Breastfeeding

The benefits of breastfeeding extend well beyond basic nutrition. In addition to containing all the vitamins and nutrients your baby needs, breast milk is packed with disease-fighting substances that protect your baby from illness.

Exclusive breastfeeding is recommended in the first six months (although any amount of breastfeeding is beneficial).

Scientific studies have shown that breastfeeding is good for your health, too. 

Benefits to Infants:

• Boosts immunity
• Improves cognitive & mental development
• Protect against allergies
• Protect against illness
• Decreases respiratory infection
• Reduces risk of becoming overweight or obese as a teen or adult
• Decreases kids chances of developing stomach viruses, lower respiratory illnesses, ear infections, and meningitis
• Decrease chance of deaths for babies aging 1 month – 12 months by 20%
• Cuts risk of sudden infant deaths syndrome (SIDS) by half
• Reduces risk of developing childhood cancers
• Help avoid illnesses later in life like: type 1 and type 2 diabetes, high cholesterol, inflammatory bowel disease and high blood pressure.

Benefits to Mothers:

• Reduce your stress level and your risk of postpartum depression
• Reduce your risk of breast and ovarian cancer
• Lower your risk of osteoporosis
• Gives you natural birth control, breastfeeding may stop menstruation
• Easier and saves time, no need to sterilize bottles or heat water
• Burns calories, help lose pregnancy weight [Hyperlink – Is it True that BF Help in Losing Weight]
• Helps uterus return to its original size
• Reduces uterine bleeding after birth

Breastfeeding Benefits (In-depth):

(References in Ronesca’s Website)

Breast milk has long been recognized as giving babies the best start in life and research over many years has shown that it provides a number of advantages1-5. The World Health Organization recommends exclusive breastfeeding for the first 6 months of life.

With over 80 specific components, breast milk has the right balance of nutrients in a form that baby’s immature digestive system can absorb easily6 and contains enzymes like amylase to break down starches and lipase to help break down fats7,8. It also has lower levels of sodium and chloride than cow’s milk so puts less strain on immature kidneys in excreting excess electrolytes and by-products of protein metabolism9-12.

Breast milk helps prevent infection in the infant13-18. Particularly, mothers’ first milk (colostrum) is rich in substances that help destroy disease-causing microorganisms like bacteria and viruses, as it contains lymphocytes, macrophages and neutrophils from mothers’ own immune system13,16,17.

It also contains other protective elements such as the immunoglobulin Secretory IgA which protects against harmful viruses and bacteria in the intestine13,14,18 and Bifidus factor that promotes the growth of protective intestinal bacteria19, 20. Lactoferrin is an iron-binding protein that inhibits harmful intestinal bacteria by denying them iron and Lysozyme helps kill them13,14. It is also believed that Nucleotides encourage the growth of protective intestinal bacteria21, 22 and that some of the lipid (fat) molecules in breast milk help combat harmful viruses23.

It has been suggested that breastfed babies may have lower risks of developing diseases like Type 1 diabetes, lymphoma and Crohn’s disease later in life24-26. Experts have also observed a lower incidence of gastrointestinal infections in infants who are breastfed compared to those who are not and have suggested this may be due to protective factors in mother’s milk2, 13.

Not to be underestimated is the role of close physical contact in the establishing of a strong mother-baby relationship2 or the fact that breastfeeding is convenient – no preparation needed.

Breast feeding benefits mother in a number of ways – including increasing self-esteem23. It is also thought to reduce the risk of post-partum hemorrhage and help bring the uterus back to its original size23,24 as well as reducing the risk of ovarian and pre-menopausal breast cancers23.

Also known as Kangaroo care, Skin-to-Skin care has benefits for both mother and baby. It promotes bonding25 as well as stimulating milk production26 and may help extend breastfeeding duration26. It may also trigger mammary antibody production to help protect the infant but this is not yet proven27.

Colostrum

What is Colostrum?

Early milk is known as colostrum. Colostrum is made throughout the pregnancy. It is yellowish-orange and is thick, sticky and creamy. It may also appear as a clear fluid. Colostrum will gradually change into milk following the first few days of delivery.

Although it is little but it is rich and enough for your baby in the first few days.

Colostrum is Rich In:

• Carbohydrates (energy source)
• Proteins
• Vitamins: like A, B6, B12 and K
• Minerals: like zinc and calcium
• Cholesterol (essential for nervous system development)

Benefits of Colostrum:

• Acts as a natural laxative: helps baby pass stools
• Expels excesses of bilirubin which aid in preventing jaundice.
• Contains natural vaccine IgA: will help to ward off sickness
• Protects the digestive track passageways by making a barrier which aids in preventing foreign substances from upsetting baby’s tummy.
• Contains high concentrations of protective white blood cells (leukocytes): protect the body from bacteria and microorganisms that can cause diseases.
• Easily digested by newborns
• Prepares baby’s digestive system for milk

Key Nutrients in Breast Milk

(Source: Ronesca Website)

Breast milk is a miracle food that changes depending on the needs of the infant and is recognized as the best way to feed babies in the first 6 months of life.

It contains the correct balance of proteins, fat, carbohydrate, vitamins and minerals for optimal growth and development in a form that is easily absorbed. Breast milk also provides elements that support the immune system and help protect against infection.

Protein

Whey and casein are the two types of protein present in breast milk. In mature milk they are found in the proportions 60/40.

Whey is more easily digested than casein with the main protein being alpha-lactalbumin. This is 27% of breast milk protein and is rich in essential amino acids like tryptophan and cysteine.

Fats

Due to their rapid rate of growth, infants have much greater energy needs relative to bodyweight than adults. The fat in breast milk helps provide this, accounting for half its energy content.

Palmitic acid makes up 20-25% of the fatty acids in breast milk. Other essential fats include linoleic acid, alpha-linoleic acid, docosahexanoic acid and arachidonic acid – needed for brain and neural tissues.

Carbohydrates

Most of the other half (40%) of energy in breast milk is provided by carbohydrates. These are mainly monosaccharides and oligosaccharides, the latter promoting the growth of intestinal flora and supporting gut health. The main carbohydrate in breast milk is lactose which helps the absorption of calcium to promote optimum bone growth. Lactose splits into glucose and galactose during digestion.

Far far away, behind the word mountains, far from the countries Vokalia and Consonantia, there live the blind texts. Separated they live in Bookmarksgrove right at the coast

Producing Breast Milk:

Pregnant women start to produce breast milk at around six months into the pregnancy and some women find that they occasionally ‘leak’ a liquid called colostrum [Hyperlink]. There is no need to worry as this is quite normal. It may be practical for them to keep some breast pads handy (What to buy?).

Colostrum is a thin and watery liquid that is replaced by breast milk a few days after birth. It is rich in protein and antibodies and helps baby pass meconium [Hyperlink – Stool], a greenish, sticky mixture that precedes proper stools.

Breastfeeding Restrictions

• In the following health issues, a mother should consult the doctor before breastfeeding:
  • Related to mother:
    • Mothers infected with HIV
    • Mothers infected with tuberculosis
    • Mother has cancer and is under chemotherapy
  • Related to baby:
    • Metabolic disorder such as galactosemia (in ability to metabolize the sugar galactose)
    • Birth defect making breastfeeding impossible
• Other (non-health related) factors that can affect exclusive breastfeeding:
  • Maternity leave is over
  • Mother died
  • Insufficient breast milk (How to increase my milk supply?)
  • Nipple fissure
  • Inverted nipple

Breastfeeding in the First Few Days:

Initially, babies may only feed a little at a time. Mothers should be advised to feed ‘on demand’ – whenever baby seems to want to suckle. This will help stimulate her breasts to produce milk. Frequent nursing encourages good milk supply and reduces engorgement.

Many doctors advise to wake up newborns every 2 hours for nursing.

As mum’s milk ‘comes in’ her breasts will become fuller and the milk will become thicker and more ‘milky’ than the initial colostrum.

Read more:
Is my baby getting enough milk?
Breastfeeding challenges.
How often should I breastfeed & how long each feed takes?
How can I know if my baby is getting enough milk? 
How to increase milk supply
Breast milk composition during a feed 

Breast Milk Composition Differs During the Feed

At each feed, mother will first produce ‘foremilk’ which is watery, rich in lactose (sugar) and is designed to satisfy baby’s thirst. This will then change to ‘hindmilk’, which is rich in fat and is designed to satisfy baby’s hunger. The change between foremilk and hind milk is very gradual i.e. fat levels gradually increase during the feed. When this gradual change happens, milk flow starts to decrease.

Mothers are advised to feed their babies for as long as they want in order to make sure baby is satisfying both hunger and thirst.

Why is Foremilk Different from Hind Milk?

When milk is produced, fat globules in milk tend to stick to each other and to milk ducts. During the feed or ‘let down’, milk ducts dilate to release watery part of milk that is low in fat (foremilk). Fat globules start to dislodge and gets released in milk; this increases fat content in milk (hind milk).

Foremilk/Hind milk Imbalance:

Also called ‘oversupply’. It’s when milk production is high, making I difficult for baby to digest the lactose rich foremilk.

Breast Milk Composition & Quantities Variation Trends & Factors:

Only the volume of milk is correlated with weight gain of exclusively breastfed infants, and not fat content.

• Breast milk composition may differ during the day
  • Late night: lower fat content
  • Early morning: higher fat content
• Composition of breast milk may be affected by:
  • Breastfeeding routine: affects fat content.
    • Mothers who breast feed on demand during day and nurse during night have high breast milk fat concentration in early morning.
  • Volume of milk produced:
    • Fuller breasts tend to have lower fat content than emptier breasts.
  • Time interval between feedings: frequent feeding increases fat content
• Protein concentration is only slightly affected during day and night and foremilk and hind milk.
• Calcium levels are not affected during day or night, foremilk or hind milk.
• Age of baby:
  • First few days: Colostrum. Colostrum is high in nutrients but low in volume.
  • Milk composition and volume change continuously to meet the needs of baby at every age.
• Single breast feedings: second feeding from the same breast may have higher fat content. It is important to switch between breasts when feeding
• Mother’s diet during breastfeeding may affect type of fat and not composition.

Healthy Eating During Breastfeeding

A healthy diet is as important for a breastfeeding mum as it is for pregnant women. Healthy eating help keep up energy levels. In addition, nutrients obtained from diet will pass to baby through breast milk. It is important, therefore for a breastfeeding mother to consume a varied and balanced diet.

Eating meals regularly should be a priority. If mums are finding it difficult to find the time to eat properly, suggest that they keep meals simple (meals that take less preparation) and eat smaller meals more frequently.

A Breastfeeding Mother’s Diet Should Include the Following:

• Fruits & Vegetables:
  Preferably 5 portions a day. This can be fresh, frozen, tinned, dried or juiced.

• Starchy Foods:
  Starch provide the extra energy needed by a breastfeeding mother.

This includes bread, pasta, rice and potatoes.

• Fibers:
  After childbirth, some mothers suffer from painful constipation but a good intake of fiber can help prevent this.

Wholegrain bread and cereal, pasta, rice, pulses (beans & lentils), fruit and vegetables are all good sources.

• Protein:

Best found in lean meat, chicken, fish, eggs and pulses.

• Fish:
  Should be eaten at least twice a week.

Oily fish like trout, salmon, sardines, mackerel and fresh, not canned and tuna, should be limited to two portions a week.

No more than one portion of shark, swordfish or marlin should be eaten per week due to the high levels of mercury found in them.

• Dairy Food
  These are good sources of calcium and include milk, cheese and yoghurt.

• Vitamins
  Breastfeeding mothers should take 10mg (micrograms) of Vitamin D supplements each day. Other vitamins should come from a varied diet, unless prescribed by the doctor.

• Fluids/Drinks:
  Water, milk and unsweetened fruit juices are the healthiest choices. Small amounts of whatever mother drinks will be passed to baby in breast milk.

Strong tea, coffee and coke can cause problems. Mothers have reported babies being unsettled, irritable or constipated as a consequence of such drinks.

If parents think their baby is being affected by the food that mother is eating, they should seek advice from a healthcare professional.

How Often Should I Breastfeed & How Long Does Each Feed Take?

Initially, babies are likely to feed inconsistently and mothers should feed ‘on demand’ for as long and as often as baby wants. Newborns may feed 8 to 12 times per day, they may feed every 2 hours or even less. Some doctors might recommend feeding every two hours, even if the baby did not demand, so as to stimulate milk production.

Try not to let your newborn cry for long before feeding, and be prepared for next feed before baby cries.

Some babies tend to feed multiple feeds frequently then go for a long time without feeding.

Feeds can vary from long to short with anything from one and a half to several hours in between.

During the second month, the baby may start feeding less frequently (7-9 times a day) but feedings might go back as before during rapid growth phases. By 6-9 weeks, babies will often settle into a pattern. Parents should be encouraged to keep a feeding diary, recording when and how long baby feeds. This will help to spot a pattern and establish a routine.

Regarding how long to feed – baby knows best. Some feeds may last up to 40 minutes and others only a few minutes.

When baby has had enough they will either let go of the breast or just fall asleep.

Formula fed babies feed less often than breastfed babies. This is because breast milk is easier to digest than formula milk.

Switching Between Breasts

If baby empties one breast, they should be offered the other. Some babies may not want both in one feed. When baby has had enough they will either let go of the breast or just fall asleep.

Mothers should begin the next feed with the unfinished breast during the last feed. It is a good idea to wind/burp the baby when switching breasts.

If a mother switch breasts before emptying current breast, the baby will only get foremilk [Breast milk composition differs during a feed]. Foremilk is the initial part of milk that is watery and low in fat. Researches showed that offering foremilk only to babies might cause gas and cramps.

Is My Baby Getting Enough Milk?

The rule is ‘baby knows best’. They will feed when they are hungry and stop when that hunger is satisfied. Despite that, many breast feeding mothers will worry their child is not getting enough milk. They may need reassurance.

What are the Indications that My Baby is Feeding Well?

Weight Gain:

Most babies loose a little weight during the first couple of days. If your baby has regained their birth weight by the time they are two weeks old then you can be pretty sure that feeding is effective.

Wet Nappies/Diapers:

Plenty of wet nappies are also a good indicator although some are so absorbent that it is difficult to tell. Placing a ball of cotton wool in the nappy and checking it when changing is a good way of making sure.

Dirty Diapers/Regular Bowel Movements:

Regular bowel movements are another good way of checking. By the end of the first week, baby should be passing 2-3 substantial yellow stools per day. Persistent green stools are an indicator that baby is not getting enough milk.
This does not apply in the very early days. In the first day your baby will have only one dirty diaper, the stool will be greenish black and sticky.

Keep I mind that color, consistency and frequency of stool different in breastfed and formula fed babies. [Stool: color, consistency and frequency of stool in formula & breastfed babies]

Jaundice

Jaundice is another sign that baby is not getting enough milk. ‘Breast milk jaundice’ can occur when mother’s milk has not yet ‘come in’ as the limited contents of the milk may affect the baby’s liver. Some of the enzymes in breast milk are also thought to contribute to ‘breast milk jaundice’.

Other Signs

Baby settling for a while after feeding is a good sign, as are being awake and alert for some of the time and waking regularly for feeds.

How to Increase My Milk Supply?     

If your baby is getting enough milk there is no need to worry about milk supply.

The following tips may help increase your milk supply:

• Frequent feeding: The suckling action of baby’s mouth stimulate the production of prolactin hormone which is responsible for milk production.

• Efficient nursing: Emptying the breasts during feeding is an important factor in increasing milk production. If your baby did not empty the breast, then you should express milk [Hyperlink – Expressing/Pumping Milk] between feeds so as to maintain adequate milk supply. You can store the expressed milk and offer it later. Your baby won’t nurse efficiently if breastfeeding position and latching were improper. Also avoid nipple shields, you will only produce sufficient amount of milk when nipples are stimulated with direct sucking action.

• Switch between breasts: Make sure your baby is offered both breasts every nursing session. Or, offer the next breast in the following session.

• Exclusive breastfeeding: The more you nurse, the more milk you produce. Try not to offer formula milk.

• Respond to demand and pick up early hunger signals: Nurse as much as your baby wants and as long as needed.

• Be available to nurse all the time: going back to work or being away from your baby will decrease stimulation and hence supply.

• Sucking action is stronger than pumps: delay bottles in the first weeks, to let baby learn to suck and to empty breasts.

• Avoid alcohol, heavy smoking and some medicines : birth control pills, decongestants and some other medicines may reduce milk supply. Consult your doctor before taking any medications.

• Stay hydrated: Drink fluids when thirsty especially water, and eat foods that are rich in water like fruits and vegetables.

• Eat a balanced diet: Do not go into diet while breastfeeding, nursing mothers need 500 extra calories than regular female adults. Make sure you are eating healthy and nutritious foods.

• Rest, sleep, stay away from stress and ask for support.

Are there natural foods that increase milk supply?

There are foods and supplements that are believed to increase milk supply. But are not necessary proven scientifically (ask your doctor before taking any supplements):

• Fenugreek

• Fennel seeds

• Black sesame seeds

• Dill leaves seeds

• Barley

• Oatmeal

• Cumin

• Thistle supplements

• Nuts

• Dried fruits

• Salmon

• Garlic

• Carrots

• Green leafy vegetables e.g. spinach

• Fruits like apricots and papayas

Breastfeeding Positions:

Why is Positioning Important?

It is important to properly master breastfeeding positions for multiple reasons:

• Stimulation: proper positioning help stimulate milk production

• Sufficient nursing: proper positioning aids in providing enough milk to baby.

• Eliminate sore nipples

• Comfort: proper positioning provides comfort for both mother and baby

Breastfeeding Positions Basics & Tips:

• Find a comfortable spot, use pillows to support back and arm.

• Baby’s face and body should face you.

• Baby’s ear, shoulder and hip should be aligned (straight lined).

• Keep baby’s body close to your nipple to avoid nipple pulling.

• Bring baby to your breast, not the other way round.

• Baby’s head should be higher than rest of body

• Hold breast with your fingers in a ‘U’ or ‘C’ shaped manner, so as to remove breast weight from baby’s chin and avoid nose blocking.

Positions:

Apply all basic tips (mentioned above) in all positions.

Cradle Hold:

This is the most common hold.

• Support baby using the arm of the same nursing side

• Rest baby’s head on crook of your elbow

• Support baby’s body with your inner arm and palm.

• Hold breast using opposite hand

Cross-cradle Hold:

• Support baby on a pillow on your lap to lift baby up

• Hold breast using hand of same side of breast

• Support baby’s head using opposite hand. Your palm should be placed at the back of neck with index and thumb right behind ears.

Football Hold:

This is advised for mothers who underwent C-section as it keeps baby away from away from incision site.

• Hold the baby’s head using the hand on the same side of feeding breast, with arm supporting on your form arm.

• Support baby on a pillow on your lap to lift baby up

• Hold breast with the other hand.

• Tuck baby’s leg under same feeding side arm.

Side-laying Hold:

This position is also comfortable for mothers who had C-section.

• You and your baby lay down facing each other.

• Support your back and baby’s back using pillows or support baby with your forearm of the lower arm (the arm on the same side of feeding breast)

• Nurse baby on the lower breast

• Hold breast with opposite arm

Laid-back breastfeeding (biological nurturing):

• Position yourself in a reclined manner (either on a recliner or on a bed with pillows supporting your back) supporting your head, back and shoulders.

• Lay baby vertically on your body facing the breast, with baby’s front touching your front. 

• Allow one of your baby’s cheeks to rest on the breast (next to nipple)

• Baby will naturally start sucking

• You may or may not hold breast.

Football Twins Hold:

This position allows you to nurse twins at the same time.

• Put a pillow on your lap.

• Place each baby at one side, with elbows bent

• Support each baby with an arm (forearm)

Latching

What is Latching & Why is it Important?

Latching is baby’s mouth grip on nipple. Proper latching stimulates milk production and enables child to get sufficient milk. Milk production is dependent on demand, the more the demand, the more milk will be supplied. Sufficient and efficient breastfeeding will help initiate and maintain a demand and supply cycle.

If you have sore cracked nipples or your breast are engorged, your baby will have difficulty to latch on.

Read more:

Breastfeeding tips
Breastfeeding in the first days
Breast feeding challenges
How to increase milk supply?
Breastfeeding positions 

Latching Steps and Tips:

• Make sure that you are holding your baby correctly

• Support/hold your breasts in one of the following holds, the aim is to remove weight of breasts off baby’s chin and to avoid nose blockage:

  • ‘C’ hold:
    Thumb on top of areola and rest of fingers on the bottom of areola.
    Or, index on top and middle finger under areola.

  • ‘U’ hold:
    Thumb and index finger vertically and placed on the sides of nipple in a parallel manner.

• While holding your breast, apply slight pressure.

• Make sure your baby’s mouth is wide open is if he or she was yawning. If the baby’s mouth was not open, tickle the check or let your nipple touch the bottom lip.

• Bring the baby closer to your breast while aiming nipple into upper palate.

• As the baby’s mouth closes, all the nipple and part of areola (the pink to brown area around nipple) should be placed in. The chin should gently touch breast, and nose should be barely touching breast, with lips being flanged.

Hints that the Latch is Poor Include:

• Nipple pain.

• Baby is sucking and not swallowing.

• Baby is making clapping like noise while sucking.

If you notice any of these, unlatch by inserting finger in the inner corner of baby’s lips and re-latch.

Breastfeeding Challenges

There are a number of problems associated with breast feeding that mothers may suffer from. Including:

Painful Nipples:

If you experience painful, sore or cracked nipples during breastfeeding, you are advised to:

• Ensure proper positioning of baby is correct.

• Try different position to determine which position suits you best.

• Ensure proper latching

• Clean nipples with normal saline (water and salt) after nursing.

• Rub some expressed milk into nipples following feeding and cleaning of nipples. Allow nipples to dry naturally or otherwise, try to carefully dry nipples after feeding.

• Never rub nipples.

• Avoid using soap on breasts

• Use dry breast pads in bra. Breast pads should be replaced when they become damp.

• Expose nipples to air between nursing sessions.

• Make cold compresses if you have cuts in nipples

• Apply lanolin ointment, soothing gels or antibiotic ointments prescribed by your doctor. Always refer to your doctor as some ointments gels are contraindicated in breastfeeding women.

Sore/Swollen Breasts (Engorgement):

Sometimes mothers produce more breast milk than their babies need. This can cause breasts to be tender, full and heavy – often called ‘engorged breasts’. This is uncomfortable and can make it difficult for babies to ‘latch on’. It is a common mistake that women that encounter engorgement limit their fluid intake.

When Will I Encounter Engorgement? What to Expect?

Usually between the third and fifth day of delivery. You may feel that your breasts are warm, hard and tender (this feeling may be felt near the armpit). The nipple area (areola) may become stiff, glossy and large. Making latching more challenging.

To Minimize Engorgement & to Decrease Discomfort:

• Nurse often

• Don’t skip feedings, even at night

• Nurse on demand

• Ensure good latch/positioning [Hyperlink – Breastfeeding Positions]

• Let baby finish the first breast before offering the other breast [Hyperlink – Switching Breasts]

• Pump/express milk [Hyperlink – Pumping Milk]

• Use cold compresses between feedings

• Massage breast towards nipple during and before breastfeeding sessions.

• Have a bath before breastfeeding

• Express milk using your hand (squeeze extra milk out)

• Avoid tight bras

Latching Difficulties

A baby might have trouble latching on due to engorgement. A reverse pressure softening or expressing milk until the nipple is soft, might help.

Read more about latching 

Hard/Lumpy Breasts:
This can be caused by a blocked milk duct. Feeding on demand may help as can a warm flannel or shower to soften breast tissue. Massaging any lumps in the direction of the nipple during feeding may also assist.

Hot and Very Painful Breasts:
This may be due to mastitis. Symptoms include parts of the breast being painful, red and swollen and may involve flu-like symptoms such as chills, fevers and aches. There are two types – infectious and non-infectious.

Non-infectious mastitis is caused by a blocked milk duct but can lead to the infectious version. During breastfeeding, nipples can become sore and cracked so that bacteria are able to enter. The high sugar content in the milk nourishes the bacteria so that they multiply and cause an infection in the breast.

This usually begins 2-4 weeks after delivery but occurs in only 3-5% of breast feeding women.

If necessary, an antibiotic can be prescribed that is safe for a nursing mother to take but there are also other practical measures that can be taken. ‘Feeding on demand’ will keep milk flowing and help unblock a blocked milk duct as, once again, will massaging any lumps towards the nipple. It is worth checking that the baby is in the right position when feeding and suggesting different feeding positions to empty different parts of the breast.

Expressing Milk (Pumping Breast Milk):

When breastfeeding is well established, mothers may wish to express breast milk in order to bottle feed. This can be for a number of reasons. It may be to relieve uncomfortable full breasts, to feed while away from home or simply so that someone else can feed baby.

The act of expressing milk will probably boost milk supply as it tells the body to supply more milk.

When beginning expressing, allow time for ‘let down’. During the process, change breasts when the milk flow slows down and continue to alternate till the flow stops or drips very slowly.

When is the Best Time to Pump Milk?

The best time to express milk varies from mother to mother and is influenced by the reason for doing so.

Milk producing hormones are highest at night so a good time to express may be first thing in the morning. To boost milk supply, it is probably best done after daytime feeds. But if you wanted to relieve engorged breasts, you may hand express or pump a little milk before a feeding.

It helps to be relaxed when expressing milk, so mums should be encouraged to choose a time when they are not pressurized. A warm shower may help with relaxation and should increase blood supply to the breasts, just as with breastfeeding. Warm showers may help relieve engorged tender breasts.

Do not express milk immediately before breastfeeding, as they may not have enough milk left for baby to take.

Breast Pumps

There are 3 kinds of breast pumps available and what suits one mum may not suit another. How often mums want to express milk and how much money they want to spend will influence their choice.

Manual Pumps:

The advantage of a manual pump is that the mother stays in complete control. The pump should be set up according to the manufacturer’s instructions and the suction cup should be placed over the breast. Milk can then be extracted using the manual squeezing mechanism.

Manual pumps are inexpensive to buy and cost nothing to run. They are quiet, easy to use and put mum in complete control. However, some users find that the action of pumping makes their hands ache after a while and can find it initially difficult to maintain the suction while holding and pumping.

Battery Operated Pumps:

These are easy to use and work well but batteries need changing frequently. This can prove costly and performance deteriorates considerably when battery power is low.

Electric Pumps:

Electric pumps have the advantage of being quick, effortless and easy to use but are the most expensive option. Models vary but they can be quite noisy. After setting up the pump using the manufacturer’s instructions, the suction cup is placed over the breast and the machine is turned on. The machine will then extract the milk.

Storing Expressed Milk:

Expressed milk must be stores safely.

How to Store Expressed Milk?

Breast milk should always be stored in a sterilized bottle or specially designed breast milk freezer bag/container. This should be sealable and must not be stored if the contents have already been fed from. Write the date of expressing on the container in order to avoid confusion.

How Long Can Expressed Milk be Stored?

Breast milk should be refrigerated or frozen as soon as possible after being expressed. It should be stored in the coolest part of the fridge (usually the top back) and can be kept for up to 5 days at 4°C or less. It can be kept in the freezer for up to 6 months.

How to Defrost Stored Expressed Breast Milk?

To defrost frozen breast milk, it should be placed in the fridge or in lukewarm water or using specialized milk bottle heaters. The milk should be warmed to room temperature and used straight away. If not used immediately, it should be thrown away. It should never be refrozen.

Do not defrost or warm expressed breast milk in a microwave as this can heat unevenly and may scald baby’s mouth.

The bottle should always be shaken thoroughly before feeding.

Preparing for Breastfeeding:

What to Buy?

• Nursing bra
• Nursing pads
• Ointments for sore nipples
• Pajamas with easy access for nursing (shirt with a zipper or buttons on chest area)
• Pump
• Breast milk storage containers/bottles
• Nursing pillow or regular pillow to support arm
• Aprons for baby
• Burping mini-towels
• Feeding Equipment Sterilizer [Hyperlink – Sterilizer Types)

Breastfeeding Tips

Many of these tips might seem pretty obvious but it is worth mentioning them – particularly to first-time mums.

• Educate yourself about breastfeeding (benefits on baby, benefits to breastfeeding mothers, colostrum, breastfeeding positions, breastfeeding frequency, colostrum, taking medications while breastfeeding, how to increase milk supply…) 

• Pick a comfortable place to breastfeed – feeding may only take a few minutes but can also take 40 minutes or so.

• Spend a few moments getting prepared

• Wear a front opening bra (nursing bra), stretchy tops, tops with front zippers or buttons and scarves.

• Use nursing pads.

• Breastfeed your baby as soon as you deliver

• Ask the caregiver in the hospital to help you with your first breastfeeding experience

• Sleep in the same room your baby sleeps in

• Sleep when your baby sleeps

• Breastfeeding can be tiring. If baby falls asleep, have a rest too.

• Do not use scented lotions, soaps or perfumes on or around the nipple, only use lotions or ointments that are approved by your doctor or pharmacist

• Do not rub your nipples, rubbing will hurt your nipples even more.

• Gently unlatch [Hyperlink – Latching] (remove baby away from the breast), slide your little finger into the side of baby’s inner mouth corner. This breaks the suction and helps avoid sore nipples

• Do not go on a diet! It is not a good time to go on a diet while breastfeeding [Healthy Eating During breastfeeding] – it will affect the milk that baby gets. Do not skip meals, skipping meals will make you hungrier, more tired and more irritable.

Is it True that Breastfeeding Help in Losing Weight?

The answer is yes! Breastfeeding uses up a lot of the calories that the body stored up during pregnancy and most women are going to lose half a kilogram (1lb) a month while they are breastfeeding.

Breastfeeding help get mothers back to their pre-pregnancy weight, if they consume daily 500 extra calories from that recommended for female adults.

Gentle exercise will help. New mums should try to walk every day with baby. The fresh air should be beneficial for both of them.

Breastfeeding and Medications:

Always tell your doctor or pharmacist that you are breastfeeding before taking any medicine.

Most medications may pass in different degrees into breast milk and may affect milk supply. This includes prescription, over-the-counter, complementary and alternative medications.
Some medicines may even harm your baby.

Complementary and alternative medications are not well researched, therefore they are not recommended for breastfeeding mothers.

Breastfeeding and Coffee:

Most breastfeeding mothers can drink caffeine in moderation

• Caffeine does cross into breast milk.
• Best time to drink coffee is half an hour before breastfeeding (the level of caffeine is highest one hour after drinking).
• Infants under 6 months, may be more sensitive to caffeine.
• Newborns have a much harder time metabolizing caffeine than older infants.
• Preterm or ill infants might also have more problems with mom’s caffeine intake.
• Babies whose mothers avoided caffeine completely during pregnancy seem to react more to caffeine in mom’s diet.
• Too much caffeine (more than 750 mL per day) can cause babies to become fussy. This can result in a baby who shows signs of caffeine stimulation (wide-eyed, active, alert baby who doesn’t sleep for long).
• Cut caffeine for 2-3 weeks by decrease caffeine intake gradually, abruptly stopping caffeine can result in headaches or other symptoms. It takes 3-7 days for caffeine to be eliminated and baby to become less fussy.
• One study has indicated that chronic coffee drinking might decrease iron content of breast milk.
• There is no evidence that caffeine decreases milk supply.
• Some studies indicates that caffeine can stimulate milk production. Yet a baby who is fussy from caffeine stimulation may not nurse well which could lead to a decreased milk supply over time.

Breastfeeding and Smoking:

Should I Continue Breastfeeding if I Can’t Quit Smoking?

The answer is yes. Breastfeeding is the best nutritional source that can be given to babies. But, that does not mean you shouldn’t quit smoking! Cigarettes contain nicotine and other harmful chemicals that pass into breast milk when you smoke. If you were unable to quit, try to smoke less right after nursing session. The more cigarettes you smoke, the higher the risks to your baby is. You should also never smoke or allow others to smoke around your baby, because he/she might inhale those chemicals.

How Does Smoking Affect Breast Milk?

Smoking negatively affects quantity and quality of milk.

• Smoking may decrease milk supply. Nicotine reduces prolactin hormone that is responsible for milk production. That may explain why smoking moms are more likely to wean their babies early.
• Low levels of iodine and possibly some other vitamins and minerals.

How Does Smoking Affect My Baby?

• Increase risk of respiratory infection (including, pneumonia, bronchitis, asthma)
• Increased risk of eye irritation
• Increased risk of gastrointestinal discomfort (including, colic, vomiting, nausea, diarrhea)
• Increased risk of allergy
• Increased risk of developmental brain issues due to decrease of iodine transportation into breast milk that is caused by smoking
• Increase risk of sudden infant death syndrome (SIDS)
• Increase risk of cancer
• Due to decreased milk supply, baby may not gain weight normally.

When is Breastfeeding Not Advised?

Breast feeding is regarded as the most complete kind of nutrition for all infants. However, there are some cases where it is not advisable. Physicians need to consider each case on its merits to decide whether there are factors that warrant either interruption or preclusion of breast feeding.

Breast feeding is not advisable for women where any of the following conditions apply:

• Treatment involving drugs that are secreted in breast milk – narcotics, barbiturates, steroids, anticoagulants or anticonvulsants
• Taking antiretroviral medication
• Dependency on illegal drugs
• Taking cancer chemotherapy agents
• Undergoing radiation therapy (temporarily)
• Suffering from untreated, active tuberculosis
• Infection with human T-cell lymphotropic virus type I or II
• HIV positive patients

Breastfeeding Preterm Infants

Preterm

Preterm babies are born before 37 weeks of gestation and will weigh much less than babies who have gone to term. This is because infants in the womb will gain significant weight between the weeks 36-40. Preterm babies need to catch up on this loss.

Preterm Infants are classified as:

1. Low birth weight (LBW): less than 2.5kg (5,5lbs)
2. Very low birth weight (VLBW): between 1kg (2.2lbs) and 1.5kg (3.3lbs)
3. Extremely low birth weight (ELBW): less than 1kg (2.2lbs)

The aim in feeding preterm babies is to achieve the same growth rate as a normal fetus of the same gestational age1. Much of the stores and body reserves of the infant in the uterus are received and laid down via the umbilical cord and placenta during the third trimester. A preterm baby, therefore tends to have low stores and needs the correct nutrients to achieve catch-up growth.

A statement for ESPGHAN (The European Society of Paediatric Gastroenterology, Hepatology and Nutrition) highlights the fact that ‘those preterm infants who fail to achieve their growth potential during the first weeks of post-natal life have a less favourable outcome with respect to growth and neurodevelopment’2.

Preterm infants often also have immature physiology and digestive enzymes that are not fully functional and they can often not initially tolerate feeds by mouth.

Depending on their maturity and overall health, they will receive nutrients in a combination of ways. This can be through total parenteral nutrition, a combination of parenteral and minimal enteral feeding or through full enteral feeding.

Guidelines

Better outcomes in the management of preterm infants due to advances in nutrition have resulted in new guidelines for LBW, VLBW and ELBW infants.

The Tsang Guidelines (2005)3 are the result of several experts combining their efforts to make recommendations for nutrients and energy intakes. They include information on specific nutrients – proteins, carbohydrates, vitamins & minerals, water & electrolytes and lipids. Also examined are the roles of enteral and parenteral feeding along with that of breast milk.

The LSRO (Life Sciences Research Office) Guidelines4 were released in 2002 in the USA and address the nutrient content of infant formulas for preterm and low birth weight infants. LSRO is a mixture of permanent staff and outside consultants who provide objective scientific advice. They brought together a panel of world experts to make recommendations for the best clinical care of premature infants from birth to leaving hospital.

Nutrition for Preterm Infants

The aim of nutritional management of a preterm infant is to achieve full enteral feeding as soon as possible. If enteral feeding (by tube) is not initially possible, intravenous nutrition is given where nutrients are passed into the bloodstream – often using the umbilical vein.

Total Parenteral Nutrition (TPN)

This is also known as hyperalimentation. The need for it can be due to feed intolerance, gastric disease or just while enteral nutrition is being established. Very low birth weight infants can take time to tolerate gastric tube feeds1 as they often have delayed gastric emptying and intestinal peristalsis.

Survival rates of infants who would not otherwise have had enough nutritional support, have significantly improved with the provision of parenteral nutrition2.

TPN rapidly provides the preterm infant with vital nutrition3. It also helps to achieve a positive nitrogen balance by reducing tissue catabolism4.

It is important to be aware of possible problems, however. Bloodstream infections are the most common complication and TPN has been associated with hyperbilirubinemia and hyperglycemia2. Infants can also suffer too high or too low a level of vitamins due to bypassing the usual absorption regulators and sole use of parenteral nutrition with an absence of nutrients in the gut can lead to gut atrophy5.

Tube Feeding

For preterm infants of more than 34 weeks of gestation, it is possible that breast or bottle feeding can be adopted as they should be able to coordinate sucking, swallowing and breathing.

But for those younger infants who may have compromised respiration or be neurologically less well developed, this may not be advisable1 and nutrients may need to be passed into the stomach through a fine tube either through the mouth (oro-gastric) or the nose (naso-gastric). Breast milk is the food of choice as it is best tolerated and includes other benefits as well as nutrition.

For the first few days, very small preterm infants can be given ‘minimal enteric feedings’, also known as ‘trophic’ or ‘non-nutritive’ feeds. These are given in very small volumes due to the inability to cope with large feeding volumes6.

Minimal enteral feeding should be begun as soon as is possible as it promotes improved weight gain7,8 and a quicker ability to cope with full enteric feeds9. Also, whole gut transit is reduced10, intestinal motility10 and lactose activity11 are increased and gastrointestinal hormone release is stimulated11.

If possible, parents should be allowed to help with tube feeding to promote ‘skin-to-skin’ contact and help build a bond with baby.

Moving on from tube-feeding

Preterm infants are just like any other babies – some learn more quickly than others and parents will often need reassurance. It can take weeks before a sucking reflex is established well enough for baby to feed properly as this also depends on their general condition and how prematurely they were born.

If a baby being tube fed starts opening and closing their mouth during the feed, they are probably ready to practice sucking. Giving them a dummy (pacifier) can often help develop the reflex. It has been shown that this can help the preterm baby make the move from tube-feeding to normal feeding1.

Sometimes called ‘non-nutritive suckling’, this has also been shown to help with gastric motor functions2 and craniofacial/dental development3.

As soon as possible after birth, mothers should be encouraged to express breast milk as often as they can. This can then be frozen and stored for when the baby is ready to take it.

But for those mothers in hospital who are not able to provide breast milk, a specially designed low birth weight infant formula is available. This contains the particular nutrients in proportions that the preterm baby needs and will usually be given by naso-gastric or oro-gastric tube until baby can manage the sucking/swallowing/breathing process when they can begin to be bottle-fed.

Leaving Hospital

Even by the time they leave hospital, low birth weight/preterm infants weigh less4,5 and have lower nutrient stores than term babies6. Specially developed ‘Premature formulas’ have been created to provide the extra protein, energy, vitamins and minerals needed by preterm infants.

How long an infant will need to stay on a Premature formula will depend on their individual weight and progress. The smaller the premature baby is at birth, the more benefit is likely to be derived from an enriched premature formula. There are no established guidelines for when a premature formula should be used or for when the transition to a ‘term’ formula should be made but clinical studies have demonstrated benefits of premature formulas for up to12 months.

Their use is recommended by ESPGHAN (The European Society of Paediatric Gastroenterology, Hepatology and Nutrition) until a post-conceptual age of 40-52 weeks7. The observation of the Committee on Nutrition, American Academy of Pediatrics 2009 is that premature formulas are often continued until 9-12 months corrected age or till the baby’s weight for age is maintained above the 25th percentile8.

Preterm Breastfeeding

The benefits of breast milk for term infants have long been known – less diarrhoea, fewer skin allergies, ear infections, upper respiratory infections and less chance of becoming overweight or obese in adulthood. Studies have now shown that preterm infants given breast milk show greater mental development1 and have fewer hospitalizations after initial discharge than those who were not given breast milk.

Not only does breast milk change over time to suit the needs of the baby but also changes during the feed itself. At the beginning of the feed, foremilk is higher in carbohydrate and lower in fat and energy 2,3. At the end of the feed, the opposite is true with hindmilk being higher in fat and energy and lower in carbohydrate2.

Some of the nutrients in breast milk (glutamine and nucleotides) may help infants tolerate enteral feeds by assisting gastrointestinal (GI) function, thus reducing the chance of necrotizing enterocolitis (NEC – inflammation and necrosis of the gut.)4.

It is also thought that some of the contents of breast milk (amino acids, glycoproteins, hormones, peptides, epidermal and nerve growth factor) help with GI maturation5.

The GI tract is not only an organ for digestion and absorption of nutrients. It also performs major endocrine, neural and immunological functions.

Proteins

Preterm infants have unique nutritional requirements that need to be addressed if they are to grow at a rate comparable to that observed in utero at a similar gestational age.

Preterm breast milk has elevated levels of proteins and a vastly different fatty acid profile to term breast milk. It is whey dominant – whey proteins are easily digested and whey helps with rapid gastric emptying3.

Whey protein also contributes to the immune system of the preterm infant, containing secretory Immunoglobin A (sIgA) which is the main immunoglobin in the gastrointestinal tract and provides protection against microbes that multiply in body secretions6. It is particularly thought to lower the incidence of NEC7.

Whey protein also contains other immune system components like lysosomes and lactoferrin which has antibacterial activity8.

Carbohydrates

In order to catch up on growth, preterm infants need to absorb calcium for bone mineralization9. Lactose is the principal carbohydrate in breast milk and helps with calcium absorption10,11. It also helps develop intestinal flora by increasing beneficial gut bacteria10-12.

Fats

Half of the energy requirement of a preterm infant is provided by fats in breast milk. It also provides lipid soluble vitamins and the essential polyunsaturated fatty acids (PUFAs)13. Animal models suggest high levels of PUFAs may help lower NEC incidence 14.

The long-chain polyunsaturated fatty acids (LCPs) in breast milk are important to preterm infants not least for cognitive development. In the third trimester of pregnancy, the brain undergoes rapid growth with LCPs involved in forming new neural cells. Studies show that low birth weight infants fed breast milk enjoyed benefits regarding cognitive development1.

LCPs are also involved in visual acuity and the formation of eicosanoids.

Eicosanoids are signaling molecules. They control many body systems mainly in inflammation or immunity and act as messengers in the central nervous system. Arachidonic acid (AA) is the LCP associated with the formation of eicosanoids15.

Another LCP, docosahexanoic acid (DHA) helps form neural cells – part of the nerves that transmit messages from eyes to brain. This process needs large numbers of neural cells and consequently a high concentration of DHA,

Preterm infants are born with much less total body AA and DHA than term babies.

Fortifying Breast Milk

Despite being designed specifically to meet the needs of a newborn, preterm babies have particular needs that breast milk may not fulfill – amounts of proteins, calcium and other nutrients may be insufficient and unable to match the desired intrauterine rates of growth16-18.

Studies have shown that fortification of breast milk increases bone mineral content, growth, short-term weight gain and nitrogen retention19-22.

Weaning

Preterm infants have nutrient deficiencies due to their premature birth and can benefit from earlier weaning than term infants. Term babies usually begin weaning around four to six months but preterm infants can start weaning 5-7 months from birth9,10.

The signs that a preterm baby is ready to start weaning are the same as those for a term baby – putting things in their mouth, showing interest in other people eating and seeming to want more than just milk.

Babies start using their mouths to explore toys at about 4 months but may not have a sufficiently developed digestive system to take solid food before 5 months. Reducing the proportion of milk to solid foods too early may affect the right intake of nutrients and affect growth. It is important not to start weaning too early but equally important not to wait too long11 – starting solids and chewing helps mouth and jaw development.

Although weaning often begins when the infant is comfortable being supported in a sitting position, it is important to support head and back when feeding to reduce the risk of choking.

Breastfeeding Preterm Infants

The benefits of breast milk for term infants have long been known – less diarrhoea, fewer skin allergies, ear infections, upper respiratory infections and less chance of becoming overweight or obese in adulthood. Studies have now shown that preterm infants given breast milk show greater mental development1 and have fewer hospitalizations after initial discharge than those who were not given breast milk.

Not only does breast milk change over time to suit the needs of the baby but also changes during the feed itself. At the beginning of the feed, foremilk is higher in carbohydrate and lower in fat and energy 2,3. At the end of the feed, the opposite is true with hindmilk being higher in fat and energy and lower in carbohydrate2.

Some of the nutrients in breast milk (glutamine and nucleotides) may help infants tolerate enteral feeds by assisting gastrointestinal (GI) function, thus reducing the chance of necrotizing enterocolitis (NEC – inflammation and necrosis of the gut.)4.

It is also thought that some of the contents of breast milk (amino acids, glycoproteins, hormones, peptides, epidermal and nerve growth factor) help with GI maturation5.

The GI tract is not only an organ for digestion and absorption of nutrients. It also performs major endocrine, neural and immunological functions.

Proteins

Preterm infants have unique nutritional requirements that need to be addressed if they are to grow at a rate comparable to that observed in utero at a similar gestational age.

Preterm breast milk has elevated levels of proteins and a vastly different fatty acid profile to term breast milk. It is whey dominant – whey proteins are easily digested and whey helps with rapid gastric emptying3.

Whey protein also contributes to the immune system of the preterm infant, containing secretory Immunoglobin A (sIgA) which is the main immunoglobin in the gastrointestinal tract and provides protection against microbes that multiply in body secretions6. It is particularly thought to lower the incidence of NEC7.

Whey protein also contains other immune system components like lysosomes and lactoferrin which has antibacterial activity8.

Carbohydrates

In order to catch up on growth, preterm infants need to absorb calcium for bone mineralization9. Lactose is the principal carbohydrate in breast milk and helps with calcium absorption10,11. It also helps develop intestinal flora by increasing beneficial gut bacteria10-12.

Fats

Half of the energy requirement of a preterm infant is provided by fats in breast milk. It also provides lipid soluble vitamins and the essential polyunsaturated fatty acids (PUFAs)13. Animal models suggest high levels of PUFAs may help lower NEC incidence 14.

The long-chain polyunsaturated fatty acids (LCPs) in breast milk are important to preterm infants not least for cognitive development. In the third trimester of pregnancy, the brain undergoes rapid growth with LCPs involved in forming new neural cells. Studies show that low birth weight infants fed breast milk enjoyed benefits regarding cognitive development1.

LCPs are also involved in visual acuity and the formation of eicosanoids.

Eicosanoids are signaling molecules. They control many body systems mainly in inflammation or immunity and act as messengers in the central nervous system. Arachidonic acid (AA) is the LCP associated with the formation of eicosanoids15.

Another LCP, docosahexanoic acid (DHA) helps form neural cells – part of the nerves that transmit messages from eyes to brain. This process needs large numbers of neural cells and consequently a high concentration of DHA,

Preterm infants are born with much less total body AA and DHA than term babies.