Nothing is more natural and nourishing than the mother’s breast milk for the infant. The World Health Organization (WHO) advocates exclusive breastfeeding for at least six months of age. If all infants were breastfed exclusively till six months of age, WHO believes every year at least 820,000 infants world over would not die. Although breastfeeding can seem like a natural process that can be taken for granted, there are many challenges that many new mothers encounter. The more help and support a new mother receives from health agencies, family and maternal nurses, the better she is able to cope and overcome the challenges.
World Health Organization’s recommendations on breast milk
The WHO has highlighted the ten facts related to breastfeeding and some of these include the below:
The first of these relates to commencing breastfeeding within one hour of birth. Exclusive breastfeeding for the initial six months after birth is advised for optimal health, growth and development of the infant according to WHO.
After six months, to meet the growing nutritional needs, breastfeeding should be continued while infants should also receive safe and nutritional complementary foods. WHO recommends continuing to breastfeed for up to two years.
Breast milk, being the “ideal food for infants”, provides all the key nutrients the infant needs for growth and health. While being safe, human milk offers protection against a host of illnesses and infections due to the antibodies and immune protective factors. Pneumonia and diarrhoea are the leading causes of infant mortality across the globe and breast milk protects the infant against these.
The third fact is that mothers also benefit from breastfeeding. It offers a natural way to achieve birth control although it is not entirely fail-proof. It helps in losing excess weight gained during pregnancy and reduces breast, uterine and ovarian cancer risks.
The fourth fact is that breastfeeding provides long-term benefits for infants well into their adulthood. Risks of chronic diseases including diabetes, cardiovascular disease, certain cancers, obesity, bone diseases and others are reduced because of breastfeeding.
Infant formula is not advised unless there is a total lack of breast milk or certain medical emergencies arise. The formula does not provide the immune protection through antibodies and does not contain bioactive substances. WHO strongly discourages the use of infant formula if breast milk is available and feasible.
Composition of breast milk
Being a bioactive and dynamic fluid, the composition of breastmilk changes throughout the lactation phase. There is variation in composition between different mothers as well as in each feed. The composition of milk for a pre-term infant is also different from that for a full-term infant. Many factors can influence the composition including the nutritional status of the mother, food intake, medications taken if any and the overall health condition of the mother.
The colostrum, which is a thick, yellow-coloured fluid that is made during the first three days after birth is rich in immunity-protecting substances such as white blood cells, lactoferrin, secretory IgA, as well as the epidermal growth factor. Colostrum is produced in very small amounts. Compared to the regular breast milk, there are higher quantities of electrolytes such as sodium, magnesium and chloride. But the levels of calcium and potassium are lower in colostrum as compared to the “later” breast milk. There are also very small amounts of lactose – the milk sugar. Scientists believe lactose in colostrum assumes an immune protection role rather being an energy source.
The breast milk starts to come in from the third day onwards. During the transition phase, the composition begins to change where lactose concentration is higher, while electrolytes decrease slightly. From five days post birth to six weeks, the composition of breast milk is in transition and achieves full maturity after six weeks. This transition can also vary in mothers and depends on many factors including maternal obesity, pre-term birth and other metabolic health conditions. The transition phase changes are more dramatic than the changes that occur later during the entire lactation phase. After the mature milk is formed at six weeks from birth, the composition of the milk changes in subtle ways.
On an average, breast milk usually is composed of the following:
Macronutrients: Nutrients that are needed in larger amounts for health, energy and growth are termed macronutrients and include protein, fat and carbohydrates. On an average, 87% of breast milk is water, while 3.8% is fat. About 1.0% is made up of protein and lactose makes up 7% of human milk.
Mature milk on an average contains in a decilitre, 0.9 to 1.2 grams of protein, 3.2 to 3.6 grams of fat and 6.7 to 7.8 grams of lactose. Lactose is the form of carbohydrate in mature milk. On an average, the total energy received by the infant in a decilitre of milk is about 65 to 70 kilocalories. This varies mostly with the changes in fat composition. Fat, being the most concentrated source of energy at 9 kilocalories per gram, has a major impact on the overall calorie content of human milk.
The ratio of macronutrients is slightly different in pre-term milk with fat and protein concentrations being higher than in full-term milk. A California based study found that the concentration of macronutrients can vary after four months. These variations are due to body mass index of the mother, her intake of proteins, the frequency of feeding and commencing of menstruation. Some women produce larger milk volumes and the California based study found that in these cases, lactose concentration was higher while protein and fat were lower.
About 60% of human milk is comprised of whey proteins, with casein forming 40%. This ratio is optimal to enable easy digestion. In the early stages of lactation, the whey concentration can vary between 70 to 80% while in the later stages of lactation, 50% of proteins are made up of whey.
When it comes to fats, half of the fat content in human milk is made up of saturated fats. About 36% is made up of oleic acid, which is a monounsaturated fatty acid. Two essential polyunsaturated fats including linoleic and alpha-linolenic acid (ALA) are present in 15% and 0.35% concentrations respectively. ALA is further converted in the infant’s body into EPA (eicosapentaenoic acid ) and DHA (docosahexaenoic acid). DHA is a critical nutrient which regulates many important brain functions such as cognition, learning, motor skills, vision, immunity and growth.
The human milk has adequate amounts of most micronutrients needed for the infant. Some Vitamins including A, B2, B6, B1, B12, and D may vary depending on the body stores of the mother and her nutritional status. When the mother is well-nourished, there are usually enough quantities of vitamin B12, other B Complex vitamins. Mothers who are strict vegans may have insufficient amounts of B12 and vitamin D.
One vitamin that is not adequate in human milk is vitamin K. Iron is present in breast milk on although not in high concentrations. Breast milk contains 76 micrograms of iron in about 100 millilitres. But since the baby is born with iron reserves that last until six months of age, there is usually no need for iron supplementation.
Bioactive and anti-infective factors
Breastmilk is replete with substances that promote immunity and protect the infant against infections. Some bioactive substances include hormones, antibodies, growth factors and cytokines. Besides, the white blood cells, secretory IgA, IgM and IgG antibodies, lactoferrin and lysozyme possess anti-infective properties. Lactose in milk promotes the growth of healthy bacteria in the gut and hence is pre-biotic in nature.
Benefits of breastfeeding
Breastfeeding promotes the health of both the mother as well as the infant. Exclusive breastfeeding reduces risk of
- Contracting infections including respiratory, gastrointestinal and other infections
- Allergies or intolerances
- Vomiting or diarrhoea and as a result, there is minimal risk of dehydration
- Childhood leukaemia
- Sudden infant death syndrome (SIDS)
- Obesity later in childhood or adulthood
- Type 1 and type 2 diabetes
- Cardiovascular diseases later in adulthood
- Pyloric stenosis
- physiological reflux
- urinary tract infection
- otitis media
Besides the lowered risk of many health conditions, breastmilk promotes healthy growth and development of jaws, teeth and bones. With the natural sources of EPA and DHA, babies have the advantages of a healthy brain development and improved IQ later in life. In case of a known family history of asthma or allergies, breastfeeding can lower the risk of the infant developing wheezing, allergies or asthma.
For mothers, breastfeeding helps lower the risk of
- Breast and uterine cancer
- Cardiovascular disease
- Helps in bonding closely with the baby
How soon should you start to breastfeed?
Infants show they are ready for their first feed usually within an hour of birth when born full-term. The encouraged practice is to put the baby on the mother’s chest immediately after birth to encourage suckling at the breast and provide warmth to the infant. As long as both the mother and the child are healthy, it is advisable to encourage the infant to feed at the breast as soon as possible after birth.
While some infants latch on immediately and begin to suckle, other babies may take time to latch on. Frequent feeding promotes more milk production. Although there is no set pattern of feeding in the first few days or weeks as the baby is still growing and adapting to the changes, it can help to feed small amounts frequently. Small feeds are ideal also because the baby’s stomach is tiny and can only hold little amounts at a time during the initial days post-birth.
The first two days: Both the infant and the mother need a lot of rest the first two days with the baby sleeping most of the time. The infant may take up about half a teaspoon of colostrum at each feed which is enough to meet the calorie needs. Feeding could happen only once in three hours. More frequent feeds are not needed since the baby is already hydrated adequately from within the womb due to placental supplies. If the baby is asleep for more than five hours, it is recommended to rouse the baby to feed. Usually, about eight to twelve feeds may be required in the first 24 hours. But some babies also feed for four to six times every hour and then sleep for the same duration.
The next two to three days: This is the time when the infant is more active and feeds more frequently. The mother’s milk also changes from colostrum to more mature milk. The mother’s breasts feel heavier due to the large volume of milk.
After day four or five, there is more or less a predictable pattern of feeding and sleeping. Although this is typical in normal childbirth and healthy infants, there are variations when there has been a caesarean section and painkillers have been given. This can delay milk production a little, but the mother is still encouraged to offer the breast to the infant. A baby shows hunger by making soft sounds or cooing, making sucking movements in the mouth, moving eyes rapidly or crying. The size of the breast has no bearing on the amount of milk stored in the breast. If a mother produces large amounts of milk, the baby may feed less frequently and vice versa. Weighing the baby will give an adequate indication of whether the baby is feeding well.
During pregnancy and the initial days following birth, breast milk production is controlled by the endocrine system. After the supply of milk is established, the localized or “autocrine” control takes over. This means that milk production depends on its consumption or removal. The more the demand, the more the supply. The supply of milk is directly impacted by the frequency and volume of feeding.
Sometimes low breast milk supply can be due to:
- Infant not able to feed frequently or adequately
- Structural defects in the mouth or jaw of the infant that prevents adequate sucking or transferring of milk
- Improper latching
- Health conditions that affect the endocrine system in the mother
- Underdeveloped breast tissue
- Maternal malnutrition or underweight status
- Certain medications that affect the breast milk production
Full-term babies have the following reflexes that help them in breastfeeding:
- Rooting: The infant has an inborn instinct to locate the nipple. Also, the baby has the instinct to open the mouth and puts the tongue forward and downwards when in contact with something.
- Sucking: Sucking instincts are evident even in the womb at 18 weeks of gestation.
- Swallowing: This reflex also develops in the womb at around 12 weeks and is stimulated by a fluid bolus reaching the tongue.
- Gag reflex: This reflex protects the infant against swallowing large objects
- Coughing: This prevents fluid entering the airways.
Optimal feeding is promoted when the positioning of the mother and the infant is right. The following guidelines help in positioning the baby as well as yourself!
- Make sure you are in a comfortable position
- Support the infant so as to be not fatigued by the weight of the infant
- Bring the baby to the breast rather than the other way around
- Put a hand on the top of the baby’s neck to prevent pressure on the infant’s head. With the pressure on the head, the infant can arch away and is unable to suck.
- Support the infant’s head to ensure it is not flexed or extended
- Align the chest of the baby with yours and the baby’s chin to the breast
- Make sure the mouth and nose are in line with the nipple
- Tuck the limbs to prevent them from swinging or flailing
How to know if the baby has latched on correctly?
You will know if the latching on is appropriate when you notice the following:
- The baby’s mouth should be wide open with outwards turned lips. The chin of the infant is in contact with the breast and the lower lip is completely curled back
- Tip of the nipple is to the palate of the infant while the whole of the nipple is in the baby’s mouth.
- The ears move at times with the sucking and the cheeks of the infant are rounded instead of being drawn.
- After feeding, the nipples are lengthened and not flat or squashed.
- The infant’s lower jaw moves upwards and downwards to express the milk.
- There are quick and short movements initially of the sucking which changes to a rhythmic deep suckling after the milk begins to flow.
The following indicate if the milk production and ejection are adequate for mothers:
- Tingling sensation as the milk flows although this may sometimes take some weeks to become noticeable. Some women notice this sensation sooner.
- Fullness in the breasts which turns to light feeling post feeding
- Slight increase in temperature of the skin
- Relaxed feeling or a feeling of wellbeing due to release of hormones
- Contractions in the uterus
Common breastfeeding related concerns and management
New mothers can experience problems in breastfeeding particularly in the initial days or weeks. Most of these are not serious concerns and can be overcome with the support, guidance and assistance from healthcare providers, family or friends.
Refusing to feed: Many mothers are concerned when infants refuse to feed initially. This could be due to many reasons such as:
- Attachment problems
- Recent immunisation
- Illness such as a cough, cold or earache
- Changing feeding pattern
- Overuse of pacifiers
- Too Fast a flow
- Inadequate milk or too slow milk flow
- Unusual foods in the maternal diet
Seeking the advice of a medical professional will help rule out any medical concerns for the infant’s refusal. In most cases, being patient, calm and bonding with the infant can help overcome refusal to feed.
Painful nipples: Sore or painful nipples is a very common problem most women face in the initial days of breastfeeding. While it is a natural occurrence, it also resolves over time and breastfeeding should not be stopped because of this. Persistent pain that gets worse should be brought to the notice of a medical professional. Wrong positioning or sucking, structural defects in the infant’s palate or mouth, excessive chewing of an empty breast or long periods of not feeding can be some reasons for a painful breast.
Comprehensive antenatal and postnatal education given by trained healthcare providers helps families understand how to manage the problem. Warm water compress, fresh air and massage may help relieve pain.
Swelling of the breast: Also called engorgement, sometimes the breasts can swell due to increased milk production normally after five days from birth. Expressing milk is recommended to remove excess milk if the infant is not feeding frequently. An electric pump can help remove milk from both breasts if the engorgement does not get better with frequent feeding.
Mastitis: This also is a condition that causes inflammation of the breasts and rarely can progress to an infection. Fever, swelling, pain, and redness of the breast, is noticed. Insufficient removal of milk due to either poor feeding or excessive milk production are believed to cause mastitis. Massaging the breast to remove any blocks and recognising feeding cues for the infant are some ways to tackle mastitis. Rest, positioning the infant right, frequent feeding and warm cloth over affected breast will help in managing mastitis better. Doctors may prescribe antibiotics if necessary if the condition does not resolve.
Inadequate milk: Many mothers are worried that they are not producing adequate milk. Many times these worries are unfounded. As long as the baby is feeding frequently, is sleeping well, is alert when awake and gains weight, there is no need to be concerned. Because infants tend to vary their feeding pattern, a slower weight gain by itself is not an indication of poor milk supply.
Some other factors can impact breastmilk production and these include:
Smoking: Tobacco has been found to have a negative impact on breastfeeding relating to initiation as well as the volume of milk. Smoking also results in passive exposure of the infant to tobacco and increases the risk of sudden infant death syndrome. Parents should receive advice on the harmful effects of smoking and its impact on breastfeeding.
Alcohol: Alcohol passes on to the breast milk quickly and is harmful to the infant who is on breast milk. Alcohol is also known to harm the developing fetus. Both pregnant and lactating women are advised to not consume alcohol as long as the infant is being breastfed. When excess alcohol levels are in the milk, the infant experiences deep sleep, poor growth, weakness and drowsiness.
Caffeine: It is a common belief that caffeine in mother’s diet can lead to the infant becoming restless and agitated. There is no clinical evidence of the same. After one hour of consuming a caffeine-rich beverage such as coffee, tea, soft drinks, maximum levels of caffeine is found in the breast milk.
Moderate consumption of coffee, tea and other caffeine-containing beverages are advisable.
Drugs: Illicit mood-altering drugs including marijuana and others pass on to breast milk. These affect quality and quantity of breast milk while also affecting the infant’s health.
HIV: HIV positive women in Australia are not encouraged to breastfeed if “replacement feeding is acceptable, feasible, affordable, sustainable and safe .”
Medications: It is advisable to seek the guidance of a qualified healthcare professional to know which medications can affect the infant while breastfeeding. Most medications pass on to the breast milk.
Nutrition: Women who are breastfeeding need additional nutrition in terms of calories and other micronutrients. They should eat a healthy balanced diet from the five different food groups that supplies an additional 2000 kilo-calories per day. Some supplements such as iodine and iron may be needed and these are best prescribed by the medical professional.
Restrictive diets if being followed such as vegan or keto diets may also need special attention to supplements such as B12, D, K and others.
Diabetes: Mothers who have had gestational diabetes or have Type 1 diabetes may experience a delay in milk production because of the lack of insulin needed to balance sugar levels. If sugar levels are well controlled and managed, these problems are not likely to arise. Despite diabetes, mothers can successfully breastfeed their babies and there is no adverse impact on the breast milk composition due to diabetes.
Work schedules: Mothers who have to return to work face increased pressure related to breastfeeding. Evidence shows that the duration and frequency of breastfeeding is negatively impacted by the mother having to resume her job. Lack of paid leave or breaks for breastfeeding at work can hamper efforts to breastfeed. The WHO as well as the Australian National Breastfeeding Strategy advocate provision of adequate facilities at the workplace to support breastfeeding along with other necessary support. Breaks at work, paid leaves and support from counsellors are necessary to manage breastfeeding while resuming work.
Other factors that can impact breastfeeding include unrealistic expectations related to breastfeeding, myths, the pressure to breastfeed and depression or anxiety. All of these factors can be effectively managed with adequate support, both antenatal and postnatal counselling and guidance from healthcare providers.
Expressing and storing milk
At times you may need to express milk, store it for later feeding. This is particularly helpful if you are a working mother or if the baby is unable to feed well.
Other conditions that make it necessary for milk expression include:
- Premature baby or pre-term baby that is not able to feed
- For a medical reason, the infant is in the hospital and you are not able to stay all the time in the hospital
- Baby is not able to be brought to you at the hospital for each feed
- Work, study or other commitments
- Engorgement of breasts, excessive volume of milk or heaviness of breasts
How much of milk you need to express depends on the situation or the reason behind doing so. Pre-term babies need all the milk you can express each time while older infants may need less if they are on solids. Once you express milk, store it no longer than six hours at room temperature. In the refrigerator, it can be stored for up to 72 hours when placed in the area which is coolest. In the freezer compartment, breast milk can be stored for up to two weeks, provided it is not thawed intermittently. Breast milk can last for six to twelve months in deep freezer. When thawing the breast milk stored in the freezer, it is recommended to not refreeze it and to use it as soon as possible for the next feed. Remaining thawed out milk needs to be discarded. Any stored milk that the infant has already started to feed on should be discarded if left over.
Ensure equipment used for expressing are sterile and cleaned every time. Begin with washing hands with soap and water thoroughly. After drying them with a clean towel, remove all containers or breast pump used for storing or expressing breastmilk. Clean by rinsing in cold water to remove any old milk. Oil, grease, dirt should be removed with hot water and dishwashing liquid. Use a separate brush for cleaning the containers. Rinse again twice using hot water. Drain the water from the containers, bottles or other equipment by holding them upside down on a paper towel that is clean or on a clean cloth. Let them air dry. Store the dried equipment in a new, clean plastic kit or bag till needed.
Support for breastfeeding in Australia
According to the Australian National Infant Feeding Survey (ANIFS) conducted in 2010, 96% of new-born babies were breastfed initially. Exclusive breastfeeding was continued for less than four months in 39% of infants. Only 15% were exclusively breastfed for 6 months. With an objective to educate parents and promote breastfeeding, Australian National Breastfeeding Strategy was formulated. The goal of this strategy was :
“to increase the percentage of babies who are fully breastfed from birth to six months of age, with continued breastfeeding and complementary foods to twelve months and beyond”.
The Australian Breastfeeding Association (ABA) provides the National Breastfeeding Helpline at 1800 686 268 which is available all seven days of the week.
Other resources that offer support include:
- Maternal and Child Health Centres
- The Australian Breastfeeding Association
- Family Care Cottages
- Poisons Information Line
- The Family Planning Association
- The Australian Multiple Birth Association
- Mothercraft Facilities
- Women’s Health Clinics/Centres