Fritzi Drosten, RN, IBCLC
Patricia Robertson, MD, Professor, Department of Obstetrics and Gynecology
Sharon Wiener, CNM, MPH, Associate Professor, Department of Obstetrics and Gynecology
Lactation Task Force, University of California at San Francisco
2008-03-29
Breastfeeding
Your decision to breastfeed is a very important one. Human milk is a complex natural secretion that provides the optimal nourishment for the baby. Human milk contains a balance of nutrients that is readily digestible and easy on the immature kidneys of the infant. The fats and enzymes in human milk promote efficient digestion and utilization of nutrients. In addition, human milk assists in the development of a healthy immune system and brain for the infant. Antibodies produced by the mother and transferred into the breast milk help the baby resist infection. The process of breastfeeding also provides a form of human attachment that has lasting effects on a baby’s ability to form human attachments.
Maternal breast milk is present in small amounts at birth and slowly increases over the following few days, due mostly to response to the hormonal changes caused by the birth itself. By several days after birth, the baby’s suckling sustains the milk supply at a fairly stable volume that will provide adequate growth for the first several months of life. As the infant begins to take solid foods, little by little, the mother’s milk supply decreases.
Most mothers are able to provide adequate nutrition through an abundant milk supply, that the infant regulates as needed, though in some cases, a mother cannot or chooses not to breastfeed. In those cases, a baby can be well nourished with infant formula. However, before you assume you can’t breastfeed, or decide not to breastfeed, do some reading, and bring your questions to your obstetric provider, your designated pediatric provider, or other knowledgeable health professionals such as lactation consultants. If you choose to breastfeed, getting the proper support and guidance is crucial.
Breastfeeding studies in recent years have shown that breastfeeding promotion, education, and societal support (e.g. policies in the workplace) improve the health of millions of babies around the world. (http://www.who.int/topics/breastfeeding/en/). However, many cultures have practices that interfere with normal breastfeeding, and consequently mothers and families need information on how to initiate, establish and maintain breastfeeding, which you will find below.
BENEFITS FOR THE BABY
Breast milk is made of fats, sugars, proteins, hormones, minerals, vitamins, and enzymes that are easily digested and rapidly absorbed. When the supply is well established, and the baby takes a steady amount of milk per day, milk is made during the feeding in response to the baby’s sucking. The sucking is soothing to the baby and the milk satisfies the baby’s hunger. Breastfeeding also has numerous health benefits for the infant.
Breastfeeding is associated with a reduced risk for the baby of:
· stomach infections
· ear infections
· lower respiratory tract infections such as pneumonia
· atopic dermatitis (allergies)
· asthma
· obesity
· type 1 and 2 diabetes
· childhood leukemia
· sudden infant death syndrome (SIDS)
· intestinal inflammation and diarrhea
Here are other benefits of breastfeeding for the baby:
· your baby is introduced to the flavors of the mother’s foods
· breast milk is always ready
· breast milk is always just the right temperature
· the activity of suckling at the breast helps your baby enhance the development of oral muscles and facial bones as well as speech development
· breastfeeding comforts an upset infant.
BENEFITS FOR THE MOTHER
Mothers who breastfeed often experience a hormonal type of euphoria during breastfeeding. They frequently describe feeling closer to their babies because they breastfeed. The close proximity of the baby and the fact that you have an extra hand (not needing to hold a bottle) to stroke and touch the baby helps with the baby’s attachment to you; this begins the process of normal relationships with other people that the baby will establish in the future. However, if you cannot or choose not to nurse your baby, you and your baby will still develop a powerful attachment.
Breastfeeding is associated with a reduced risk of:
· postpartum bleeding from the uterus
· postpartum depression
· type 2 diabetes
· breast and ovarian cancer
BENEFITS FOR THE FAMILY
· Infant formula is very expensive. It is estimated that the cost of formula and the supplies that are needed cost about $1000.00 for the first year. Breast milk is free.
· Because of the health benefits to the baby, there are less medical expenses for babies that are breastfed, including fewer pediatric visits, prescriptions, and hospitalizations.
· Breastfeeding is environmentally economic, using fewer of the earth’s resources
WHEN NOT TO BREASTFEED
Breastfeeding may not be an option for women with certain medical conditions. If you have a medical condition, or you are taking medications that might prohibit breastfeeding, discuss this with your obstetric provider as well as your chosen pediatric provider. Sometimes there is a difference of opinion about breastfeeding while taking a particular medication. You might want to consult the Pregnancy Risk Information Line at the University of California at San Diego, which is a free service to pregnant and breastfeeding mothers, with a large database of medications and supplements: 1- 800-532-3749. Remember that formula fed babies do very well and are very healthy too.
Breastfeeding is strongly discouraged in mothers with:
· human immunodeficiency virus (HIV) infection
· anti-retroviral medication use
· untreated, active tuberculosis
· illicit drug use such as amphetamines, cocaine, PCP, and/or heroin
· cancer chemotherapy agents use
· radiation therapies use
· other medications and/or therapies as specified
If you are unable to breastfeed, or have chosen not to, inform your obstetric provider and nurses (if you have a birth plan, clearly state this). Sometimes providers will try to encourage you to change your mind if there is no medical contraindication. If you prefer not to discuss it, let them know that as it may feel intrusive despite their good intentions. However, in some situations, discussing it might be appropriate. For instance, if you unexpectedly have a premature baby, breast milk is very important, and may protect the infant who is more susceptible to infections than a baby born full-term. Premature infant milk is specifically geared for the premature infant and has more nutrients in it. Many physicians consider breast milk a medicine for the infant born prematurely. There are human milk banks in some urban areas, however fresh milk from the mother is best.
Women who have had breast reductions often can breastfeed successfully, although supplementation may be needed as sometimes milk volume is reduced. If you have had a breast reduction and your breast surgeon told you that you would not be able to breastfeed, this may have to do with the method of the surgery. However, many surgeons use techniques for breast surgery now that are more favorable for future breastfeeding. If you have had a breast augmentation (implants) you will most likely be able to breast feed, at least partially, especially if the implants were placed behind your pectoral muscles. If you can’t remember what your plastic surgeon told you about the implants and future breastfeeding, contact them and ask them to look up your operative report. A good source of information on breastfeeding after breast surgery is this website: http://www.bfar.org A lactation consultant can help you maximize your breastfeeding in these situations.
Occasionally, postpartum women are only able to breastfeed for a limited amount of time – for example, when needing to resume a medication postpartum for treatment of an ongoing disease. Even a few weeks of breastfeeding can be very valuable to your post partum recuperation, your infant’s health, and your enjoyment.
PREPARING FOR NURSING DURING THE PREGNANCY
Physiology of Milk Production
From the beginning of the first trimester of pregnancy, breasts undergo dynamic physiologic changes. There are several hormones that are responsible for these changes. In early pregnancy the rise of estrogen initiates ducts to develop and progesterone causes milk lobe formation. These changes are manifested by growth in the size of the breasts and in some cases by discomfort. By the third month of pregnancy, prolactin begins to be secreted by the pituitary gland. Prolactin stimulates specific cells to initiate milk secretion and colostrum can appear by the beginning of the second trimester. Colostrum is often referred to as the first milk and appears thick and yellow. Compared to breast milk, colostrum is richer in protein, some vitamins, antioxidants, and antibodies that protect the immature digestive system of your baby. Colostrum drops may appear when your breasts are massaged, or sexually stimulated during the pregnancy. It is also common that some women do not have adequate early colostrum available to the baby and yet will produce and provide sufficient milk. It is during the first five months of pregnancy that the breast undergoes the most rapid changes. After the birth of the baby and nipple stimulation occurs, oxytocin is usually released from the pituitary gland numerous times during each breastfeeding. This release of oxytocin is often called the let-down reflex. When let down occurs, milk is flowing in the ducts, making it easy for the baby to obtain milk. Leaking may occur if baby is not at the breast. This process can often be felt by the mother as heaviness or tingling of the breasts. By week two to three after the birth, women who are exclusively breastfeeding produce about three cups of milk a day. Milk levels vary and can range from two to five cups a day.
Physical and Prenatal Preparation
Many women think that they need to prepare their nipples for breastfeeding, but there is no research that supports physical preparation prior to birth. You are, however, encouraged to attend breastfeeding classes during the pregnancy. There are many studies that suggest that breastfeeding classes actually provide the support and education that increases success with breastfeeding. Today the average stay in the hospital after delivery is two days, which is not enough time to learn effective breastfeeding techniques. We recommend that your partner (if partnered) or a friend or family member (if single) also attend breastfeeding classes because their knowledge and support has been shown to increase duration of breastfeeding. Check with your clinician about breastfeeding classes that are offered in your hospital or community. Although you might find breastfeeding classes on-line, a personal class is much more beneficial.
Minimal supplies are needed to successfully breastfeed. A good bra is often quite helpful. Some women prefer to have a breast pump available at home upon return from the hospital. Breast pillows and breastfeeding clothing are expensive, and not necessary immediately post partum.
EARLY BREASTFEEDING
Breastfeeding, ideally, should begin within the first two hours after birth. Even just after birth, the newborn infant is capable of crawling up to the mother’s breast, attaching to the nipple, and sucking in an effort to begin feeding. (http://www.breastcrawl.org/). There are several factors in the early post partum period that help contribute to a successful breastfeeding experience:
· Assure skin-to-skin contact after delivery. Allow the baby to rest on your chest or nurse naked (with dry blankets on top) within the first hour after the birth: this skin-to-skin has been shown to increase breastfeeding rates. Immediately after delivery, babies are alert and interested in nursing. It has also been reported that skin-to-skin helps with temperature regulation, respiration, and oxygenation, reduction of apnea (periods of inability to breathe), and acceleration weight gain of the infant in the immediate post partum period. Many common nursery routines such as weighing the infant, administration of vitamin K, and application of eye antibiotics can be safely delayed until after the initial skin-to-skin and breastfeeding. If you are unsure that the birthing situation where you will be delivering supports skin-to- skin, ask your obstetric provider how skin-to-skin can be facilitated for you and your baby.
· Initiate early breastfeeding. Colostrum (“liquid gold” is the liquid that is ready for the newborn infant. It
provides immunologically beneficial proteins and energy, promotes the growth of healthy intestinal bacteria,
and helps the baby pass meconium, the tar-like substance that is the baby’s first bowel movement. This small
volume of drink for the infant helps to perfect the suck-swallow-breathe rhythm, so that when the mother has
more milk in a few days, the infant is well practiced in feeding from the mother’s breast. Colostrum begins to
increase in volume until there is a sudden increase in breast fullness and a large increase in milk volume, which occurs at about 60 hours after birth.
· Keep the baby with you at all times (rooming-in). Rooming-in is a term that is used to convey that the baby is with the mother at all times and is not taken to the nursery. Some birthing institutions discourage babies going to the nursery. These hospitals are set up to accommodate all pediatric care at the mother’s bedside. It allows new parents to care for their baby; all baby supplies are at the mother’s bedside while lactation help is readily available. This helps parents learn skills and develop confidence before going home with their baby – and allows the mother the feed the baby upon demand. Even if you are really tired from a long labor or a complicated delivery such as a Cesarean Section, try to keep the baby with you at all times during your recovery. It can also be helpful to have an adult from your family or a friend spend the night with you to provide support.
· Allow your baby total, unrestricted access to the breast. Many babies are sleepy their first day of life, and then they are very interested in breastfeeding. Babies should be allowed to feed at one breast as long as they want, which is usually up to 20 minutes. After a short rest, if they are interested in feeding from the other breast, then offer the second breast. If they want to feed an hour later go ahead and let them practice more. Work towards comfortable feedings, guided by your baby’s feeding cues. Most babies will want to feed every one to four hours around the clock during the first few weeks.
· Ask for help. Mothers and infants are routinely assisted with breastfeeding during a postpartum hospital stay. Breastfeeding has only begun at this point, so the new mother and baby still are learning this process, and should be followed closely so that feeding is established. The baby begins to gain weight on milk supplied by the mother’s breasts after a few days of birth. In the United States most babies leave the hospital after a two to three day hospital stay, and are seen again two to three days after discharge. Infants are checked then by pediatric clinicians who are versed in evaluating and treating inadequate milk intake.
HOW TO KNOW IF THE BABY IS GETTING ENOUGH MILK
Because it is hard to actually see how much milk the baby is getting with each breastfeeding, it is important to recognize when the infant is not getting enough, as dehydration can have serious consequences for a newborn infant. The following is a list of behaviors that help you know that the newborn infant is getting enough milk.
· You will hear the baby swallowing during the feedings (swallows sound like faint puffs, or “uh-uh” sounds).
· You will feel your baby pulling on the nipple and areola. You will feel this strong sucking for most of the time the baby is feeding at the breast.
· Your breasts will soften after a feeding.
· Your baby will want to feed at the breast every two to four hours around the clock, feeding for several minutes usually about 10 to 20 minutes on one breast or alternating for that amount of time between breasts
· Your baby will usually be content after a feeding. A contented infant will be calm, and may fall asleep, or may be quietly awake for a while. The infant will not be actively searching and will not look as if trying to suck. Some babies may protest being placed alone in a bed (always on their back or side) after a feeding
· Your baby will have wet diapers increasing over the first few days, to six to eight wet diapers or more every day.
· Your baby will have bowel movements which initially are the dark meconium, but then will change to a very soft, almost runny, yellow color. The movements will occur at least a couple of times a day, usually more during the first few weeks.
· Your baby will gain weight. During first weeks and months, health care visits assess baby’s weight gain. After birth, babies generally lose weight, averaging 4-7 % of their birthweight, and as they reach their lowest weight, they begin drinking more milk. Your mothers’ milk volume then increases (the “milk is in”). If your baby has not re-gained his/her birth weight by two weeks of age, a breastfeeding evaluation is generally indicated. The breastfed infant begins gaining weight (about 4-7 ounces per week) over the next few weeks, with birth weight usually doubling by about six months of age.
MAKING MORE MILK
Perhaps you may be told that you are not making an adequate amount of milk or you may feel you do not have enough milk to satisfy your baby. In either case, before you begin supplementation, it is imperative to understand the basics of milk production and supply. Although there is often a sense of frustration if you are not able to produce milk or not enough milk, there are some things you can try.
· Increase the frequency of feedings. Breasts work on a supply-and –demand principle. Young infants will sometimes cluster-feed, feeding every hour or so for several feedings in a row, then go for a few hours between feedings. Most newborn babies will feed 10-12 times in 24 hours Some infants will not “demand” to be fed frequently enough during early infancy. Infants often can be easily awakened after two to three hours to add another feeding or two per day to stimulate the breasts to produce more milk.
· Increase the length of the feeding. Infants generally will feed until satiated. While infants often feed for 10-15 minutes, they may not be through feeding if a strict time limit is used. Sometimes “switch nursing” where the baby is fed from both breasts at a sitting will help baby bring up the milk supply. When the baby slows down, switch breasts; repeat this twice so the baby feeds at each breast two times during each feeding.
· Fix the latch. If the baby does not suck the milk that is available at each feeding, the breasts will get the idea that the baby does not need more milk, and eventually will lower milk production. This may mean the baby needs to learn to grasp the nipple and areolar tissue more fully, deeply, and more strongly, without pinching, to take more milk volume from the breast. The baby should have lips flanged outwards, the tongue should be cupped around the nipple and areola, and the jaws should be moving, drawing the nipple without a lot of friction. Sometimes just pulling the baby a little closer to the breast so that the nose is almost touching the breast, will solve this. Sometimes supporting the breast with your hand underneath the breast will help keep the nipple in the mouth, making it easier for the baby to get more volume of milk from the breast.
· Rest a little more. Try napping in the daytime, especially if you are up with the baby much during the night. This can help increase milk production.
· Check your diet. Make sure your diet has sufficient calories, nutrients, and fluids (caution : drinking too many fluids may impact milk supply negatively).
· Use breast massage and breast compression. Both of these often help with milk supply. Gently massage the breast before the feeding or when the baby pauses during the feeding. Breast compression consists of gently compressing the breast as the baby feeds to aid in milk transfer.
· Check with your local lactation resources. Do this as soon as possible for latch and milk supply. Many lactation consultants are located through the International Lactation Consultant Association (http://www.ilca.org/).
· Use a good breast pump. If your breasts are being stimulated by vigorous sucking from your baby about every two to three hours, an electric breast pump should provide more stimulation for milk production. Offer the breast first, and then use the pump for 10 – 20 minutes afterwards.
BREAST PUMPS
Type
Advantages
Disadvantages
Notes
Manual or hand expression
No electricity needed
Inexpensive
Some are more effective than others
Some much more comfortable than others
Usually slower
One breast at a time
Requires effort
Many inefficient manual pumps are on the market. Try to buy a reputable brand.
Electric
Small portable
Dual, both simultaneously pumped in most dual pumps
Easy
Faster
Plug needed- most have battery option
Cost
May not work well for some mothers
May not have options like larger flanges, or speed adjustment
Small battery pumps may go thru batteries very quickly. Most also have an electric adapter if electricity is accessible.
Electric Midsized
High End portable
Faster, more efficient. Most have options like larger flanges, or speed adjustment
Battery may not be option
Cost
Many are not designed for multiple users, so buying used ones may be risky.
Electric Hospital grade
May be fastest of all
More efficient
Cost – most are available for rent
May not be very portable
Designed for multiple users.
The following website has a detailed discussion on pumps: http://patients.uptodate.com/toc.asp?toc=pregnancy&title=Pregnancy
(click on pregnancy, then breastfeeding).
· Consider medications to increase milk supply ( in conjunction with adequate breast stimulation)
There are a few medications available to increase your milk supply. There are also some medications that may negatively affect milk supply, so check with your provider if you taking medications other than vitamins. Metoclopramide (Reglan), often used for stomach upsets, has been shown in small studies to increase milk production. However, it can also have some side effects such as depression and fatigue. This is a prescription medication and you need to talk with your obstetric clinician or pediatrician if you are interested in using this. Domperidone is also used to increase the volume of breast milk (this medication is not available in the United States). Many herbs also have been used for centuries to help a mother make more milk. Many are generally regarded as safe and are available in health food stores and pharmacies, the most common being fenugreek. There are ongoing studies assessing the effectiveness of fenugreek, in increasing milk volume. Goat’s rue (galega officinalis) and milk thistle (Silybum marianum) are common herbs used as to stimulate milk supply, although there are no studies to evaluate their efficacy. In the latter, a tea made from a teaspoon or so of crushed leaves is steeped in one cup of hot water for 10 minutes.
MAKING TOO MUCH MILK
Sometimes a mother is making too much milk for her baby, which may result in several problems, such as the baby spitting up milk when too much is taken at a feeding, or overly full, leaky breasts. When a baby takes less milk, then less milk is produced, and the situation can correct itself. Other times, a shorter feeding duration may be more comfortable for the baby. Sometimes feeding just on one breast during a feeding can help lower the milk volume. Some babies have difficulty handling the milk flow when there is too much milk, and they gulp and swallow air during the feeding, which results in stomach discomfort and general fussiness. Slowing the feeding and changing position so that the baby gulps less air will often remedy the situation. Some mothers find that pumping or expressing a little bit of milk before the feeding is also helpful. Pumping large volumes of milk will continue the process of too much milk production. Seek help if this continues to be a concern.
BREASTFEEDING THE OLDER BABY
As babies get older, breastfeeding changes in many ways
· Babies often become much more efficient, and breastfeeding becomes much easier.
· After a few weeks many babies begin to sleep longer at night.
· Many babies do not need to feed as frequently during the daytime.
· The breasts become much softer.
· Breastfeeding continues to be a source of comfort for the baby, who may want to breastfeed for its calming effect.
BREASTFEEDING TWINS AND OTHER MULTIPLES
It is possible to make plenty of milk after a birth of twins or more. Milk is made according to a supply and demand system. The more stimulation the breasts receive, the more milk will be produced. The milk supply is very sensitive to stimulation in the early weeks of breastfeeding. Two infants feeding simultaneously take advantage of the milk ejection reflex that occurs in both breasts simultaneously. Although orchestrating this process with two, three, or four newborn infants is usually initially difficult, as breastfeeding progresses it often becomes much easier and faster. As babies get older and even more efficient, two babies may not feed at the same time. Mothers who breastfeed multiple infants (triplets, quads or more), who typically consume more than four liters per day if exclusively breastfed, will need tremendous support for other infant caretaking needs.
BREASTFEEDING BABIES WITH SPECIAL NEEDS
Infants with cleft lip can often feed better at the breast than with a bottle, while an infant with a cleft palate will probably be unable to feed directly at the breast for some time. Premature infants and infants with most medical conditions can benefit from breast milk although it may have to be pumped, at least initially. Again, one clear value of breast milk is that it is easy to digest and protects infants from illness.
WEANING
How long should you breastfeed?
The Office of Women’s Health in the United States, in its Blueprint for Action on Breastfeeding
(http://womenshealth.gov/breastfeeding), recommends that infants should be exclusively breastfed for the first six months of life. Ideally breast milk, along with the addition of solids and other liquids after the first six months, is the best nutrition for the baby. The World Health Organization recommends breastfeeding for at least two years – and around the world, there are mothers who breastfeed their infants for two to three years. However, different circumstances may affect how long the mother is able to breastfeed, including lifestyle, economic circumstances, and cultural norms. Respect and support is needed for each mother’s decision.
Natural weaning: As the child takes in more solid foods and liquids after the first year of breastfeeding, the need for mother’s milk decreases. The mother’s milk supply then decreases, because the infant is less hungry when put to the breast. As the child and/or the mother lose interest in breastfeeding, milk supply continues to drop, and the breasts undergo involution, returning to their pre-pregnancy state.
Earlier weaning: Weaning under the age of a year, may be accomplished most easily by replacing a breastfeeding every two to three days with a formula feeding.
Abrupt weaning: If a mother must urgently stop breastfeeding, depending upon the age of the infant, the breasts will become hard and full of milk. This fullness sends signals to the breasts to stop production. If the mother is uncomfortable, the following comfort measures may help:
· wear a comfortable bra
· express enough milk to feel full but not in pain
· use ice for a few minutes at a time
· place green cabbage leaves on the breasts as compresses
SEEKING LACTATION HELP
Many times family and friends who have had positive experiences with breastfeeding can encourage and support you with minor issues. However, if there are major issues such as poor weight gain in the infant, you should seek professional help.
Lactation training of physicians, other providers, and their support staff varies. Lactation training has some variation in certification. The Internationally Board Certified Lactation Consultant (IBCLC) has a minimum amount of training and class work, an exam, and re-certification every five years. These lactation consultants are certified by the International Board of Lactation Examiners (http://www.iblce.org/). A lactation educator has usually taken some number of courses in the field of lactation, typically two to five days of course work . Both types of providers work in hospital settings and often have private practices in many communities. Many lactation consultants are located through the International Lactation Consultant Association. (http://www.ilca.org/). An international organization of volunteer peer support women is the La Leche League (http://www.lllusa.org ), providing free support groups and phone support (1-877-452-5324) to mothers having difficulties. There is also the federal government website for women’s health (http://www.womenshealth.gov/breastfeeding).
SORE NIPPLES, PLUGGED DUCTS, AND INFECTIONS
Sore Nipples
Many mothers experience painful nipples, which may progress to broken skin with cracks and bleeding during the feeding. It is important that the baby be positioned on the breast to facilitate a wide open mouth, so that the baby is able to draw on the nipple and areola without them being pinched and pulled with undue force. Mothers should be helped with the baby’s latch onto the breast if pain is occurring. Below are strategies to help prevent or treat sore nipples.
· Correct the infant’s latch if needed. The baby’s mouth must be open, with tongue extended enough to draw nipple into mouth. The baby’s chin should be close to or touching the breast when feeding The lips should flange outward and not be tucked under. More of the lower areola is generally drawn into the mouth than the upper portion, creating the “asymmetric latch.” Try changing positions. The way that the infant is held, can often help the infant open the mouth more, or move the tongue and jaws more comfortably on the breast.
If you need to take the baby off the breast, insert your finger in the corner of the baby’s mouth and push
down on the breast to gently break the suction and then take the baby off the breast. When re-positioning the baby back on the breast, wait until the baby opens the mouth wide with the tongue down and out over the lower lip, then place the baby so that the breast fills the entire open mouth (the brown area around the nipple call the areola should be inserted into the baby’s mouth as much as possible). Another method of helping the baby latch is to bring the baby to the breast with the chin touching below the nipple while pressing the areaola above the nipple away from the infant’s mouth until the baby opens the mouth wide, and then release the areola allowing the nipple to “flip” into the baby’s mouth.
· Support the breast, or bring baby more to nipple level if breasts are heavy.
· Avoid pulling nipple from infant’s mouth without first breaking the seal with a finger placed in the corner of the mouth.
· Try to get skilled help if pain occurs with breastfeeding.
· Temporarily use a high quality breast pump if breastfeeding is too painful or consider temporarily using a nipple shield (flexible artificial nipple covers with a hole through which the baby draws milk).
Nipple care
Allow your nipple to air dry after feedings. When a nipple is tender, express a small amount of milk onto the nipple and allowing it to dry. Purified lanolin is widely used, safe, and when applied sparingly to very tender nipples, soothes the skin, and prevents formation of scabs. Keep nipples clean and only wash gently using very small amount of soap when bathing. Creams designed for the nipples may have ingredients that are not safe for the baby, and may need to be removed prior to feeding, causing even more skin breakdown. Hydrogel dressings worn between feedings may be a comfortable alternative. All of these measures have studies with mixed results as to which is the best product, but virtually all studies state that the best thing to do with sore nipples is correct the cause (correct the breastfeeding technique) while continuing to breastfeed.
Plugged ducts
Plugged ducts are blocked milk channels in the breast. Their cause is not always known, but sometimes faulty positioning or a poor latch seem to be factors in their development. Bras with constricting underwires, backpack straps, and seat belts can also restrict circulation to some breast tissue. When milk cannot drain, breasts can become full and painful lumps can develop.
Treatment
· Warm compresses applied to the plugged area before feedings and pumping may help the milk drain from the plugged duct.
· Gentle massage before pumping may help drain the plugged duct.
· Drain the breast frequently by nursing or pumping with a good breast pump. Make sure the pump you are using is working well and that your nipple fits the cone. Assure that your baby is actively and frequently feeding. Feeding with the baby’s nose and chin pointed towards the plugged duct may help with draining that area.
· Drink adequate fluids.
· Avoid exhaustion and try to get adequate rest.
Breast Infection (Mastitis)
Mastitis is an infection of the breast. It is believed that one possible cause of mastitis is inadequate or poor breastfeeding technique. If the mastitis is bacterial, it is usually caused by staphylococcus or streptococcus bacteria, which has entered the ducts via skin breaks in the nipple area. Mastitis is most commonly seen between the second to third week post partum, but can develop any time during the nursing period. Most reports in the United States indicate that 75%-95% occur in the first 12 weeks postpartum. Women who have had a prior breast infection are at a significant increased risk to develop it again in a subsequent pregnancy.
Mastitis is often accompanied by fever, chills, and a red, painful area on the breast that might be lumpy, or not. If you think you have mastitis, call your obstetric provider right away. Often you will not have to be seen; a diagnosis can often be made via the phone and an antibiotic prescription called to your local pharmacy.
Treatment
Antibiotics: Your obstetric provider will usually prescribe an oral antibiotic treatment for you. Usually treatment lasts for 10-14 days. Although the optimal length of treatment is not known, it has been found that shorter courses may result in a recurrence so finish your antibiotics even if you feel a lot better in two to three days. The most common antibiotics used to treat mastitis are dicloxacillin, cephalexin, erythromycin, or amoxicillin.
Additional important measures you should take:
· Apply warm compresses to the affected breast every two hours.
· Massage the lumpy area after the warm compresses to assist with adequate drainage.
· Take acetaminophen or over the counter anti-inflammatory medications (ibuprofen) for the discomfort.
· Stay in bed for about 24 hours and rest, drink 6-8 glasses of water.
· Continue to breastfeed or pump every 2 hours.
· Try breastfeeding in various positions in order to facilitate the emptying of all ducts.
It is very important to contact your obstetric provider if you do not notice improvement within 48 hours. You should be personally evaluated at this time for an abscess and a change of antibiotics. Although a breast abscess is an uncommon problem for breastfeeding mothers, it is a significant complication of mastitis. Breast abscesses develop in five to 11 percent of women with mastitis, often due to inadequate antibiotic therapy. The symptoms of a breast abscess are similar to mastitis: breast pain, fever, and chills; a tender lump or mass is usually felt. Sometimes an ultrasound is used for a diagnosis of a breast abscess.
Management :The management of a breast abscess consists of antibiotic therapy and drainage of the mass. Usually a surgeon will perform the drainage by needle aspiration, with or without using ultrasound for guiding the needle. However, in many cases a surgical incision and drainage is needed. During this time, continue breastfeeding with both breasts if the incision does not interfere with the latch of the baby. If you have problems putting the baby to breast, try pumping instead. Follow the recommendations of your surgeon
Candida of the Nipples and Breast
Candida albicans is a common cause of nipple pain and infection. Candida is a yeast infection that can occur on many parts of the body. A nipple yeast infection usually presents with burning, sore, red, flaky nipples and/ or areola. The burning can cause severe sensitivity and usually a temptation to terminate breastfeeding. Go to your lactation consultant prior to seeing your obstetric provider so the latch and positioning are evaluated. If you are breastfeeding properly and the nipples or breast are very painful, you will need treatment.
The following local treatment is often recommended: an antifungal ointment such as clotrimazole 1% or miconazole applied to the nipples. Your obstetric provider might prescribe a combination ointment that includes a mixture of an antibiotic, mupirocin, a steroid (betamethasone 0.1 percent), and an antifungal powder (miconazole), known as "all purpose nipple ointment.” This is available in compounding pharmacies. This ointment should be applied after each nursing and does not need to be washed off before the next feeding. Sometimes the nipples are painted with Gentian Violet. Your baby should be treated for thrush (yeast infection in the mouth) while you are being treated. It is important to keep all your bras, breast pump equipment, and pacifiers clean in order to prevent a recurrence.
Candida infection in the breasts refers to a yeast infection in the ducts. This is a type of mastitis that can occur when a nipple infection is not treated thoroughly. The pain that is associated with ductal yeast is described as stabbing, sharp, and radiating outward from the nipple during and after the feedings. Fever, chills and flu like symptoms are not seen with candida mastitis. Treatment consists of a prescription oral medication called fluconazole that is taken orally from one to two weeks.
Raynaud’s of the Nipples
Raynaud phenomenon of the nipples is a vasospasm (spasm of the blood vessels) of the nipple usually initiated by cold sensitivity. The pain and throbbing are often severe and can be misdiagnosed as a candida infection. The symptoms include bilateral pain associated with discoloration of the nipple (nipple could be white, purple, or red), without symptoms of infection, cracks or fissures.
Treatment Discoloration of the nipple can be caused by compression due to poor positioning and latch-on and it is important that your obstetric provider refers you to a lactation consultant to evaluate how the baby is latching. If you have proper technique and pain and discoloration remains, then a good medical history needs to be taken. Once a probable diagnosis of Raynaud’s is made, preventative treatment is recommended:
· increase the environmental temperature
· wear warm clothing
· avoid tobacco, oral contraceptives, caffeine, and certain medications
Nipple pain due to vasoconstriction that is not responsive to these measures can be treated with nifedipine, a prescription medication (dosage is 10 -20 mg for the initial dose and then 10 - 20 mg daily for two weeks).
NUITRITION WHILE BREASTFEEDING
As long as the postpartum mother is in good health and eating a nutritious diet, it is unlikely that she and her baby are likely to be deficient of any vitamins or minerals. Mothers who are exclusively breastfeeding need about 500 extra calories per day to maintain their present weight. Milk production could be affected if a mother loses excessive weight. Calories should not go below 1500 calories per day. The total amount of calories a postpartum mother needs is dependant upon her weight, height, activity and age. Balancing the right foods is the key for optimal health.
· Pregnancy and breastfeeding cause a decrease in bone mass that is reestablished after you stop breastfeeding. All adult women need approximately 1000 mg of calcium a day. You need about four servings per day of calcium-rich food/drink – one serving is equal to eight ounces of milk. If you do not eat/drink calcium-rich foods, you should take a calcium supplement. The primary sources of calcium are dairy products, and green vegetables.
· Vitamin D is important for the absorption of calcium. Both lactating and non- breastfeeding mothers need at least 200 IU of vitamin D daily when sunlight is inadequate.
· Iron supplementation is not necessary postpartum unless you left the hospital with anemia after the birth of your baby. One or more servings of iron rich foods are recommended per day.
· Protein servings, three per day, are recommended.
· You need green leafy and yellow vegetables, as well as fruits, three to four servings per day.
· Whole-grain and complex carbohydrates are also important at three or more servings per day.
· Eight cups of water, juice, or other non-caffeinated, nonalcoholic beverages per day are important for your hydration.
Post-partum mothers who eat a well balanced diet and are healthy usually do not need to take a vitamin supplement. However, for women who maintain a vegan diet, vitamin B12 supplementation is highly recommended.
Many women want to start actively losing weight postpartum; the Weight Watchers Program has an excellent on-line program for the breastfeeding mom.
Foods to Avoid
Alcohol: Remember that everything you consume is transferred into your breast milk and will be ingested by your baby. It is unclear how much alcohol consumption, if any, is considered safe while breastfeeding. There are several factors that determine the amount of alcohol that is transferred into the breast milk. A serving of alcohol is equal to five ounces of wine, 12 ounces of beer or 1.5 ounces of hard liquor. Although not recommended, an occasional glass of alcohol can be consumed. If you want to drink alcoholic beverages, it is recommended to consume alcohol immediately after nursing, allowing enough time (two hours) for the alcohol to be metabolized. Some sources recommend not to drink more than one serving per day while breastfeeding.
Fish: While nursing, fish consumption precautions are the same as in pregnancy. Some fish have high levels of mercury that can be harmful to the developing nervous system of a baby. The seafood that are the lowest in mercury levels are salmon, shrimp, catfish, and pollock. It is recommended to consume about two to three servings of these fish per week.
Soft cheeses, Deli meats: It is less important now to eat thoroughly cooked foods. Sushi and soft cheeses and cold cuts can be resumed. During the pregnancy, concern for listeria bacteria in these foods required restricted consumption. However, listeria does not pass in to the breast milk.
Caffeine: The American Academy of Pediatrics considers a moderate consumption of caffeine safe (two to three cups per day) during breastfeeding. However, some babies might be very sensitive to caffeine and can experience difficulty sleeping or be irritable.
Tobacco Use: Women who smoke should try to stop. There are many effects on the baby from tobacco exposure, which can increase a baby’s risk for ear infections, pneumonia, asthma, and sudden infant death syndrome (SIDS).
GOING TO THE WORKPLACE WHILE BREASTFEEDING
The age of baby when mother returns to work – as well as a mother’s schedule – will determine how to adapt a breastfeeding schedule to the workplace. A mother of a six-week old infant will have a much different plan than a mother of a nine-month old infant. For the young infant, if the mother plans to be away all day or night it might be helpful to begin some practice bottles at about four weeks of age, preferably with mother’s pumped milk,. Having the baby in a child care situation in which the mother can return periodically to breastfeed would eliminate the need for expressing or pumping breast milk.
Having enough pumped milk on hand for the entire day with several extra ounces is better than having a whole freezer full of milk pumped over several weeks. Pumping at work should take place in a comfortable, private location, preferably with comfortable chairs, sink, and refrigerator. Pumping frequency may vary, but ideally should be every two to four hours, depending upon supply, pump, and age of baby. Pumping more frequently may increase supply, and an adequate pump will pump more efficiently. An older baby may feed less frequently and, eventually, may be breastfeeding when mother is at home and receiving weaning foods while mother is away.
Returning to work can be very stressful for a mother and a baby. Starting back with a shorter work week and/or work day would be most ideal for any age of baby. Mothers who work report feeling a special bond with the baby when returning home from work.
ADOPTIVE BREASTFEEDING
Non-biological mothers can often induce milk supply with adequate breast stimulation. Mothers who have previously been pregnant are more likely to establish a full milk supply than mothers who have never been pregnant. If there is advanced knowledge of a pending adoption, then prior to the birth, mothers can begin a series of hormones and medications to help induce milk, in conjunction with using an electric breast pump to stimulate the milk supply. If there is no advanced preparation, the newborn infant can be put to the mother’s breast for sucking stimulation, and supplemental milk may be given at the breast with a special feeding tube called supplemental nutrition system (SNS), so the baby’s sucking provides the stimulus to the breasts. Lactation consultants have expertise in this area and can refer mothers to providers familiar with the process.
BIRTH CONTROL AND BREASTFEEDING
On of the most common myths about breastfeeding is that breastfeeding protects from getting pregnant for many months after delivery. Although breastfeeding exclusively delays the beginning of ovulation, the return of fertility is unpredictable. By three months postpartum, 33%-45% of breastfeeding women will ovulate. This ovulation happens before the onset of regular menses, so there is no warning that fertility has returned, and a pregnancy can be conceived without a period every happening. Therefore, choosing a contraceptive method is very important especially during the first year after birth. If you are exclusively breastfeeding and not using a birth control method – and if you feel pregnant – you need to do a pregnancy test.
Birth control pills are not encouraged during the first four weeks postpartum. If you choose birth control pills as your method of contraception, it is best to start your pills about four to six weeks after the birth, once your breast milk is well established and the risk of blood clots from being pregnant is decreased. There are two types of birth control pills: progesterone only, and the combined progesterone and estrogen birth control pills. There is some concern that combination birth control pills may decrease the quantity of your milk supply but this has not been rigorously studied.
Often progesterone-only birth control pills are prescribed for breast-feeding mothers, and once breastfeeding is completed, then there is a switch to the combined estrogen and progesterone pills. There are also many other birth control methods available; discuss which one is best for you and your partner with your obstetric provider.
CONCLUSION
Breastfeeding should be considered for infant-feeding unless there are medical or surgical contraindications. There are plentiful benefits for both babies and mothers that are health and attachment-related. The more a woman and her family are educated about breastfeeding before the birth, the easier the process is. Just after birth, skin-to-skin contact and early breastfeeding are encouraged. Having an appropriate latch for the baby on the breast, rest, nutrition, and family support are critical to a good start to breastfeeding. Lactation educators and consultants are available to help mothers who are having challenges with breastfeeding, Exclusive breastfeeding/breast milk should be continued for about six months; after that, continued breastfeeding with the addition of solid foods and other liquids until the end of the baby’s first year, continuing as long as mother and baby desire. Pregnancy can happen while a mother is breastfeeding, so contraception should be considered.