Breastfeeding

Overview

Breastfeeding is one of the most effective ways to ensure child health and survival. However, nearly 2 out of 3 infants are not exclusively breastfed for the recommended 6 months—a rate that has not improved in 2 decades.

Breastmilk is the ideal food for infants. It is safe, clean and contains antibodies which help protect against many common childhood illnesses. Breastmilk provides all the energy and nutrients that the infant needs for the first months of life, and it continues to provide up to half or more of a child’s nutritional needs during the second half of the first year, and up to one third during the second year of life.

Breastfed children perform better on intelligence tests, are less likely to be higher-weight person and less prone to diabetes later in life. Women who breastfeed also have a reduced risk of breast and ovarian cancers.

Inappropriate marketing of breast-milk substitutes continues to undermine efforts to improve breastfeeding rates and duration worldwide.[3]

Anatomy

• The breast is made up of glandular tissue, supporting tissue and fat.
• The glandular tissue consists of small clusters of sac-like spaces which produce milk.
• Each sac is lined by network of myoepithelial cells that propel the milk into lactiferous ducts towards nipple.
• Before reaching the nipple, the ducts widen to form lactiferous sinuses which store milk.
• The lactiferous sinuses lie beneath the junction of areola and rest of breast.
• The areola and nipples are extremely sensitive as they are supplied by a rich network of nerve endings.
• On the areola there are small swellings of glands which produce an oily fluid to keep the nipple skin soft.
• Since the lactiferous sinuses lie beneath the areola, a baby must suck at the nipple and areola.
• The gum line of the baby should rest at the junction of areola and rest of breast tissue in order to express milk stored in lactiferous sinuses.[1]

Physiology

• Lactogenesis is a complex phenomenon involving many hormones and reflexes. Two hormones are most important, prolactin and oxytocin Prolactin reflex (milk secretion reflex).
• Prolactin produced by the anterior pituitary gland is responsible for milk secretion by the alveolar epithelial cells.
• When the baby sucks, the nerve ending in the nipple carry impulse to the anterior pituitary which in turn release prolactin and that acts on the alveolar glands in the breast to stimulate milk secretion.
• This cycle from stimulation to secretion is called the prolactin reflex or the milk secretion reflex.
• The more the baby sucks at the breast, the greater is the milk production. The earlier the baby is put to the breast, the sooner this reflex is initiated.
• The greater the demand more is the production. It is, therefore, important for mothers to feed early, frequently and empty out the breasts completely at each feeding session.

Other factors

• Since prolactin is produced during night time, breastfeeding during night is very important for maintenance of this reflex.
• This cycle from stimulation to secretion is called the prolactin reflex or the milk secretion reflex. The more the baby sucks at the breast, the greater is the milk production.
• The earlier the baby is put to the breast, the sooner this reflex is initiated. The greater the demand more is the production.
• It is, therefore, important for mothers to feed early, frequently and empty out the breasts completely at each feeding session.
• Since prolactin is produced during night time, breastfeeding during night is very important for maintenance of this reflex.

Oxytocin reflex

• Oxytocin is a hormone produced by the posterior pituitary.
• It is responsible for ejection of the milk from the glands into the lactiferous sinuses.
• This hormone is produced in response to stimulation to the nerve endings in the nipple by suckling as well as by the thought, sight, or sound of the baby.
• Since this reflex is affected by the mother’s emotions, a relaxed, confident attitude helps the milk ejection reflex. On the other hand, tension and lack of confidence hinder the milk flow.[1]

Benefits

Breast milk is the best source of nutrition for most babies-

• As the baby grows, the mother’s breast milk will change to meet her baby’s nutritional needs.

Breastfeeding can help protect babies against some short- and long-term illnesses and diseases-

• Breastfed babies have a lower risk of asthma, obesity, type 1 diabetes, and sudden infant death syndrome (SIDS). Breastfed babies are also less likely to have ear infections and stomach bugs.

Breast milk shares antibodies from the mother with her baby-

• These antibodies help babies develop a strong immune system and protect them from illnesses.

Mothers can breastfeed anytime and anywhere-

• Mothers can feed their babies on the go without worrying about having to mix formula or prepare bottles. When traveling, breastfeeding can also provide a source of comfort for babies whose normal routine is disrupted.

Breast feeding can reduce the mother’s risk of breast and ovarian cancer, type 2 diabetes, and high blood pressure-

• Breastfeeding has health benefits for the mother too! Some cancers, type 2 diabetes, and high blood pressure are less common among women who breastfeed.[4]

Composition

The composition of breast milk varies at different time points of lactation to suit the needs of the baby.

Milk of a mother who has delivered a preterm baby is different from milk of a mother delivered a term baby.

Colostrum

Colostrum is the milk secreted during the initial 3—4 days after delivery. It is small in quantity, yellow and thick and contains large number of antibodies and immune-competent cells and vitamins A, D, E and K.

Transitional milk

Transitional milk is the milk secreted after 3-4 days until two weeks. The immunoglobulin and protein content decreases while the fat and sugar content increases.

Mature milk

Mature milk follows transitional milk. It is thinner and watery but contains all the nutrients essential for optimal growth of the baby.

Preterm milk

Preterm milk is the milk of a mother who delivers before 37 weeks. It contains more proteins, sodium, iron, immunoglobulins and calories as per the requirement of preterm baby.

Foremilk

Foremilk is the milk secreted at the start of a feed. It is watery and is rich in proteins, sugar, vitamins, minerals and water that quenches the baby’s thirst.

Hindmilk

Hindmilk comes later towards the end of feed and is richer in fat that provides more energy and gives a sense of satiety. Thus, the composition of milk also varies during the phase of feeding. For optimum growth, the baby needs both fore as well as hind­ milk. Therefore, the baby should be allowed to empty out one breast completely before switching over to the other.[5]

• Human breast milk is recognized by health organizations around the world as an ideal source of nutrition to support early life.
• A diet of exclusively breast milk is recommended for the first 6 months of life followed by the addition of solid foods plus breastmilk for up to 2 years of age.
• Breast milk is produced by a woman’s body specifically to meet her child’s nutritional needs.
• It provides everything a baby’s body requires for proper growth and development, changing in response to the baby’s needs.
• Not only is breast milk a complete source of nutrition and hydration, but it also helps protect babies from getting sick through antibodies that pass from mother to baby through the milk.
• Breast milk is composed of hundreds of distinct bioactive molecules, some of which are not yet fully understood by scientists.
• Although infant formula also provides complete nutrition, it doesn’t fully replicate the immune benefits of breast milk.

Macronutrient Composition

Breast milk is primarily composed of water, carbohydrates, lipids, and proteins. Each of these nutrients plays a role in contributing to infant growth and development.

Water

• Human breast milk is made up of about 90% water.
• The human body depends on water to function.
• Water maintains hydration, helps regulate body temperature, lubricates joints, and protects organs.
• Luckily, breast milk alone provides all of the water required by young babies for survival.

Carbohydrates

• Carbohydrates are a preferred energy source for the brain.
• The main carbohydrate in breast milk is milk sugar, known as lactose.
• Human milk contains more lactose than cow’s milk.
• Other carbohydrates found in breast milk (such as oligosaccharides) promote healthy bacteria in your baby’s intestines. These bacteria protect your baby’s gut and can help fight off diseases like infant diarrhea.

Lipids (Fats)

• Lipids may only make up about 4% of breast milk, but they provide over half of the calories that your baby receives from it.
• Lipids are a major source of energy, cholesterol, and essential fatty acids such as DHA.
• These nutrients are necessary for the development of your baby’s brain, nervous system, and vision.
• The high-calorie content of lipids in breast milk is also responsible for the baby’s healthy weight gain. Breast milk should naturally contain all the lipids your baby needs to grow for the first 6 months of life.

Proteins

• Proteins build, strengthen, and repair the body’s tissue. They are also needed to make hormones, enzymes, and antibodies.
• The protein in breast milk is easy for babies to digest and these proteins are essential throughout every stage of the lifecycle for humans to survive.
• Lactoferrin is a form of protein in breast milk that moves iron through your baby’s body. It also helps protect your newborn’s intestines from infections.10

Bioactive Components

There are several elements of breast milk that cannot be found in formula. These unique substances are passed from the mother.

Immunoglobulins (Antibodies)

• Immunoglobulins are antibodies that fight off illness and disease. Because of these natural immune substances, breast milk can almost be thought of as a baby’s first vaccine.
• The properties of breast milk help protect against the common cold, ear infections, vomiting, diarrhea, and other potentially dangerous infections.​
• The primary antibody in breast milk is Secretory Immunoglobulin A (IgA). IgA coats the baby’s lungs and intestines, sealing them to prevent germs from entering the body and bloodstream.

Hormones

• Hormones have many jobs in the human body. They influence growth and development, metabolism, stress and pain responses, and blood pressure regulation.
• Hormones involved in milk production include prolactin, thyroid hormones, and growth factors.

Enzymes

• Several key enzymes are found in human breast milk. Some aid digestion by breaking down fats or proteins, while others provide immune support.
• Many of the enzymes in human breast milk have unknown functions. While we may not fully understand what all of these enzymes do, there’s a good chance they play beneficial roles in infant development.

Micronutrients

Breast milk contains the vitamins and minerals needed to support young babies. Formulas also contain many of these vital micronutrients.

Vitamins

• Vitamins support healthy bones, eyes, and skin. They are necessary to prevent diseases of malnutrition, such as scurvy and rickets.
• Breast milk typically contains all the vitamins needed to support your baby’s health as they grow. However, the amount of vitamin D, folate, or vitamin B6 in your body may be lower if you follow certain dietary restrictions.

Minerals

• Like vitamins, breast milk is also full of minerals that your baby’s body needs to grow healthy and strong.
• These include iron, zinc, calcium, sodium, chloride, magnesium, and selenium.
• Minerals are used to build strong bones, produce red blood cells, and promote proper muscle and nerve function.[3]

Affecting Factors which reduce milk production

• Dummies, pacifiers and bottles not only interfere with breastfeeding but also predispose the baby to diarrhea.
• Giving supplements such as sugar water, gripe water, honey, breast milk substitutes or formula, either as prolateral (before initiation of breastfeeding) or supplemental (concurrent to breastfeeding) feeds. Studies have reported that even 1 or 2 supplemental feeds reduce the chances of successful breastfeeding.
• Painful breast conditions like sore or cracked nipples and engorged breast.
• Lack of night feeding, as the prolactin reflex is not adequately stimulated.
• Inadequate emptying of breast such as when baby is sick or small and the mother does not manually express breast milk or when baby is fed less frequently.[1]

Reflexes in the Baby

A baby is born with certain reflexes which help the baby to feed. These include rooting, sucking and swallowing reflexes.

The Rooting reflex

• When cheek or the side of the mouth is touched, the baby opens her mouth and searches for the nipple.
• This is called rooting reflex. This reflex helps the baby to find the nipple and in proper attachment to the breast.

The Suckling reflex

• When baby’s palate is touched with nipple, the baby starts sucking movements.
• This reflex is very strong immediately after birth.

The sucking reflex consists of:

• Drawing in the nipple and areola to form an elongated teat inside the mouth.
• Pressing the stretched nipple and areola with the jaw and tongue against the palate.
• Drawing milk from the lactiferous sinuses by wave­

like peristaltic movement of the tongue underneath the areola and the nipple and compressing them against the palate above.

suckle effectively, the baby has to attach (latch) well.

Obtaining good attachment at breast is a skill, which both the mother and the baby have to learn.

Technique of Breastfeeding

Mothers require substantial assistance to learn the technique of breastfeeding. With correct technique, breastfeeding is natural and a pleasurable experience for the mother.

However, a variety of breastfeeding problems do occur in large proportion of mothers that require counseling and support from the health providers for their prevention and appropriate treatment.

Provision of lactation support services by lactational counsellor or trained health providers greatly increase the success of breastfeeding.

Positioning

• Position of the mother. The mother can assume any position that is comfortable to her and the baby.
• She can sit or lie down, her back should well support and she should not leaning on her baby Position of baby.
• Make sure that baby wrap properly in a cloth.

1. Firstly, Baby’s whole body supported not just neck or shoulders
2. Secondly, Baby’s head and body are in one line without any twist in the neck

iii. Baby’s body turned towards the mother (abdomens of the baby and the mother touching each other)

1. Baby’s nose is at the level of the nipple.[1]

Attachment (Latching)

• After proper positioning, the baby’s cheek touch and that initiates rooting reflex.
• Allow the baby to open his mouth widely and at that point, the baby should latch on to the breast ensuring that the nipple and most of the areola are within baby’s mouth.
• It important that the baby brought on the mother’s breast and mother should not lean on to baby.

Signs of good attachment

1. The baby’s mouth is wide open
2. Most of the nipple and areola in the mouth, only upper areola visible, not the lower one

iii. The baby’s chin touches the breast

1. The baby’s lower lip everted

Effective Suckling

• Baby suckles slowly and pauses in between to swallow (suck, suck, suck. and swallow). One may see throat cartilage and muscles moving and hear the gulping sounds of milk being swallowed.
• Baby’s cheeks are full and not hollow or retracting during sucking. [1]

The Do’s and Don’ts

Do:

Nurse frequently:

• Let your baby set the feeding schedule. Frequent nursing helps establish your milk supply.

Offer both breasts at each feeding:

• This ensures your baby gets both foremilk (thinner, thirst-quenching milk) and hindmilk (richer, fattier milk).

Seek support:

• Attend La Leche League meetings or consult with a lactation consultant if you have any questions or concerns.

Trust your instincts:

• You know your baby best. Listen to your intuition when it comes to feeding and caring for your little one. [7]

Ensure a good latch:

• A proper latch is crucial for comfortable and effective breastfeeding.

Pay attention to your baby’s cues:

• Learn to recognize your baby’s hunger signs and offer the breast promptly.

Take care of yourself:

• Eat a healthy diet, get enough rest, and manage stress to support milk production.[8]

Don’ts:

Introduce bottles or pacifiers too early:

• These can interfere with breastfeeding and may lead to nipple confusion.

Limit feeding time:

• Let your baby nurse until they are satisfied. Restricting feeding time can negatively impact milk supply.

Give up easily:

• Breastfeeding can have challenges, but with support and perseverance, most mothers can successfully breastfeed. [7]

Supplement with formula unnecessarily:

Unless medically necessary, avoid supplementing with formula, as it can decrease your milk supply.

Compare yourself to other mothers:

• Every breastfeeding journey is unique. Focus on your and your baby’s needs.

Ignore pain:

• If you experience nipple pain, seek help from a lactation consultant to correct any latch issues. [8]

Terminology: