Breastfeeding

 

Article By:

R. Shah

S. Nimbalkar

 

Abstract

Breastfeeding is the right of every newborn child. It has many benefits for the newborn, the infant, as well as the mother. The results of breastfeeding can affect a society and its economy. Understanding the reflexes behind breastfeeding and the skills required by the mother is essential for every physician that looks after a child. Breastmilk has many stages which are responsive to the physiology and stage of the neonate. Breastfeeding is also beneficial to the mother which a physician can help explain. If the physician can encourage and stress to the mother how vital it is to breastfeed, then it can be followed by the mother in a proper manner.

 

Introduction:

Breast milk is the ideal source of food for a newborn. A primary care or general physician should also be able to help mothers understand the significance of breastfeeding. An understanding of basic physiology is of paramount importance to be able to counsel mothers. Two reflexes involving two hormones are vital to the production and secretion of breastmilk. The first is the prolactin reflex, also known as the milk secretion reflex, which comes into play when the baby sucks on the nipple. In response to latching at the breast, the nerve endings in the areola carry signals to the anterior pituitary gland which releases prolactin.[1]

Prolactin stimulates the alveolar glands in the breast resulting in milk production. In other words, if the baby sucks the breast more, there will be a greater quantity of milk produced. Greater demand is equal to more production. Therefore, mothers need to nurse early, frequently, and completely empty the breast at each session. Breastfeeding at night is vital to maintain this reflex because prolactin is produced more in the night.[1]

The second is the oxytocin reflex, also known as the milk ejection reflex, which is initiated by sucking as well as any thought, sight, or sound  of the baby.[1] As this occurs, oxytocin is released from the posterior pituitary gland and milk is ejected from the glands into the lactiferous sinuses.[1] The mother’s emotions influence this reflex; hence, a calm and serene attitude is necessary. If the mother is worried or frustrated, it may affect this reflex. Hence, it is vital that no negative comments related to breastfeeding be passed in the presence of the mother. Mothers are often worried that their baby may not be getting enough milk. They may blame either flatus or normal crying of the baby as indigestion of their milk. It is essential to assure the mother and alleviate her anxiety. Supplementation with other milk or casting a doubt of inadequacy can set up the mother for future failure in breastfeeding. Some other factors which reduce milk production are pacifiers and bottles. This will also introduce the prospects of diarrhea in the infant. Giving any supplemental foods before six months will also hamper breastfeeding. Night feeding and full emptying of the breast at each feeding will maintain the oxytocin reflex.[1]

As the infants become older, mothers who work may enquire about the usage of formula as they may need to go away from the infant for extended periods of time. Is breastfeeding better or can formula replace it? It is crucial for doctors to convince every mother that nothing can replace breastfeeding. Breastmilk is advantageous in many ways both for the mother and child. If necessary, breast milk can be pumped using a breast pump, and stored in the refrigerator for the infant.

At birth a neonate is susceptible to many infections. One of the advantages of breastfeeding is the immunity that it provides against many illnesses. It decreases the chances of respiratory tract infections, otitis media, gastrointestinal tract infections, necrotising enterocolitis, and allergic diseases.[2] It also reduces the risk of Type 1 diabetes mellitus and obesity.[2] Neurodevelopment and consequently intelligence is higher in breastfed infants as well.[2] They receive all the nutrients they need for normal growth and development. Breast milk also contains sufficient amount of water hence baby does not require additional water and will not get dehydrated. Breastfeeding also helps the baby bond well with the mother.[1,2]

The mother also receives many benefits by breastfeeding. First, it helps with involution of the uterus and reduces the risk of postpartum bleeding.[2] Breastfeeding also causes lactational amenorrhea which provides a natural contraceptive method leading to increased child spacing.[2] It also helps in post pregnancy weight reduction. It prevents many diseases such as Type 2 diabetes mellitus, ovarian cancer, breast cancer, and cardiovascular diseases.[1,2]

The composition of breastmilk needs to be stressed because the composition of breast milk has its own significance for the baby, commensurate with the growing needs/age of the baby. Initially, during the first three to four days after delivery, the mother produces colostrum.[3] Colostrum is thick and yellow and includes a substantial number of antibodies, and vitamins.[3] After colostrum comes the transitional milk which lasts up to two weeks after colostrum.[1] It has a higher fat and carbohydrate content with less protein and immunoglobulins. Lastly comes the mature milk. This is generally thin and watery but contains all the necessary nutrients and vitamins the baby requires.[1] If the baby is born preterm, the mother produces milk which is rich in proteins, sodium, iron, immunoglobulins, and calories and thus appropriate for the preterm baby.[1]

Breast milk has two components, fore-milk and hind-milk, both of which are important for the baby. Fore-milk which the baby consumes during the initial part of a breastfeeding session contains proteins, sugar, vitamins,  minerals, and water which satisfies the baby’s thirst.[3] Hind-milk is thicker and comes at the end of the feed.[3] It consists of more fat that provides energy and gives the baby the feeling of fullness. As both are important for the baby, the mother should be counseled to empty the breast completely before switching to the other side.[1,3] Emptying the breast also ensures better milk production, as a non-empty breast having some residual milk does not allow milk production to occur. Hence, the mother needs to feed on one breast during a session and empty it completely before switching to the other side if the baby is still hungry. Usually feeding from one breast suffices and the mother should remember to start with the other breast during the next feeding session.

Breastfeeding is a skill that needs to be learned by the mother and hence the mother needs to be taught the technique of breastfeeding. If the technique is inappropriate, the baby may not get enough milk, or the mother may face difficulties and feel inadequate. Instruction of correct positioning, attitude, and technique need to be explained. Mother’s position should be a comfortable one, sitting or lying down. The baby’s whole body should be supported, and the baby’s head and body should be in line.[1] The baby should be turned towards the mother (both mother’s and baby’s abdomen touching) and the nose of the baby should be at the level of the nipple.[1] The baby’s attachment to the breast is equally as important which is called “latching on.” Signs of good attachment include the baby’s mouth being wide open, only the upper areola of the mother is seen, baby’s chin touches the breast, and lastly, baby’s lower lip is everted.[1] The mother should also be counseled to check if the baby is sucking effectively. Generally, the pattern is as follows, suck, suck, suck, and swallow. The baby’s cheeks should be full and not hollow or retracting during the sucking.[1]

Breastfeeding can be easily done in case of twins or triplets or even more. The size of the breast has no relation to the amount of milk produced and hence should not be a cause of concern by the mothers. It has been seen that mothers can produce as much as 5 liters of milk in a day if required, while the average daily requirement usually does not cross 700-800 milliliters in infants.

If the mother is working and away from the baby for long periods, she may ask the physician about the use of a breast pump. It is convenient and another caregiver can feed the infant breast milk whenever the mother is not available. It also reassures the mother that her breast milk is being fed and not a formula replacement.[4] However, there are some risks to using a breast pump such as infection or contamination of the milk if inadequately stored, and breast tissue damage.[4] The physician should explain to the mother that if she can nurse her child, that would be the ideal situation. If that is not possible, other methods can be used.

The physician should also advise when it is contraindicated to breastfeed the baby. Infants with the metabolic disorder of classic galactosemia are not to be breastfed. Mothers with positive tests for human T-cell lymphotropic virus (HTLV) type I or II, untreated brucellosis, untreated open tuberculosis, or active herpes should not breastfeed their babies.[2] Mothers that develop varicella five days before to two days after delivery should be roomed away from their babies however, they can feed the babies with expressed breast milk.[2] The same is applied to the febrile period of H1N1 influenza infection.[2] Generally, in developed countries, HIV-positive mothers are not recommended to feed their babies.[2] Nevertheless, in developing countries where babies are malnourished and mortality rates are high, breastfeeding outweighs the risk of acquiring HIV. Daily alcohol ingestion is not advised to breastfeeding mothers but an occasional,  small  drink  may  not  be harmful.[2]

Smoking is not an absolute contraindication but it is related to increase incidences of sudden infant death syndrome and respiratory allergies and hence best avoided.[2] In addition, if the mother is on certain drugs such as lithium, chemotherapy agents, or radio-therapeutic agents breastfeeding should not be advised.[2] There are a few other drugs which may be harmful to the baby which the physician should check prior and inform the mother.

The mother’s diet during the lactational period is also of importance. She should increase her daily caloric intake by 500 calories in a normally balanced diet.[5] This is recommended in the first six months of exclusive breastfeeding. After which, the calorie count can be reduced to additional 400 kcal per day.[5] The mother should eat foods rich in vitamin B, iodine, and omega-three fatty acids which provide the baby with nutrients needed for normal growth and neurodevelopment.[2,5]

The mother should be advised to continue exclusive breastfeeding for 6 months and feed the baby at least 8-12 times daily.[1,2] Supplementary food should be started after 6 months and foods should be rich in iron and zinc.[2] Breastfeeding should be continued at least up to the second year and then beyond that if it is mutually desired by the mother and child. Should the mother have any problems with breastfeeding such as inverted nipples, sore nipples, breast engorgement, and/or not enough milk she should be counseled appropriately and needs to be seen by a physician experienced in lactation management or a lactation consultant.[1] It is encouraged to check proper positioning and attachment of the baby to the breast which are usually the prime reasons for problems.[1,2]

If the mother cannot breastfeed the child, she should be explained about expressed breast milk. Expressed breast milk can be stored at room temperature for about 6-8 hours, in the refrigerator for 24 hours, and in a freezer at -20oC for up to 3 months.[1] The mother should express the milk in a clean wide-mouthed container.[1] She should be explained how to express the milk from her breast. She should empty both breasts at a sitting and do this at least eight to ten times a day.[1]

Breastfeeding is a vital step to a healthy baby’s future. As physicians we should support and encourage breastfeeding always during our interactions with mothers. Any general practitioner in contact with mothers who have just delivered should encourage and counsel them to breastfeed their babies as long as possible.

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References:

  1. Paul VK, Bagga A. Ghai Essential Pediatrics. 8th ed. New Delhi, India. CBS Publishers and Distributors Pvt Ltd. 2013. 150p.
  2. Eidelman AI, Schanler RJ. Breastfeeding and the Use of Human Milk. The American Academy of Pediatrics. 2012; 129(3):e827-841.htttp://www.pediatrics.org/cgi/doi/ 10.1542/ peds.2011-3552
  3. Ballard O, Morrow AL. Human Milk Composition: Nutrients and Bioactive Factors. Pediatric clinics of North America. 2013;60(1):49-74. http://doi.org/10.1016/j.pcl.2012.10.002
  4. Buckley KM. A Double-Edged Sword: Lactation Consultants’ Perceptions of the Impact of Breast Pumps on the Practice of Breastfeeding. The Journal of Perinatal Education. 2009; 18(2):13-22. http://doi.org/10.1624/105812409X426297
  5. Picciano MF. Pregnancy and Lactation: Physiological Adjustments, Nutritional Requirements and the Role of Dietary Supplements. The Journal of Nutrition. 2003; 133(6):1997s-2000s.