Guide to Breastfeeding
Breastfeeding is the ideal nutritional source for infants. The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of a child’s life with continuation through at least the first year of life and thereafter as long as mutually desired by mother and child. However, although women have breastfed their babies for hundreds if not thousands of years, there was a lengthy period of time during the twentieth century when breastfeeding fell out of practice. This was during the heyday of formula, when it was widely believed that formula provided equal or superior nutrition to mother’s milk. In 1968, Lee Forrest Hill bemoaned the fact that formula feeding had become so simple, safe and uniformly successful that, for many mothers, breast-feeding no longer seemed worth the bother. Today research has filled the knowledge gaps and conclusively established that mother’s milk is ideal for your baby. As a result, more mothers are returning to breastfeeding.
In 1970, only 20% of women left US hospitals nursing their infants, with only 10% still nursing by 6 months. In 1993-1994, 60% of infants were (ever) breastfed and in 2005-06 that number increased to 77%. That exceeds the 2010 Healthy People goal of 75%!
While initiation rates are higher, breastfeeding continuation rates remain low. The 2010 Health People goal is 50% breastfeeding at 6 months and 25% at 1 year. In 1998, 29% of infants were breastfed at 6 months, and there has been no significant change in those numbers since that time.
So, if 60% or 70% of women start breastfeeding, why are only 29% succeeding? A main reason is lack of support. For millennia, mothers and grandmothers supported their daughters and granddaughters in breastfeeding, helping them overcome obstacles and challenges by sharing the accumulated experience of generations of mothers. During the period when formula became dominant, that experience fell off a cliff. A generational gap developed such that when women began to choose breastfeeding in greater numbers, they could no longer fall back on the traditional support of family.
Despite this fact, some supports remain and others are developing. Mothers still find support with family and friends, and society is becoming more breastfeeding-friendly. Public breastfeeding is much more accepted, and in fact Ohio is one of the states that passed a law making it legal to breastfeed in public. Workplaces are starting to make accommodations for breastfeeding mothers. Finally, health care practitioners are becoming much more attuned to the needs of breastfeeding mothers, and health care resources are improving. As pediatricians, we want to be part of that support.
What role does the pediatrician have in the breastfeeding equation? Our job is to take your lead and support your decision. We recognize that not all women and infants can/will breastfeed. However, if your decision is to breastfeed, we want to give you the greatest possible chance for success. So when you have questions, call! If we don't know the answer, we will look it up or refer you to someone who does. One caveat - for ease of presentation in this article, we will use he rather than she or he/she when referring to the baby. Keep in mind that everything stated here applies equally to boys and girls.
Advantages of Breastfeeding
The following is a listing of some of the advantages of breastfeeding.
- Protection against infection
- Gastrointestinal disease - There is a marked decrease in the number of stomach virus infections in the infant who is breastfed. The benefit is greatest if a child is exclusively breastfed because it minimizes the child’s exposure to foreign pathogens (viruses and bacteria).
- Respiratory disease - There is a fivefold excess of lower respiratory tract infections, such as pneumonia, in formula fed infants. Studies show that infants exclusively breastfed for greater than 4 months have a 72% lower risk of being hospitalized in their first year of life for a respiratory infection than an infant who is formula fed. Moreover, when respiratory infections occur in breastfed infants, they tend to be less severe.
- Ear infections - There is a 50 % lower chance of getting an ear infection in a child exclusively breastfed for 6 months as compared to a child exclusively formula fed.
- The mechanism for protection against these diseases involves a combination of immune factors including antibody secretion in the mother’s milk. The antibodies bind to the bacteria and viruses in the infants gut and respiratory tract minimizing exposure and thus infection.
- Bonding –While harder to quantify through research, nursing women describe a special feeling of attachment and particular concern for protecting the vulnerability of their infants. This effect continues long after effective nutritive sucking has ceased; many women will continue to nurse their children at night for the comfort of both parent and child.
- Asthma and eczema – Research continues to evolve on the benefits of breastfeeding for allergy reduction. The benefit appears greatest to those with a strong family history of allergies. For example, those children with a family history of eczema who are exclusively breastfed for 3 months will have an approximately 40% decreased risk of developing eczema. The AAP recommends exclusively breastfeeding and waiting on the introduction of solids until 6 months of age to reduce the chance of developing food allergies.
- SIDS: A history of breastfeeding is associated with 36% reduction in risk of SIDS compared to a formula fed infant.
- Childhood illnesses: Research has shown a lower risk of childhood diabetes, leukemia and obesity in breastfed children.
- Necrotizing Enterocolitis (NEC): This is a severe intestinal disease that occurs in preterm infants. Feeding preterm infants breast milk (including pumped breast milk) greatly decreases their chance of NEC with its complications and prolonged hospitalization.
Mechanism of protection for all these diseases are not completely understood but include a combination of antibody’s transmitted through the mother’s milk and multiple other immune substances. The immune mechanisms in breast milk overall trigger a lower inflammatory response in the infant. They also teach the infant’s immune system how to respond to foreign substances.
Breast Anatomy and Physiology
An understanding of how the breast works is essential in working out any problems that may arise during breastfeeding.
- Anatomy - The breast is composed of alveolar glands which have milk secretory units surrounded by muscle tissue. The muscles help eject milk into ductules. The ductules widen in response to the milk ejection reflex during feeding. Milk ducts lead to openings in the nipple. During pregnancy, the hormones stimulate growth of the secretory units which results in the breast changes and growth experienced by women during pregnancy.
- Hormonal changes - During each menstrual cycle, the female sex hormones, estrogen and progesterone, stimulate growth of glandular tissue and secretion of a milky-like substance (breast discharge). During pregnancy, this substance is called colostrum and is produced in increasing amounts as early as the 3rd month. (Don't worry, however, if you don't notice this colostrum; it is present even if not very obvious.) Estrogen and progesterone help the breast develop but inhibit or decrease the production of prolactin, the hormone responsible for actual milk production. This enables the breast to develop nicely during pregnancy without the discomfort of milk production. When the baby is born, there is a relative drop in the estrogen and progesterone levels and the consequent rise in prolactin levels allowing for the dramatic rise in milk production seen in the first few days of life. Suckling stimulates secretion of prolactin as well as oxytocin, the hormone responsible for the ejection or letdown of milk. You need these two hormones for effective breastfeeding. Oxytocin (also known as pitocin) is also responsible for uterine contractions; thus, effective sucking by the infant frequently causes abdominal pain related to uterine contractions.
Chemistry of Breastfeeding
There are three types of breast milk. Colostrum, transitional milk and mature milk. Colostrum has a lower energy content but higher salt, protein, vitamin and mineral content than mature milk. Its purpose is to facilitate the transfer of protective antibodies, to assist in the passage of newborn stool or meconium and to aid in the establishment of the appropriate digestive milieu in the gut. What follows is transitional milk and typically your breasts are making mature milk by about day 5. Mature milk is composed primarily of water. The sugar is lactose or milk sugar, the protein is the most easily digested combination of casein and whey and the fat is a combination of polyunsaturated and saturated fats. In addition to nutrients, breastmilk has antibodies, enzymes, proteins and immune cells that provide immune protection and help protect and teach your infant’s developing immune system. All the vitamins and minerals needed for your baby are found in your breastmilk.
Learning to Breastfeed
We strongly suggest taking a breastfeeding class prior to delivery. There are several excellent one-nighter sessions in town led by competent lactation consultants. For most people these classes simply get you enthused about your decision; for some, they provide a valuable backup source of support should problems arise. Most women still opt to learn on the job. Most of the local hospitals have excellent support nurses and lactation consultants who, in many cases, can get milk out of a stone. Don't go into this with a martyr mentality; use the support staff, ask questions and don't worry - the more advice, the more equipped you will be to handle the nuances of breastfeeding.
Most infants know exactly what to do! Sucking and swallowing have occurred in-utero and are reasonably coordinated by the time of birth. The rooting reflex is the normal reflex by which bumping/stroking a nipple against the cheek of an infant results in movement of the mouth toward the nipple. Sucking is the process by which the nipple and areola are drawn into the mouth and held there in a tight seal. The tongue is responsible for moving the milk down the breast ducts and out the nipple.
Positioning is everything. A baby is correctly positioned when his gums are deep on the areola, not the nipple. With this setup, he will be able to compress the area beneath the areola to draw out the milk. Sucking on the nipple only leads to chewed nipples and inadequate feeding.
There are a number of holding positions. With all these positions the general principles are the same.
- Support your baby’s upper back,
- Allow the head to tilt back some so that his chin comes to the breast first positioned so the nipple lines up at the upper lip/nose of your baby.
- As your baby’s chin touches the breast your baby will open wide and reach over the nipple.
- This enables a deep latch on the areola with the nipple positioned deep in the mouth by the baby’s soft palate.
- Remember to support your baby’s back and buttuck and keep his body pulled close to your body
Specific positions often mentioned include:
- Cradle hold - In this standard position, the infant's head rests in the crook of the mother's arm and the forearm supports the back. The hand is then free to support the buttocks.
- Football hold - This hold is particularly useful for women who have had a C-section, and when nursing twins. The standard football hold places the infant's body alongside the mother's with the head supported in her hand and positioned against the closest breast. This hold often allows greater visibility
- Side lying hold - In this position, the woman and infant lie next to each other. This is particularly helpful during night feedings, and following a C-section
- Baby-led – in this position we let your baby follow his instincts and take advantage of reflexes like the rooting reflex. Start with your baby skin to skin upright between your breasts. When your baby is ready to feed, they will use their reflexes and sense of smell and touch to scoot toward your breast and latch on to feed. Baby’s latching themselves often end up in a diagonal position across their mother’s abdomen.
Experiment with different positions in the hospital. Have the nurses and lactation consultants show you the various holds; As you try you will find the position that works best for you and your baby. Remember if it hurts the latch should be corrected. Ask for help. Nurses, Lactation Consultants, La Leche, other breastfeeding moms and we are all great places to start if you need help getting a pain free latch.
Establishing Your Milk Supply
When your baby is first born they need very little volume of milk. In fact the size of a newborn infant’s stomach is 7 ml or about ¼ of an ounce (30ml = 1 ounce). This increases over the next several days just as your milk supply does. By day 3 their stomach capacity is about 1 ounce. Your baby may feed more frequently in the hospital but for shorter periods of times. This matches the amount of colostrum available to the size of your newborn’s stomach. Furthermore the frequent short feeds helps put in an order for your milk production.
Timing is also very important. Often, the initial breastfeeding takes place shortly after birth. Studies show that an infant placed on the mother's abdomen after the cord is clamped, will often inch up the abdomen in search of a breast. If your infant does not seem interested, don't panic. Breastfeeding can and will succeed wonderfully even if your baby does not have the perfect first feed.
The first days in the hospital is when you are putting your order in for your milk supply. Milk is stimulated by emptying of the breasts and frequency. In general the goal is 8 to 12 feedings a day. Some babies will follow a schedule of every 2 to 3 hours while others might cluster feed. With cluster feeding a baby may have several feedings about an hour apart followed by a longer four hour sleepy period.
Whatever your baby’s pattern, the important things to remember to look for are:
- active sucking and swallowing (ask the nurses or us how to listen for a baby’s swallow),
- good stool production
- good urine output
- We will have you follow-up a couple days after discharge to check your baby’s weight and see how feeding is going
- Call if you have any concerns
What about Diet for a Breastfeeding Mother
Depending on where she lives, a breastfeeding mother may eat different foods. As long as the diet is reasonably well balanced it should be nutritionally adequate. In general, poor eating while breastfeeding will harm the mother more than it will harm the child. This is because the child scavenges from the mother. In third world countries, babies do wonderfully until they are weaned, at which point they become nutritionally deficient. Thus, quantity of milk, protein content and calcium content are relatively independent of maternal nutritional status and diet. However, a good maternal diet will certainly enhance the experience and contribute to the overall health of the mother. Don’t forget to continue to take your prenatal vitamins for as long as you continue to breastfeed.
Vitamin D has become a concern because overall the women in our society are eating fewer foods with Vitamin D (milk, oily fish, kale and collard greens) and spending a lot less time outside (where the sun converts Vitamin D from the inactive form to the active form). Furthermore, time spent outdoors is spent with sunscreen on board and sunscreen of all types interferes with active Vitamin D production. In October, 2008, the American Academy of Pediatrics revised its previous recommendations to state that all breastfeeding infants regardless of skin color (darker skinned people produce less Vitamin D), should receive a supplement of 400 IU of Vitamin D which is 2 droppers of Tri-vi-sol/day.
Many mothers wonder if what they eat affects their children’s allergies. In general, breastfeeding decreases your babies chance of developing allergies and continuing to breastfeed while your baby is introduced to solids helps teach your child’s immune system how to react to foods and further helps decrease their chance of allergies. If your previous child had an allergy to a particular food, it is helpful to eliminate that food in the last trimester and for at least the first 2 months of the newborn’s life.