ABCs of Breastfeeding

Introduction.

Breast-feeding of little baby in a close up photo.

Breastfeeding (casually known as nursing) is the feeding of human babies and young children with milk from a woman’s breast. It should be distinguished from breast milk feeding in which breast milk is fed through a bottle. It’s a practice as old as humanity itself but it’s form and significance hasn’t changed much. The forms, perceptions and nature of breast feeding have however, been shaped by different societies, social classes, ethnicity, and times.

In the early times, before the total world population ever reached a billion, breastfeeding was an honorable responsibility reserved for the biological mother and in fact was seen to be a “crown of mother hood”. The rise of social stratification and female emancipation however, stirred negative sentiment towards the practice. Moses of the Bible, perhaps one of the 20 elders before the almighty throne today, was himself to be breastfed by a wet nurse. Interestingly, the appointed wet nurse was his biological mother! A majority of female European royals for instance, never breastfed their babies and almost entirely relied on wet nurses (a woman charged with the responsibility to nurse an infant which is not hers, by providing breast milk). Previously, this was only done to preserve an unfortunate infant who couldn’t be nursed by their mother due to natural impossibilities. When slavery took hold, one of the duties assigned to female slaves by their mistresses was wet nursing since they themselves perceived breastfeeding as a lowly indulgence.

As a result, the portrait of breast feeding was repainted, it then got to be viewed as something to be avoided by all women of a “certain form”.
The haughty spirit tricked well into the industrial world where, increasingly, the women are taking part in the public stage. Humanity once again revisited this issue in the mid 20th century through research and there has been tremendous change for the better! Breast feeding is once again common to all humanity and is altogether being celebrated as a wonderful practice ( to the extent that the entire first week of August every year is dedicated to just that). Thanks to modern day science, it’s now a practice whose value shall never be undermined.

How does breast feeding naturally occur (the physiology) and how is it possible (the mechanism)?

Inherently, a woman’s body is primed to prepare for breastfeeding (BF) the moment they get pregnant. There is a general weight gain (much as most of it is directly due to the growing pregnancy) in which the pregnant woman’s body stores more fat in preparation for a higher energy expenditure after birth.

The breasts grow and modify in internal arrangement under the influence of hormones which rise in blood levels as pregnancy progresses, all in preparation for larger and efficient milk production. Progesterone (pregnancy hormone) causes the lobules (milk producing sacs) to increase in size and number, estrogen (female hormone) prepares the passage ways (ductules and lactiferous ducts), prolactin (the lactating hormone) ‘powers the factory’, but despite rising in maternal blood levels does not produce a full-blown effect due to interference by placenta produced hormones. Otherwise an adult female human breast has the capacity to produce milk in 2 weeks of hormonal stimulation, never the less, some production takes place and a pregnant mother can express some colostrum right from 16 weeks post conception! The surrounding breast smooth muscles also ‘get cocked’ by increasing the number of receptors for Oxytocin (the cuddle hormone), the same happens in the uterus.

Preparations take place in other areas as well for the betterment of the oncoming nursing course. The pituitary gland, that part of the brain which produces hormones including oxytocin and prolactin, increases in size which relates to higher production. A psychological shift which favors nursing (maternal instinct) crops up, and as some scientists postulate, an adjustment in hearing to better capture higher pitch and frequencies. No wonder they say; “a nursing mother is always the first to hear a baby cry and her breasts ‘run’ when she holds a baby”!

At birth, both the baby and placenta come out. The inhibition to prolactin production and activity is eliminated, milk production gets amplified and with the help of little baby’s suck which induces a pulsatile production of oxytocin, smooth muscles around the milk producing sacs contract, thus pushing out the ‘good juice’ (milk let-down reflex). Oxytocin performs a similar magic on the uterus enabling it to regress to pre-pregnancy size along with the nasty gift of ‘after-pains’. From then on, the arrangement is maintained on a supply demand basis. Thus, the reason the healthcare professionals always accost new mothers on “putting the baby to the breast” as soon as possible,  in order to commission the ‘dairy’ early enough and increase chances of higher production!

Types of breastfeeding…

Exclusive breastfeeding (EBF); means giving the infant breast milk as the only source of food. It is excludes the use of formula feed, any other milk source or even water to any degree except for prescribed medicines and vitamin supplements. It’s the ultimate choice of feeding for all infants up to the age of 6 months as recommended by WHO and UNICEF but quite often cut short to 4 months which is still good enough any way.

Mixed Breast feeding; Is when part of the daily calorie requirements of the infant below the age of 4 months are met through formula feeds. It’s only recommended when the mother is practically not meeting the daily breast milk requirements of the baby. This occurs in a few circumstances like; multiple birth, absence of a breast, breast milk suppressing chronic medication). Most “fancy mothers” create reasons to do this but to the detriment of infant health.

The maximum capacity of breast milk production should first be exploited before supplementation is done and this is better handled in the hands of healthcare providers. This also means maneuvers to maximize milk production like galactagogues (breast milk production augmenting medicines and supplements), use of breast pumps should be fully exploited. When the breast milk provides a higher proportion of the daily intake, this form of mixed feeding is called predominate feeding and is preferred in this instance.

Complementary feeding; refers to providing the greater nutrient requirement of the young through other foods with breast milk being the primary supplement. It’s recommended this runs for up to 18 months and if it’s to be discontinued early, conducted for at least 6 months. So that, the total duration of breast feeding lasts at least 1 year.

Continued breastfeeding; refers to breastfeeding occurring after 6 months (the introduction of complementary feeding) but mostly used to mean BF after 1 year of age. Since BF has undoubted benefits for up to 2 years of age, it’s a good practice to continue past the age of 1 year. At this stage it can be done leisurely, to maintain a bond, and to deliver comfort to the young in times of distress like illness (comfort nursing).

 

Good practice at the time of a breastfeed…

Breastfeeding being something natural, might be assumed to smoothly occur instinctively but is not as obvious as it sounds. Therefore, a mother whose ‘dairy’ is operational has to make some preparations before every feed.
The chest and breasts are washed with a mild soap, then thoroughly dried with a towel. She then dresses in that nursing attire (not essential) or any light clothing that allows relaxed exposure of the breasts and chest. In an instance in which such a gown is absent, a breastfeeding clip can be used to tuck that top a way and inability to carry out that ‘shadow’ shower shouldn’t stop the process. Some mothers prefer to apply lubricant jelly to their nipples to prevent soreness (Note; there is no medical backing for the practice), before putting their babies to the breast. She should then assume a comfortable sitting posture (preferably at a chair with a non reclined back rest), with the spine upright and hold the baby in the most appropriate position. To help comfortably keep the infant next to the chest, a breast feeding pillow or nursing sling can be employed. Skin to skin contact is encouraged while breast feeding, for there is additional benefit of ‘molding’ baby’s normal flora and helping them build active immunity.

Baby positioning should be tailored to suit; mothers habitus, infant size, enable good latching and maximize comfort and feeding duration. There are three medically recommended infant holding positions for effective latching.

  • The cradle position (my favorite); perhaps the friendliest of positions is appropriate for average maternal and infant habitus. It’s easy to deploy even for new mothers and is applicable in older infants. The infant is held to the breast along the mothers chest using the arm on the same side of the breast. It involves applying pressure to the abdomen and won’t be appropriate after cesarean section.

 

  • The cross cradle(modified cradle) position ; quite similar to cradle position, but the infant is held to the breast by the arm on opposite side. Appropriate for small infants.
  • The foot ball hold; the infant is held to the side of the chest and supported by their necks. Appropriate in mothers with large breasts and for feeding multiple infants in one go.
  • Other practiced positions include; semi reclining, side by side, supine and parallel positions (for twins). These however, do not emphasize positioning of infant relative to the mother for appropriate latching. Some of these positions are practiced with good reason, for instance, side by side when both feeder and the fed have got “a rest and eat arrangement”. (The mother has to be cautious, she might easily snore off on her precious little one!)
side by side position

For latching to be satisfactory, the areola should be asymmetrically covered (appears above the upper lip), the lips should be flanged and wide open (meticulous ones say >130 degrees), the chin attached to the breast and the nose free. The mother should observe the infant for the classical open-suck-pause-swallow pattern which indicates effective breast feeding. On her part, she should notice a spontaneous flow of milk from the unfed side. Endeavor to feed on both breasts allowing for emptying of both in the same sitting, one at a time. It’s time to quit when; the infant demonstrates satisfaction/contentment,  the breasts are soft and non leaky, mother might also feel thirsty and slightly exhausted. The mother should then express or pump out the remaining milk and safely store it as the baby is left to do what they do best, chill and sleep.

After the breastfeeding job well done as above, the breasts are wiped clean and dry, supported in a comfortable brassiere with absorbent breast pads in place. The mother can then, relax, drink, feed,  and look forward to the next occasion! All in all, the experience and efficacy of breastfeeding is improved if a mother rightly accessorizes.

 

Common concerns regarding Breastfeeding…

How often should a mother breastfeed?

Infants on a median breastfeed 8 times in 24 hours; 6 in the day and 2 in the night, this might be low on the first and second days, never the less, the newborn should be urged. As they acclimatize and grow, the frequency can  reach 12 times with durations of about 40 minutes. The frequency falls a little bit around the introduction of other feeds with daily frequency ceiling at 9. This should however be fulfilled in an on demand basis rather than schedules. Rooming in ( a practice of letting 24 hours in a day uninterrupted mother to infant access) allows for maximal breastfeeding and milk production.

How do I tell the baby needs to feed?

Well, since babies don’t speak, you’ll have to observe for specific cues, which include, staring, moving the head side to side, lip smacking, moving hands and objects to the mouth with tendency suck, stretching and eventually crying (don’t wait for this though, sick babies might never cry). Newborns might not express the above. In fact, they sleep for about 18 hours in a day. The mother should therefore make deliberate efforts to breastfeed them at frequencies no longer than 4 hourly. Don’t jerk the baby out of the bassinet though, a simple massage, changing clothing or even affectionate kissing can wake them up. They also have the ability to feed while somnolent just like a hippo can take a nap in deep water!

How do I know I have been feeding enough?

  • the infant shows contentment after feeding,
  • they pass stool ~ 3 times in a day and urine ~ 6 times in a day (in first 3 days, frequencies are lower).
  • They progressively gain weight except for the first 3-5 days in which they actually lose weight. They however, regain their birth weight by 2 weeks of age from which time they keep accumulating.

What should I feed on while breast feeding?

A nursing mother’s energy demands rise by about 1000 K cal/day so her intake of carbohydrates should be raised to account for this. However, the required top up on calorie intake is 300-500 K cal since mothers gain ~ 4 kg which helps to buffer for extra energy needs during lactation, vitamin requirements rise by 20% except folate which rises by 100%, extra emphasis is made for vitamin A intake, minerals requirements rise by ~ 33% (note; all these apply for previously normal weight mothers), adequate hydration should be emphasized. So, what does all that translate into? It’s actually the usual recommended adult female diet with a little misbehavior allowed IE up to 3 parts of dairy products per day, meats on alternate days, greens with all major meals, and drinking at ad lib (make deliberate efforts to take in more fluids).

  • Alcohol; is better avoided, can suppress milk production and hamper the mothers ability to nurse. The Die hards can consume up to a unit in a day and avoid breast feeding for at least 2 hrs after the last drink (unfortunately, the Die hards are the least disciplined when it comes to alcohol consumption).
  • Caffeine; is safe to use for up to 3 servings in a day.
  • Recreational drugs (marijuana, cocaine, heroin, PCP [‘Meth’ or the ‘crystal’], cigarettes) are preferably discontinued and with all deliberate efforts to do so. Recreational drugs are detrimental to mother’s/baby’s health, breast milk production and the process of breast feeding itself. Addicted mothers are known to have the least Breastfeeding Self-Efficacy  which is the ability of a woman to nurse an infant on her own; judged by self commitment, confidence and understanding of breast feeding). Strict healthcare systems simply take infants away from such mothers or put them to rehabilitation with supervision of nursing by Lactation consultants if they are compliant.

Some foods or herbs are known to improve milk production like Moringa. Prescription medications can be recommended to improve breast milk production.

How do I improve breast milk production?

Firstly, have the recommended diet as discussed above and drink, drink, drink! Higher frequency and duration of Breastfeeding begets higher milk production. So, don’t forget rooming in. Pick on the good practice recommendations mentioned above. Breast feeding to fulfillment then pumping out the remaining milk to total emptiness will help maintain if not boost milk production. some foods, medicines or supplements to consider are;

  • Fenugreek; a celebrated naturally existing galactagogue. (it’s present inform of teas, powders, liquids and even capsules and dressings). Endeavor to take with meals though, it’s capable of causing sudden drops of blood sugar levels which manifests with drowsiness, general body weakness.
  • Moringa: one of those herbal preparations with a tone of benefits. Moringa helps boost milk production by up to 50 percent! It’s available inform of teas, capsules and powder.
  • Milk thistle (saint Mary thistle/our lady thistle); contains silymarin which is postulated to increase prolactin production.
  • Nursing teas (breastfeeding teas); are singular or combined herbal preparations designed for use as beverages to help boost milk production, some come with other bonuses. They include; Traditional Organic medicinals, Earth Mama’s milkmaid, Bell lifestyle, Fairhaven milkies nursing time. All of them contain most or some of the following herbal supplements; Fenugreek, milk thistle, goats-rue, fennel, alfalfa, anise seed, and lemon verbena, marsmallow, stinging nettle, carraway seed, orange peel etc. Just a caution here, it is better to use single supplements than use mass combinations so that incase of any unwanted reaction, it’s easy to single out the offender. Any way, the teas have been known to be safe.
  • Mainly two prescription medicines are in use as galactagogues; Domperidone and Metoclopramide. You’ll need a doctors prescription and supervised use!

What can reduce or stop breast milk production?

Some foods and Medicines besides limited breast feeding, keep down milk production

  • Medicines include; Bromocriptine with classmates, tamoxifen (used in breast cancer), estrogens, ergotamine, pseudoephedrine ( common in flu meds) .
  • Foods or supplements include; parsley, peppermint and sage. Besides being savory greens, they are used to make common products like toothpaste, jams and even candy! So, don’t let them sneak in that way.

Wearing a tight brassiere and discontinuing breastfeeding for a few days will stop milk production altogether.

Can I breastfeed if I have been diagnosed with breast cancer?

YES you can. It’s only avoided if one is on active treatment. Women treated in the past or who have been newly diagnosed without any treatment initiated should keep breastfeeding.

When is breast feeding discouraged ?

Infection with; HIV (breastfeeding is avoided in the western world). In developing countries, the benefit of breastfeeding out weighs the danger of transmission in the presence of HAART. An algorithm in which breastfeeding is carried out for a year alongside infant prophylaxis and maternal treatment has been perfected and adopted (known as; Option B+) and many infants have enjoyed the benefit of breast milk as well as escaped infection at the same time! Breastfeeding is contraindicated in infection with Human Lymphotrophic Virus 1 (HLV-1); risk of childhood leukemia. The take on TB depends on local guidelines.
Toxoplasma is transmissible through breast milk and there is a report of infection in an infant attributed to this. Many other infections are detected in milk but do not warranty discontinuation of BF.

Others include; maternal Herpes on the breast, Infantile galactoseamia or phenylketonuria (PKU), lactose intolerance, mother on specific treatment like chemotherapy, breast abscess.

 

Common problems associated with breast feeding

Nursing can come with it’s own load of health issues. These can affect both the mother and baby and here we’ve categorized them into two:

  • Maternal; which include sore nipples, swollen & painful breasts, milk production problems, psychological issues and others
  •  The Infant category; which include unfavorable breastfeeding habits, unfavorable anomalies and health conditions, others.

These are covered in significant detail in another discussion linked to this very chapter.

 

Benefits of breast feeding…

To the infant; reduced risk for infections (especially GI-diarrhoea), allergies ( asthma, eczema, hay fever), better weight gain, and better IQ (postulation).

To the mother; breast milk is cheap, readily available, easy to administer. Breastfeeding helps prevent primary Postpartum hemorrhage, favors bonding, reduces risk of pre-menopausal ovarian and breast cancer, anemia in high risk areas, contraceptive effect.

Conclusion.

Breastfeeding has been well researched around the world and is one of those few things in which humanity has got a common consensus. It’s good and remains to be practiced. Several legitimate sources have been used in the preparation of this information including, Breastfeeding Guide (registered nurses association of ontario-RNAO), Oxford books (pediatrics and Obstetrics), Nelsons pediatrics, excerpts from Web MD and research articles on breast feeding, personal experience.

I hope to have delivered the help needed in the most friendly way, all the best in your new journey of motherhood!

Please leave questions, comments, suggestions or requests if you have any.

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