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Building the foundations for breastfeeding

Sharon Breward
Lactation Consultant
and UK Vice Chair
Breastfeeding Counsellor
Association of Breastfeeding Mothers

Breastfeeding is increasingly seen as a hugely significant issue in the public health stakes. It doesn't matter in which clinical field you practise, there will be research somewhere to show that breastfeeding is thought to have some sort of protective effect in areas of diabetes, childhood obesity, breast cancer, ovarian cancer, HIV, neurological development, dental health ... the list goes on.(1)
In building terms, a foundation is a strong, load-bearing part of a structure, and the scaffolding is a temporary framework providing a platform for building work. But you wouldn't be able to do any building work if you hadn't put in strong foundations, and without strong foundations the building would simply topple over. We can transfer these principles to feeding babies.

"Foundations" for health professionals
Many health professionals have limited knowledge and skills about breastfeeding, because there is no compulsory structure for ensuring that benchmarked clinical competencies for breastfeeding are achieved during training. For a health professional, helping a breastfeeding mum can be a frustrating and lonely task as they are often left trying to desperately shore up a precarious, wobbly "scaffold" of support while the situation gradually topples into breastfeeding failure. The conscientious health professional will often search out help for the mum from the voluntary sector, but this is not the usual approach when we face clinical difficulties, is it? In other areas of clinical care a health professional would be expected to know how to resolve the issue, or in the case of complex or persistent problems there will be an established mechanism for referral to a specialist. This is rarely the case for breastfeeding issues.

Structural failure?
Why, though, are we assuming the breastfeeding mum will be in difficulties? Because, sadly, this is all too often the case. Despite the majority of mums starting off breastfeeding, an average of about 50% of them stop breastfeeding in the first few months, with the overwhelming majority of these mothers reporting that they had wanted to carry on breastfeeding for longer.(2) This high level of breastfeeding failure is now accepted pretty much as normal in our society. Can you imagine, however, the furore if 50% of mothers were readmitted with perineal breakdown due to poor intrapartum care or there was a 50% drop in immunisation rates?
"Foundations" for pregnant women
What about foundations for a mum then? For many mothers, breastfeeding her baby is the fundamental and intrinsic start to her mothering experience. It would make sense then that a new mum also needs a good solid knowledge and skills base on which to build her breastfeeding experience. Yet is the average pregnant woman given sufficient information to reach a properly informed decision regarding feeding her baby? Is she empowered to breastfeed successfully by the routine inclusion in her antenatal care of practical knowledge and skills teaching? Could the building of an antenatal pathway towards breastfeeding be the "missing link" in our maternity services?

What can we do to build stronger foundations for health professionals and mothers?
Fortunately an evidence-based framework of best practice clinical standards for breastfeeding care already exists. The UNICEF Baby Friendly Initiative (BFI) is a global programme of UNICEF and the World Health Organization that works with health services to improve practice so that parents are enabled and supported to make informed choices about how they feed and care for their babies.(3) The BFI programme consists of the 10 steps to successful breastfeeding for maternity units and the seven-point plan for community settings.(4,5) Higher education institutions can also apply to be assessed and accredited as "baby friendly".

How important are these standards?
Any good builder would tell you that you need building regulations so that everything gets done properly, and so it is with breastfeeding. The following is a list of requirements for breastfeeding success:

After the birth
Skin-to-skin contact, an early first breastfeed, and keeping mothers and babies close together are important for the successful initiation of breastfeeding. When mums and babies are kept very close, prolactin levels are elevated in the mother. Prolactin is often referred to as the "mothering hormone" as it stimulates instinctive mothering behaviours; it is also a key lactational hormone.
The milk-producing cells in breasts are awaiting high levels of prolactin in order to be "switched on" to milk production. If prolactin levels are suboptimal due to nonadherence to the best clinical practice standards, then the milk-producing cells may not switch on properly and mum may subsequently struggle with her milk supply.
Getting the technique right
Most breastfeeding difficulties arise because the baby is not attached to the breast properly. All nurses working with mothers and babies should be able to provide accurate guidance on how to position and attach a baby. Research has shown us that babies are born knowing how to breastfeed, so our job is to help mothers learn the new skill.(6) The mother's "job" is to put herself and her baby in the best, comfortable position (see Figure 1) that will allow the baby to latch onto the breast (see Box 1).



How to tell if baby is well attached?
Mum will be feeding comfortably, more of the areola should be visible above baby's top lip, and baby should have rounded cheeks. You will note that, after initial shallow sucks to "call down" the milk, the baby settles into a rhythm of deeper sucking and swallowing as mum's milk ejection (let-down) reflex works under the influence of the hormone oxytocin, or the "love hormone". Prolactin and oxytocin are endorphins or "feel good" hormones, and studies have suggested that oxytocin may make positive social contact more rewarding.(7)
How often should a baby feed?
Mothers often worry because their baby is feeding too often or for too long or at irregular intervals. A normal human milk-fed baby feeds an average of 8-12 times in 24 hours. Feeds will sometimes be close together ("cluster feeding") and will vary in duration. Cluster feeding often occurs in the evening, and mothers worry that their milk has "run out" at this time as their breasts may feel soft. Mum should be reassured that her milk is at its richest when her breasts feel softer and that feeding baby at this time gives an important boost to her milk supply. In order to cope with periods of more frequent feeding, it is important for mum to be shown how to feed her baby lying down so that she can rest as well as feed her baby.

How do you know baby is "getting enough"?
Good attachment at the breast is crucial for efficient milk transfer. A useful rule of thumb for assessing this under six weeks of age is how often the baby has his bowels opened and passes urine. About 4-6 tablespoon-sized yellow stools in 24 hours would be expected and about six noticeably wet nappies. Weighing the baby periodically will also reveal whether breastfeeding is going well or whether breastfeeding management needs to be reviewed.

How to ensure a good milk supply?
Regular, efficient emptying of the breast ensures a good milk supply. If milk is regularly left in the breast then a protein called the feedback inhibitor of lactation will build up and cause less milk to be made.

Time to get the hard hat out?
Over the last quarter of a century, despite acres of print devoted to promoting its importance, there has really been remarkably little change in breastfeeding rates in the UK.(2) The only areas that have shown significant increases in breastfeeding are those, such as Scotland, that have made significant progress towards implementation of the standards of the BFI clinical care framework. The National Institute for Health and Clinical Excellence has recently recommended that the BFI clinical care standards be implemented.(8)
It is quite a puzzle that such best practice clinical care standards remain optional when any planning inspector would tell you that if your foundations are poor and you don't adhere to the regulations then the whole lot will come tumbling down.
The challenge for health professionals responsible for delivering improvements in breastfeeding rates is to start digging for deeper knowledge about breastfeeding, sharpen up those practical skills and implement a sound framework of care for breastfeeding mothers and their babies.


  1. UNICEF UK Baby Friendly Initiative. Health benefits of breastfeeding. Available from URL:
  2. Department of Health. Infant feeding 2000: a summary report. Available from URL:
  3. UNICEF UK Baby Friendly Initiative. Available from URL:
  4. UNICEF UK Baby Friendly Initiative. Ten steps to successful breastfeeding. Available from URL:
  5. UNICEF UK Baby Friendly Initiative. The seven point plan for the protection, promotion and support of breastfeeding in community healthcare settings. Available from URL:
  6. Glover R. Learned attachment techniques changes outcomes. Available from URL:
  7. Turner RA, Altemus M, Enos T, Cooper B, McGuinness T. Preliminary research on plasma oxytocin in normal cycling women: investigating emotion and interpersonal distress. Psychiatry 1999;62(2):97-113.
  8. NICE. Post natal care - routine postnatal care of women and their babies: draft consultation November 2005. Available from URL:

Association of Breastfeeding Mothers

UNICEF UK Baby Friendly Initiative