Breastfeeding Fundamentals

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

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! 27 May 2024

Introduction

Breastfeeding is not only a natural and essential process but also a powerful tool for promoting the health and well-being of both infants and mothers. As healthcare providers, we 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.

Recognising 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 strives to highlight the importance of improving breastfeeding knowledge and practice among individuals caring for breastfeeding women. By understanding and addressing the common questions and concerns surrounding breastfeeding, we can contribute to empowering and enabling 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 day 7 to 14, the milk is termed transitional, and after two weeks, it becomes mature milk.

The production of milk 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 the cells from secreting more milk when the breast is too full, but 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 estrogen, the pregnancy hormones. After delivery, as the levels of progesterone and estrogen 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, resulting in increased milk production. This is especially crucial 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 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 by various stimuli associated with the mother, such as touching, smelling, seeing, or hearing her 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 ml to 1220 ml throughout the first six months. Infants feeding on demand based on their appetite typically remove only 63-72% of the available milk from the breast, indicating that they stop feeding due to satiety rather than the breast being empty. It's worth noting that breasts may differ in their capacity to store milk, and women with lower storage capacity may require more frequent feedings 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 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, Mastitis, Blocked Ducts and Blebs

Engorgement

Breast engorgement refers to the physiological bilateral fullness of the breast that commonly occurs between the third and fifth day postpartum. This occurrence generally signifies the secretion of mature milk and is considered a reassuring sign. The distention of the alveolar ducts with milk can lead to vascular and lymphatic compression, with varying levels of incidence and severity. 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.

Watch this video for the technique on 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 compressing 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, warmth of the breast, red and inflamed skin surrounding the nipple, and a tender lump in the breast indicating 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.

Here follows a video 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 stemming from the initial blockage of lactiferous ducts. The condition is characterised by a combination of breast symptoms such as redness and swelling, as well as flu-like symptoms including fever and chills, typically experienced during the breastfeeding period. It is estimated to affect up to 20% of breastfeeding women, with the majority of cases reported within the first month of the postpartum period. This condition can be extremely painful and distressing for affected individuals.

Painful Nipples

Nipple damage often leads to the premature discontinuation of exclusive breastfeeding as a result of significant and restrictive nipple pain. High nipple pain scores are commonly reported in breastfeeding women 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.

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

The diverse factors contributing to nipple pain in breastfeeding mothers, potentially stemming from a complex interplay, underscore the significance of proactive early lactation care to mitigate 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 averting nipple trauma and associated infections. Timely identification and intervention for conditions such as ankyloglossia, 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.(15)

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

Supplement Feeding

The widespread practice of supplementing breastfed infants with formula is often driven by non-evidence-based reasons. Despite being perceived as a harmless intervention, it can lead to several unnoticed adverse effects. These effects may negatively impact maternal milk supply, the duration and exclusivity of breastfeeding, and the infant's gut microbiome. Formula supplementation has the potential to disrupt the neonatal gut environment, which could lead to mucosal inflammation, autoimmune disorders, and allergic conditions in both childhood and adulthood.

Even a single bottle of formula can negatively impact the infant. Infants from susceptible families who are breastfed can develop sensitisation to cow’s milk protein as a result of receiving just one formula bottle (whether inadvertently, intentionally, or unnecessarily) in the newborn nursery within the initial 3 days of life. Additionally, formula supplementation has been linked to the onset of type 1 diabetes in vulnerable infants. It is believed that inflammation in the infant gut and/or heightened gut permeability upon exposure to cow’s milk–based infant formula could potentially contribute to the development of diabetes.

Early factors such as perceived insufficient 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.

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, an early introduction of pacifiers, in comparison to a later introduction, was associated with a detrimental effect on the overall duration of breastfeeding.

Cupfeeding is a more favourable method for providing supplementary feedings to breastfed infants.

Watch this video to know more about cupfeeding.

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.