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Breast-Feeding

Human breast milk is now widely acknowledged to be the most complete form of nutrition for infants, with a range of physiological and psychological benefits for both the infant and mother. Through the ages, humans have been dependent on it for its sustenance and even contraceptive attributes. Research supports the observation of benefits for infants' growth, immunity, and development, as well as reduced financial cost to the family. Prevention of diarrheal diseases and even dental cavities are just some of its protective powers. Likewise, breast-feeding has been shown to improve maternal health, including reduction in postpartum bleeding, earlier return to prepregnancy weight, reduced risk of premenopausal breast cancer, and reduced risk of osteoporosis. Yet, in spite of these advantages, ambivalence surrounds the practice because of the myriad of factors that influence a woman's ability and decision to commit to breast-feeding.

Pregnancy and Preparation

This is an ideal time to assess attitudes and readiness for breast-feeding. A breast health assessment, including a review of breast self-examination and nipple evaluation, is prudent. Also, an understanding of the anatomy and physiology of lactation (milk production) is an essential complement to successful breast-feeding. Human breast tissue begins to develop in the sixth week of fetal life; thus, when you are born, you already have breast tissue (as does your newborn). These mammary glands or secretory glands undergo most of their maturation postnatally, during adolescence and adulthood. They are considered mature once capable of producing milk, and fully functional once lactation actually begins. Each portion of the breast has a function. The external dome is comprised of the nipple that is the exit point for all the milk ducts (aka lactiferous ducts) and the pigmented areola that houses the nipple, nerve endings, Montgomery's glands (small, pimple-like openings that secrete a substance that lubricates and protects the nipple and areola during pregnancy and lactation), lymph drainage ports, and hair follicles. Internally, there are four main types of tissues: glandular (alveolar) tissue that produces milk; ducts that transport the milk; connective tissue that supports the breasts' upright position; and adipose (fat) tissue that protects the breast from injury (note that adipose tissue determines the size of the breast, but size has absolutely no effect on milk production or quality). Arterial blood supplies nourishment to the actual breast tissue as well as essential nutrients and hormones to make milk. The lymphatic system removes cellular waste, and the nervous system is essential for, among other things, transferring the stimulus of suckling to trigger a hormonal pathway responsible for milk production and letdown.

In the early days of pregnancy, when the hormone estrogen (E) begins to increase, it directly stimulates the ductules to grow, while the surge in the hormone progesterone (P) stimulates the alveoli and lobular tissue (grapelike collection of alveoli) to grow; hence the feeling of breast fullness in the early phases of pregnancy. This glandular growth is also influenced by insulin and cortisol. In spite of the structural changes that occur in the breast because of E and P, these hormones inhibit actual milk production. The two main hormones responsible for milk production are prolactin and oxytocin. Prolactin, which has peak production at night, stimulates the production of specific milk proteins as well as attracts immunoglobulin A from gut-associated lymphoid tissue. Oxytocin, a trigger for uterine contractions, also contracts the myoepithelial cells surrounding the alveoli, causing them to squeeze the newly formed milk into the duct system. This process is also referred to as "milk ejection reflex" or "milk letdown." Both of these hormones are released from the pituitary gland, into the blood, in response to the ovarian hormones (E and P), as well as the stimuli from the senses (visual, tactile, auditory, and olfactory). A number of factors, typical to the nursing mother, can also affect prolactin levels, including psychogenic stress, anesthesia, surgery, exercise, nipple stimulation, and sexual intercourse, to name a few. The most specific and effective stimulus for prolactin secretion, however, is suckling or nursing.

The early stage of pregnancy is an opportune time to acknowledge and assess your personal feelings and biases toward breast-feeding. Whether a health professional, a first-time mother, father, or friend, understanding our health beliefs is an integral component of making healthy behavior choices. Many times these beliefs are rooted in cultural practices, past personal experiences of others or ourselves, and even the teachings of those we respect as authorities on the subject. For example, many people believe breast-feeding is "intuitive" because it is a "natural" phenomenon. The art of breast-feeding is a learned skill, irrespective of a woman's education level. Also, in some cultures, mothers who wish to breast-feed may be reluctant to give colostrum (premilk) to their newborn because they consider it unclean or harmful. Use this time to expand and alter your knowledge, skills, and attitude based on fact, not fiction or anecdotes (see resource list at the end of the chapter). Speak with a lactation consultant or attend a breast-feeding support class or group.

As delivery and childbirth become more of a reality, the opportunity to nurse or breast-feed should again be entertained, with focused choices to ensure a successful and positive experience. Anticipating what will be needed, what to expect, and arming yourself with information and practical skills are shared sentiments from lactation consultants and mothers who have had positive and negative experiences. Feeding all newborns (whether breast or bottle) will have challenging moments. Likewise, it seems that the support system you align yourself with during breast-feeding is one of the most important decisions a woman can make in this endeavor. Support can be defined as anything or anyone who provides healthy guidance or solutions to perceived stressors. This may be someone to burp a baby after a feeding or someone with words of encouragement. Choosing a health provider who supports the practice and is knowledgeable about breast-feeding, as well as surrounding oneself with experienced women, have been shown to dramatically increase the duration and success of nursing. Even the hospital or birthing center selected will impact on the decision to start or continue breast-feeding. The "Ten Steps to Successful Breastfeeding" as defined by the World Health Organization, the United Nations Children's Fund, and adopted by the Department of Health and Human Services, outlines key practices for health care institutions. It recommends:
  • a written breast-feeding policy that is communicated to all health care staff
  • staff training in the skills needed to implement the policy
  • education of pregnant women about the benefits and management of breast-feeding
  • early initiation of breast-feeding
  • education of mothers on how to breast-feed and maintain lactation
  • limited use of any food or drink other than human breast milk
  • rooming-in
  • breast-feeding on demand
  • limited use of pacifiers and artificial nipples
  • fostering of breast-feeding support groups and services

Selecting a "breast-feeding friendly hospital" or institution with the above policies and philosophy provides a good environment for a healthy start.

Cautions About Breast-Feeding

Human milk provides the most complete form of nutrition for infants, including premature and sick newborns, with rare exception. When direct breast-feeding is not possible, expressed milk should be provided. In cases of maternal infection, the basic tenet is that breast-feeding is rarely contraindicated. The few exceptions are situations where infectious agents may be associated with significant morbidity and mortality. Advice against breast-feeding should be based on careful consideration of the general benefits for mother and baby, the risks of not receiving human milk, and the most current information about the condition.

Reproductive Function During Lactation

It is helpful to know that the elevation of prolactin, and the abrupt withdrawal of ovarian and gonadotrophin hormones after childbirth and during lactation may lead to decreased breast sensitivity during lovemaking, vaginal epithelium atrophy, dryness, and decreased cervical mucus as well. These changes may, in turn, lead to discomfort during sexual intercourse and increase dyspareunia. Locally applied lubricants are helpful, and these changes usually improve over time. These hormonal changes also produce a lactational amenorrhea, or a cessation of ovulation and menses. The length of this hiatus from the ovulatory cycle varies, lasting longer with exclusive breast-feeding. Consequently, a measure of conception protection occurs for the first few months; however, ovulation, menstruation, and regaining fertility become a reality with decreased lactation. Family planning, birth intervals, and a reliable method of contraception should be addressed in advance of starting to breast-feed.

Postpartum and Beyond

In the first few days of breast-feeding, immediately after delivery and before the mature milk comes in, a thick, yellowish liquid known as colostrum is produced in small quantities and secreted from the nipples. Yet this "premilk" is sufficient to nourish the baby, satisfy the baby, and protect the baby from jaundice and many infectious diseases during the first few days of life. Colostrum that can even be present early in the second trimester of pregnancy contains complex immunological proteins, white blood cells, and factors that activate bowel function, a necessary stimulus to excrete the yellow pigment bilirubin (a by-product of red blood cell damage) into the stool. "Foremilk," which is the first portion of expressed milk, is similar to skim milk in both appearance and fat content. It is also larger in volume than "hindmilk," the creamier milk with a higher fat content that comes toward the end of the feeding. The volume of milk production will only diminish if the hormonal pathway regulated by frequent suckling is inhibited, if there is severe malnutrition, or if the mother is more than 10% dehydrated.

Nursing frequency and its influence on both infant and maternal nutrition can be categorized into one of three breast-feeding patterns. Exclusive breast-feeding (also known as unrestricted breast-feeding) is the term applied when infants are fed only by this method, on demand, and for unrestricted periods. Typically this entails an average of 10-12 feedings per day and occurs during the first 6 months of life. Partial breast-feeding is the term coined when breast-feeding is supplemented with limited amounts of formula, juice, water, or solid foods. Minimal breast-feeding, sometimes referred to as "token" feeding, usually means that the infant receives nearly all sustenance from formula and other foods. Research has found that the benefits of breast milk increase with increased exclusiveness of breast-feeding, and in fact, "token" breast-feeding has little or no nutritional value.

The chemical makeup of breast milk changes with every feed, making it tailored for the infants' needs. Its nutritional content is primarily fat, protein, lactose, water, vitamins, and minerals, including calcium and iron. Nutritional requirements of the lactating mother should begin with a balanced diet and supplements based on maternal dietary deficiencies. Health care providers should give particular attention to vegetarians and malnourished women, as calcium and B vitamins, among other things, may need to be supplemented. Also, living in an industrialized, developed country is not a guarantee against malnourishment and thus every woman should have a nutritional assessment. Other supplements like vitamin D, iron, and fluoride may be recommended for the infant beyond 6 months of age depending on other environmental and lifestyle factors. Assessment of the infant's nutritional status begins with monitoring the number of wet and soiled diapers, weight gain, and signs of jaundice. A health provider should observe suckling techniques and evaluate feeding frequency if any concerns arise.

Trends and Practices

From the dawn of civilization women have entertained the use of special feeding flasks, wet nurses, and mixed concoctions of animal milk as alternate methods to nurture infants. Uninformed concerns about maternal beauty, nobility, and the etiquette of the wealthy fueled many of these practices. In the mid-1900s, when most advances in science were perceived as beneficial, the "scientifically" prepared formulas were marketed as medical and commercial solutions to the problems of infant feeding. "Scientific motherhood" coupled with the impact of urbanization and industrialization led to a worldwide downward trend in breast-feeding. This impact was especially harmful to the breast-feeding practices of mothers in developing countries. Modified "formulas" that were closer to human milk in nutrient quantity were still very different in quality and lacked immune factors. In developed countries, there were negligible differences in mortality between breast-fed and artificially fed infants; however, the evidence became increasingly clear regarding the prevention of infant and later illness among those breast-fed. In developing countries, artificially fed infants had an associated higher morbidity and mortality than breast-fed infants, primarily caused by infection and malnutrition. Poor access to clean water along with inadequate preparation, dilution, and storage of "formulas" are large contributors to these outcomes.

Global trends toward increasing breast-feeding have been noted since the late 20th century. Data from the International Breastfeeding Compendium suggest that in the unindustrialized countries, most children are breast-fed for a few months. This is due in great part to the strong work of mother support groups, more educated women, and available evidence as to the benefits of breast milk, along with control of the marketing of artificial formula preparations.

In the United States, a national health initiative, Healthy People 2000, was outlined in 1978. It defined clear targets for improved maternal and child health measures and included improving breast-feeding rates as a priority.

Target (%)

1978

1998

2010

In early postpartum

30

64

75

At 6 months

<5

29

50

At 1 year

<5

16

25

The international community has similar objectives; however, the baseline rates are lower in many developing countries, with slow but steady advances toward the target rates. Studies confirm that the rate of breast-feeding is higher for married, well educated, higher socioeconomic status women. Maternal employment outside the home and non-Anglo American ethnicity were related to higher rates of bottle-feeding. Many of these women, well informed about the benefits of mother's milk, chose not to breast-feed because it was "too difficult" and "there were too many rules." The most frequent reasons cited for stopping breast-feeding by women who started at hospital discharge were (1) not enough milk, (2) felt tired, and (3) infant's pediatrician told mother to stop. Asking for help from lactation consultants, mother and father support networks, and trained health professionals allows access to practical guidance and accurate information and should be sought before making any decision to stop nursing. Nursing is a flexible practice that should be tailored to fit the lifestyle needs of you and your baby. Most problems, typically experienced in the first 2-3 weeks of breast-feeding, have simple solutions. Proper positioning and feeding on demand can lead to avoidance of many of the common problems that affect milk supply and breast health such as engorgement, sore nipples, and blocked ducts. Positioning is the single most important factor for getting breast-feeding started well. This refers to (1) the physical alignment of mother and infant, (2) the way the mother holds the infant, (3) the position of the mother's hand as it supports her breast, and (4) the position of the baby's mouth, lips, and tongue-often called the "latch-on"-around the areola and nipple. Addressing problems early is also important to prevent outcomes such as infant failure to thrive, mastitis, yeast infections, and maternal discouragement, all of which require professional attention. Recommendations for routine breast care involve washing the breast following each nursing session with only lukewarm water, if at all; and massaging a small amount of expressed milk onto the nipple and areola following every feed.

Milk banking and pumping are notable options in expressing breast milk that provide optimal infant nutrition while the mother is not physically able to nurse due to health problems, employment demands, physical absence, or simple fatigue. Special instructions are available in the cited references regarding these practices and the storage of expressed milk.

Summary

The evidence for the short- and long-term benefits of breast-feeding on the health of the infant, women, and their families continues to grow. This has led a renewed commitment from the health care community to encourage and support this practice. The forces that improve success, however, lie not only in the guidance of health professionals, but seem grounded in the stories and support of mothers who have had positive or negative experiences. Understanding that breast-feeding is natural but is a learned skill is at the foundation of successful nursing. Consequently, the approach to breast-feeding requires a humble respect for the emotional, physical, and time commitment involved, as well as skill grounded in the experience of our ancestors. There are numerous books, videos, websites, support groups, and health professionals available to guide a woman and her family through this lifestyle practice. A referral listing with some of these resources is available at the end of this chapter.

See Also: Lactation, Pregnancy

Suggested Reading

  • 1. American Academy of Family Physicians. (2001, Fall). Position paper: Breastfeeding. Leawood, KS: Author.
  • 2. American Academy of Pediatrics. (1997). Policy statement: Breastfeeding and the use of human milk (RE9729). Pediatrics, 100(6), 1035-1039.
  • 3. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), & Johnson & Johnson Consumer Products, Inc. (1996). Compendium of postpartum care (1st ed., pp. 1.24-1.27). Skillman, NJ: Johnson & Johnson Consumer Products.
  • 4. Bronner, Y. L., Bentley, M., Caulfield, L., et al. (1996). Influence of work or school on breastfeeding among urban WIC participants. Abstracts of the 124th Annual Meeting of the American Public Health Association, New York.
  • 5. Kleinman, R. E. (Ed.). (1998). Pediatric nutrition handbook (4th ed.). Elk Grove Village, IL: American Academy of Pediatrics, Committee on Nutrition.
  • 6. La Leche League International. (1987). The womanly art of breastfeeding (4th rev. ed.). Markham, Ontario, Canada: Penguin Books.
  • 7. Lawrence, R. A., & Robert, M. (1999). Breastfeeding: A guide for the medical profession (5th ed.). St. Louis, MO: C. V. Mosby.
  • 8. Mohrbacher, N., & Stock, J. (1997). The breastfeeding answer book (rev. ed.). La Leche League International.
  • 9. Renfrew, M., Fisher, C., & Arms, S. (2000). The new bestfeeding. Getting breastfeeding right for you. Berkeley, CA: Celestial Arts.
  • 10. Riordan, J., & Auerbach, K. G. (1999). Breastfeeding & human lactation (2nd ed.). Sudbury, MA: Jones & Bartlett.
  • 11. Robin, P. (1998). When breastfeeding is not an option. A reassuring guide for loving parents. Rocklin, CA: Prima.
  • 12. UNICEF & WHO. (1990). Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding. Florence, Italy: Author.
  • 13. U.S. Department of Health and Human Services, Office of Women's Health. (2000). HHS blueprint for action on breastfeeding.
  • Suggested Resources
  • 1. www.breastfeeding.com
  • 2. www.lalecheleague.com
  • 3. www.nursingmothers.com
  • 4. www.waba.org.br/