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Breastfeeding

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A breastfeeding infant

Breastfeeding is the process of a woman feeding an infant or young child with milk produced from her breasts, usually directly from the nipples. Babies have a sucking urge that usually enables them to take in the milk, provided there is a good latch, a detached phrenulum, and a milk supply.

Breast milk has been shown to be best for feeding a child if the mother does not have any transmissible infections. Nevertheless, some mothers do not breastfeed their children, either for personal or medical reasons. Some diseases, such as HIV and HTLV-1, which are transmitted through bodily fluids, can be passed through the breast milk, and may therefore preclude breastfeeding in these cases. Some medicines may also transfer through breast milk. However, most medicines are transferred in very small amounts and are considered safe to take during breastfeeding. Therefore most women are not precluded from breastfeeding, and doctors and governments are keen to promote the practice. Nevertheless, many medications are labeled as unsafe for use while breastfeeding, and the mother who desires to breastfeed and her physician must carefully weigh the risks and benefits to her baby.

Many governmental strategies and international initiatives have promoted breastfeeding as the best method of feeding a child in his or her first year. So do the World Health Organization (WHO) [1], the American Academy of Pediatrics (AAP) [2], and many others.

Beginning lactation

File:Breastfeeding(milkfinal).png
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

Main article: Breast milk

Throughout the last two trimesters of pregnancy a woman's body produces hormones which stimulate the growth of the milk duct system in the breasts:

  • Progesterone -- influences the growth in size of alveoli and lobes. Progesterone levels drop along with estrogen levels after birth, triggering the onset of copious milk secretion. (Mohrbacher, IBCLC, Nancy; Stock, MA, IBCLC, Julie (2003). The Breastfeeding Answer Book, Third Revised Edition. La Leche League International, Inc. ISBN 0-912500-92-1)
  • Estrogen -- stimulates the ductule system to grow and become specific. Estrogen levels drop at delivery and remain low for the first several months of breastfeeding. (Ibid) (This is also why it is recommended that breastfeeding moms avoid estrogen-based birth control methods while they are planning to breastfeed. A spike in estrogen levels compromises a mother's milk supply level.)
  • Follicle stimulating hormone (FSH)
  • Luteinizing hormone (LH)
  • Prolactin -- contributes to the accelerated growth of the alveoli druing pregnancy (Rilemma 1994).
  • Oxytocin -- contracts the smooth muscle of the uterus during birth, after birth, and during orgasm. After birth, oxytocin contracts the smooth muscle layer of band-like cells surrounding the alveoli to squeeze the newly-produced milk into the duct system. Oxytocin is necessary for a let-down, or milk ejection reflex, to occur. (Ibid)
  • Human placental lactogen (HPL) -- HPL is released in large amounts by the placentra during pregnancy (beginning in the second month) that appears to be instumental in breast, nipple, and areolar growth before birth. (Ibid)

By the fifth or sixth month of pregnancy, the breasts are sufficiently developed to produce milk (although it is also possible to induce lactation as described in a later section).

During the latter part of pregnancy, the woman's breasts enter into the Lactogenesis I stage, where the breasts are making colostrum (a thick, sometimes yellowish fluid), but high levels of progesterone inhibit most milk secretion and keep the volume “turned down”. It is considered medically normal for a pregnant woman to leak colostrum before her baby's birth, and also normal not to leak at all. Neither situation is an indicator of future milk production levels in the mother.

At birth, the delivery of the placenta results in a sudden drop in progesterone/estrogen/HPL levels. This abrupt withdrawal of progesterone in the presence of high prolactin levels cues Lactogenesis II (copious milk production).

Prolactin blood levels rise when the breast is stimulated, and peak around 45 minutes later. The return to pre-breastfeeding levels about three hours afterward. The release of prolactin triggers the cells in the alveoli to create milk. Some research (Cregan 2002) indicates that prolactin in milk is higher at times of higher milk production, and that the highest levels tend to occur between 2 a.m. and 6 a.m.

Other hormones (insulin, thyroxine, cortisol) are also involved, but their roles are not yet well understood. Although biochemical markers indicate that Lactogenesis II commences approximately 30-40 hours after birth, mothers do not typically begin feeling increased breast fullness (the sensation of milk "coming in") until 50-73 hours (2-3 days) after birth.

The colostrum is the first milk the baby receives; it contains higher amounts of white blood cells and antibodies than mature milk, and is especially high in immunoglobulin A (IgA), which coats the lining of babies' immature intestines, helping to prevent germs from invading baby's system. Secretory IgA also works to help prevent food allergies. (Sears, MD, William; Sears, RN, Martha: The Breastfeeding Book,Little, Brown, 2002. ISBN 0316779245)

After a baby has been nursing for 3-4 days, the colostrum in the breast slowly begins the process of changing into mature breast milk over the next two weeks. (Breastfeeding Answer Book, p. 36)

During pregnancy and the first few days postpartum, milk supply is hormonally driven. This is the endocrine control system. After milk supply has been more firmly established, Lactogenesis III begins - the autocrine (or local) control system.

At this stage, milk production is made on the law of supply and demand: The more milk removed from the breast, the more milk the breast will produce. Thus milk supply is strongly influenced by how often the baby feeds and well it is able to transfer milk out of the breast. "Low supply" can often be traced to A) too infrequent feeding/pumping, B) a jaw/mouth structure or latch inhibiting baby's ability to transfer milk effectively or C) a metabolic or digestive inability in the infant, rendering it unable to utilise the milk it receives.

Research on mothers who express their milk (Hopkinson 1988; deCarvalho 1985) indicate that for most women the more times per day a mother expresses her milk, the more milk she produces. Ongoing research (Daly 1993) shows that more fully draining the breasts also increases the rate of milk production.

The production, secretion and ejection of milk is called lactation. Most breastfeeding experts recommend at least one feeding every two to three hours to maintain the milk supply. For most women, a target of eight (8) nursing sessions/pumping sessions per 24 hours seems to keep a milk supply high not only during the early months of lactation, but especially past the fourth month. (AAP, 1997) It is not at all uncommon for newborn infants to nurse far in excess of this amount: 10 to 12 nursing sessions per 24 hours is the comparitive norm, while some may even nurse 18 times in the same time frame.

The exact properties of breast milk are not entirely understood, but the nutrient content of mature milk is relatively consistent and draws its ingredients from the mother's food supply and the nutrients in her bloodstream at the time of feeding. If that supply is inadequate, content is obtained from the mother's bodily stores. (Some studies estimate that a woman burns an extra 500 calories per day simply producing milk for her offspring.) The exact composition of breast milk varies from day to day, and even hour to hour, depending on both the manner in which the baby nurses and mom's food consumption and environment, so the ratio of water to fat fluctuates. Foremilk, the milk released at the beginning of a feed, is watery, low in fat and high in carbohydrates compared with the creamier hindmilk which is released as the feed progresses. There is no sharp distinction between foremilk and hindmilk – the change is very gradual. Research from Peter Hartmann's group tells us that fat content of the milk is primarily determined by the emptiness of the breast -- the less milk in the breast, the higher the fat content. The breast can never be truly "emptied" since milk production is continuous.

The let-down reflex

The let-down reflex, also known as the milk ejection reflex, is caused by the release of the hormone, oxytocin. Oxytocin stimulates the muscles of the breast to squeeze out the milk. Breastfeeding mothers describe the sensation differently, with some feeling a slight tingling, some feeling immense ammounts of pressure and slight pain/discomfort, and still others not feeling anything different.

The reflex is not always consistent, especially at first. The thought of nursing or the sound of any baby can stimulate the let-down reflex, causing unwanted leakage, or both breasts give out milk when one infant is feeding. However, this and other problems often settle after two weeks of feeding. If the mother is in a stressed or anxious state of mind this can cause great difficulties with breastfeeding.

Causes of a poor let-down reflex:

  • Sore or cracked nipples
  • Separation from the infant
  • A history of breast surgery

If a mother has trouble breastfeeding she can try different methods of assisting the let-down reflex. These include:

  • Feeding in a familiar and comfortable location
  • Massage of the breast or back
  • Warming the breast with a cloth or shower

Benefits

The benefits of breastfeeding are both physical and psychological for both mother and child. Nutrients and antibodies are passed to the baby while hormones are released into the mother's system. The bond between baby and mother can also be strengthened during breastfeeding.

Benefits for the infant

Breastmilk, when fed directly from the breast, is immediately available with no wait and is at body temperature.

Breast fed babies have 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.

The many health benefits of breastfeeding have been well documented. According to the American Academy of Pediatrics' policy statement, "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. These include health, nutritional, immunologic, developmental, psychological, social, economic, and environmental benefits."[3]

Breast milk helps to lower the risk of or protect against:

Recent studies show that children who had been breastfed on average score higher on IQ tests than children who had not [13]. However, Jain (2002) said: Although the majority of studies concluded that breastfeeding promotes intelligence, the evidence from higher quality studies is less persuasive. [14]

Studies on eczema and breastfeeding give mixed results. One study said breastfeeding is protective [15]. However, a study from Germany found that breastfeeding was associated with higher social status, more eczema in the parents and an increased risk of eczema in the children. [16].

Benefits for the mother

Breastfeeding also benefits the mother. Breastfeeding releases hormones that have been found to relax the mother and cause her to experience nurturing feelings toward her infant. Breastfeeding as soon as possible after giving birth increases levels of oxytocin which encourages the womb to contract more quickly. This helps to decrease bleeding after the birth. Breastfeeding can also help the mother to return to her previous weight as the fat accumulated during pregnancy is used in milk production. Frequent and exclusive breastfeeding delays the return of menstruation and fertility (known as lactational amenorrhoea). This allows for improved iron stores and the possibility of natural child spacing. Breastfeeding mothers experience improved bone re-mineralisation after the birth, and a reduced risk for both ovarian and breast cancer both before and after menopause.

Bonding

Madonna Litta, a circa 1490 painting by Leonardo da Vinci showing the Madonna and her child

The maternal bond is strengthened through breastfeeding, with the hormonal releases strengthening the mother's nurturing feelings towards the child. Strengthening the maternal 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 father can support the mother in a variety of ways and is an important factor in successful breastfeeding [17]. This support can also help to establish the paternal bond in fathers.

Breastfeeding can also greatly affect the relationship between the partner and the child. While some fathers 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 father and the family, because the partner has to care for the mother and also perform tasks she would otherwise do. However, as fathers are often very willing to give this support, this pressure can help to strengthen family bonds.

When looking after the child while the mother is away, an alternative caregiver may feed the child using expressed breast milk (EBM). Sometimes this may be impractical as the mother must produce and store enough milk to feed the child for the duration of her absence. If the two caregivers are separated, feeding the breast milk may also be awkward. These two situations may prompt the carers to use an alternative feeding method for the child either temporarily or permanently. However, a variety of breastpumps now on the market, both for sale and for rent, make it possible for working mothers to exclusively breastfeed their babies for as long as they wish.

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) [18]

"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 is: expressed milk from the infant's own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast milk substitute fed with a cup, which is a safer method than a feeding bottle or a teat; depends on individual circumstances"

WHO Global Strategy for Infant and Young Child Feeding. Geneva, World Health Assembly, May 2002, page 10 [19]

"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 [20]

Difficulties with breastfeeding

It is not uncommon for a mother and child to have difficulties breastfeeding in the beginning, but most of these problems resolve in the early weeks.

A small percentage (between 2 & 3%) of women are unable to provide a full day's calories. It is not known what causes insufficient milk supply, but extended separation at birth, insufficient glandular tissue, and Polycystic Ovary Syndrome (PCOS) are all known culprits. Even among this small group, it is feasible to continue breastfeeding while supplementing with donated breastmilk or artificial baby milk. Many of these mothers breastfeed exclusively by using thin tubing taped to the breast to deliver the supplementary food. This is called a supplementary nursing system, or SNS.

While some may find it too problematic or choose not to attempt or continue breastfeeding for personal reasons, most women who have initial difficulties can go on to breastfeed successfully.

Breast refusal

Though babies have a natural sucking reflex, they still have to learn how to feed and may occasionally resist feeding from the breast. To establish breastfeeding firmly, it is important for the baby to be put to the breast soon after birth so that the baby is accustomed to feeding from the breast from the very beginning. The AAP policy on breastfeeding says: Delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed.

Causes of breast refusal include:

  • Formula feeding, sometimes without the knowledge of the mother.
  • The use of artificial teats (nipples) or dummies leading to "nipple confusion"
  • Poor feeding technique
  • Over-handling after birth
  • Thrush in the baby's mouth [21] [22]
  • Distractions or interruptions during feeds
  • Long separations from the mother
  • Breathing difficulties, often caused by a common cold [23]
  • Swallowing difficulties, sometimes the painful result of ear or throat infections
  • Pain from surgery (most commonly circumcision), blood tests, vaccinations, and other procedures commonly done without anesthesia [24] [25]

In later stages teething could be perceived by the mother as a hindrance to breastfeeding. While it is seen by some as a good time to wean the infant, teething difficulties can usually be overcome.

Medical conditions of the infant

Reasons for the inhibition of an infant to feed include:

Premature babies can have difficulties if their sucking reflex is still underdeveloped and if they tire during feeds.

For many sucking related feeding difficulties, the infant can receive proper nutrition by use of a Haberman Feeder, a special bottle with a carefully designed nipple that simulates breastfeeding.

Medical conditions of the mother

Many women with previous surgeries, abscesses and cancer can breastfeed successfully. However, damage to the breast tissue can cause problems or prevent manageable breastfeeding for women with history of breast surgery or infection. Cancer (particularly breast cancer) and chemotherapy treatments have also been shown to cause difficulties. 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 [26]. The presence of herpes lesions on the breast is also contraindicative to breastfeeding.

Mastitis is inflammation of the breasts caused by the blocking of the milk ducts. Mastitis 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.

When breastfeeding can be harmful to the infant

Breastfeeding can be harmful to the infant if the mother:

  • has HIV or active tuberculosis
  • 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).

Most of these problems are avoidable as they relate to the nursing mother's behavior.

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 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. The Subcommittee on Nutrition during Lactation advises approximately 1500–1800 calories per day [27]. While mothers in famine conditions can produce milk with highly nutritional content, a malnourished mother may produce milk with decreased levels of vitamins A, D, B6 and B12. She may also have a lower supply than well-fed mothers [28].

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 smoke and therefore consume nicotine. Heavy use of cigarettes by the mother (more than 20 per day) has been shown to reduce the mother's milk supply and cause vomiting, diarrhoea, rapid heart rate, and restlessness in breastfeeding infants. Research is ongoing to determine whether the benefits of breastfeeding out-weigh the potential harm of nicotine in breast milk. Sudden Infant Death Syndrome (SIDS) is more common in babies exposed to a smoky environment [29]. Breastfeeding mothers who smoke are counselled not to do so during or immediately before feeding their child. They are encouraged to seek advice to help them reduce their nicotine intake or quit.

Heavy alcohol consumption is known to harm the infant, causing problems with the development of motor skills and decreasing the speed of weight gain. There is no consensus on how much alcohol may be consumed safely, but it is generally agreed that small amounts of alcohol may be occasionally consumed by a breastfeeding mother. However, some believe that a single daily glass of wine is enough 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 preferable to err on the side of caution 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.

Cannabis is listed by the American Association of Pediatrics as a compound that transfers into human breast milk.[30] This is based on research which demonstrated that certain compounds in marijuana have a very long half-life. Cannabis exposure via the mother's milk during the first month postpartum appears to be associated with a decrease in infant motor development at one year of age.

Feeding options and requirements

Exclusive breastfeeding means feeding a baby nothing but breast milk. Predominant or mixed breastfeeding means feeding breast milk along with some form of substitute – infant formula or baby food and even water, depending upon the age of the child. Babies feed differently with artificial teats than from a breast. When feeding from the breast, the tongue massages the milk out rather than sucking, and the nipple does not go as far into the mouth; when feeding from a bottle, an infant will suck harder. Therefore the advice is not to mix breastfeeding and bottle-feeding (or the use of a pacifier) until the baby is used to feeding from its mother. Orthodontic teats, which are generally slightly longer, can be used to better replicate the breast.

Exclusively breastfed infants feed, on average, 6-14 times a day. The requirement varies greatly between children. Newborns consume about 30 to 90 ml (1 to 3 US fluid ounces). and after the age of four weeks, babies consume about 120ml (4 US fluid ounces) per feed. Each baby is different, and as it grows the 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 how much 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. The birth weight of the baby may affect its feeding habits, and mothers may be influenced by what they perceive its requirements to be. For example, a baby born small for gestational age may lead a mother to believe that her child needs to feed more than if it larger; they should, however, go by the demands of the baby rather than what they feel is necessary.

One concern about breastfeeding is that it is hard to accurately measure the amount of food the baby consumes. This should not be a worry; the baby will feed to meet its own requirements. It is also easy to monitor output from wet and soiled nappies. 8 wet cloth or 5-6 wet disposable, and 2-5 soiled per 24 hours) indicates an acceptable amount of input for newborns older than 5-6 days old. After 2-3 months, stool frequency is a less accurate measure of adequate input as some infants may go up to 10 day between stools as part of their normal function.

Expression

Expressed breast milk (EBM) or infant formula can be fed to an infant by bottle

When direct breastfeeding is not possible a baby may still be fed breast milk. By expressing (artificially removing and storing) her milk, a mother can enable her child to be fed while she is away from the child. With expression through manual massage or the use of a breast pump the woman can draw out her milk and keep it in supplemental nursing system or a bottle ready for use. This bottle may be kept on the counter for up to seven hours, refrigerated for up to eight days or frozen for up to four months. Research suggests that antioxidant activity in expressed breast milk decreases over time [31] but it still remains in higher levels than in infant formula.

Expression can be used to maintain lactation such as when the mother and child are separated for an extended period. If the baby is unable to feed, expressed milk can be fed through a nasogastric tube.

Expressed milk can also be used to help a mother who is having difficulty breastfeeding, such as when a newborn causes grazing and bruising or when an older baby grows teeth and bites the nipple (though the reaction of the mother to a bite - a jump and a cry of pain - is usually enough to discourage the child from biting again).

Some women donate their expressed breast milk (EBM) to others, 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

The World Health Organization recommends that all mothers be encouraged to breastfeed. Hospitals that are accredited by the World Health Organization are tolerant of formula feeding but do not offer it to infants who can be breastfed. (Feeding a new baby with formula undermines the establishment of breastfeeding.)

If the decision is made not to feed the child with breast milk or if breastfeeding is not possible, then infant formula is given to the infant, usually using a baby bottle. Infant formula may also be introduced as a supplemental liquid drink to weaned babies. Because it is proportioned for human babies it may be seen as healthier than simply drinking the milk from another mammal.

While it is clearly inferior to breastfeeding, Infant formula has been effectively marketed and promoted to new mothers as a modern, easy or convenient option to feeding a baby. A 2004 UK Department of Health survey showed that 34% of women believe infant formula to be very similar to or the same as breast milk. [32] In 1979 the International Baby Food Action Network (IBFAN) was formed to help raise awareness of such practices as supplementary feeding of new babies with formula, inappropriate promotion of baby formula and to help change attitudes that discourage or inhibit mothers from breastfeeding their babies.

Tandem, extended, and shared breastfeeding

Feeding two infants simultaneously is called tandem breastfeeding. 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 its own 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 breasts can produce a high quantity of milk, according to the demand placed upon them, and many mothers have been able to feed their infants successfully [33]. It is common, however, for the woman to use other alternatives.

Tandem breastfeeding is also convenient if a woman gives birth to a newborn while still feeding an older baby or child. Under these circumstances during the late stages of pregnancy the milk will change to colostrum for the benefit of the newborn. Some older nurslings will continue to feed even with this change while others may wean due to the change in taste.

Although some may find it controversial, some women breastfeed their offspring for as many as 3 to (rarely) 7 years from birth. This is referred to as extended breastfeeding. Supporters of extended breastfeeding say that all the benefits of human milk, both nutritional and emotional, continue for as long as a child nurses. Detractors believe that prolonging breastfeeding for several years can result in the child developing emotional or psycho-sexual problems, though there is no research that supports this theory. There has, however, been at least one study linking extended breastfeeding with adverse cardiac outcomes later in life.[34]

In developing nations within Africa and elsewhere, it is sometimes common for more than one woman to feed a child. This shared breastfeeding has been highlighted as a source of HIV infection amongst infants born HIV-negative [35].

See also: wet nurse

Breastfeeding method

There are many texts available to new mothers to assist in the establishment of breastfeeding. 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. Breastfeeding 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 replace lost water by drinking during the process.

Feeding and positioning

It is essential for the infant to feed in the correct position and with an adequate latch.

While for some people the process of breastfeeding 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, which should then be pushed in so that the baby has a mouthful of nipple and areola; the nipple should be at the back of the baby's throat. Achievement of this position is referred to as latching on. Inverted or flat nipples can be massaged to give extra area for the baby to latch onto. Many women 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.

The length of feeding is quite variable. Regardless of the duration, it is important for the breastfeeding woman 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 breastfeeding. Doing so permits the mother to incorporate breastfeeding into the varied work of daily life.
  • 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 breastfeeding.
    • 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).

When tandem breastfeeding the mother is 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

Breastfeeding may hurt some women. Sometimes this is related to an incorrect technique, but it 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. The presence of thrush in the nipples can also be painful. Limiting feeding time does not prevent soreness.

Although it is said that fair skinned mothers are most likely to experience cracked nipples, cracked nipples can happen to anyone whose baby is not positioned correctly. The baby's rough tongue can also cause grazes and the suction can cause bruising if the mother and baby have not learned to latch and unlatch. To break the suction, mothers should wait for the baby to come off the breast, insert a finger just inside the baby's mouth, or press down gently on the breast. The use of nursing pads or tight bras can lead to breast and nipple pain, as can hair dryers, sun lamps, soap, alcohol, perfume, deodorant, hair spray, body powder and incorrect use of breast pumps. Bottles and nipple shields may change the way the baby sucks, as well.

Some mothers apply medical grade lanolin to sooth nipples; La Leche League International has endorsed Lansinoh, an ultrapure medical grade lanolin cream designed for breastfeeding mothers. Mothers can also express milk and rub it on the nipples.[36] After six weeks of breastfeeding, the process 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.

Nipple damage due to breastfeeding can increase the liklihood of a Candidiasis infection. If a baby develops symptoms of oral thrush, both the mother and the child must be treated at the same time.[37] Proper antibiotic treatment will help neutralise the infection and aid in the nipple healing process.

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 and begins to rely on baby food or other solid foods for all its nutrition. Most mammals cease the production of the enzyme lactase at the end of weaning, becoming lactose intolerant. Many humans have a mutation that allows the production of lactase throughout life and can drink milk well beyond the age of weaning [38]. Typically, this milk comes from domesticated animals.

History of breastfeeding

An early 20th century Korean woman wearing a traditional breastfeeding clothing.
Two early 20th century Korean women feeding their babies while working.
File:National geographic 1910 11 korean laboring women.jpg
Three early 20th century Korean women.

In the early years of the human species, breastfeeding was as common as it was for other mammals feeding their young. There were no alternative foods for the infants, and the mother, along with other lactating females, would have no choice but to breastfeed the children. This process is still seen in many developing countries and is known as shared breastfeeding.

The Egyptian, Greek and Roman empires saw women only feeding their own children. However, breastfeeding began to be seen as something too common to be done by royalty, and wet nurses were employed to feed the children of the royal families. This was extended over the ages, particularly in western Europe, and saw women of noble birth (or who married into nobility) making use of wet nurses.

According to some Brahminical literature, breastfeeding in 2nd century India was commonly practised but not until the fifth day, allowing the colostrum to be discarded and the true breast milk to flow.

Developing alternatives

Alternatives first became popular in the late 15th century with many parents substituting cow or goat's milk for their own breast milk. This was particularly necessary for those families working the land whereby time could not easily be taken out to regularly breastfeed the child. Such trends soon faded when the problems associated with these milks started to show, and by the mid to late 16th century breastfeeding once again became the preferred feeding method for most families. The Italian Hieronymus Mercurialis wrote in 1583 that women generally finished breastfeeding an infant exclusively after the third month and entirely after around 13 months.

Dry nursing, the feeding of flour or cereal mixed with broth or water, became the next alternative in the 19th century but once again quickly faded. Around this time there became an obvious disparity in the feeding habits of those living in rural areas and those in urban areas. Most likely due to the availability of alternative foods, babies in urban areas were breastfed for a much shorter length of time, supplementing the feeds earlier than those in rural areas.

Though first developed by Henri Nestlé in the 1860s, infant formula received a huge boost during the post World War II "Baby Boom". The aggressive marketing campaigns when business and births decreased saw Nestlé and other such companies focus on non-industrialised countries, while government strategies in industrialised countries attempted to highlight the benefits of breastfeeding.

Breastfeeding in Japan

Traditionally, Japanese babies were born at home and breastfed with the help of breast massage. Weaning was often late, with breastfeeding in rare cases continuing until early adolescence. After World War II Western medicine was taken to Japan and the women began giving birth in hospitals, where the baby was usually taken to the nursery and fed formula. In 1974 a new breastfeeding promotion by the government helped to boost the awareness of its benefits and the uptake has seen a sharp increase. Japan became the first developed country to have a Baby-friendly hospital (and has since gone on to have another 24 such facilities).

Breastfeeding in Canada

A 1994 Canadian government health survey found that 73% of Canadian mothers initiated breastfeeding, up from 38% in 1963.[39] Western Canadians are more likely to breastfeed; just 53% of Atlantic province mothers breastfeed, compared to 87% in British Columbia. More than 90% of women surveyed said they breastfeed because it provides more benefits for the baby than does formula. Of women who did not breastfeed, 40% said formula feeding was easier (the most prevalent answer). Women who were older, more educated, had higher income, and were married were the most likely to breastfeed. Immigrant women were also more likely to breastfeed. About 40% of mothers who breastfed do so for less than three months. Women were most likely to discontinue breastfeeding if they perceived themselves to have insufficient milk. However, among women who breastfed for more than three months, returning to work or a previous decision to stop at that time were the top reasons.

A 2003 La Leche League International study found that 72% of Canadian mothers initiate breastfeeding and that 31% continue to do so past four to five months.[40]

A 1996 article in the Canadian Journal of Public Health found that, in Vancouver, 82.9% of mothers initiated breastfeeding, but that this differed by Caucasian (91.6%) and non-Caucasian (56.8%) women.[41] The article reported that just 18.2% of mothers breastfeed at nine months, and that breastfeeding practices were significantly associated with the mothers' marital status, education and family income.

Breastfeeding in Cuba

Since 1940, Cuba's constitution has contained a provision officially recognising and supporting breastfeeding. Article 68 of the 1975 constitution reads, in part:

During the six weeks immediately preceding childbirth and the six weeks following, a woman shall enjoy obligatory vacation from work on pay at the same rate, retaining her employment and all the rights pertaining to such employment and to her labour contract. During the nursing period, two extraordinary daily rest periods of a half hour each shall be allowed her to feed her child.

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 and in many countries there are now laws in place to protect the rights of a breastfeeding mother when feeding her child in public.

The World Health Organization (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 breastfeeding. Under this advice they have developed national breastfeeding 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:

However, there has been a long, ongoing struggle between corporations promoting artificial substitutes and grassroots organisations and WHO defending breastfeeding. 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.

Developing nations

In many countries, particularly those with a generally poor level of health, malnutrition is the majority cause of death in children under 5, with 60% of all those cases being within the first year of life [42]. International organisations such as Plan International and La Leche League have helped to promote breastfeeding around the world, educating new mothers and helping the governments to develop strategies to increase the number of women exclusively breastfeeding.

Traditional beliefs in many developing countries give different advice to women raising their newborn child. In Ghana babies are still frequently fed with tea alongside breastfeeding [43]. This reduces the benefits of exclusive breastfeeding and the drink can inhibit the absorption of iron, important in the prevention of anaemia.

Developed nations

In 1981, 118 countries voted in favour of the International Code of Marketing of Breast-milk Substitutes, but the USA voted against, on the grounds that it was a violation of freedom of speech guaranteed by the First Amendment of the Constitution of the USA, since due to corporate personhood, corporations have the same human rights as individual humans. [44]

Breastfeeding 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 breastfeeding can make the situation uncomfortable for those involved. There are numerous laws around the world that have made public breastfeeding legal and disallowed companies from prohibiting it in the workplace.

In the U.S. an appropriations bill (H.R.2490) with a breastfeeding amendment (H.AMDT.295 to H.R.2490) 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. Recent attempts to codify a child's right to nurse found success in Ohio, but failed in West Virginia and some other states. By June 2005, 35 states had enacted legislation to protect breastfeeding mothers and their children. Nowhere is breastfeeding in public illegal.

A survey reported by the UK Department of Health stated that most people (84%) find breastfeeding in public acceptable as long as it is done discreetly [45]. Contrastingly, 67% of mothers are worried about general opinion being against public breastfeeding. To combat these fears in Scotland, a bill [46] (pdf) safeguarding the freedom of women to breastfeed in public has been passed [47] in the Scottish Parliament [48]. The legislation sets up a fine of up to £2500 for preventing breastfeeding in legally permitted places.

In Canada, the Canadian Charter of Rights and Freedoms affords some protection under sex equality. Although Canadian human rights protection does not explicitly include breastfeeding, 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.

Some mothers choose to pump or express milk by hand so that they can carry a small bottle of milk with them if they plan to be out at mealtimes.

Recent global uptake

The following table shows the uptake of exclusive breastfeeding. Sources: WHO Global Data Bank on Breastfeeding and UNICEF Global Database Breastfeeding Indicators

Country Percentage Year Type of feeding
Armenia 0.7% 1993 Exclusive
20.8% 1997 Exclusive
Benin 13% 1996 Exclusive
16% 1997 Exclusive
Bolivia 59% 1989 Exclusive
53% 1994 Exclusive
Central African Republic 4% 1995 Exclusive
Chile 97% 1993 Predominant
Colombia 19% 1993 Exclusive
95% (16%) 1995 Predominant (exclusive)
Dominican Republic 14% 1986 Exclusive
10% 1991 Exclusive
Ecuador 96% 1994 Predominant
Egypt 68% 1995 Exclusive
Ethiopia 78% 2000 Exclusive
Mali 8% 1987 Exclusive
12% 1996 Exclusive
Mexico 37.5% 1987 Exclusive
Niger 4% 1992 Exclusive
Nigeria 2% 1992 Exclusive
Pakistan 12% 1988 Exclusive
25% 1992 Exclusive
Poland 1.5% 1988 Exclusive
17% 1995 Exclusive
Saudi Arabia 55% 1991 Exclusive
Senegal 7% 1993 Exclusive
South Africa 10.4% 1998 Exclusive
Sweden 55% 1992 Exclusive
98% 1990 Predominant
61% 1993 Exclusive
Thailand 90% 1987 Predominant
99% (0.2%) 1993 Predominant (exclusive)
4% 1996 Exclusive
Zambia 13% 1992 Exclusive
23% 1996 Exclusive
Zimbabwe 12% 1988 Exclusive
17% 1994 Exclusive
38.9% 1999 Exclusive

Lactation without pregnancy

Although it is not widely known in developed countries, women who have never been pregnant are able to lactate and therefore breastfeed as well. This is called induced lactation; while a woman who has lactated before and re-starts is said to "relactate". If the nipples are stimulated as in breastfeeding for a while (such as by a breast pump or actual suckling), eventually the breasts will begin to produce milk which can be used to feed a baby. Once established, lactation adjusts to demand. For this reason, adoptive mothers, usually initially in conjuction with some form of supplementation, are able to breastfeed their infants and young children [49]. There is thought to be little or no difference in milk composition whether lactation is induced or a result of pregnancy. There is also evidence of male lactation.

See also

References

Printed references:

  • Breastfeeding, Biocultural Perspectives; Editors Patricia Stuart-Macadam & Katherine A. Dettwyler.
  • Hausman, Bernice (2003). Mother's Milk: Breastfeeding Controversies in American Culture. New York: Routledge. ISBN 0-41596-656-6
  • Huggins, Kathleen (1999). The Nursing Mother's Companion. Harvard Common Press; 4th edition. ISBN 1-55832-152-7
  • La Leche League (2003). The Breastfeeding Answer Book.
  • Lothrop, H. (1998). Breastfeeding Naturally, Fisher Books, USA. ISBN 1-55561-131-1
  • Mercurialis, H. (1583). De Morbis Puerorum.
  • Minchin, M. (1985). Breastfeeding matters, Almo Press Publications, Australia. ISBN 0-86861-810-1
  • Moody, J., Britten, J. and Hogg, K. (1996). Breastfeeding your baby, National Childbirth Trust, UK. ISBN 0-72253-635-6
  • Pryor, Gail. (1996). Nursing Mother, Working Mother: The Essential Guide for Breastfeeding and Staying Close to Your Baby After You Return to Work. Harvard Common Press ISBN 1-55832-117-9.
  • Royal College of Midwives (1991). Successful Breastfeeding: A Practical Guide for Midwives, Royal College of Midwives, London.
  • Stuart-Macadam, P. and Dettwyler, K. (1995). Breastfeeding: Biocultural Perspectives (Foundations of Human Behavior), Aldine de Gruyter. ISBN 0-20201-192-5
  • Perez-Reyes M, Wall ME Presence of delta9-tetrahydrocannabinol in human milk. N Engl J Med 1982; 307:819-820 PMID 6287261
  • Astley SJ, Little RE., Maternal marijuana use during lactation and infant development at one year. Neurotoxicol Teratol. 1990 Mar-Apr;12(2):161-8. PMID 2333069
  • Leeson CPM, Kattenhorn M, Deanfield JE, Lucas A Duration of breast feeding and arterial distensibility in early adult life: population based study BMJ, Mar 2001; 322: 643 - 647.

Website references:

Infant pain and breastfeeding

Health risks of formula feeding

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