Breastfeeding

BREASTFEEDING

- © Dr. Taher Y. Kagalwala M.D., D.C.H.

Why Breastfeeding is best for the baby:

Breast is best. How many times have you heard that? Perhaps it irritates you when your pediatrician extols the virtues of mother’s milk and practically passes judgement on your capabilities as a successful mother based only on one criterion: Did you breastfeed your baby/Are you planning to breastfeed your baby? How long?

Come to look at it from the baby’s point of view and you will see the wisdom of our elders, who almost always managed to successfully breastfeed their progeny for one, or even, two whole years. How did they do this? What was their secret formula?

The truth is, they had no secret formula, and did not follow any special regimens of diet, sleep, exercise or rest. They lived their normal lives, as to them, breastfeeding was but a normal routine activity that they did – as naturally, as perhaps changing the baby’s nappy, or cooking family food. With the advent of modern times, mothers are increasingly failing at this most incredible, natural and time – honoured activity simply because they consider it a “chore” and not a pleasurable activity. They call it their “duty” to feed the baby; to them, giving the baby breast- milk is a “sacrifice”!

And yet, it is a miracle that almost 95 – 98 % of all mothers DO breastfeed their babies successfully. This is so because they stop worrying about whether their babies will get enough milk or not, whether they are putting on weight adequately or not and whether they are “healthy” or not.

Successful infant feeding requires cooperation between the mother and the baby, beginning with the first feed, and continuing throughout the child’s period of dependency. Promptly establishing comfortable, satisfying routines contributes greatly to your baby’s emotional well-being. Feeding times should be pleasurable to both mother and baby.

When to start:

As soon as possible after birth, the baby should be put to the breast for feeding. This will enable her to acquire the needed energy to successfully transit to extra-uterine life, promote mother-infant bonding and decrease the risk of the infant getting a low-blood sugar, jaundice, low blood calcium levels and many other metabolic problems. It may be possible to make mistakes, and give the baby too much or too little milk. She may then vomit (too much) or become feverish (dehydration fever) (too little). Babies usually begin to breast feed within a few hours after birth, although some may start after 4-6 hours. After this, the baby may feed “on demand”, that is, whenever she is hungry. The interval between feeds may vary from one child to another and even in the same infant from time to time, and will depend on the time it takes for her stomach to empty after a feed. However, by the end of the first fortnight, your baby will have established a reasonable schedule of feeding. Feeds can be considered adequate if your baby stops losing weight by a week and regains her birth-weight by 10-12 days.

It should be remembered that babies cry for reasons other than hunger too, and on no account should the baby be fed every time she cries. Nor should you immediately suspect either that the baby is ill, or that you are not having enough breast milk.

Too much clothing, gas, colic, soiled, wet or uncomfortable diapers and a hot or uncomfortable environment can all cause the baby to cry. Some may even cry to gain additional attention, while some may be actually sick.


Advantages of Breastfeeding:

Everyone knows that breast milk is the best milk for the baby! But few mothers realise that it is also best for them!

I shall enumerate its advantages here so that you may realise just how good it is for your baby and for you as well.

Advantages for the baby:

1. It is the natural food for her. It is always available at the right temperature, and needs no preparation. It is fresh, free and has no contaminating germs which could produce attacks of diarrhea.

2. Cow’s milk often causes allergies, characterised by intestinal bleeding, diarrhea, spitting up, colic, or even wheezing or eczema. Infants fed breast milk have no such problems. They also suffer less from middle ear infections, pneumonia, meningitis and some other illnesses.

3. Human milk is full of antibodies against the disease causing germs. These antibodies protect your baby within the gut as well as in the body from an attack by many different kinds of bacteria and viruses. Besides antibodies, human milk has many other immunity boosting chemicals and hormones that protect the baby from an onslaught of diseases. Breastfed babies have a 14 – fold reduction in the incidence of deaths by diarrhea, 4–fold reduction in deaths by acute respiratory tract infections and 3–fold reduction in deaths by other infections.

4. Milk from an adequately nourished mother will supply most essential vitamins and minerals, except, perhaps fluoride (in the West), and Vitamin D (after several months).

5. Certain ingredients in breast–milk actually help the baby gain more intelligence than top–fed babies.


6. Breastfed babies have a lower chance of developing heart, blood–pressure, obesity and diabetes–related ailments in later life.

7. Breast feeding has tremendous psychological benefits for both, the baby, and the mother. The mother feels a sense of accomplishment at having nourished and nurtured her baby; the baby is provided with a close and comfortable relationship with her mother.

Advantages to the mother:

8. Breastfeeding hastens the healing of the womb; it is said to impart a sensually happy feeling to the mother; it also promotes a better shape to the bust of the mother in later life; it may actually protect against some types of cancer in the mother; and finally, it provides some protection against an unwanted pregnancy for a variable length of time, as long as the mother is nursing. However, conception may occur despite this, so some form of contraception is still recommended. This is because when a baby is conceived, the expectant mother misses her next period and not the previous one.

9. Breastfeeding provides emotional bonding between the mother and baby, which will stand both of them in good stead when they face emotional crises in the family. The mother is less likely to beat or abuse her daughter/son if she/he has been given her milk.

10. There is a definite economic saving to the family, as the cost of buying feeding bottles, teats and milk powder are added to the cost of sterilisation and cleaning of the bottles, the cost of treating the infective illnesses and the time–cost of preparing the feeds.

Establishing and Maintaining Milk Supply:

The most satisfactory way of maintaining adequate lactation is to feed the baby regularly to empty the breasts. During the initial days, although the mother may feel that she has less milk, she should continue to put the baby to her breast every time she cries, or at least every 2-3 hours, so that the baby stimulates the production of more milk.

Remember: More suckling means more milk. Sometimes, baby may suckle just for comfort and not for milk. Still, this will increase milk production too.

Once the mother’s lactation is established, she will easily produce more milk than what the baby requires. Breast-feeding should begin as early as possible after birth, and preferably within the first few hours. The baby may be given to the mother whenever she cries, or at least every 2-3 hours. About 75% of the milk that has been taken by the baby in the previous feed gets replenished in the next two hours.

The first two weeks are crucial for the successful establishment of breastfeeding, and unnecessary supplementation of bottle-feeds, raising doubts about the adequacy of milk flow, giving “other” foods like honey etc. and cracks in the nipple or other breast-related problems can compromise the success of breast-feeding. Hence, please JUST PUT THE BABY TO THE BREAST. Do not do anything that can take her away from the mother’s breast.

Worry and unhappiness in the mother are the most potent dampeners of breast-milk flow. Fatigue, tenderness (pain) in the nipples, full, engorged breasts, tensions about the home, other children, husband, etc. can all create nursing problems.

Care of the breasts:

The breasts should be washed once a day and the nipple area must be kept dry at all times. A comfortable brassiere, with support at the bottom, and absorbent pads under the cup to absorb leaking milk will allow the mother to stay comfortable and at peace.

What should a Nursing Mother eat?

The nursing mother should eat a well-balanced, varied diet that imparts health to her and to her baby. Her diet should be supplemented (if needed) with extra calcium, iron etc. in consultation with her obstetrician. She may find that the baby has gas or loose motions when she (that is the mother) eats tomatoes, onions, certain berries, spicy food or chocolates in excess.

She must completely stay away from alcohol, smoking, recreational or addictive drugs and sleeping pills.

What to do if mother is ill?

By and large, the mother can continue to breast feed her baby provided she has the strength to do so. She may even take most medicines without any fear that they may affect the baby. Before taking any drugs or going for any special X-rays, the mother should consult the doctor about whether breast feeds may be continued or not.

The conditions where the mother needs to stop breastfeeding are when she is critically sick, she has cancer and is receiving anti–cancer medicines, or she has AIDS. Some drugs taken for heart problems and thyroid diseases are also contraindications for breastfeeding.

Technique of Breastfeeding:

At the time of feeding, the baby should be hungry, dry, neither warm nor cold, and be held in a comfortable semi-sitting position. The mother should also be comfortable. The baby is held in the crook of the elbow of one hand, while the breast is supported by the other hand and the nipple is taken near the baby’s searching mouth. The baby’s lips should engage a considerable portion of the areola as well as the nipple.

You should realise that if the baby is hungry, she will energetically “root” for the nipple, and her sucks will be deep and accompanied by a slight thrusting action to enable the easy expulsion of milk. On the other hand, a baby that does not “root” for the breast, or does not suck vigorously is usually not hungry… unless she is sick. Usually, the baby gets the major part of her milk in the first few minutes after she begins to feed; almost 80-90% has been already ingested within the first 4 minutes. However, the baby should be permitted to suckle till she is satisfied. She should never be “pulled” away from the breast, for this may cause nipple cracks or tenderness. Waking a sleepy infant “to feed” is also usually inappropriate and unsuccessful.

At the end of the nursing, the baby should be held erect, either on the shoulder or mother’s lap for assistance in expelling swallowed air (burping). Her back may be gently rubbed or patted to aid the process. When the burping is completed, the baby must be laid in her cot on her back, or on her right side to aid the digestion process.

What are the stools of a breastfed baby like?

Most normal, healthy babies pass 6–8 golden–yellow sticky stools. These stools have small, moong–dal sized granules, and there may be some water also. The stools are passed without any straining, and have a curd–like smell. Most babies pass the stool while they are actually suckling, and they also pass gas with it. You should remember to change her soiled nappy immediately after she has been burped.

What is burping and how is it done?

Burping is the process of aiding the baby to expel the gas which she might have swallowed into the stomach while feeding or crying.

Most babies tend to swallow some air when they are very thirsty or hungry and are sucking vigorously. The likelihood of gas being ingested is increased if the mother’s milk flow is too fast, too slow or too chaotic; when the latching–on position is not correct; and when the baby is irritable and feeds in fits and starts or cries a lot while feeding.

If this ingested gas is not removed, the baby will, upon being laid in her bed, become restless and vomit a large amount of milk and curd. Therefore, you should, after the baby has been fed, lift her up in front of you, and make her sit either on your abdomen or in your lap, and gently stroke her back till she expels gas. Another alternative is to carry her on your shoulder and stroke her back till she burps.

What to do if the baby is sick?

Breastfeeding, if it can be done by the sick baby, should be continued as before, since breast milk is also ideal for a sick baby. If she does not suckle because she is weak, the mother can remove her milk manually and feed it to the baby using a cup and a spoon.

How to remove milk from the breast?

Removing milk from the breast is an art that a mother should learn as soon as possible. There are two ways to do so.

The manual method is the more popular of the two basic methods. In this method, we take advantage of the fact that the milk collects in small sacs just under the nipple before it is ejected or sucked out by an energetic normal baby.

The actual removal, or expression as we call it, involves two movements. In the first movement, you should massage the entire breast in a centripetal direction (from outside towards the centre), and try and loosen the lumps of milk and move the milk to an area just under the nipple. Do not forget to bring milk from the breast tissue that extends to the armpit, and also the tissue that lies in the lower fold of the breast.

Just under the nipple, the milk ducts are enlarged into so–called “sinuses” or sacs, where the milk collects prior to it being ejected into the baby’s mouth when the baby suckles the breast. If you continue to massage this area forwards, towards the nipple, the sinuses get compressed, and the milk will NOT flow outward but stay inside.

Thus the second movement: in this, you grasp the areola just behind the nipple with a thumb and an index finger, and move these backward and towards each other on to your rib–cage. This backward movement will help to empty the sinuses very effectively. Initially, this process may be painful, but as you practice it, you will be able to express your milk easily. Sometimes, the milk flows in a trickle, and sometimes it flows so liberally that lots of it can be collected without any difficulty.

The second method is through use of a pump, which can be either mechanical or electrical. The mechanical pump consists of a large glass syringe which has a narrow, tubular mouth at one end (to which a rubber ball is attached), and a large hole at the other end. You apply the large hole over the breast with the rubber ball pressed hard; the areola and the nipple are both within the glass. Now you slowly release the rubber ball; the milk will flow into the syringe because of negative pressure. The syringe often has a small receptacle inbuilt into the glass on one side, and this allows the milk to collect in it while continuing the suction process.

Electrical pumps are not freely available in India, but if you can procure them, they are hard task masters and achieve complete removal within minutes.

Early Problems with breastfeeding:

1.Breast–engorgement: This can happen after the milk “comes in”. The breasts feel full and heavy and hard lumps can be felt in it. The lumps are nothing but milk, and all that is needed is to allow unrestricted suckling to the baby. If the engorgement is too painful to bear, the mother will not be able to feed the baby comfortably, and the tight breast tissue makes it difficult even for the baby to “pull” milk out into her mouth. This can create a major problem.

What to do? The right thing to do is to remove some milk from the breasts, either by manual expression, or with the help of a hot bottle with a narrow neck applied to the areola (as it cools, it creates a partial vacuum inside, which pulls the milk out), or with a manual or electrical breast pump.

2. Milk Fever: Engorgement can produce fever in the mother, and this usually subsides within 48 hours. If the engorgement has been relieved, but the fever persists, please consult the doctor.

3. Blocked Duct: Sometimes, one of the ducts that bring milk from the glands that secrete milk to the base of the nipple gets blocked by thick milk. This generally occurs if that particular segment is not being emptied properly because of tight brassieres, or improper position of the mother while feeding. Left untreated, a lump forms inside the breast. The undrained area can cause pain. It can be the beginning of a breast inflammation (mastitis) or even a breast–abscess.

What to do? The mother should be asked to vary her position so that all the areas of the breast get emptied. She should wear loose, comfortable brassieres and clothes. She should massage the lumpy area and try and “move” the milk towards the nipple.

4. Mastitis and Abscess: A hot, inflamed breast can be a harbinger of an abscess. To prevent mastitis from progressing to an abscess (pus formation), the mother should be shown to a doctor, who should begin a course of effective antibiotics and anti–inflammatory medications. Feeding at the breast need not be stopped. If, in spite of all this, an abscess does form, it will need surgery: the pus will HAVE to be removed.

5. Sore Nipples: Soreness of nipples is due to improper latching position of the baby at the breast. Using soap to clean the nipples or too frequent washing of the nipples can also do the same. The pain hinders feeding, and this can cause milk production to also decline.

What to do? You should seek help to see that the position of the baby’s mouth on to the breast is proper and that the baby latches on comfortably. Once this is done, you will be pleasantly surprised to see that the pain will disappear, the baby will feed better and the problem will vanish. If the pain persists for more than 5–7 days, examine the baby’s mouth and your nipple for small, white spots; these can be due to a fungal infection called candidiasis. See the doctor for advice on treating it.

6. Cracked Nipples: A persistently poor suckling position leads to development of cracks on the nipple. These can be around the base, across the tip, or both. The cracks are extremely painful.

What to do? Seek help to improve the baby’s latching–on position and continue feeding her. If one breast is less painful than the other, nurse the baby on that side. Usually, this is sufficient to heal the crack(s). Leave the nipples open to allow them to dry. Do not wash them too often. It will help if you leave a drop of your hind–milk on the crack. It has healing properties. If the crack still does not heal, you may have to stop feeding the baby temporarily, and remove the milk from the affected breast using any of the above methods till the crack heals.

7. Blood in the Milk: Although this is frightening, it is harmless, and is due to a slight leakage of blood from one of the ducts inside the breast. Continue suckling the baby and the problem will disappear on its own.

8. Flat Nipples: Since the baby suckles the breast and not just the nipple, the length of the latter is not really important. If your nipple looks too small, do not worry. Grasp it with your first finger and thumb and pull it. If it comes out, then there is no problem at all and the baby will be able to pull it into her mouth and feed easily. If it does not come out, try pulling it frequently when you are free. This “exercise” will allow it to come out properly in a few days. Your husband can do the job of sucking the nipple out if this is acceptable to the two of you.

9. Inverted Nipples: In some mothers, the nipples turn inwards when an attempt is made to pull them out. Such true inverted nipples are rare. To help such mothers, doctors have an unusual remedy.

What to do? You take a 5– or 10– milliliter plastic syringe (the device doctors use to give injections). The outer tube is cut halfway after removing the inner piston. The end with the tip where the needle has to be attached is thrown away. The piston is re–inserted from the broken end and the smooth end of the outer tube (with a flange) is then put over the affected nipple so that the flange rests around the nipple on the areola. You then try and pull the piston out so that a negative pressure is created within the syringe. The inverted nipple also gets pulled out with the piston. Try and keep the position for a few seconds till you can no longer bear the pain. Then slowly release the piston. Some milk may have also come into the syringe. Pull the syringe away, remove the milk; then repeat the process again. Over one or two days, with patience and perseverance, the inverted nipple will become everted.

A Baby who refuses to suck:

There are many reasons why a baby may not suck.

These include:

a) The baby may be ill. This can be serious. If she has any other symptoms of illness, consult the doctor immediately.
b) The baby may be too small or weak. If she weighs less than 1500 grams, she may not suck well. You may have to remove your milk manually and then feed it to her with a dropper or a cup and spoon.
c) The baby may have a blocked nose, due to a cold. Babies cannot breathe through their mouths, and get into trouble if their nose is blocked. Help them to remove the blockage by instilling salt–water nose drops inside both the nostrils. To prepare salt–water drops, dissolve a pinch of salt in a glassful of water, boil the water and allow it to cool. Fill it into a bottle with a dropper. Your old vitamin drops bottle will do.
d) The baby may have a fungal mouth infection. This can be treated with anti–fungal mouth solutions applied with a gauze–piece over the affected areas of the mouth.
e) The process of breastfeeding has gone wrong somewhere along the line, and the baby is frustrated.

i) The milk may be coming too fast – in this case, the mother should pinch the nipple with her first and second fingers and control the flow of milk.
ii) The milk is coming too slow and the baby is getting tired – here, more and more suckling is the answer, but the mother can help the baby by dripping some of her milk (or any milk) over her breast and nipple so that it flows into the baby’s mouth; this helps to increase the milk production as it allows the baby to feed without any idea that the milk is coming from an external source.
iii) There was a delay in starting the first feed, or the baby was separated from her mother for some days – just be patient, and the baby will take the feeds properly.
iv) There has been some emotional or physical upheaval in the mother’s life – and she has had no time to feed her baby, or is emotionally too upset to feed her.
v) The baby is also being given bottle– feeds – if that is so, it must be stopped forthwith.
vi) The mother has restricted the feeds to the baby – this causes the baby to get confused and frustrated, so don’t do it.

Later Problems and Other Issues:

1. Insufficient Milk: There are many instances where the mother, or more often, the other family members – most likely the baby’s grandmother – look at the baby’s crying, or feeding frequently, or for a longer duration – and announce that the mother has insufficient milk.

Sometimes, someone sees a baby sucking her fingers or thumb and say the same thing. Sometimes, someone actually prepares a bottle of top–milk, and because the baby takes that milk, they say it’s because the mother has insufficient milk.

So how to decide if you have been giving enough milk? If, while feeding on one breast, the milk leaks from the other one, then the milk production and ejection is probably adequate. The next easiest way is to check the baby’s pattern of urination. If she is passing normal amounts of urine at least 6-8 times in a 24–hour time-frame on exclusive breast feeding, then she is getting enough breast milk.

A baby who is putting on sufficient weight, say 200–250 grams in a 10–15 day time frame is getting enough breast milk.

What if she isn’t getting enough? If the above two tests tell you that the baby isn’t getting enough milk into her, it is time to study the problem further.

a) She may be weak or ill or have some congenital heart disease.
b) The mother does not feed frequently enough.
c) The baby does not want to feed longer, because of discomfort.
d) Mother has already started early supplements.
e) Mother cannot breast – feed properly because she is in a public – place and shy to feed in public
f) The mother lacks confidence in herself.
g) The mother is uninterested in giving breast – feeds but won’t say so because of her mother-in-law’s presence.
h) The mother herself is undernourished.

In all the above cases, proper counselling and advice will go a long way in turning the case around.

2. Crying Baby: The only language that the baby can communicate in is the cry. She cries only when something is wrong. In relation to breastfeeding, there are several reasons why the baby may cry. However, one must remember that hunger is not the only cause of crying.

Before you begin to doubt that your milk is not enough or it is not “suitable” for the baby, check out the following:

a) See if you are allowing the baby unrestricted, unlimited feeding times and schedules.
b) Is the baby latching-on properly?
c) Is your mind at ease or filled with tensions?
d) Has the baby wet herself or soiled her nappy?
e) Is she crying because she has fever, blocked nose, or any other illness?

At times, due to rapid growth, the baby may temporarily face a lactation crisis around 2–3 months of age. Let the baby continue to suckle, and the crisis will pass off as milk production will once again “catch up” with the baby’s needs.

Babies who do not get enough “hind–milk” (the last portion of a feed, which is thick and filled with calories) will be calorie–deprived and will cry more often for feeds. This happens when you try and shift to the second breast before the first breast has been properly emptied. The initial milk flowing from the breast is thin and watery and is meant to quench the baby’s thirst, while the hind–milk is thick and satisfies the hunger and calorie needs of the baby. So, if you are switching sides before the first breast has been fully emptied, the baby will cry for milk sooner, will pass more urine, and will often be constipated, as she isn’t getting enough milk solids.

At times, the baby may cry because some substances ingested by the mother, and passed to the baby through breast–milk do not agree with the baby. Cow’s milk, dals and legumes, or any other food may produce such a problem. Try eliminating some of these foods from your diet to see what substance was the cause of the baby’s crying.

Some babies are literally “crying babies”. They cry for no apparent reason, fidget a lot while at the breast, “fight” at the breast, and generally create a “tense” environment. For such babies, my advice is simple. Wait till she is three or four months old, and the problem will disappear on its own. You might want to carry her a lot, or rock her, or sing to her – anything may just work, or nothing may.

Last but not the least, some babies cry only because they feel “lonely” and desire only your company and closeness. They quieten as soon as you pick them up, and stay quiet as long as you carry them; conversely, they begin to scream the moment you put them down.

3. Working Mother: If you are a working mother, then you need guidance on how to maintain breastfeeding even when you resume work. Most mothers get a three–month maternity leave. During these three months, give exclusive breastfeeds. Have some good person to take care of the baby in your absence. Teach her how to give EBM (expressed breast–milk) or any other top milk with a cup and spoon.

To collect EBM, you should first give your baby one or two morning feeds directly at the breast; after this, sit comfortably and remove your milk from each of the breasts successively to the maximum limit. This milk can be kept in any clean container, covered with a muslin cloth or saucer and left in a cool corner, or in the refrigerator if available. It should be given to the baby without heating, as heat destroys the anti–bacterial chemicals in the milk.

Some mothers are able to express as much as 400–500 ml. of milk and leave it behind for their babies. If this stored milk is not enough, cow’s milk or powder milk can also be used.

Mothers should, if their breasts fill up, remove the milk formed in them, even in their office or work place, and either throw it, or collect it in a clean thermos flask, and take it back home to feed it to the baby.

How long to breastfeed:

There is no limit to the amount of time for breastfeeding. Most traditional views recommend exclusive breast feeding for the first six months, after which supplements can be begun, of either top–milk or other weaning foods. After six months, breast feeding is continued for as long as the baby takes it … even up to two years or more.

However, there are some babies who themselves leave the breast by one year of age, without any trouble to their mothers or anyone else.

Any other crucial advice?

Just one. Do not start a feeding–bottle “just like that” for the baby who is successfully breastfeeding. It can mean the end of breast–feeding. This is because the baby quickly “learns” to prefer the easy, passive means of feeding over the more “difficult” active method involved in feeding at the breast. The baby will rapidly “unlearn” what it took her days to master; soon, it will suckle less and less at the breast, and as a result, the mother’s milk production will decline.

Unnecessary use of the bottle even once a day can ring the death knell for breastfeeding.

There are many excellent books and web–sites dedicated to helping mothers successfully breastfeed their young ones. A list is appended below. If you do not have the time to look up all these sources, you may elect to just look at all the other animals on this planet: how they deliver their babies naturally, and begin to instinctively breastfeed their little ones within moments of birthing, and how they continue to successfully nurse their babies for months together without any professional advice!

The miracle that is breastfeeding is all around you! Learn from it!

Suggested Reading:

1. http://www.breastfeeding.com

2. http://www.aap.org/policy/re9729.html

3. Jellife, D. B., and E. F. P. Jellife. 1978. Human milk in the modern world. Oxford:
Oxford University Press

4. http://www.lalecheleague.org/

5. “The Womanly Art of Breastfeeding” by Gwen Gotsch, et al (September 1997)

6. “The Breastfeeding Book: Everything You Need to Know About Nursing Your Child from Birth Through Weaning” by Martha Sears R.N., William Sears M.D.

7. “Eat Well, Lose Weight While Breastfeeding: Complete Nutrition Book for Nursing Mothers, Including a Healthy Guide to Weight Loss Your Doctor Promise
by Eileen Behan (October 1992)

8. http://www.vh.org/pediatric/patient/pediatrics/cqqa/breastfeeding.html

9. “Helping Mothers to Breastfeed” by Felicity Savage King (1992).


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