Breastfeeding
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Wikipedia-Article "Breastfeeding"
Breastfeeding is when a woman feeds an infant or young child with milk produced from her breasts, usually directly from the nipples. Babies have a sucking urge that usually enables them to take in the milk, provided there is a good latch, a detached phrenulum, and a milk supply.
Breast milk has been shown to be best for feeding a child if the mother does not have any transmissible infections. Nevertheless, some mothers do not breastfeed their children, either for personal or medical reasons. Some diseases, such as HIV and HTLV-1, which are transmitted through bodily fluids, can be passed through the breast milk, and may therefore preclude breastfeeding in these cases. Some medicines may also transfer through breast milk. However, most medicines are transferred in very small amounts and are considered safe to take during breastfeeding. Therefore most women are not precluded from breastfeeding, and doctors and governments are keen to promote the practice. Nevertheless, many medications are still required by law to be labeled as not safe when breastfeeding.
Many governmental strategies and international initiatives have promoted breastfeeding as the best method of feeding a child in its first year. So does the World Health Organization (WHO) [1] and the American Academy of Pediatrics (AAP) [2] and many others.
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Beginning lactation
Main article: Breast milk
Throughout the last two trimesters of pregnancy a woman's body produces hormones which stimulate the growth of the milk duct system in the breasts:
- Progesterone -- infludences the growth in size of alveoli and lobes. Progesterone levels drop along with estrogen levels after birth, triggering the onset of copious milk secretion. (Mohrbacher, IBCLC, Nancy; Stock, MA, IBCLC, Julie (2003). The Breastfeeding Answer Book, Third Revised Edition. La Leche League International, Inc. ISBN 0-912500-92-1)
- Estrogen -- stimulates the ductule system to grow and become specific. Estrogen levels drop at delivery and remain low for the first several months of breastfeeding. (Ibid) (This is also why it is recommended that breastfeeding moms avoid estrogen-based birth control methods while they are planning to breastfeed. A spike in estrogen levels compromises a mother's milk supply level.)
- Follicle stimulating hormone (FSH)
- Luteinising hormone (LH)
- Prolactin -- contributes to the accelerated growth of the alveoli druing pregnancy (Rilemma 1994).
- Oxytocin -- contracts the smooth muscle of the uterus during birth, after birth, and during orgasm. After birth, oxytocin contracts the smooth muscle layer of band-like cells surrounding the alveoli to squeeze the newly-produced milk into the duct system. Oxytocin is necessary for a let-down, or milk ejection reflex, to occur. (Ibid)
- Human placental lactogen (HPL) -- HPL is released in large amounts by the placentra during pregnancy (beginning in the second month) that appears to be instumental in breast, nipple, and areolar growth before birth. (Ibid)
By the fifth or sixth month of pregnancy, the breasts are sufficiently developed to produce milk (although it is also possible to induce lactation as described in a later section).
During the latter part of pregnancy, the woman's breasts enter into the Lactogenesis I stage, where the breasts are making colostrum (a thick, sometimes yellowish fluid), but high levels of progesterone inhibit most milk secretion and keep the volume “turned down”. It is considered medically normal for a pregnant woman to leak colostrum before her baby's birth, and also normal not to leak at all. Neither situation is an indicator of future milk production levels in the mother.
At birth, the delivery of the placenta results in a sudden drop in progesterone/estrogen/HPL levels. This abrupt withdrawal of progesterone in the presence of high prolactin levels cues Lactogenesis II (copious milk production).
Prolactin blood levels rise when the breast is stimulated, and peak around 45 minutes later. The return to pre-breastfeeding levels about three hours afterward. The release of prolactin triggers the cells in the alveoli to create milk. Some research (Cregan 2002) indicates that prolactin in milk is higher at times of higher milk production, and that the highest levels tend to occur between 2 a.m. and 6 a.m.
Other hormones (insulin, thyroxine, cortisol) are also involved, but their roles are not yet well understood. Although biochemical markers indicate that Lactogenesis II commences approximately 30-40 hours after birth, mothers do not typically begin feeling increased breast fullness (the sensation of milk "coming in") until 50-73 hours (2-3 days) after birth.
The colostrum is the first milk the baby receives; it contains higher amounts of white blood cells and antibodies than mature milk, and is especially high in immunoglobulin A (IgA), which coats the lining of babies' immature intestines, helping to prevent germs from invading baby's system. Secretory IgA also works to help prevent food allergies. (Sears, MD, William; Sears, RN, Martha: The Breastfeeding Book,Little, Brown, 2002. ISBN 0316779245)
After a baby has been nursing for 3-4 days, the colostrum in the breast slowly begins the process of changing into mature breast milk over the next two weeks. (Breastfeeding Answer Book, p. 36)
During pregnancy and the first few days postpartum, milk supply is hormonally driven. This is the endocrine control system. After milk supply has been more firmly established, Lactogenesis III begins - the autocrine (or local) control system.
At this stage, milk production is made on the law of supply and demand: The more milk removed from the breast, the more milk the breast will produce. Thus milk supply is strongly influenced by how often the baby feeds and well it is able to transfer milk out of the breast. "Low supply" can often be traced to A) too infrequent feeding/pumping, B) a jaw/mouth structure or latch inhibiting baby's ability to transfer milk effectively or C) a metabolic or digestive inability in the infant, rendering it unable to utilize the milk it receives.
Research on mothers who express their milk (Hopkinson 1988; deCarvalho 1985) indicate that for most women the more times per day a mother expresses her milk, the more milk she produces. Ongoing research (Daly 1993) shows that more fully draining the breasts also increases the rate of milk production.
The production, secretion and ejection of milk is called lactation. Most breastfeeding experts recommend at least one feeding every two to three hours to maintain the milk supply. For most women, a target of eight (8) nursing sessions/pumping sessions per 24 hours seems to keep a milk supply high not only during the early months of lactation, but especially past the fourth month. (AAP, 1997) It is not at all uncommon for newborn infants to nurse far in excess of this amount: 10 to 12 nursing sessions per 24 hours is the comparitive norm, while some may even nurse 18 times in the same time frame.
The exact properties of breast milk are not entirely understood, but the nutrient content of mature milk is relatively consistent and draws its ingredients from the mother's food supply and the nutrients in her bloodstream at the time of feeding. If that supply is inadequate, content is obtained from the mother's bodily stores. (Some studies estimate that a woman burns an extra 500 calories per day simply producing milk for her offspring.) The exact composition of breast milk varies from day to day, and even hour to hour, depending on both the manner in which the baby nurses and mom's food consumption and environment, so 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 compared with the creamier hindmilk which is released as the feed progresses. There is no sharp distinction between foremilk and hindmilk – the change is very gradual. Research from Peter Hartmann's group tells us that fat content of the milk is primarily determined by the emptiness of the breast -- the less milk in the breast, the higher the fat content. The breast can never be truly "emptied" since milk production is continuous.
The let-down reflex
The let-down reflex, also known as the milk ejection reflex, is caused by the release of the hormone, oxytocin. Oxytocin stimulates the muscles of the breast to squeeze out the milk. Breastfeeding mothers describe the sensation differently, with some feeling a slight tingling, some feeling immense ammounts of pressure and slight pain/discomfort, and still, others not feeling anything different.
The reflex is not always consistent, especially at first. The thought of nursing or the sound of any baby can stimulate the let-down reflex, causing unwanted leakage, or both breasts give out milk when one infant is feeding. However, this and other problems often settle after two weeks of feeding. If the mother is in a stressed or anxious state of mind this can cause great difficulties with breastfeeding.
Causes of a poor let-down reflex:
- Sore or cracked nipples
- Separation from the infant
- A history of breast surgery
If a mother has trouble breastfeeding she can try different methods of assisting the let-down reflex. These include:
- Feeding in a familiar and comfortable location
- Massage of the breast or back
- Warming the breast with a cloth or shower
Benefits
The benefits of breastfeeding are both physical and psychological for both mother and child. Nutrients and antibodies are passed to the baby while hormones are released into the mother's system. The bond between baby and mother can also be strengthened during breastfeeding.
Benefits for the infant
Breastmilk, when fed directly from the breast, is immediately available with no wait and is at body temperature.
Breast fed babies have 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.
The many health benefits of breastfeeding have been well documented. According to the American Academy of Pediatrics' policy statement, "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."[3]
Breast milk helps to lower the risk of or protect against:
- Diabetes [4]
- Gastroenteritis [5]
- Diarrhoea [6] [7] [8] [9]
- Asthma [10]
- Allergies
- Urinary tract infections
- Chest infections and wheezing
- Ear infections
- Obesity [11] [12]
- Attention-deficit hyperactivity disorder
Recent studies show that children who had been breastfed on average score higher on IQ tests than children who had not [13]. However, Jain (2002) said: Although the majority of studies concluded that breastfeeding promotes intelligence, the evidence from higher quality studies is less persuasive. [14]
Studies on eczema and breastfeeding give mixed results. One study said breastfeeding is protective [15]. However, a study from Germany found that breastfeeding was associated with higher social status, more eczema in the parents and an increased risk of eczema in the children. [16].
Benefits for the mother
Breastfeeding also benefits the mother. Breastfeeding releases hormones that have been found to 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 the womb to contract more quickly. This helps to decrease bleeding after the birth. Breastfeeding can also help the mother to return to her previous weight as the fat accumulated during pregnancy is used in milk production. Frequent and exclusive breastfeeding delays the return of menstruation and fertility (known as lactational amenorrhoea). This allows for improved iron stores and the possibility of natural child spacing. Breastfeeding mothers experience improved bone re-mineralisation after the birth, and a reduced risk for both ovarian and breast cancer both before and after menopause.
Bonding
The maternal bond is strengthened through breastfeeding, with the hormonal releases strengthening the mother's nurturing feelings towards the child. Strengthening the maternal bond is very important as studies show that up to 80% of mothers suffer from some form of postpartum depression, though most cases are very mild. The partner can support the mother in a variety of ways and is an important factor in successful breastfeeding [17]. This support can also help to establish the paternal bond in fathers.
Breastfeeding can also greatly affect the relationship between the partner and the child. While some fathers may feel left out when the mother is feeding the baby, others may see the whole process as a chance to bond as a family. Breastfeeding, possibly alongside birth-related health problems, takes a lot of time. This may add pressure to the father and the family, because the partner has to care for the mother and also perform tasks she would otherwise do. However, as fathers are often very willing to give this support, this pressure can help to strengthen family bonds.
When looking after the child while the mother is away, an alternative caregiver may feed the child using expressed breast milk (EBM). Sometimes this may be impractical as the mother must produce and store enough milk to feed the child for the duration of her absence. If the two caregivers are separated, feeding the breast milk may also be awkward. These two situations may prompt the carers to use an alternative feeding method for the child either temporarily or permanently. However, a variety of breastpumps now on the market, both for sale and for rent, make it possible for working mothers to exclusively breastfeed their babies for as long as they wish.
Recommendations and research
"Pediatricians and parents should be aware that exclusive breastfeeding is sufficient to support optimal growth and development for approximately the first 6 months of life[...] Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child."
- – The American Academy of Pediatrics (AAP) [18]
"A vast majority of mothers can and should breastfeed, just as vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother's milk be considered as unsuitable for her infant. For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative is: expressed milk from the infant's own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast milk substitute fed with a cup, which is a safer method than a feeding bottle or a teat; depends on individual circumstances"
- WHO Global Strategy for Infant and Young Child Feeding. Geneva, World Health Assembly, May 2002, page 10 [19]
"If we allow the 'breast versus bottle' argument to be reduced to a simple issue of nutrition, we ignore the much greater potential breastfeeding has to enhance the lives of parents and children."
Difficulties with breastfeeding
It is not uncommon for a mother and child to have difficulties breastfeeding in the beginning, but most of these problems resolve in the early weeks.
A small percentage (between 2 & 3%) of women are unable to provide a full day's calories. It is not known what causes insufficient milk supply, but extended separation at birth, insufficient glandular tissue, and Polycystic Ovary Syndrome (PCOS) are all known culprits. Even among this small group, it is feasible to continue breastfeeding while supplementing with donated breastmilk or artificial baby milk. Many of these mothers breastfeed exclusively by using thin tubing taped to the breast to deliver the supplementary food. This is called a supplementary nursing system, or SNS.
While some may find it too problematic or choose not to attempt or continue breastfeeding for personal reasons, most women who have initial difficulties can go on to breastfeed successfully.
Breast refusal
Though babies have a natural sucking reflex, they still have to learn how to feed and may occasionally resist feeding from the breast. To establish breastfeeding firmly, it is important for the baby to be put to the breast soon after birth so that the baby is accustomed to feeding from the breast from the very beginning. The AAP policy on breastfeeding says: Delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed.
Causes of breast refusal include:
- Formula feeding, sometimes without the knowledge of the mother.
- The use of artificial teats (nipples) or dummies leading to "nipple confusion"
- Poor feeding technique
- Over-handling after birth
- Thrush in the baby's mouth [21] [22]
- Distractions or interruptions during feeds
- Long separations from the mother
- Breathing difficulties, often caused by a common cold [23]
- Swallowing difficulties, sometimes the painful result of ear or throat infections
- Pain from surgery (most commonly circumcision), blood tests, vaccinations, and other procedures commonly done without anesthesia [24] [25]
In later stages teething could be perceived by the mother as a hindrance to breastfeeding. While it is seen by some as a good time to wean the infant, teething difficulties can usually be overcome.
Medical conditions of the infant
Reasons for the inhibition of an infant to feed include:
- Difficulties latching onto the breast
- Poor sucking reflex
- Poor stamina
- Medical conditions such as cleft palate
- Hypoglycemia or hyperglycemia
Premature babies can have difficulties if their sucking reflex is still underdeveloped and if they tire during feeds.
For many sucking related feeding difficulties, the infant can receive proper nutrition by use of a Haberman Feeder, a special bottle with a carefully designed nipple that simulates breastfeeding.
Medical conditions of the mother
Many women with previous surgeries, abscesses and cancer can breastfeed successfully. However, damage to the breast tissue can cause problems or prevent manageable breastfeeding for women with history of breast surgery or infection. Cancer (particularly breast cancer) and chemotherapy treatments have also been shown to cause difficulties. 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. resulted in the HIV-positive mother being reported to social services for her continued breastfeeding and non-treatment of the child for HIV [26]. The presence of herpes lesions on the breast is also contraindicative to breastfeeding.
Mastitis is inflammation of the breasts caused by the blocking of the milk ducts. Mastitis cause painful areas on the breasts or nipples and may lead to a fever or flu-like symptoms. It is not necessary to wean a nursling simply because of mastitis; in fact, nursing is the most effective way to remove the blockage and alleviate the symptoms, and is not harmful to the baby. Sudden weaning can cause or exacerbate mastitis symptoms.
When breastfeeding can be harmful to the infant
Breastfeeding can be harmful to the infant if the mother:
- has HIV or active tuberculosis
- 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. However, the vast majority of medications are compatible with breastfeeding.
- has had excessive exposure to heavy metals such as mercury
- uses potentially harmful substances such as cocaine, heroin and amphetamines. Substances such as caffeine, tobacco, and alcohol, while possibly harmful to the nursling if consumed in large quantities, are safe to use in moderation while breastfeeding (see below).
Health and diet
Since the nutritional requirements of the baby must be satisfied solely by the breast milk in exclusive breastfeeding it is important for the mother to maintain a healthy lifestyle, especially her diet. If the baby is large and grows quickly, the fat stores gained by the mother during pregnancy can be quickly depleted, and she may have trouble eating well enough to keep developing sufficient milk. The diet usually involves a high calorie, high nutrition diet which follows on from that in pregnancy. The Subcommittee on Nutrition during Lactation advises approximately 1500–1800 calories per day [27]. While mothers in famine conditions can produce milk with highly nutritional content, a malnourished mother may produce milk with decreased levels of vitamins A, D, B6 and B12. She may also have a lower supply than well-fed mothers [28].
There are no foods which are absolutely contraindicated during lactation, although a baby may show a sensitivity to particular foods in the mother's diet. Some breastfeeding advisers suggest mothers avoid certain gas producing food, such as beans, if the baby starts to develop colic or gas.
Breastfeeding mothers must use caution if they smoke and therefore consume nicotine. Heavy use of cigarettes by the mother (more than 20 per day) has been shown to reduce the mother's milk supply and cause vomiting, diarrhoea, rapid heart rate, and restlessness in breastfeeding infants. Research is ongoing to determine whether the benefits of breastfeeding out-weigh the potential harm of nicotine in breast milk. Sudden Infant Death Syndrome (SIDS) is more common in babies exposed to a smoky environment [29]. Breastfeeding mothers who smoke are counselled not to do so during or immediately before feeding their child. They are encouraged to seek advice to help them reduce their nicotine intake or quit.
Heavy alcohol consumption is known to harm the infant, causing problems with the development of motor skills and decreasing the speed of weight gain. There is no consensus on how much alcohol may be consumed safely, but it is generally agreed that small amounts of alcohol may be occasionally consumed by a breastfeeding mother. However, some believe that a single daily glass of wine is enough to cause distress, with levels of alcohol in breast milk peaking 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 preferable to err on the side of caution and have breastfeeding women restrict or eliminate 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.
Cannabis is listed by the American Association of Pediatrics as a compound that transfers into human breast milk.[30] This is based on research which demonstrated that certain compounds in marijuana have a very long half-life. Cannabis exposure via the mother's milk during the first month postpartum appears to be associated with a decrease in infant motor development at one year of age.
Feeding options and requirements
Exclusive breastfeeding means feeding a baby nothing but breast milk. Predominant or mixed breastfeeding means feeding breast milk along with some form of substitute – infant formula or baby food and even water, depending upon the age of the child. Babies feed differently with artificial teats than from a breast. When feeding from the breast, the tongue massages the milk out rather than sucking, and the nipple does not go as far into the mouth; when feeding from a bottle, an infant will suck harder. Therefore the advice is not to mix breastfeeding and bottle-feeding (or the use of a pacifier) until the baby is used to feeding from its mother. Orthodontic teats, which are generally slightly longer, can be used to better replicate the breast.
Exclusively breastfed infants feed, on average, 6-14 times a day. The requirement varies greatly between children. Newborns consume about 30 to 90 ml (1 to 3 US fluid ounces). and after the age of four weeks, babies consume about 120ml (4 US fluid ounces) per feed. Each baby is different, and as it grows the amount will increase. It is important to recognise the signs of a baby's hunger and it is advised that the baby should dictate the number, frequency, and length of each feed, based on the assumption that it knows how much milk it needs. The supply of milk in the breast is determined by the frequency and length of these feeds or the amount of milk expressed. The birth weight of the baby may affect its feeding habits, and mothers may be influenced by what they perceive its requirements to be. For ex