Breast Feeding

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Some babies are born

naturally "sucky" . . .

Getting started with breast-feeding is not always easy. Just as many babies need to be tactfully shown how to use their sucking reflexes, so many breasts have to be gradually persuaded into easy performance of the function for which they are designed. Many first-time mothers find the first few days worrying, strange and uncomfortable; as a result some abandon the attempt to breast-feed within a week of the birth. Don't give up before you have given yourself a chance to experience the glorious time ahead when these early problems are over and the milk is there, like magic, whenever the baby wants it. Because they know, from experience, that this happy state is coming, second-time mothers who have breast-fed before hardly ever let early difficulties put them off. They know that once the milk supply is fully established, breast-feeding will be worthwhile.

If you have a small breasts, don't let glimpses of more lavishly endowed women, feeding their babies in the hospital, make you feel inadequate. The size of your breasts has no relevance to their ability to produce an abundant supply of milk. Milk is produced in deeply buried glands, not in the surrounding fatty tissue.

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. . . others need to be helped. The baby

has reflexes which tell him what to do

if you give him the cues . . .

It will probably be three to five days, after the birth before your real milk comes in. When it does, don't decide that it is no good because it looks bluish and watery compared with thick yellowy colostrum, or the creamy-looking formula given to the baby in the next bassinet. Breast milk is meant to look like that. It is perfect.

Your baby should be put to the breast regularly during these first days, both to get that vital colostrum and to practice feeding while your breasts are still soft. Without practice in the whole business of sucking, the newborn will find your larger, harder, milk-filled breasts more difficult to cope with.

When the milk does come in there are various minor, short-lived but uncomfortable problems which may arise.

. . . a gentle touch on his cheek from breast

or finger, and he will turn in toward you

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. . . mouth open, lips pursed,

the right moment is now

Anatomy of the Breast

The breasts are well designed to make milk. The internal structures change during pregnancy so that your breasts can make colostrum (the first milk) when the baby is born. As soon as you become pregnant, the duct system inside your breasts begins to develop and enlarge in response to estrogen. The milk-producing glands begin to increase in size in response to progesterone. Blood supply to the breasts also increases to support this growth and later to supply the nutrients in breast milk.

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The illustration shows a cross section of the breast. Each breast contains fifteen to twenty lobes, or milk-producing units. Each lobe has approximately twenty to forty lobules; within each lobule are numerous alveoli that contain the milk-producing cells. Milk flows from the alveoli through the ductules into longer lactiferous ducts. It then enters the milk sinuses located under the areola and leaves the breast through many nipple openings. As the infant compresses the sinuses with her lips and gums and massages the extended areola with his tongue, he draws milk into his mouth. The Montgomery glands, small glands on the areola, secrete a lubricating substance that keeps the nipple supple and helps prevent infection.

Milk Production

Two hormones, prolactin and oxytocin, play a significant role in milk production and milk ejection (flow). The infant suckling at your breast stimulates the release of prolactin by the anterior pituitary gland, located in your brain. The prolactin in your bloodstream causes the cells in the alveoli to draw water and nutrients from your blood to make milk. In the same manner, oxytocin is released into your bloodstream by the posterior pituitary gland in response to the infant's suckling (or sometimes just by thinking about the baby or hearing a cry). Oxytocin causes the small muscles around the milk-producing cells to contract, releasing milk. It also widens and shortens the ducts, facilitating milk flow. This process is called the let-down reflex. You probably will not be aware of a let-down until your mature milk is in. You may feel the let-down as tingling, itching, or burning sensation in your breasts, or you may experience no sensation even though your baby is getting your milk. The sensations of let-down vary widely. While the first let-down is most noticeable, you will have many let-downs during a feeding.

The amount of milk you produce is generally controlled by the "supply and demand response." The more your baby suckles at your breast, the more milk you produce. Delaying feedings by using a pacifier, offering supplements of water or milk, or attempting to place your baby on a three- to four-hour feeding schedule will decrease your milk production. Breast surgeries and some maternal illnesses can also affect milk production. Feeding frequently, in response to your baby's hunger cues, and for at least ten to twenty minutes at each breast, will increase your milk production in most instances.

Composition of Breast Milk

The first milk produced by the breasts, colostrum, is a yellowish fluid that is higher in protein and lower in fat than mature milk. It is ideally suited to the newborn's needs: it provides a laxative effect that helps to speed the passage of meconium; it helps establish the proper balance of bacteria in the infant's digestive tract; and because colostrum is rich in antibodies, it protects the infant from infection.

Transitional milk is produced next. It is higher in fat and calories and lower in protein and antibodies than colostrum. Soon, the mature milk comes in, containing more calories than both the transitional milk and colostrum. Its components include the following:

Water

Water is the largest constituent of breast milk.

Fats

Fats account for most of the calories in human milk. Cholesterol, a fat in human milk, is necessary for proper growth. In addition, it is thought to trigger the enzyme systems that later help the adult to safely utilize cholesterol. Other fats in human milk aid digestion by helping to form a soft curd in the infant's stomach.

Carbohydrates

Lactose (milk sugar), the primary form of carbohydrate in human milk, is present in greater quantities than in cow's milk. It helps the infant absorb calcium and is easily metabolized into two simple sugars that are necessary for the rapid brain growth occurring in infancy.

Proteins

Whey and casein constitute the proteins in milk. Whey is the primary protein in human milk. It is easily digested and becomes a soft curd from which nutrients are easily absorbed. By contrast, casein is the primary protein in cow's milk. When cow's milk is fed to a human baby, the casein forms a rubbery curd, which is less easily digested. Other components of the milk proteins have an important role in protecting the infant from disease and infection. This helps to explain why breast-fed infants have a significantly lower incidence of respiratory infections and diarrhea than formula-fed infants.

Vitamins and minerals

Some of the vitamins and minerals present in breast milk deserve special attention. Although iron is present in human milk only in small quantities, it comes in a highly absorbable form. A full-term, healthy, breast-fed baby rarely needs iron supplementation before six months of age.

Changing Composition of Breast Milk

Milk varies in composition during a single feeding. The first milk early in the feeding, called the foremilk, is continuously secreted into the lactiferous ducts between nursings. It represents a small amount of the milk volume in each feeding. The hindmilk contitutes the remaining portion of the feeding. It is released with the let-down reflex. Hindmilk contains more fat and protein than foremilk, and provides more of the calories your infant needs to thrive. As your infant grows, his requirements for nutrients change and the composition of your breast milk changes according to his needs.

Diet for Breast Feeding

By the time your baby is one month old, you will be producing about 20ounces (2-1/2cups) of milk each day. By three months, you will produce about 23 to 25ounces a day, and by six months, you will produce about 25 to 27ounces a day. When you introduce solid foods, the amount of milk you produce may decline.

How will you manage to produce so much milk? Your diet plays an important part. A good prenatal and postpartum diet in addition to sufficient liquids, adequate rest, and frequent stimulation of your breasts by your baby's suckling help you to produce all the milk your baby needs. In addition, a good diet prevents your body from being depleted of the nutrients you need to feel well and remain healthy.

During pregnancy, your body prepared for lactation by storing energy in the form of five to seven pounds, which provides some of the extra calories necessary for milk production in the early months. In addition, during lactation your body has the added advantage of being more efficient in absorbing nutrients from the foods you eat. Still, you may also need extra calories beyond your normal recommended daily requirement.

If, after the initial large weight loss in the first month or so following birth, you are still heavier than your recommended weight (allowing for two to four pounds for the weight of your lactating breasts), you may want to go on a reducing diet. It is best to lose only one or two pounds per week and avoid fad or crash diets. Losing weight at this rate and not more rapidly, you will meet your nutritional needs and maintain a sufficient quantity of milk. The amount of food and the number of calories you need each day depends on a variety of factors. If you are quite active, have a large baby, or are nursing more than one baby, you may need to consume more calories each day to maintain your weight. On the other hand, if you are less active or are supplementing with formula, you may not need extra calories. The best advice is to continue to eat good foods just as you did in pregnancy and to let your weight guide your calorie intake. Regular exercise helps control weight, too.

Foods to Eat

Your diet while nursing should include some more extra protein, more calcium-containing foods, more vitamins, and more fluids than your normal diet. But you can easily get the foods you need by eating a balanced diet similar to your pregnancy diet. In addition, you might drink more milk, continue to take your prenatal vitamins, and pay atention to your fluid intake. Two to three quarts of fluids a day are helpful for milk production. If you feel you are not getting enough liquids, pay attention to how concentrated (yellow) your urine is. If it is deep yellow, you probably need more liquid. On the other hand, too much liquid can interfere with let-down.

With the lack of sleep and the sometimes overwhelming responsibility of caring for a newborn, you may feel too tired to even think about eating and drinking. Loss of appetite and tiredness are your body's ways of telling you that you need to put a priority on rest and on caring for yourself. If you severely limit your calories, your milk production will decline, and over time, your body's stores of important elements such as calcium will be depleted.

Food Sensitivity

Your breast-fed baby will probably tolerate your milk well, no matter what you eat. But there is a slim chance that he will react adversely to a particular food or group of foods.

A baby who has a strong family history of food allergies may have allergic reactions to some foods that his mother eats. The most common foods with the potential to cause these reactions include cow's milk, eggs, fish, shellfish, and nuts.

If you notice that your infant has a chronic runny nose, diarrhea, or rash, discuss the possibility of a food allergy with your baby's doctor or a lactation counselor. They may be able to help you identify the problem and provide you with nutritional guidelines.

Drugs in Breast Milk

Many nursing mothers wonder whether drugs appear in breast milk and have an effect on their babies. With a few exceptions, any drug you take will be present to some degree in your breast milk. Some drugs do not present a problem for your baby, while others do. Here is information on some of the commonly used drugs and some dangerous drugs that may cause problems for your baby:

Vitamin B6, when taken in large doses (more than the amount in most prenatal vitamins), may inhibit lactation in sensitive women. Check the amount in your prenatal tablet. The RDA (Recommended Daily Allowance) for B6 is 2.1 milligrams during lactation. Some tablets contain as much as 10 milligrams. If your milk output is low, consider B6 as a possible cause.

Some mothers have found that if they consume large quantities of caffeine, found in beverages such as coffee and cola, their babies become fussy. Very little of the caffeine you consume is present in your breast milk, but if you suspect your baby's fussiness is aggravated by caffeine, try reducing or eliminating caffeine from your diet. Large amounts of chocolate may have a similar effect on your baby. Chocolate contains theobromine, which is similar to caffeine.

The alcohol content in breast milk is approximately equal to the concentration in your blood. Therefore, the effects on the baby correspond to the amount you have consumed. Too much alcohol can inhibit the let-down reflex and reduce the amount of hindmilk available to the baby. Though an occasional drink has not been proven harmful, it is probably wise to limit or eliminate alcohol consumption during lactation.

Heavy smoking has been shown to reduce milk production, reduce the vitamin C content of milk, and increase the incidence of nausea, colic, and diarrhea in infants. Smoking near the baby increases the incidence of pneumonia and bronchitis in the baby. As in pregnancy, it is wise to abstain or to limit smoking during lactation and to avoid smoking in the presence of the baby. Marijuana use is inadvisable, too, for all the same reasons as smoking tobacco, in addition to the effect of the active drug in marijuana on your developing baby. A drugged baby has less opportunity to develop socially, physically, and emotionally in an optimal way.

Cocaine use during lactation should be avoided. Cocaine will be present in breast milk and can affect the baby at least as profoundly as an adult. It can cause serious changes in heart function and is associated with an increased incidence of Sudden Infant Death Syndrome (SIDS).

Check with your doctor, baby's doctor, or pharmacist before taking any prescribed or over-the-counter drugs. If you need medication, remind your doctor that you are breast-feeding so he or she will choose the medication best suited for you and your baby.

Supply and Demand

How much milk have you got? How often should the baby have it? In breast-feeding these two questions go together because your breasts will make as much milk as your baby sucks from you. The more he takes the more you will make. The more often he takes it the quicker you will make more. This is why a mother can make exactly the right amount of milk for a 6lb (2.7kg) baby or exactly the right amount of milk for twins who weigh 13lbs (5.9kg) between them. This is why she can make enough for the baby in his second week of life and also in his twenty-second week....

Breast-feeding is a natural supply and demand system. It therefore depends on the baby being allowed to behave naturally. The system often fails if he is kept to an unnaturally rigid schedule. The natural system works like this:

The breasts make milk and the baby drinks it. As the breasts are emptied, so they at once start to make more milk. If the baby had his fill at that first feeding, he will be satisfied for some time - perhaps for as much as three hours - so the breasts will only make about that same amount of milk again. But if he did not get quite enough at that first feeding, he will be hungry quite soon. He will want to suck again. If he is allowed to, he will empty the breasts yet again and they will be stimulated to make more milk.

The more often he empties the breasts, the more milk they will make. Eventually, perhaps after a day, perhaps after a week, the breasts will be making so much milk that the baby will stop being hungry so often. He will only empty the breasts every three or four hours, so they will slow their production down to that level.

Let the baby suck as often as he is hungry.

For a few days he may want to be put to the breast 10, 12 or even more times in the 24 hours. As long as your nipples do not get sore or cracked and as long as you use these almost non-stop feedings as periods of rest, it does not matter how often you suckle him.

Give both breasts at each feeding

and start him on each alternately so that each breast gets its fair share of stimulation from his hungriest sucking.

Don't rigidly limit the baby's sucking time.

The composition of the milk changes as he sucks with thirst-quenching foremilk first and then the more concentrated hindmilk. Two minutes on each breast may give him as much to drink as he can hold without giving him all the calories he needs. You could try, for example, five minutes on the first side and as long as he wants on the other.

Don't offer a bottle instead of the breast,

even if he sucked so recently that you are sure there cannot yet be any more milk for him. There will always be a little, and preventing him from taking it will make your breasts fill up more slowly.

Don't offer a bottle as well as the breast

because his demands are so frequent that you feel he must have more. Frequent sucking will sustain him and cue your breasts to make more milk.

Expressing Milk

At the beginning, the baby's demands may be very variable, because he is not very settled or efficient at sucking. It is worth expressing any milk that he leaves, so that your breasts make plenty for the next feeding when he may be hungrier.

Don't try to express until no milk comes out. As you drain the breast, it makes more milk, so you will never completely empty it. Stop when the milk only appears in drops

If You are Worried about Your Milk Supply

Don't give up until you have checked all the following points:

Are you letting the baby suck whenever he likes?

It doesn't matter to him if he has to suck very often to keep himself satisfied. That's the way he puts right any temporary shortage of milk.

What makes you think you haven't enough?

Frequent crying just means frequent feeding; the only real signs of milk-scarcity are failure to gain weight - and that means any weight, not just gaining 3oz (85g) this week instead of the "recommended" 8oz (225g) - and, more immediately, having dry diapers after two or three hours, or not producing at least eight really wet ones in 24 hours.

Does your worry relate to extra work?

A temporary shortage when you first come home from the hospital or first start coping with your household and perhaps your toddler, as well as the baby, is very comon. You need more help and more rest.

Are visitors or older children getting in the way?

In the early days the let down reflex can be inhibited by other people so that the baby cannot get the milk that is there for him.

Are you uncertain of the quality of your milk?

Don't be. Breast milk is always perfect. If your breast-fed baby has spots or indigestion, they would certainly be as bad and would probably be worse if he was bottle-fed.

Have you started taking contraceptive pills?

These hormones can reduce the supply of breast milk. You are right to use contraception from the first time you make love after having the baby, because breast-feeding is not an adequate protection against pregnancy even if your periods have not started again, but you need an alternative method.

Are you in touch with a breast-feeding counselor?

Your doctor may give you excellent advice and support but an experienced breast-feeding mother from a post-natal support group, may be able to give you the kind of one-to-one, ever-available support which can make all the difference.

Breast Feeding and Fertility

Breast-feeding usually suppresses or delays ovulation and menstruation, especially if breast milk is the only food your baby receives and you nurse frequently around the clock. You cannot count on breast-feeding for birth control, however, because some breast-feeding women ovulate as early as several weeks post partum, while others do not ovulate for twelve to eighteen months. Because you can ovulate before menstruating, you cannot assume that breast-feeding will prevent you from becoming pregnant.

Your physician can advise you about the most appropriate methods of contraception while you are breast-feeding. Oral contraceptives, either estrogen-progestin or progestin only are not recommended for nursing mothers. The use of oral contraceptives has been associated with reduced milk production and potential harmful effects for the infant who receives them through the breast milk. These possible harmful effects must be weighed against the risk and personal cost of future pregnancies.

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