Breast-Feeding

Breast-Feeding

All mothers need to make an informed decision about how they want to feed their infant. You may have thought about it before becoming pregnant, but once the pregnancy is well established, it's important to discuss the question with your physician, your spouse, and other members of your family. If no one in your family has breast-fed before, you may find it helpful to contact one of the local groups such as International Childbirth Education Association (ICEA), La Leche League International (LLLI), or Nursing Mother's Counsel. Your obstetrician's office also can provide information about available childbirth classes in which the topic is thoroughly covered.

Why Breast-Feed?

The advantages of breast-feeding are numerous. Mother's milk is the ideal nutrition for a growing infant. The newborn human, one of the least mature of all the mammals, experiences the greatest brain growth in the first year of life. Human milk has the perfect ingredients to develop the brain. It has exactly the right elements to build strong bodies and to develop the brain and nervous system.

Mother's milk contains many active enzymes that help the infant to digest milk and help the infant's intestinal tract to mature and absorb the nutrients. Mother's milk, however, is more than just good nutrition. It contains antibodies to protect against infection. Breast- fed infants have fewer diarrhea and gastrointestinal infections, fewer otitis media (ear infections) and upper respiratory infections, and even have fewer urinary tract infections. They have fewer hospitalizations and fewer visits to a physician's office for illness. Infants are never allergic to their mother's milk, so breast-fed infants have fewer allergies.

Studies of chronic illness in childhood also indicate that infants who have been exclusively breast-fed for 4 or more months have less incidence of childhood onset diabetes, Crohn's disease, and childhood cancers (especially leukemia and lymphoma). In some studies, premature infants who receive their mother's milk early in life have been shown to score better on intelligence tests than those receiving only formula.

There are benefits for the mother as well. Women who breast-feed seem to have a lower incidence of breast cancer and ovarian cancer. Breast-feeders are less likely to become obese and less likely to develop calcium problems in later life than those who did not breast-feed or did not bear children.

Finally, breast-feeding can create a special relationship between mother and infant, which provides nurturing as well as nutrition and results in intimate contact many times a day.

An Informed Decision: Breast-Feeding Versus Formula

The alternative to breast-feeding is formula feeding. Today, commercially available formulas provide adequate nutrition as determined in laboratories. Most formulas (except the hypoallergenic ones) are made with cow's milk, which is altered to make it digestible for a human infant. While breast milk is always readily available at the correct concentration and temperature, formula requires preparation and the sterilization of bottles and nipples.

Some women prefer formula feeding, because their babies can be fed by other caregivers. In some ways, formula feeding is easier, because others can take over when the mother cannot be present. This may be important if the mother plans to return to school or work. Breast milk can be expressed, or pumped, from the breast and fed to the infant in a bottle or small cup.

The Role of the Father

When the infant is breast-fed, the role of the father is very important but different from the mother's. The father provides cuddling and comforting when the infant does not need to be fed. Most infants have a fussy period each day, usually in the evening (5:00 to 10:00 p.m. ), when they need to be held, rocked, and stroked. The infant will nuzzle and root to be fed and may remain unsettled if she or he can smell milk. Babies settle down quickly if held by someone who is not lactating (making milk).

Prenatal Preparation to Breast-Feeding

As soon as pregnancy begins, the hormones produced to support the pregnancy, the placenta, and the uterus also have an effect on the breasts. The breasts begin to enlarge, the ducts that will carry the milk develop, and the cells that will produce the milk increase in number. By 16 weeks of pregnancy, the breast is ready to provide milk when the baby is born even if the infant arrives prematurely. The woman's nipples and areolas are also prepared for lactation. They become more pigmented and the Montgomery glands, which are invisible when not pregnant or lactating, enlarge and secrete a special sebaceous material that softens and lubricates the surface of the nipple and areola to protect them when the infant suckles. The nipple and areola also develop elastic tissue that will help the infant in drawing these tissues into the mouth during suckling.

If you're thinking of breast-feeding your unborn child, simply bathe and dry your breasts as you normally do. Do not use any ointments, oils, or medicines unless prescribed by your doctor. Normally, you do not need to do nipple exercises, nipple rolling, or buffing with rough cloth. These practices may cause irritation or, toward the end of pregnancy, may stimulate the uterus to contract. You should, however, have your breasts examined by an obstetrician.

Breast Examination

Breast examination is part of prenatal care. You may have questions about your breasts that you should discuss with your obstetrician early in pregnancy. Breasts, for example, come in many different different sizes and shapes. Usually one is slightly bigger than the other, but a major discrepancy in size and shape should be discussed with your physician.

Of more common concern is the size and shape of the nipples, which also vary among women. If your nipples do not protrude, a simple procedure will identify their ability to become erect so they can be easily grasped by the infant and drawn into her or his mouth. Support your breast with your fingers at the level of the areola, with the thumb above. Compress the areola. Does your nipple protrude? If your nipple becomes more inverted or indented, this suggests a true inverted nipple. Discuss this with your obstetrician, who may wish to suggest some treatment after evaluating your nipples. (Some doctors prefer to wait until after delivery and rely on the infant and an electric breast pump to draw the nipple out.)

If the uterus has been very irritable or there is concern about premature delivery, it is best to delay treatment with breast shells until delivery. A breast shell is a simple device that consists of a plastic disc about the size of the areola that has a hole in the center for the nipple. A dome of plastic with air holes in it fits over the disc. The shell, worn under your brassiere, gently encourages the nipple to protrude. (See Figure 18.1)

Flat nipples may also be of concern. They respond to simple treatment with breast shells or an electric pump used just before the infant begins to feed. After the infant has been successfully nursing for a few days, these special procedures should no longer be necessary, as the nipple will become erect on stimulation.

Surgery

The question of previous surgery is always an important one. Simple procedures to remove a cyst or other benign mass usually present no problem to successful breast-feeding. If a small duct was cut during the procedure, a collection of milk could form behind it during lactation, forming a lump called a galactocele . Galactoceles can be drained by your physician with a needle and syringe if you become uncomfortable.

When contemplating surgery to reduce the size of your breasts, the matter of breast-feeding should be discussed with the surgeon. If you wish to breast-feed in the future, remind the surgeon so that the procedure will preserve the duct system to the areola and nipple. That is, these structures will not be removed but will be centered on the remaining breast tissue, allowing a normal flow of milk through the ducts.

Augmentation mammoplasty, or surgery to increase the size of the breasts, usually presents no problem when a woman wishes to breast-feed. The implant is placed between the glandular tissue and the chest wall; the duct system is not disturbed, and the nerve supply is not interrupted. Silicone implants, however, have been the subject of considerable concern and controversy because of reports of rupture and associated scarring of the breast tissue. Extensive scarring may interfere with milk production and release. Whether the silicone itself is the problem remains an open question. If the implant is intact, breast-feeding is safe. If there is any question, the milk can be examined in the laboratory for the presence of silicone.

Burns to the chest wall and other causes of breast scarring should be evaluated by your obstetrician. Breast-feeding is usually successful, and most women will find that with a little extra instruction, they can enjoy this special relationship with their infant. Your physician may refer you to another member of the staff experienced in breast-feeding or independent licensed lactation consultant.

Supporting the Breasts

Ordinarily, during pregnancy and lactation most women find that wearing a suitable brassiere relieves the "weighty" feeling in their breasts. Nursing bras, specially designed to allow you to feed the infant without getting completely undressed, can be purchased during the last trimester. They have adjustable shoulder straps and a long series of hooks in the back so they accommodate any changes in size that occur from the end of pregnancy into lactation. Many women wear their nursing bras day and night for weeks or even months. Avoid nursing brassieres that have narrow shoulder straps or built-in plastic-lined guards in the cup.

When lactating, it is wise to wear a disposable pad inside your bra so that milk does not leak through onto your clothing. It is also smart to avoid wearing pure silk or any other fabric that may show a ring of wetness. Many styles of blouses and dresses open in the front, have hidden zippers, or can be pulled up from the waist so that your infant can be nursed at any time or any place without undue exposure or disruption of your clothing. Flowered or print blouses have the obvious advantage of obscuring any signs of moisture.

Preparatory Classes

Infants are born knowing how to breast-feed, but women must learn; it is not a reflex. In some mammalian species, females learn by observing other breast- feeding females that live with them. Today, women in the United States may have to learn how to breast-feed from a special organization. Furthermore, their own mothers may not have any advice, because they themselves did not breast-feed. La Leche League International, International Childbirth Education Association, and Breastfeeding Mother's Council have local branches that can be contacted about prenatal classes and assistance after delivery.

After the Birth: Breast-Feeding in the First Few Days

Breast-feeding begins shortly after birth. Infants are born with the right reflexes and instincts to breast-feed. In a normal delivery of a healthy child, the newly born infant will find his or her way to the breast and latch on, if left undisturbed on the mother's abdomen after the umbilical cord is clamped and cut. When in the uterus, infants suck and swallow amniotic fluid during the second and third trimesters. They are born with a rooting reflex, which means they will try to suck any object that stimulates the surface around their mouths. Their sucking motion, or undulating motion of the tongue, triggers the back of the throat to swallow.

Unless you have witnessed other women breast- feeding, you may need help in properly holding your baby for feeding. Hold your infant so that she or he is facing your breasts. Rest your infant's head in the crook of your elbow and support her or his buttocks. With your other hand, you may want to swaddle your child in a light blanket, because it has a calming effect. Draw the infant to your breast with the her or his face squarely facing it. (See Fig. 18.2) With your other hand, support your breast and compress the areola so that the infant can draw the nipple and areola into her or his mouth. (See Fig. 8.3) As the nipple and areola elongate to form a teat, the infant's tongue compresses it against the hard palate and suckles. The undulating motion of the tongue causes the milk to move along the ducts and be ejected from the nipple. (See Fig. 18.4)

You may feel comfortable supporting the breast with three fingers below the breast and the thumb and index finger above and well behind the areola. (See Fig. 18.5) An alternative position is to place all four fingers below the breast and the thumb above. (See Fig. 18.6) Choose the grasp most comfortable for you, ensuring that your fingers do not block the infant from getting most of the areola in the mouth. Whether you lie down or sit up to nurse, the same principles apply: The infant's total body faces your breast, and your hand supports the breast and compresses the areola without obstructing the infant from getting a proper grasp.

To encourage the infant to latch on, stimulate the center of the infant's lower lip. (See Fig. 18.7) The rooting reflex will stimulate the infant to move forward, extend the tongue, and draw the nipple and areola into the mouth and begin suckling. If a good comfortable latch on is not achieved the first time, break the suction by slipping your finger into the corner of the infant's mouth and then repeat the process of positioning, stimulating the rooting reflex, and latching on.

The Let-Down Reflex

The infant will begin to suckle as soon as he or she is latched on. When the nipple is stimulated by the infant suckling or by a breast pump, this stimulation triggers what is known as the let-down reflex . The let-down reflex sends a message through the nerves in the nipple to the mother's brain. The mother's pituitary gland releases two hormones: prolactin and oxytocin. Prolactin stimulates the milk-producing cells in the breast to make milk, and oxytocin stimulates the duct system to move the milk to the nipple and eject, or let it down. (See Fig. 18.2) A little oxytocin is released when a woman hears or sees her baby, thus a little milk will drip. A new supply of milk, however, is not produced unless the nipple is stimulated by the infant or a pump.

It is important in the early days of breast-feeding to lie down or sit comfortably and to relax before feeding the infant. Feed your baby when he or she is ready, not when he or she has begun to cry frantically. Stress and discomfort can interfere with letting down.

You can prevent the development of sore nipples by proper positioning. If your nipples do get sore, evaluate and adjust your position. While there are several ways to hold an infant while feeding, find one or two that are best for you and your baby.

In the hospital, the nursing staff in the birthing center, postpartum floor, or newborn nursery can assist in getting you started. If you have problems such as flat or inverted nipples, a sleepy baby, or a baby with a cleft palate, talk to your physician. She or he can evaluate the situation and, if necessary, call for an appropriate consultant.

Because there are many things to learn about a new baby, it's difficult for a new mother to retain all the information that the health care staff provides. In addition, women are often discharged from the hospital with their new babies 24 to 48 hours after birth. There is simply not enough time for the doctors and nurses to assess the newborn and its needs completely. It is important, then, to make an appointment with the baby's doctor in the 1st week after birth. Ideally, try to schedule a home visit from an office nurse practitioner or a visiting nurse who is skilled at looking at mothers and babies in the first few days postpartum.

When the Milk Comes In

At about 16 weeks of pregnancy, a small amount of milk can be expressed or may seep from the nipples. This early milk is called colostrum . Colostrum increases in volume so that at birth, after the placenta has been passed, the infant can suckle and obtain up to 0.5 ounce. Colostrum is yellowish, a little thicker than milk, and contains a lot of protective antibodies and cells that will protect the infant against infections and disease. It has more protein but a little less fat than later milk. Colostrum persists for 4 or 5 days and is gradually replaced by mature milk. (See Fig. 18.8) (The interim milk is called transitional milk.) Mature milk is available after about 10 days.

Right after delivery, the breasts feel soft, but over the next day, the body increases the blood supply to the breasts and they become full. As the infant nurses and receives the colostrum, the breast makes more and more fluid. About the third or fourth day after birth, you will be aware of an increase in the size of your breasts and the increased flow and change in texture and color that indicate transitional milk. This means your milk has "come in." Mothers who have nursed other infants will find that their milk comes in earlier. While some swelling and engorgement of the breast is to be expected, excessive swelling can be uncomfortable. Your physician or nurse can suggest some means of relief.

Is Your Baby Getting Enough?

While it is not possible to measure the exact amount of milk that the infant gets at each breast-feeding, there are ways to tell if it is enough.

Feeding patterns vary, but a baby should be fed at least every 3 to 4 hours or a minimum of 6 times a day in the 1st month of life. Most breast-fed infants feed every 2 to 3 hours, resulting in 8 to 12 feedings a day. Often the infant will feed frequently for a few hours, especially between 5:00 and 10:00 p.m. and then stretch it out to 2 or 4 feedings overnight until 6:00 a.m. Feedings usually last 20 to 30 minutes, but others may be shorter. The actually vigorous suckling time usually adds up to about 90 minutes a day.

Breast-fed infants should wet at least six diapers a day, soaking at least one. (It is easier to keep track of wettings with cloth diapers than with disposable ones, especially the super-absorbent kind.) The urine should be pale in color. It should not be dark, concentrated, or leave a dusty deposit. A breast-fed infant also has a bowel movement every day in the first 4 to 6 weeks. Most breast-fed infants pass a stool with every feeding, because of the physiologic stimulus to the intestinal track. Right after birth, the infant passes a substance called meconium , which is a dark green, almost black material that is smooth and sticky. It should be totally passed by 3 days, and stools then become green brown (transitional stools) and then yellow and seedy. Yellow, loose, and seedy is the normal breast-fed stool, and it should begin by the third or fourth day. Failure to stool every day and to have loose yellow stools by the fourth day should be reported your pediatrician. Failure to wet enough diapers and failure to feed long enough should also be discussed with the doctor.

Home scales are not very accurate, so take your infant to the physician's office for a weight check. Most infants lose weight after birth. A loss of 5 percent of birth weight is acceptable (5 ounces for a 7-pound baby). If the infant loses 7 to 8 percent of his or her birth weight, have the infant checked by the baby's physician. A loss of 10 percent is the maximum before aggressive interventions are introduced. Usually problems can be solved by adjusting the pattern of feeding, the frequency, or the positioning. The physician will want to check the infant every day or two until the milk supply is well established and weight gain persists. By 14 days, the infant should have returned to birth weight.

There are many community resources for nursing mothers to call for reassurance and guidance in the art of breast-feeding. La Leche League and Nursing Mother's Council have members who have nursed and who are willing to share their experiences. Management advice, however, should come from a certified licensed practitioner that your physician recommends and who will work with your physician to solve the problem.

Day-to-Day Breast-Feeding: Special Care and Treatment

Ordinarily, no special treatment is necessary for the nipples, areola, or breasts. During normal showering or bathing, avoid putting soap directly on the nipples. Dry breasts gently but thoroughly. Between feedings, allow the milk to air dry on the skin. Bras should be kept dry and a dry nursing pad placed in the cup. As time goes on, there will be less leaking and less fullness. This does not mean the milk has dried up but that the breast is adapting to the process of producing and releasing milk on a continual basis.

If the nipples become sore, seek help before there are cracks and further trauma. Remember, it should not hurt to breast-feed. If it does, get advice from the nursing staff or from a lactation consultant referred by your doctor.

Occasionally, a lump may appear in the breast that does not go away. (The lactating breast feels lumpy but usually the lumps change.) The lump may be a milk- filled cyst caused by a plugged duct. Gentle but firm massage will usually drain it, especially after applying warm compresses. If you become feverish or feel sick or if the lump is painful, red, and warm, it may be mastitis. Mastitis must be treated. Call your physician promptly. You may have to take special antibiotics for 10 days to 2 weeks. Continue to breast-feed on both sides; start with the unaffected side and end up fully emptying the involved side. The most important part of the treatment is rest . Mastitis usually occurs when you have taken on too much activity or have become exhausted from caring for your baby. You'll need help with the baby and you will need to be relieved of other chores until you are rested and feel better. Hot or cold compresses will relieve local discomfort. Aspirin or ibuprofen can be taken for the fever, pain, and headache.

When the nipples become raw and painful, local treatment may be necessary. Treatment differs in different parts of the country. If the climate is very dry, as in desert areas, then treatment with bland ointments (Vitamins A and D or purified lanolin) will provide relief. In areas with high humidity, drying may help. Air drying or gentle blowing with a hair dryer on low heat and low air may be soothing. Your local health care provider will recommend the best skin treatment for the environment in which you live.

Working and Breast-Feeding

You may have to return to work, but it is still possible to continue to breast-feed. The baby's schedule can be adjusted to fit the requirements of the job. Breast- feeding can also be adjusted, depending on your work hours, breaks, and lunch hours. Some women continue to nurse or pump so the baby receives only mother's milk. Others may provide formula and breast-feed only while at home. There are no hard-and-fast rules. The feeding should be comfortable for you, the baby, and the child care provider. For best results, you need to find safe child care where breast-feeding is understood and supported. You should be able to nurse at day care when you drop off your infant, before you leave, and when you return to pick up the child. If your job permits, you should be able to breast-feed at other times during the day. Any amount of mother's milk continues to provide special nourishment, antibodies and protection against disease.