Breastfeeding

Breastfeeding is the practice of a human mother feeding a baby (and sometimes a toddler or a young child) with milk produced from her mammary glands, usually directly from the nipples. Babies have a sucking instinct allowing them to extract the milk.

While many mothers choose to breastfeed their child there are some who do not, either for personal or medical reasons. Breast milk has been shown to be very beneficial for a child, though, as with other bodily fluid transfers, some conditions can be passed from the mother to the infant. As an alternative the baby may be fed infant formula until the time that the child may move on to baby food.

Overview

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Throughout pregnancy a woman's body produces hormones which stimulate the growth of the milk duct system in the breasts: progesterone, estrogen, follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, oxytocin, and human placental lactogen (HPL).

By the fifth or sixth month of pregnancy, the breasts are sufficiently developed to produce milk. Near the time of birth, the breasts may begin to secrete a thick, yellowish fluid called colostrum (or "beestings"), which is the first milk the infant receives. It contains important antibodies from the mother's body providing immunological protection. Colostrum has no fat and little sugar - these substances appear three to four days after birth when the suckling action of the infant further stimulates the breast to produce mature breast milk. Thereafter the breast produces milk on a basis of supply and demand in response to how often a child feeds and how much milk he or she consumes. The production, secretion and ejection of milk is called lactation. Some breastfeeding advisers recommend at least one feeding every four hours to prevent premature termination of lactation.

Properties of breast milk

The exact integrated properties of breast milk are not entirely understood, but the nutrient content after this period is relatively consistent and draws its ingredients from the mother's food supply. If that supply is found lacking, content is obtained from the mother's bodily stores. The exact composition of breast milk varies from day to day, depending on food consumption and environment, meaning that 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 relative to the creamier hindmilk which is released as the feed progresses. The breast can never be truly "emptied" since milk production is a continuous biologic process.

The let-down reflex

The let-down reflex, also known as the milk ejection reflex, is the stimulation of the muscles of the breast to squeeze out the milk by the release of the hormone oxytocin. Breastfeeding mothers describe the sensation differently, with some feeling slight tingling and others not feeling anything different.

The reflex is not always consistent, especially at the start of the breastfeeding process. The thought of nursing or the sound of any baby can stimulate the process causing unexpected leakage. Commonly both breasts can give out milk when one infant is feeding, but this and other problems often settle after two weeks of feeding. One major cause of difficulties during breastfeeding is when the mother is in a stressed or anxious state of mind.

Causes of a poor let-down reflex

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

Assisting the let-down reflex

When a mother has difficulties breastfeeding they may try different methods of assisting the let-down reflex, including:

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

Benefits

Benefits for the baby

Breast milk consumption has been linked to 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.

Numerous health benefits of breastfeeding have been medically documented. According to the American Academy of Pediatrics' policy statement on breastfeeding and the use of human milk, "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."[1]

Benefits for the mother

Breastfeeding has also been shown to be beneficial to the mother. The act of breastfeeding releases hormones which have been found to both 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 a more rapid contraction of the uterus and in turn decreases postpartum bleeding. Breastfeeding can also allow the mother to return to her pre-pregnant weight as the fat stores accumulated during pregnancy are utilized in milk production. Frequent and exclusive breastfeeding delays the return of menstruation and fertility (this is known as lactational amenorrhea) allowing for improved iron stores and the possibility of natural child spacing. Breastfeeding mothers experience improved bone re-mineralization postpartum, and a reduced risk for both ovarian and pre-menopausal breast cancer. In some cases, women who breastfeed have been known to have an orgasm while feeding.

Recommendations and research

The American Academy of Pediatrics (AAP) provides the following recommendation, "Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth. [...] It is recommended that breastfeeding continue for at least 12 months, and thereafter for as long as mutually desired."[2]

The World Health Organization (WHO) states that "a recent review of evidence has shown that, on a population basis, exclusive breastfeeding for 6 months is the optimal way of feeding infants. Thereafter infants should receive complementary foods with continued breastfeeding up to 2 years of age or beyond." [3]

Contraindications

It is not uncommon for a mother to have difficulties breastfeeding, with some unable to feed their child at all. Others find it too problematic or choose not to attempt or continue breastfeeding for personal reasons.

Medical conditions

Damage to the breast tissue can cause problems or totally prevent manageable breastfeeding, especially women with history of breast surgery or infection. Cancer (particularly breast cancer) and chemotherapy treatments have also been shown to cause difficulties. Many women with previous surgeries, abscesses and cancer can breastfeed successfully.

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. saw a mother reported to social services for her continued breastfeeding and non-treatment of the child for HIV [4]. The presence of herpes lesions on the breast is also contraindicative to breastfeeding.

Mastitis, the inflammation of the mammary glands caused by the blocking of the milk ducts, can cause painful areas on the breasts or nipples and may lead to a fever or flu-like symptoms.

Problems for the infant

Breastfeeding can be harmful to the infant if the mother:

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
has had excessive exposure to heavy metals such as mercury
uses potentially harmful substances such as caffeine, tobacco, alcohol, cocaine, heroin and amphetamines

Health and diet

Breastfeeding mothers must use caution if they regularly consume nicotine through tobacco smoking. In addition to reducing the milk supply, heavy use of cigarettes (more than 20 per day) has been shown to cause vomiting, diarrhea, rapid heart rate, and restlessness in infants. In general, though, nicotine in breast milk is not easily absorbed into the infant's intestinal tract and is quickly metabolized. Research is ongoing to determine whether the benefits of breastfeeding out-weigh the potential harm of nicotine in breast milk. The effects of a smoky environment are thought to have links to Sudden Infant Death Syndrome (SIDS).

Heavy alcohol consumption is known to be harmful to the infant, but there is no consensus on how much alcohol may be safely consumed. It is generally agreed that small amounts of alcohol may be occasionally consumed by a breastfeeding mother. Levels of alcohol in breast milk peak 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 prefereable to err on the side of caution with alcohol exposure to a baby and have breastfeeding women restrict 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.

The recreational use of marijuana in conjunction with breastfeeding is a controversial issue. The AAP Committee on Drugs lists marijuana in their table of Drugs of Abuse for Which Adverse Effects on the Infant During Breastfeeding Have Been Reported yet they reference only one study in the literature and this study reports no effect. [5] There is a lack of research on the effects of marijuana on the breastfed infant.

Some breastfeeding advisers suggest mothers avoid certain gas producing food, such as beans, if the baby starts to develop colic or gas.

Alternatives

In the few cases where it is not possible for a mother to breastfeed, or if she chooses not to do so, breast milk may be expressed and fed to an infant by bottle, milk may be offered from another breastfeeding woman, or infant formula can be offered. While proven inferior to breastfeeding, infant formula has in recent times been marketed as being a superior feeding-solution.

Breastfeeding method

Preparation

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 – it is therefore common for the mother to require a drink during the process. As a habit of bending over the baby can contribute to back pain, it is a good idea to cradle the baby on a cushion or pillow for extra height.

Feeding and positioning

Inverted or flat nipples can be massaged to give extra area for the baby to latch onto. By tickling the baby's cheek with the nipple the baby will open its mouth and turns 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.

The baby may pull away from the nipple after a few minutes and is ready to start eating from the other side. It takes approximately 10 minutes for the breast to produce the hindmilk and around 30 minutes for the supply to run out.

Breast and nipple pain

Breastfeeding may hurt some women, sometimes related to an incorrect technique, but usually eases over time. Milk ducts can block up on occasion 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.

Fair skinned mothers are most likely to experience cracked nipples, but it can happen to anyone. The baby's rough tongue can also cause grazes and the suction can cause bruising. If breastfeeding is endured for the initial six weeks then this usually becomes easier. Mothers determined to breastfeed their babies can buy or hire breast pumps to extract the milk.

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 (or bottled substitute) and begins to eat baby food. This often leads to lactose intolerance.

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 companies are not allowed to deny that right.

In the U.S. the "Right to Breastfeed Act" (HR 1848) 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. Nowhere is breastfeeding in public illegal.

Many mothers choose to purchase pumping equipment or express milk ("milk" themselves) by hand so that they can carry a small bottle of milk with them if they plan to be out at mealtimes. This allows them the advantages of breastfeeding while avoiding possibly uncomfortable situations. Unfortunately, breastfed babies can have trouble transitioning to a bottle, so this may not work for everyone.

Other issues

Tandem and extended 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 their individual requirements while also trying to breastfeed them both at the same time.

Tandem breastfeeding is also convenient if a woman gives birth to a newborn while still feeding an older baby or child. Under these circumstances it is possible for the newborn baby to miss out on the beneficial colostrum.

Although some may find it controversial, some women breastfeed their offspring for as many as three to seven years from birth. This is referred to as extended breastfeeding.

Lactation without pregnancy

Although not widely known in developed countries, women who have never been pregnant are able to lactate and therefore breastfeed as well. If their nipples are stimulated in a breastfeeding manner for a while (such as a breast pump or an actual baby suckling), eventually the breasts will begin to produce milk which can be used to feed a baby. For this reason, adoptive mothers, usually initially in conjuction with some form of supplementation, are able to breastfeed their infants. (There is also anecdotal evidence for male lactation in some males.)

Circumcision

Some reports have suggested that the act of circumcision may have a negative effect on the feeding habits of the baby [6]. The topic of circumcision itself is hotly debated, however, and findings of its impact can often be reported with bias.

External links

Breast-Feeding resource page
Breast-Feeding Best Bet for Babies
La Leche League International: An international organization whose mission is to help mothers worldwide to breastfeed through mother-to-mother support, encouragement, information, and education and to promote a better understanding of breastfeeding as an important element in the healthy development of the baby and mother.
Breast Feeding FAQs: a private research site
Baby Milk Action - supports mother's rights to breastfeed.
The Circumcision Information and Resource Pages explains the deleterious effects of circumcision on breastfeeding.