Breastfeeding Your Baby
An excerpt from the book, Our Bodies Ourselves
By Anne Merewood, Assistant Professor of Pediatrics,
Boston University School of Medicine
I didn’t breast-feed my first daughter. I was a new immigrant, I wanted to be like the Americans. Do I feel bad about it? Yes. Do I keep beating up on myself? No!! We have to get beyond our personal issues. I go up to women in the street who are breast-feeding and I say, “Great job!” And when women aren’t breast-feeding, I say “What went wrong? Call me next time!” We need to help each other out on this one.
Breast milk is the best food for babies.1 It provides exactly the right balance of nutrients, adapting to your baby’s changing requirements. Breast milk helps strengthen the infant’s resistance to infection and disease. Not breast-feeding is associated with a higher risk of the child developing many short-term health problems and chronic conditions, including ear and lower respiratory tract infections, gastrointestinal problems, Type 1 diabetes, leukemia, and other childhood cancers.2 Breast-feeding also has health benefits for the mother, the most impressive of which is a greatly reduced incidence of breast cancer.3 Some studies show that women who breast-feed two years or more have half the rate of breast cancer than women who do not breast-feed.4 For premature infants, or infants with conditions such as Down syndrome, the anti-infective properties of breast milk are especially beneficial.
Studies show that most women in the United States want to breast-feed but that practical
barriers, early difficulties, and misinformation often jeopardize our success. In countries such as Sweden and Norway — where about 98 percent of mothers begin breast-feeding and 70 percent are still breast-feeding after six months — social acceptance, supportive hospital practices, and extended maternity leave all contribute to helping women achieve their breast-feeding goals. Unfortunately, in other developed nations, including the U.S., society’s influences are different, and breast-feeding rates are low, especially among poor and minority women.5 In the early 1970s, only 22 percent of women in the U.S. began breast-feeding their infants. By 2001 rates had risen to 70 percent, but only 46 percent of all babies received exclusively breast milk in the hospital setting.6 Worldwide, over eighteen thousand hospitals have earned the WHO/UNICEF "Baby-Friendly" designation for supportive breast-feeding practices, but in 2004 only forty-two of those were located in the U.S.
In developed countries in particular, where formula feeding is common, many of us do not have the wisdom and support of other women to help guide us in breast-feeding our child. The American Academy of Pediatrics recommends exclusive breast-feeding for approximately six months, then adding solids at six months, with continued breast-feeding to a year or beyond.7 The WHO recommends that children be exclusively breast-fed for six months, with breast-feeding continued two or more years.
A Good Start: Rooming-in
Infants who breast-feed in the first hour of life are more successful long-term breast-feeders.8 Those who are placed on the mother’s abdomen after birth will instinctively try to crawl to the breast and (especially if the birth was unmedicated) will usually find the breast and suckle within the first hour of life.9
Keeping your baby with you twenty-four hours a day also helps promote successful breast-feeding. Many mothers actually sleep better with their baby in the room. If you give birth in a hospital and want to room-in (as the practice is called), be clear with your caregiver and the nursing staff. It’s a good idea to let them know before birth so that your newborn is not taken to the nursery. Remember: It’s your right to be making decisions about your baby from the very beginning.
I am the nurse manager of a maternity unit at an inner-city hospital. I encourage the moms and babies under my care to room-in together. When my own daughter was born 20 years ago, hospital policy dictated that she was "not allowed" to stay with me at night. My breasts were engorged, I was in pain and longing to see my new child. I remember walking down the long hall to the nursery, crying, just so that I could glimpse her through the window. I am committed to my job because I never want another woman to go through such an experience.
The advantages to having your baby nearby in your hospital room include bonding; the chance to observe early feeding cues; and the opportunity to begin learning about your baby’s care with skilled nurses to assist you.
I have no support. It's just me and my baby. I want him with me at all times, because that's where he’s gonna be for a whole lot of years, and that’s where I want him to be.
What to Expect in the First Few Days
Colostrum
Colostrum, the liquid in a mother’s breasts before the milk actually comes in, is especially high in antibodies that protect the newborn against infections. Most women make about three tablespoons of milk in the first twenty-four hours after birth, and thirteen tablespoons on day two: just the right amount for your baby, whose stomach is only the size of her or his fist. Mothers who need to pump for medical reasons, such as the baby being in the intensive care unit, may find these first three days discouraging because the volume is so small. However, by day three or four, most mothers are pumping more milk.
Supply and Demand
The drop in progesterone levels after your baby is born starts milk production, which continues on the principle of supply meeting demand. When your baby suckles, nerves in the nipple and areola are stimulated and signal the pituitary gland to release oxytocin and prolactin. Oxytocin is responsible for the "letdown," or milk ejection reflex. It moves the milk from the glands toward and out of the nipple. Prolactin is responsible for milk production. As your breast is emptied, the milk glands respond to the prolactin, and more milk is made. The more frequently your breasts are emptied, the more milk you will make. This is why women who nurse twins make enough milk for both babies.
Latch and Positioning
The key to avoiding pain and ensuring milk transfer is for the baby to latch on well, taking as much breast as possible into her or his mouth, rather than pinching the nipple between the gums at the front of the mouth. To latch a newborn, support your breast with your fingers away from the nipple, making sure your fingers do not get in the infant’s way. Stroke the center of your baby’s lower lip with your nipple to elicit the rooting reflex. When your baby opens her or his mouth widely, hug the baby to your breast, so your nipple can get deep in his or her mouth and milk can flow easily.
Most of us naturally use the cradle hold to breast-feed our baby, with the infant in our arms on his or her side, facing us, tummy to tummy, nipple to nose. To prevent backache, use support under the baby and bring the baby to you, rather than leaning over. The football hold, with the baby at your side, feet tucked under your arm, is especially useful if you had a cesarean birth, as this position avoids pressure on abdominal sutures; and if you have large breasts, as it is easier to see the baby’s mouth. You can also lie on your side next to your baby, tummy to tummy, with the baby nursing on his or her side and facing you.
Breast-feeding Challenges
Baby Cannot Latch
Some infants, especially those born early, have trouble latching, or are sleepy beyond the expected sleepiness of the first twelve to fourteen hours. If this happens, continue to offer the breast, and watch carefully for feeding cues. To help rouse your infant, try tickling her or his feet, giving a full-body massage, undressing the baby or changing diapers, or laying the baby down in an open space away from you. Other infants are wide awake but fuss and cannot latch easily. Calming techniques — such as putting the infant skin to skin with you, offering a finger to suck before switching to the breast, and expressing colostrum onto the nipple — may calm the baby enough so he or she will begin eating. You may also need to test different holds on your breast, as one might work better than another. Some mothers need to stimulate the nipple to make it erect and firm enough for the baby to latch.
If your baby still cannot latch, you should begin to pump every three hours for about ten to fifteen minutes, with a high-quality double-pumping electric breast pump. The pump will give your body the message to make milk until your baby is sucking effectively. You can also use a small syringe to drip the milk in the baby’s mouth as your volume increases.
If you leave the hospital before your baby is breast-feeding effectively, arrange for follow-up with someone who is knowledgeable about breast-feeding, such as an international board-certified lactation consultant (IBCLC).
My first baby refused to take the breast — it felt like he was rejecting me. It took hours to latch him on, and then after 10 minutes, I would have to "change sides" like the nurse said. My family all urged me to quit. After a week, I decided to pump and bottle-feed. With my next baby, I listened only to my friend who had breast-fed successfully. I breast-fed him for 13 months and my third baby for three years! If my first had been my third, I would have felt more confident and coped better. He probably would have latched on eventually.
Inverted Nipples
Some women's nipples evert (stick out or become erect) when rubbed or stimulated, while other women’s nipples retract (invert) when pressure is put on the areola, making it difficult for most babies to latch. Other nipples have a slit or crease across the middle that can become painfully abraded. If your nipples are flat or mildly inverted, feeding the baby in the first hour of life and avoiding bottles may help. If the baby continues to be unable to latch, you may need to pump your milk and feed your baby with a bottle, cup, or syringe.
Engorgement
When your milk comes in, or transitions from colostrum to mature milk, the breasts may become so full and firm that your baby cannot latch easily. In this instance, you can either manually express milk or use an electric breast pump just long enough to soften the breast around the nipple so your baby can latch on (pumping for too long increases stimulation and leads to even more milk production). Ice packs or warm compresses can be used; whatever feels comfortable. Putting your baby to the breast as often as he or she will eat will ease engorgement more quickly. Engorgement is temporary, and with careful management, most women are more comfortable within twenty-four to forty-eight hours. However, untreated engorgement can be a serious problem, because it decreases milk production by setting up the biofeedback mechanism for inhibiting prolactin. If you notice that your breasts are not softening significantly when your baby nurses, it is important to seek professional help from a lactation consultant or another knowledgeable health care professional, because breast softening is the first sign that the baby is getting milk.
Sore Nipples
Nipple pain in the early days usually results from poor latch, not from length of time at the breast. If your nipples hurt, work on positioning (see above). Breast milk on the nipples is healing; pure lanolin to rub into the chafed skin is also available over the counter. Hydrogels that were developed to treat burns can safely be used to protect the nipples between feedings and allow the skin to heal once the baby is latching on correctly. Limiting nursing time will not prevent sore nipples. Tolerating the pain will only lead to damage, and if the baby is not well latched, he or she will not get milk effectively.
Sore Breasts
Swelling, redness, or a painful lump in one area of your breast may signal a plugged duct. Warm compresses on the swollen area (or ice, if that feels better); massaging behind the area as the baby nurses or you pump; and increased nursing will usually ease the discomfort. If the swelling is accompanied by fever and/or a tired, run-down, achy, flu-like feeling, you probably have a breast infection (mastitis). In that case, your health care practitioner will probably recommend an antibiotic covering staph and strep bacteria, which means you can still continue to breast-feed. Rarely, a breast infection will develop into an abscess that may have to be surgically drained.
Breast-feeding in Public
Some states have laws protecting a woman's right to breast-feed in public, and others are currently introducing them. If you encounter problems when breast-feeding in public, contact your local breast-feeding support organization (such as La Leche League) for supportive information regarding the laws in your area.
Returning to Work
Those of us who decide to continue breast-feeding after returning to work can hand-express breast milk or use an electric breast pump to produce a supply for our baby. An
effective breast pump should have adequate pressure and mimic the infant’s suck/swallow rhythm. Pumps may be either single or double pumping. It should take you ten to fifteen minutes to "empty" each breast. Contact your local La Leche League or the maternity unit of your hospital to obtain the names of good manufacturers.
Breast-feeding Under Special Circumstances
If you have had breast surgery, successful breast-feeding may still be possible. Breast reduction surgery for cosmetic reasons or a lumpectomy (breast cancer treatment) can cause problems with milk supply. Breast augmentation surgery is usually less problematic. If you have had a mastectomy (breast removed), you can probably nurse with the remaining breast. Tell health care providers about your surgery, and be sure to monitor your baby’s weight carefully. Even if you do not have sufficient glandular tissue to produce a full milk supply, you can usually breast-feed if you choose to, and supplement with formula.
Some of us who adopt a child also wish to breast-feed. It may be possible to create a milk supply even without giving birth, by frequently putting the baby to the breast. (Nipple stimulation can affect hormone levels that control milk supply.) It’s a good idea to make enjoyment of the nursing relationship the main goal, and to regard milk supply as a bonus rather than a necessity, as the supply may not be copious. Pumping and medication may help to increase a supply, though little research exists on this in the Western world. If you decide to try to breast-feed your adopted baby, contact a lactation consultant for expert advice.
Reasons Not to Breast-feed
In specific situations, breast-feeding is not safe for the baby. The American Academy of Pediatrics cites the five following reasons not to breast-feed:
- HIV-positive status in the mother
- Active, untreated maternal tuberculosis
- Some maternal medications
- Illegal drug use by the mother
- Infant with galactosemia (a metabolic deficiency)10
Other medical reasons breast-feeding may not be possible or advisable for a mother include previous breast surgery (see above), nondevelopment of breast tissue, and certain rare hormonal conditions. There are also instances when pumped breast milk or formula supplementation may be temporarily advisable for the infant’s health. These include: weight loss over 7 percent, low blood sugar, and unusually high levels of bilirubin (causing jaundice). For more information on formula, see p. 484.
Formula as an Alternative to Breast Milk
Some of us are unable to breast-feed, some of us prefer not to breast-feed, and some of us would like to but cannot due to situations in our lives beyond our control. In earlier times, the only option for a new mother not breast-feeding was to find a wet nurse for her infant. Today we have formula as an alternative. Depending upon the situation, some women use formula in combination with breast-feeding, and others exclusively formula-feed.
All formulas imitate human breast milk, but they are not a perfect substitute. Human breast milk contains living cells and proteins that provide immunity from disease, which formula does not have. Therefore, formula supplies the basic nutrients needed for normal growth and development, but it cannot supply the protection against disease that human milk provides.
Infant formula is made from either cow’s milk or soy products. Both have additional nutrients added so the final product imitates human milk. The two types of formula have similar amounts of many nutrients, but the types of protein and sugar differ from those found in human milk. Some new formulas on the market modify either the type of protein or type of sugar (lactose or sucrose). These formulas are designed to feed babies with special needs, such as premature babies or infants sensitive to lactose, which is the sugar in cow’s milk formulas.11 In recent years, formula manufacturers have introduced additional nutrients based on growing knowledge of the composition of human milk.12
Soy formula gained popularity in the 1990s, in response to concerns about allergies to cow's milk protein. Infants are particularly susceptible to developing allergies to the proteins in food, and about three of every hundred infants develop allergies to cow’s milk protein.13 It was thought that soy formula would prevent allergies. However, babies can be allergic to soy protein as well, so this hope was unfounded.14 More recently, concerns have been raised about soy formula causing reproductive or thyroid problems because it contains isoflavones that are similar to female hormones. To date, research has found no short-term or long-term differences in growth or in the frequency of illness in babies who are fed cow’s milk formula when compared with those who are fed soy formula.15
The inappropriate promotion of infant formula by corporations continues to undermine informed choices about breast-feeding among women worldwide. This is one reason that the U.S. government in June 2004 launched a national campaign to promote exclusive breast-feeding for the first six months of life.
Notes
1 Work Group on Breastfeeding, American Academy of Pediatrics, "Breastfeeding and the Use of Human Milk," Pediatrics 100, no. 6 (1997): 1035Ð39.
2 B. Duncan, J. Ey, C. J. Holberg, A. L. Wright, F. D. Martinez, L. M. Taussig, "Exclusive Breast-feeding for at Least 4 Months Protects Against Otitis Media," Pediatrics 91, no. 5 (1993): 867Ð72. See also Work Group on Breastfeeding, "Breastfeeding and the Use of Human Milk"; E. J. Mayer, R. F. Hamman, E. C. Gay, D. C. Lezotte, D. A. Savitz, G. J. Klingensmith, “Reduced Risk of IDDM Among Breast-fed Children: The Colorado IDDM Registry,” Diabetes 37, no. 12 (1988): 1625Ð32;
S. M. Virtanen, L. Rasanen, K. Ylonen, et al., "Early Introduction of Dairy Products Associated with Increased Risk of IDDM in Finnish Children: The Childhood Diabetes in Finland Study Group," Diabetes 42, no. 12 (1993): 1786Ð90;
X. O. Shu, M. S. Linet, M. Steinbuch, et al., "Breast-feeding and Risk of Childhood Acute Leukemia," Journal of the National Cancer Institute 91, no. 20 (1999): 1765Ð72;
F. Perrillat, J. Clavel, M. F. Auclerc, et al., "Day-care, Early Common Infections and Childhood Acute Leukemia: A Multicentre French Case-Control Study," British Journal of Cancer 86, no. 7 (2002): 1064Ð69;
V. B. Smulevich, L. G. Solionova, S. V. Belyakova, "Parental Occupation and Other Factors and Cancer Risk in Children: I. Study Methodology and Non-occupational Factors," International Journal of Cancer 83, no. 6 (1999): 712Ð17;
M. K. Davis, D. A. Savitz, B. I. Graubard, "Infant Feeding and Childhood Cancer," Lancet 2, no. 8607 (1988): 365Ð89;
L. Tryggvadottir, H. Tulinius, J. E. Eyfjord, T. Sigurvinsson, "Breastfeeding and Reduced Risk of Breast Cancer in an Icelandic Cohort Study," American Journal of Epidemiology 154, no. 1 (2001): 37Ð42;
V. Tovar-Guzman, C. Hernandez-Giron, E. Lazcano-Ponce, I. Romieu, Avila M. Hernandez, "Breast Cancer in Mexican Women: An Epidemiological Study with Cervical Cancer Control," Revista de Salude Publica 34, no. 2 (2000): 113Ð19;
M. McCredie, C. Paul, D. C. Skegg, S. Williams, "Breast Cancer in Maori and Non-Maori Women," International Journal of Epidemiology 28, no. 2 (1999): 189Ð95;
T. Zheng, L. Duan, Y. Liu, et al., "Lactation Reduces Breast Cancer Risk in Shandong Province, China," American Journal of Epidemiology 152, no. 12 (2000): 1129Ð35;
T. Zheng, T. R. Holford, S. T. Mayne, et al., "Lactation and Breast Cancer Risk: A Case-Control Study in Connecticut," British Journal of Cancer 84, no. 11 (2001): 1472Ð76;
R. Ing, N. L. Petrakis, J. H. Ho, “Unilateral Breast-feeding and Breast Cancer,” Lancet 2, no. 8029 (1977): 124Ð27;
and Collaborative Group on Hormonal Factors in Breast Cancer, “Breast Cancer and Breastfeeding: Collaborative Reanalysis of Individual Data from 47 Epidemiological Studies in 30 Countries, Including 50,302 Women with Breast Cancer and 96,973 Women Without the Disease,” Lancet 360, no. 9328 (2002): 187Ð95.
3Tryggvadottir et al., “Breastfeeding and Reduced Risk of Breast Cancer.” See also Tovar-Guzman et al., “Breast Cancer in Mexican Women”; McCredie et al., “Breast Cancer in Maori and Non-Maori Women”; Zheng et al., “Lactation Reduces Breast Cancer Risk in Shandong Province, China”; Zheng et al., “Lactation and Breast Cancer Risk”; Ing et al., “Unilateral Breast-feeding and Breast Cancer”; and Collaborative Group on Hormonal Factors in Breast Cancer, “Breast Cancer and Breastfeeding.”
4Zheng et al., “Lactation Reduces Breast Cancer Risk in Shandong Province, China.”
5Office on Women’s Health, U.S. Department of Health and Human Services, “Health and Human Services Blueprint for Action on Breastfeeding,” Washington, D.C., 2000.
6A. S. Ryan, Z. Wenjun, A. Acosta, “Breastfeeding Continues to Increase into the New Millennium,” Pediatrics 110, no. 6 (2002): 1103Ð9.
7Work Group on Breastfeeding, “Breastfeeding and the Use of Human Milk.”
8L. Righard, M. O. Alade, “Effect of Delivery Room Routines on Success of First Breast-feed,” Lancet 336, no. 8723 (1990): 1105Ð7. See also L. Righard, M. O. Alade, “Sucking Technique and Its Effect on Success of Breastfeeding,” Birth 19, no. 4 (1992): 185Ð89; L. Righard, “How Do Newborns Find Their Mother’s Breast?,” Birth 22, no. 3 (1995): 174Ð75; and L. Righard, “Early Enhancement of Successful Breast-feeding,” World Health Forum 17, no. 1 (1996): 92Ð7.
9Righard, “How Do Newborns Find Their Mother’s Breast?”
10Work Group on Breastfeeding, “Breastfeeding and the Use of Human Milk.”
11A. L. Morrow, “Choosing an Infant or Pediatric Formula,” Journal of Pediatric Health Care 18 (2004): 49Ð52.
12A. Donnelly, H. M. Snowden, M. J. Renfrew, M. W. Woolridge, “Commercial Hospital Discharge Packs for Breastfeeding Women,” Cochrane Review, in The Cochrane Library 2 (Chichester, UK: John Wiley & Sons, Ltd.).
13S. L. Bahna, “Cow’s Milk Allergy Versus Cow Milk Intolerance,” Annals of Allergy, Asthma and Immunology 89, no. 6 (2002): 546Ð60.
14C. W. Low, et al., “Infant Formula, Past and Future: Opportunities for Improvement,” American Journal of Clinical Nutrition 63 (1996): 636SÐ50S.
15B. L. Strom, et al., “Exposure to Soy-Based Formula in Infancy and Endocrinological and Reproductive Outcomes in Young Adulthood,” Journal of the American Medical Association 286 (2001): 807Ð14.
16A. LoCicero, D. Weiss, and D. Issokson, “Postpartum Depression: Proposal for Prevention Through an Integrated Care and Support Network,” Applied and Preventive Psychology 6 (1997): 169Ð78.
Current as of August 2005
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