Breastfeeding Fundamentals

Original Editor - Lenie Jacobs Top Contributors - Lenie Jacobs and Jess Bell

Introduction

Breastfeeding is not only a natural and important process, but also a powerful tool for promoting the health and well-being of infants and mothers. Healthcare providers can play a crucial role in supporting and promoting successful breastfeeding practices. Research has consistently shown that breastfeeding counselling and mother support provided by healthcare professionals have a positive impact on the duration of exclusive breastfeeding and infant growth and development.

In recognition of the numerous benefits of breastfeeding for the infant, mother, family, and community, increasing breastfeeding rates has emerged as an important health promotion strategy. The World Health Organization recommends exclusive breastfeeding for infants from birth to 6 months and encourages continued breastfeeding up to at least 2 years of age.

This page highlights the importance of improving breastfeeding knowledge and practice among individuals caring for breastfeeding women or women who would like to breastfeed. By understanding common questions and concerns surrounding breastfeeding, we can help empower mothers to make informed decisions and establish successful breastfeeding relationships with their babies.

Breastmilk Supply and Feeding Frequency and Duration

Breastmilk supply undergoes a remarkable transformation in the days following delivery.

In the initial 2-3 days after birth, colostrum is secreted. Although produced in small amounts (approximately 40-50 ml on the first day), colostrum provides all the necessary nutrients and antibodies an infant requires during this time. Between 2 and 4 days after delivery, milk production increases significantly, causing the breasts to feel full and engorged. This stage is commonly referred to as the milk "coming in." By the third day, an infant typically consumes around 300-400 ml of milk per 24 hours, which further increases to 500-800 ml by the fifth day. From days 7 to 14, the milk is termed transitional, and after two weeks, it becomes mature milk.

Milk production is regulated within each breast independently, meaning that one breast may cease milk production while the other continues if a baby predominantly suckles on one side. This localised control is facilitated by a substance called the feedback inhibitor of lactation (FIL), present in breast milk. FIL prevents cells from secreting more milk when the breast is too full. However, if milk is removed (through breastfeeding or expression), the inhibitor is eliminated, and milk secretion resumes. The amount of milk produced is determined by the baby's demand and needs, thanks to FIL.

Initially, the hormone prolactin is crucial for milk secretion, but it doesn't directly control the quantity of milk produced. During pregnancy, prolactin levels rise significantly, stimulating the growth and development of mammary tissue in preparation for milk production. However, milk is not secreted during pregnancy due to the inhibitory effects of progesterone and oestrogen, the pregnancy hormones. After delivery, as the levels of progesterone and oestrogen rapidly decline, prolactin is no longer blocked, and milk secretion commences.

When a baby suckles, prolactin levels in the blood increase, stimulating milk production by the alveoli. Prolactin reaches its peak about 30 minutes after the start of a feeding session, primarily producing milk for the subsequent feed. During the initial weeks, the more a baby suckles and stimulates the nipple, the more prolactin is produced, leading to increased milk production. This is especially important during the establishment of lactation. Although prolactin remains necessary for milk production, the correlation between prolactin levels and milk production becomes less significant after a few weeks. However, if a mother stops breastfeeding, milk secretion may cease, leading to a gradual decline in milk supply.

Breastfeeding at night is particularly beneficial for maintaining milk supply as more prolactin is produced during this time. Prolactin also induces relaxation and sleepiness in mothers, ensuring they can rest well even during nighttime breastfeeding sessions.

Another hormone involved in breastfeeding is oxytocin, which causes the myoepithelial cells surrounding the alveoli to contract. This contraction allows the milk collected in the alveoli to flow and fill the ducts, facilitating milk ejection. The oxytocin reflex, also known as the "letdown reflex," can be triggered in mothers by various stimuli, such as touching, smelling, seeing, or hearing their baby. However, severe pain or emotional distress can inhibit the oxytocin reflex, temporarily disrupting milk flow. Providing support, comfort, and allowing the baby to continue breastfeeding can help restore milk flow in such situations. Skin-to-skin contact is also a valuable tool to increase milk production.

To ensure adequate milk production and flow for six months of exclusive breastfeeding, it is essential for a baby to feed as often and for as long as they desire, day and night. This feeding approach, known as demand feeding, unrestricted feeding, or baby-led feeding, allows infants to obtain the necessary milk for satisfactory growth. The amount of milk consumed by babies varies, with an average daily intake ranging from 440-1220 ml throughout the first six months. Infants feeding on demand, guided by their appetite, typically only remove 63-72% of the available milk from the breast. This indicates that they stop feeding due to satiety rather than the breast being empty. It's worth noting that breasts may have a different capacity to store milk, and women with lower storage capacity may need to feed more frequently to ensure adequate daily intake and production.

The following video explains the physiology of breastfeeding in more detail.

It is crucial not to restrict the duration or frequency of feeds, as nipple damage is primarily caused by poor attachment (latch) rather than prolonged feeds. Mothers learn to recognise their baby's hunger cues, such as restlessness, rooting, or sucking hands, before the baby becomes distressed and cries. Babies should be allowed to continue suckling until they spontaneously release the nipple, followed by a brief rest. The other breast can then be offered, depending on the baby's preference.

Engorgement

Pathological breast engorgement (i.e. the overfilling of the breasts with milk) typically occurs when milk removal is hindered, often because of restrictive feeding practices, ineffective sucking, or, less commonly, overproduction of milk. Surgical breast enlargement may also predispose an individual to breast engorgement.

Physiological breast engorgement refers to the bilateral breast fullness that commonly occurs between days 3 and 5 postpartum. It generally indicates that mature milk is being secreted, and is considered a reassuring sign.

The distention of the alveolar ducts with milk can lead to varying levels of vascular and lymphatic compression. Factors associated with severe, symptomatic breast engorgement may include primiparity, administration of large volumes of intravenous fluids during labour, history of premenstrual breast tenderness, and a previous history of breast surgery.

This optional video demonstrates reverse pressure softening to assist with latching when breasts are engorged.

Milk Blebs

A milk bleb is a painful, blister-like formation on a lactating woman's nipple. It can appear serous or white and may lead to plugged milk ducts. Risk factors for developing plugged ducts and milk blebs include inadequate milk drainage, mastitis, tight clothing which compresses the breasts, prolonged pressure from seat belts or infant carrier straps, infrequent infant feedings, and pressure from sleeping on the stomach. Symptoms may include painful breastfeeding, tender nipples, breast warmth, red and inflamed skin around the nipple, and a tender lump in the breast - this indicates an area of the breast where milk stasis has occurred. Inflammatory or infectious mastitis may ensue if the process of inflammation extends further into the breast tissue. Additionally, some women may complain of nipple pain and shooting pain in the breast. Identifying and addressing risk factors and symptoms early on can help prevent and manage milk blebs effectively.

The following optional video demonstrates how to address milk blebs.

Mastitis and Blocked Ducts

Plugged ducts and mastitis (commonly known as lactational mastitis) represent distinct stages of breast inflammation during lactation. Both stem from the initial blockage of lactiferous ducts.

A blocked duct is the term used to refer to localised milk stasis, which affects part of the breast, such as a lobe. Clinical indicators include a painful lump in one breast, often accompanied by a patch of redness on the overlying skin. The condition typically affects only part of one breast, and the woman usually experiences no fever and feels well.

Mastitis is characterised by a combination of breast symptoms, such as redness and swelling, and flu-like symptoms, including fever and chills. It affects up to 20% of breastfeeding women, with the majority of cases reported within the first month of the postpartum period. It can be extremely painful and distressing for affected individuals.

Painful Nipples

Nipple damage and pain can cause an individual to stop breastfeeding earlier than they intended. High nipple pain scores are commonly reported by breastfeeding individuals with nipple damage during the first day postpartum, irrespective of the size and degree of the damage. Emphasising the assessment of nipple pain scores during breastfeeding is crucial, shifting the focus of care away from the size and extent of nipple damage.

Primary factors contributing to nipple damage are associated with inadequate latch-on and positioning. This encompasses issues such as a narrow mouth (opening angle less than 140 degrees), inward-turned lips, asymmetrical latch-on, a distant chin, misaligned body of the child, lack of maternal support, and the parent's body being positioned above the child.

Because many factors can contribute to nipple pain in individuals who are breastfeeding, proactive early lactation care is important to help reduce the risk of premature cessation of breastfeeding. Comprehensive prenatal breastfeeding education and prompt correction of positioning and latch issues in the initial postpartum period are pivotal in avoiding nipple trauma and associated infections. Timely identification and intervention for conditions such as ankyloglossia (tongue tie), suboptimal milk removal, vigorous infant suction, and vasospasm are essential to proactively address ongoing pain, psychological distress, and potential long-term impacts on milk production.

Hand expression can be helpful until a lactation consultant is available. The following optional video demonstrates hand expression.

Benefits of Breastfeeding

As mentioned, the World Health Organization recommends exclusive breastfeeding for infants from birth to 6 months and encourages continued breastfeeding up to at least 2 years of age. Breastmilk contains nutritional components that promote growth, as well as bioactive components, which play a role in immunological development. Some researched benefits of breastfeeding include:

• reduced risk of diabetes and obesity later in life
• improved infant survival and protection against some illnesses, such as diarrhoea and pneumonia
• potential protective influence on postpartum depression for women who had prenatal depression

Supplementary Feeding

While not all women are able to breastfeed, the widespread practice of supplementing breastfed infants with formula may not be driven by evidence-based reasons.

For women who want to, and are able to, exclusively breastfeed, supplementary feeding can negatively impact their milk supply, the duration and exclusivity of breastfeeding and the infant's gut microbiome.

It is also important to consider the impact of the early introduction of cow's milk while breastfeeding on the development of cow’s milk allergy. It has been found that the very early introduction of a cow's milk formula, followed by its discontinuation can increase the risk of allergies to cow's milk. Ulfman et al. note that "if mothers plan to exclusively breastfeed the infant, no cow’s milk formula should be given in the first weeks of life while breastfeeding is being established".

Early factors such as a perceived lack of milk, inadequate milk intake by the infant during feedings, and mechanical latching issues often prompt the early introduction of formula supplementation. Therefore, healthcare professionals should prioritise interventions aimed at overcoming these barriers through thorough assessment, guidance, and follow-up. The initial 14 days of lactation play a critical role in establishing an adequate milk volume for the entire lactation period. Consequently, efforts should be directed towards promoting abundant milk production during this crucial window to mitigate potential future issues with milk supply.

Considering the impact of formula supplementation on infant gut health and the general benefits of breastfeeding, healthcare providers should prioritise encouraging and supporting mothers to exclusively breastfeed. Healthcare providers must exercise sound judgement to ensure that babies receive adequate feeding whether via breastmilk, donor milk or formula supplementation to support the baby's thriving.

Bottles and Pacifiers

There is a potential association between the use of pacifiers and/or bottle-feeding and unfavourable breastfeeding behaviours, particularly concerning bottle-feeding.

It was discovered that the introduction of pacifiers within the first 4 weeks of an infant's life reduced the probability of exclusive breastfeeding at 1 month. Additionally, early introduction of pacifiers (vs later introduction) can shorten the overall duration of breastfeeding.

Cup feeding is a more favourable method for providing supplementary feeds to breastfed infants.

If you would like to learn more about cup feeding, please watch this optional video.

For families considering pacifier use, it is advised to refrain from introducing a pacifier until 4 weeks after childbirth, when breastfeeding is more likely to be well-established.

For families considering using a pacifier, it may be advisable to refrain from introducing a pacifier until 4 weeks after birth, when breastfeeding is more likely to be well-established.

Caesarean Section and Breastfeeding

A study by Hobbs et al. has indicated that caesarean sections can potentially postpone the onset of mature milk production. Mothers who have had a caesarean section can facilitate mature milk production by engaging in regular breastfeeding or pumping, responding to the baby's feeding cues, and ensuring they have ample skin-to-skin contact with their newborn.

Conclusion

Access to breastfeeding advice significantly influences the likelihood of women establishing and continuing breastfeeding. Given the substantial health benefits of breastfeeding for both the baby and the mother, healthcare professionals should make concerted efforts to provide comprehensive support to breastfeeding mothers.