Breastfeeding is the process of a woman feeding an infant or young child with milk produced from her breasts, usually directly from the nipples. Babies have a sucking urge that usually enables them to take in the milk, provided there is a good latch, a detached frenulum, and a milk supply.
Breast milk has been shown to be best for feeding a child if the mother does not have any transmissible infections. Nevertheless, some mothers do not breastfeed their children, either for personal or medical reasons. Some diseases, such as HIV and HTLV-1, which are transmitted through bodily fluids, can be passed through the breast milk, and may therefore preclude breastfeeding in these cases. Some medicines may also transfer through breast milk. However, most medicines are transferred in very small amounts and are considered safe to take during breastfeeding. Therefore most women are not precluded from breastfeeding, and doctors and governments are keen to promote the practice. Nevertheless, many medications are labeled as unsafe for use while breastfeeding, and the mother who desires to breastfeed and her physician must carefully weigh the risks and benefits to her baby.
Many governmental strategies and international initiatives have promoted breastfeeding as the best method of feeding a child in his or her first year.
Throughout the last two trimesters of pregnancy a woman's body produces hormones which stimulate the growth of the milk duct system in the breasts.
By the fifth or sixth month of pregnancy, the breasts are sufficiently developed to produce milk (although it is also possible to induce lactation as described in a later section).
During the latter part of pregnancy, the woman's breasts enter into the Lactogenesis I stage, where the breasts are making colostrum (a thick, sometimes yellowish fluid), but high levels of progesterone inhibit most milk secretion and keep the volume “turned down”. It is considered medically normal for a pregnant woman to leak colostrum before her baby's birth, and also normal not to leak at all. Neither situation is an indicator of future milk production levels in the mother.
At birth, the delivery of the placenta results in a sudden drop in progesterone/estrogen/HPL levels. This abrupt withdrawal of progesterone in the presence of high prolactin levels cues Lactogenesis II (copious milk production).
Prolactin blood levels rise when the breast is stimulated, and peak around 45 minutes later. The return to pre-breastfeeding levels about three hours afterward. The release of prolactin triggers the cells in the alveoli to create milk. Some research (Cregan 2002) indicates that prolactin in milk is higher at times of higher milk production, and that the highest levels tend to occur between 2 a.m. and 6 a.m.
Other hormones (insulin, thyroxine, cortisol) are also involved, but their roles are not yet well understood. Although biochemical markers indicate that Lactogenesis II commences approximately 30-40 hours after birth, mothers do not typically begin feeling increased breast fullness (the sensation of milk "coming in") until 50-73 hours (2-3 days) after birth.
The colostrum is the first milk the baby receives; it contains higher amounts of white blood cells and antibodies than mature milk, and is especially high in immunoglobulin A (IgA), which coats the lining of babies' immature intestines, helping to prevent germs from invading baby's system. Secretory IgA also works to help prevent food allergies. (Sears, MD, William; Sears, RN, Martha: The Breastfeeding Book,Little, Brown, 2002. ISBN 0316779245)
After a baby has been nursing for 3-4 days, the colostrum in the breast slowly begins the process of changing into mature breast milk over the next two weeks. (Breastfeeding Answer Book, p. 36)
During pregnancy and the first few days postpartum, milk supply is hormonally driven. This is the endocrine control system. After milk supply has been more firmly established, Lactogenesis III begins - the autocrine (or local) control system.
At this stage, milk production is made on the law of supply and demand: The more milk removed from the breast, the more milk the breast will produce. Thus milk supply is strongly influenced by how often the baby feeds and well it is able to transfer milk out of the breast. "Low supply" can often be traced to A) too infrequent feeding/pumping, B) a jaw/mouth structure or latch inhibiting baby's ability to transfer milk effectively or C) a metabolic or digestive inability in the infant, rendering it unable to utilise the milk it receives.
Feeding and positioning
There are many texts available to new mothers to assist in the establishment of breastfeeding. The baby will usually indicate hunger by crying or moaning and fussing. When the baby's cheek is stroked, the baby will move his or her face towards the stroking and open his or her mouth, demonstrating the rooting instinct. Breastfeeding can make the mother thirsty and can last for up to an hour (usually in the early days, when both mother and baby are inexperienced) – it is therefore common for the mother to replace lost water by drinking during the process.
While for some people the process of breastfeeding seems natural there is a level of skill required for successful feeding and a correct technique to use. Incorrect positioning is one of the main reasons for unsuccessful feeding and can easily cause pain in the nipple or breast. By tickling the baby's cheek with the nipple the baby will open its mouth and turn toward the nipple, which should then be pushed in so that the baby has a mouthful of nipple and areola; the nipple should be at the back of the baby's throat. Achievement of this position is referred to as latching on. Inverted or flat nipples can be massaged to give extra area for the baby to latch onto. Many women choose to wear a nursing bra to allow easier access to the breast than normal bras.
The baby may pull away from the nipple after a few minutes or after a much longer period of time. Sometimes the baby will relatch on the same breast or mother may offer the other side. The fat content of the milk increases as the breast empties.
During this stage, the expectant mother typically goes through several emotional phases. At first, the mother may be excited and nervous. Then, as the contractions become stronger, demanding more energy from the mother, mothers generally become more serious and focused. However, as the cervix finishes its dilation, some mothers experience confusion or bouts of self-doubt or giving up.
The length of feeding is quite variable. Regardless of the duration, it is important for the breastfeeding woman to be comfortable.
- Upright: The sitting position with the back straight.
- Mobile: The mother carries her nursling in a sling or other baby carrier while breastfeeding. Doing so permits the mother to incorporate breastfeeding into the varied work of daily life.
- Lying down: Good for night feeds or for those who have had a caesarean section.
- On her back: Mother is usually sitting slightly upright; particularly useful for tandem breastfeeding.
- On her side: The mother and baby lie on their sides.
- Hands and knees: The mother is on all fours with the baby underneath her (not usually recommended).
There are many positions and ways in which the feeding infant can be held. This depends upon the comfort of the mother and child and the feeding preference of the baby – some babies tend to prefer one breast to another. Most women breastfeed their child in the cradling position.
- Cradling positions:
- Cradle hold: The baby is held with its head in the woman's elbow horizontally across the abdomen, "tummy to tummy", with the woman in an upright and supported position.
- Cross-cradle hold: As above but the baby is held with its head in the woman's hand
- Football hold: The woman is upright and the baby is held securely under the mother's arm with the head cradled in her hands.
- Feeding up hill: The baby lies stomach to stomach with the mother who is lying on her back; this is helpful for babies finding it difficult to feed.
- Lying down:
- On its side: The mother and baby lie on their sides.
- On its back: The baby is lying on its back (cushioned by something soft) with the mother on her hands and knees above the child (not usually recommended).
Feeding two infants simultaneously is called tandem breastfeeding. The most common need for this is after the birth of twins whereby both babies are fed at the same time. It is not necessarily the case, however, that the appetite and feeding habits of both babies are the same. This leads to the complication of trying to feed each baby according to its own individual requirements while also trying to breastfeed them both at the same time.
In cases of multiple births with three or more children it is extremely difficult for the mother to organise feeding around the appetites of all of the babies. The breasts can produce a high quantity of milk, according to the demand placed upon them, and many mothers have been able to feed their infants successfully. It is common, however, for the woman to use other alternatives.
Tandem breastfeeding is also convenient if a woman gives birth to a newborn while still feeding an older baby or child. Under these circumstances during the late stages of pregnancy the milk will change to colostrum for the benefit of the newborn. Some older nurslings will continue to feed even with this change while others may wean due to the change in taste.
Although some may find it controversial, some women breastfeed their offspring for as many as 3 to (rarely) 7 years from birth. This is referred to as extended breastfeeding. Supporters of extended breastfeeding say that all the benefits of human milk, both nutritional and emotional, continue for as long as a child nurses. Detractors believe that prolonging breastfeeding for several years can result in the child developing emotional or psycho-sexual problems, though there is no research that supports this theory. There has, however, been at least one study linking extended breastfeeding with adverse cardiac outcomes later in life.
In developing nations within Africa and elsewhere, it is sometimes common for more than one woman to feed a child. This shared breastfeeding has been highlighted as a source of HIV infection amongst infants born HIV-negative.
Breastfeeding also benefits the mother. Breastfeeding releases hormones that have been found to relax the mother and cause her to experience nurturing feelings toward her infant. Breastfeeding as soon as possible after giving birth increases levels of oxytocin which encourages the womb to contract more quickly. This helps to decrease bleeding after the birth. Breastfeeding can also help the mother to return to her previous weight as the fat accumulated during pregnancy is used in milk production. Frequent and exclusive breastfeeding delays the return of menstruation and fertility (known as lactational amenorrhoea). This allows for improved iron stores and the possibility of natural child spacing. Breastfeeding mothers experience improved bone re-mineralisation after the birth, and a reduced risk for both ovarian and breast cancer both before and after menopause.
It is not uncommon for a mother and child to have difficulties breastfeeding in the beginning, but most of these problems resolve in the early weeks.
A small percentage (between 2 & 3%) of women are unable to provide a full day's calories. It is not known what causes insufficient milk supply, but extended separation at birth, insufficient glandular tissue, and Polycystic Ovary Syndrome (PCOS) are all known culprits. Even among this small group, it is feasible to continue breastfeeding while supplementing with donated breastmilk or artificial baby milk. Many of these mothers breastfeed exclusively by using thin tubing taped to the breast to deliver the supplementary food. This is called a supplementary nursing system, or SNS.
While some may find it too problematic or choose not to attempt or continue breastfeeding for personal reasons, most women who have initial difficulties can go on to breastfeed successfully.
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