances such as cocaine, heroin and amphetamines – substances such as caffeine, tobacco, and alcohol, while possibly harmful to the nursling if consumed in large quantities, are safe to use in moderation while breastfeeding (see below).
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Health and diet
Since the nutritional requirements of the baby must be satisfied
solely by the breast milk in exclusive breastfeeding it is important
for the mother to maintain a healthy lifestyle, especially
with regards to her diet.
If the baby is large and grows quickly, the fat stores gained by the mother during pregnancy can be quickly depleted, and she may have trouble eating well enough to keep developing sufficient milk.
The diet usually involves a high calorie, high nutrition diet which follows on from that in pregnancy. There are no foods which are absolutely contraindicated during lactation, although a baby may show a sensitivity to particular foods in the mother's diet.
Some breastfeeding advisers suggest mothers avoid certain gas producing food, such as beans, if the baby starts to develop colic or gas.
Breastfeeding mothers must use caution if they regularly consume nicotine through tobacco smoking.
In addition to reducing the milk supply, heavy use of cigarettes by the mother (more than 20 per day) has been shown to cause:
- Vomiting
- Diarrhea
- Rapid heart rate
- Restlessness
in breastfeeding infants.
Research is ongoing to determine whether the benefits of breastfeeding out-weigh the potential harm of nicotine in breast milk.
The effects of a smoky environment are thought to have links to Sudden Infant Death Syndrome (SIDS).
Breastfeeding mothers who smoke are counselled not to do so during or immediately before feeding their child, and are encouraged to seek advice to help them to reduce their nicotine intake or to quit.
Heavy alcohol consumption is known to be harmful to the infant, causing problems with the development of motor skills and decreasing the speed of weight gain.
However, there is no consensus on how much alcohol may be safely consumed and it is generally agreed that small amounts of alcohol may be occasionally consumed by a breastfeeding mother.
It is unknown what level is safe. Some believe that a single daily glass of wine is sufficient to cause distress, with levels of alcohol in breast milk peaking 30 to 90 minutes after one drink of moderate alcoholic content.
Considering the known dangers of alcohol exposure to the developing fetus, many medical professionals believe it is prefereable to err on the side of caution with alcohol exposure to a baby and have breastfeeding women restrict or eliminate their alcoholic intake.
Excessive caffeine consumption by the mother can cause irritability, sleeplessness, nervousness and increased feeding in the breastfed infant. Moderate use (one to two cups per day) usually produces no effect. Breastfeeding mothers are advised to avoid or restrict caffeine intake.
The recreational use of marijuana in conjunction with breastfeeding is a controversial issue.
The AAP Committee on Drugs lists marijuana in their table of Drugs of Abuse for Which Adverse Effects on the Infant During Breastfeeding Have Been Reported yet they reference only one study in the literature and this study reports no effect. [9]
There is a lack of research on the effects of marijuana on the breastfed infant.
Withdrawal from marijuana can cause some mild unpleasant effects, however these disappear in a few weeks, and the mother's body becomes almost free of the active ingredient in just a few days.
Baby Feeding Options and Requirements
Exclusive breastfeeding is generally defined as feeding a baby nothing
but breast milk.
Predominant or mixed breastfeeding is the practice of feeding breast milk along with some form of substitute – infant formula or baby food, depending upon the age of the child, or even water.
The baby's feeding method is different from artificial teats to a nipple.
When feeding from a bottle an infant will suck harder than on the nipple, where the tongue is used to massage the milk out more than it is sucked, and it does not go as far into the mouth.
This leads to the advice of not mixing breastfeeding and bottlefeeding (or the use of dummies) until the baby is adept at feeding from its mother.
Orthodontic teats, which are generally slightly longer, can be used to greater replicate the nipple.
Exclusively breastfed infants feed, on average, 6–10 times a day.
The requirements vary greatly between children, with newborns consuming in the range of one to three ounces and babies after the age of four weeks consuming around four ounces per feed.
Each baby is different and as it grows this amount will increase.
It is important to recognise the signs of a baby's hunger and it is advised that the baby should dictate the number, frequency, and length of each feed, based on the assumption that it knows the amount of milk it needs.
The supply of milk in the breast is determined by the frequency and length of these feeds or the amount of milk expressed.
One criticism of breastfeeding is the difficulty in accurately monitoring the amount of food taken by the baby.
This, however, is largely discounted because the baby will feed as per its own requirements.
It is also easily possible to monitor, in an exclusively breastfed infant, output – wet and soiled nappies.
An acceptable amount of output (6–8 wet cloth or 5–6 wet disposable, and 2–5 soiled per 24 hours) indicates an acceptable amount of input.
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Expression
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Expressed breast milk (EBM) or infant formula can be fed to an infant by bottle |
When direct breastfeeding is not possible the baby may still be fed breast milk.
By expressing (artificially removing and storing) her milk, a mother can allow her child to be fed while she is not present or does not have the opportunity to do so herself.
With expression through manual massage or the use of a breast pump the woman can draw out her milk and keep it in a bottle ready for use.
This bottle may be:
- Refrigerated for up to eight days
- Frozen for up to four month
though research suggests that antioxidant activity in breast milk decreases over time [10]although it still remains in levels higher than infant formula.
Expression can be used to prolong the lactation when required.
This is most common if the mother and child are separated for an extended period. In cases of the baby being unable to feed, expressed milk can be fed through a nasogastric tube.
Expressed milk can also be used to assist a mother who is experiencing difficulty breastfeeding, in the later stages because of a newborn causing grazing and bruising or because of an older baby growing teeth and biting.
Some women donate their expressed breast milk (EBM) to other people, either directly or through the hospital.
Though some dislike the idea of feeding their own child with another person's milk, others appreciate the ability to give their baby the benefits of breast milk.
Infant formula
If the decision is made not to feed the child with breast milk or
if it is not possible, then infant formula is given to the infant,
usually using a baby bottle.
While proven inferior to breast milk, infant formula has in recent times been marketed as being a superior feeding solution.
Such marketing has been successful in many areas, with a 2004 UK Department of Health survey showing that 34% of women believe infant formula to be very similar to or the same as breast milk. [11]
Infant formula may be introduced as a supplemental liquid drink to weaned babies and taken from a cup. It is treated for human babies and thus a healthier option to simply drinking the milk from another animal.
Infant formula has been heavily marketed and promoted to many new mothers as the preferred option to breastfeeding.
In 1979 the International Baby Food Action Network (IBFAN) was formed to help raise awareness of such practices.
The World Health Organization recommends that all mothers be encouraged to breastfeed, and hospitals that are accredited by the World Health Organization are tolerant of formula feeding but do not offer it to healthy infants who can breastfeed.
Tandem, Extended, and Shared Breast-Feeding
Feeding two infants simultaneously is called tandem breast feeding.
The most common need for this is after the birth of twins whereby both babies are fed at the same time.
It is not necessarily the case, however, that the appetite and feeding habits of both babies are the same. This leads to the complication of trying to feed each baby according to their individual requirements while also trying to breastfeed them both at the same time.
In cases of multiple births with three or more children it is extremely difficult for the mother to organise feeding around the appetites of all of the babies.
The mammary glands can produce a high quantity of milk, according to the demand placed upon them, and many mothers have been able to successfully feed their infants [12].
It is common, however, for the woman to look to other alternatives.
Tandem breast feeding is also convenient if a woman gives birth to a newborn while still feeding an older baby or child. Under these circumstances it is possible for the newborn baby to miss out on the beneficial colostrum.
Although some may find it controversial, some women breastfeed their offspring for as many as three to seven years from birth. This is referred to as extended breast feeding. All the benefits of human milk–both nutritional and emotional–continue for as long as a child nurses.
In developing nations within Africa and elsewhere, it is sometimes
common for more than one woman to feed a child. This shared breast
feeding has been highlighted as a source of HIV infection amongst
infants born HIV-negative [13].
Breast-feeding Method
There are many texts available to new mothers to assist in the establishment of breast feeding. The following is only meant to be a introduction.
The baby will usually indicate hunger by crying or moaning and fussing.
When the baby's cheek is stroked, the baby will move his or her face towards the stroking and open his or her mouth, demonstrating the rooting instinct.
Breast-feeding can make the mother thirsty and can last for up to an hour (usually in the early days, when both mother and baby are inexperienced) – it is therefore common for the mother to require a drink during the process.
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Feeding and positioning
While for some people the process of breast feeding seems natural there is a level of skill required for successful feeding and a correct technique to use.
Incorrect positioning is one of the main reasons for unsuccessful feeding and can easily cause pain in the nipple or breast.
By tickling the baby's cheek with the nipple the baby will open its mouth and turn toward the nipple.
When this happens you should then position your breast so that the baby has a mouthful of nipple and areola – the nipple should be at the back of the baby's throat.
Inverted or flat nipples can be massaged to give extra area for the baby to latch onto. Many mother's choose to wear a nursing bra to allow easier access to the breast than normal bras.
The baby may pull away from the nipple after a few minutes or after a much longer period of time. Sometimes the baby will relatch on the same breast or mother may offer the other side.
The fat content of the milk increases as the breast empties. Babies should be permitted to "finish the first breast first" before offering the second breast and without a time limit on feeding from either breast.
The length of feeding is quite variable.
Regardless of the duration, it is important for the breast feeding
mother to be comfortable:
- Upright: The sitting position with the back straight.
- Mobile: The mother carries her nursling in a sling or
other baby carrier while breast feeding. Doing so permits the
mother to incorporate breast feeding into the varied work of daily
life, such as shopping, working in the garden, housework, hiking,
etc.
- Lying down: Good for night feeds or for those who have
had a caesarean section.
- On her back: Mother is usually sitting slightly upright;
particularly useful for tandem breast feeding.
- On her side: The mother and baby lie on their sides.
- Hands and knees: The mother is on all fours with the baby underneath her (not usually recommended).
There are many positions and ways in which the feeding infant can
be held. This depends upon the comfort of the mother and child and
the feeding preference of the baby – some babies tend to prefer
one breast to another.
Most women breastfeed their child in the cradling position.
Cradling positions:
- Cradle hold: The baby is held with its head in the woman's elbow
horizontally across the abdomen, "tummy to tummy", with
the woman in an upright and supported position.
- Cross-cradle hold: As above but the baby is held with its head
in the woman's hand
- Football hold: The woman is upright and the baby is held securely
under the mother's arm with the head cradled in her hands.
- Feeding up hill: The baby lies stomach to stomach with the mother
who is lying on her back; this is helpful for babies finding it
difficult to feed.
- Lying down:
- On its side: The mother and baby lie on their sides.
- On its back: The baby is lying on its back (cushioned by
something soft) with the mother on her hands and knees above
the child (not usually recommended).
- On its side: The mother and baby lie on their sides.
When tandem breast feeding the mother may be unable to move the
baby from one breast to another and comfort can be more of an issue.
This brings extra strain to the arms, especially as the babies grow, and many mothers of twins recommend the use of more supporting pillows.
Favoured positions include:
- Double cradle hold
- Double clutch hold
- One clutched baby and one cradled baby
Lying down
Breast and nipple pain
breast feeding may hurt some women, sometimes related to an incorrect
technique, but usually eases over time.
Milk ducts can block up on occasion, leading to breast engorgement or mastitis, and should be addressed with massage and by encouraging the baby to suck from that side to keep it as empty as possible until the problem goes away.
A new onset of pain when nursing has previously been going well may be due to a yeast infection of the nipples.
Limiting feeding time does not prevent soreness.
Fair skinned mothers are most likely to experience cracked nipples, but it can happen to anyone.
The baby's rough tongue can also cause grazes and the suction can cause bruising.
Some mothers apply medical grade lanolin to sooth nipples; La Leche League has endorsed Lansinoh, an ultrapure medical grade lanolin cream designed for breast feeding mothers.
If breast feeding is endured for the initial six weeks, this usually becomes easier, as both mother and baby learn the best technique.
Mothers can also buy or hire breast pumps to extract the milk, if nipple pain becomes unbearable.
Weaning
Weaning is the process of gradually introducing the infant to what will be its adult diet and withdrawing the supply of milk.
The infant is considered to be fully weaned once it no longer receives any breast milk (or bottled substitute) and begins to eat baby food.
This often leads to lactose intolerance.
Publicity, Promotion and Law
In response to public pressure, the health departments of various
governments have recognised the importance of encouraging women to breastfeed.
The required provision of baby changing facilities was a large step towards making places more accessible for parents.
In many countries there are now laws in place to protect the rights of a breast feeding mother when feeding her child in public.
The World Health Organisation (WHO), along with grassroots non-governmental organisations like the International Baby Food Action Network (IBFAN) have played a large role in encouraging these governmental departments to promote breast feeding.
Under this advice they have developed national breast feeding strategies, including the promotion of its benefits and attempts to encourage mothers, particularly those under the age of 25, to choose to feed their child with breast milk.
Government campaigns and strategies around the world include:
- National
breast feeding Week (http://www.breastfeeding.nhs.uk/nb_nbaw.asp)
in the UK
- The
Department of Health and Ageing Breastfeeding Strategy (http://www.health.gov.au/pubhlth/strateg/brfeed/index.htm)
in Australia
- The National Women's Health
Information Center (http://www.4women.gov/) in the U.S.
- La Leche League (http://www.lalecheleague.org/), a volunteer mother-to-mother international group.
However, there has been a long, ongoing struggle between
corporations promoting artificial substitutes and grassroots organisations
and WHO defending breast feeding.
The International Code of Marketing of Breast-milk Substitutes was developed in 1981 by WHO.
But organisations, including those networked in IBFAN, claim that, in particular, Nestle took three years before it initially implemented the code, but in the late 1990s and early 2000s was again violating the code.
Formula marketing
In 1981, 118 countries voted in favour of the International Code
of Marketing of Breast-milk Substitutes, but the USA voted against it.
The US justified their decision on the grounds that it was a violation of freedom of speech guaranteed by the First Amendment of the Constitution of the USA.
In the USA corporate personhood, or corporations have the same human rights as individual humans. [19].
breast feeding in public
When in public with a breastfed baby it is often difficult to avoid the need to feed the infant.
The public reaction at the sight of breast feeding can make the situation uncomfortable for those involved.
There are numerous laws around the world that have made public breast feeding legal and companies disallowed from prohibiting it.
In the U.S. the "Right to Breastfeed Act" (HR 1848) was signed into law on September 29, 1999 affirming the right of a woman to breastfeed her child anywhere on federal property.
However, not all state laws have affirmed the same right in their respective public places. Nowhere is breast feeding in public illegal.
A survey reported by the UK Department of Health stated that most people (84%) find breast feeding in public acceptable as long as it is done discreetly [20]
Contrastingly, 67% of mothers are worried about general opinion being against public breast feeding.
To combat these fears in Scotland, a bill [21] safeguarding the freedom of women to breastfeed in public has been passed in the Scottish Parliament.
The legislation sets up a fine of up to £2500 for preventing breast feeding in legally permitted places.
In Canada, the Canadian Charter of Rights and Freedoms affords some
protection under gender equality.
Although Canadian human rights protection does not explicitly include breast feeding, a 1989 Supreme Court of Canada decision (Brooks v. Canadian Safeway Ltd.) set the precedent for pregnancy as a condition unique to women and that thus discrimination on the basis of pregnancy is a form of sex discrimination.
Canadian legal precedent also allows women the right to bare their breasts, just as men may. In British Columbia, the British Columbia Human Rights Commission Policy and Procedures Manual protects the rights of female workers who wish to breastfeed.
Many mothers choose to purchase pumping equipment or express milk ("milk" themselves) by hand so that they can carry a small bottle of milk with them if they plan to be out at mealtimes.
This allows them the advantages of breast feeding while avoiding possibly uncomfortable situations. Breastfed babies can have trouble transitioning to a bottle, so this may not work for everyone.
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