This site is intended for health professionals only

The myths and truths about breastfeeding

Sara Stanner
MSc RPHNutr
Senior Nutrition Scientist
British Nutrition Foundation

Breastfeeding is the optimal method of infant feeding and recommended worldwide for the first six months to ensure a good start in life. However, despite the well-publicised benefits for short- and long-term health, strong support for breastfeeding from health professionals and the media, and a number of initiatives by the Department of Health to promote breastfeeding, the UK still has one of the lowest rates in Europe. Only three-quarters of babies receive any breastmilk, falling to just over half at two weeks and to only a quarter by four months. In fact, only 2% of women exclusively breastfeed for the recommended six-month period. Women who choose to breastfeed tend to be older, better educated and of higher social status.(1)

Nutritional requirements of breastfeeding
New mothers are often very receptive to lifestyle advice, so encouraging healthy eating can support breastfeeding and promote future health. On a daily basis, lactation is more nutritionally demanding than pregnancy. However, it seems to be a robust process, and the composition of breastmilk is remarkably consistent between mothers around the world. Although some of the energy required for breastmilk production is supplied by the fat stores laid down during pregnancy, breastfeeding women need: extra energy (around 500kcal/day); an increase in macronutrients (protein and carbohydrate to supply extra energy) and a higher intake of all the vitamins (except B6); calcium; phosphorus; magnesium; zinc; copper and selenium. They also need to increase their fluid intake to ensure adequate hydration.
It is therefore essential for women who are breastfeeding to consume a healthy, balanced diet based on the same principles as those for other adults. This means eating plenty of fruit, vegetables and starchy carbohydrate foods such as pasta, potatoes, rice and cereals (particularly wholegrain versions where possible), as well as including foods that provide plenty of protein, calcium and iron (eg, low-fat dairy products, fish, lean meat and pulses). A mother's time and energy may be in short supply while she is adjusting to the changes in her life after the birth of her baby and regular healthy snacks will help meet the additional demands of breastfeeding. As always, the occasional treat can also be included. As in pregnancy, it is recommended that all lactating women should take a daily supplement containing 10mg of vitamin D.
Some women may be tempted to diet after the baby is born to help them return to their previous body weight, but limiting food intake in the early weeks of lactation may reduce milk supply. Rapid weight loss can release toxins stored in body fat into the bloodstream, causing an increase in the amount of contaminants in the breastmilk. Restrictive "fad" diets can also result in inadequate nutrient intake. Some mothers also report that certain foods (eg, spicy foods or onions) cause abdominal discomfort or restlessness for their babies. Avoiding these foods may be sensible, but advice about alternative sources of nutrients is needed as omission of the trigger foods might result in an unbalanced diet.(2)
Substances such as caffeine, alcohol and toxins found in some oily fish can pass into breastmilk, so excessive amounts should be avoided. Caffeine in moderation (equivalent of up to 3-4 cups of coffee per day) rarely causes any problems for babies, but heavy consumption of coffee, tea and cola drinks has been reported to cause restlessness in some infants. Alcohol should be largely avoided during lactation, particularly before a feed, as it may reduce the amount of milk produced and slow the time it takes for the milk to be released from the breast when the baby starts suckling.(3) Oily fish is an important source of the long-chain omega-3 fatty acids essential for babies' early development. Breastfeeding women are advised to restrict intake to no more than two portions of oily fish a week and to avoid shark, swordfish or marlin as they may contain trace contaminants.
With regards to the prevention of allergy or other food intolerances in the baby, the benefits of mothers avoiding specific foods while breastfeeding have not been proven. In fact, exposure via the mother may be an important factor in establishing a normal immune response to proteins in the diet. However, avoidance of foods associated with allergy, particularly peanuts and peanut products, should be considered when the baby is at high risk (ie, having a parent or sibling with allergic conditions such as hayfever, asthma and/or eczema).(3)

Benefits of breastfeeding
Breastmilk provides all the necessary nutrients a healthy infant needs, as well as growth factors and immunological components that may protect the baby from infection. Several studies have demonstrated that exclusive breastfeeding for at least three months is associated with a lower incidence and severity of gastroenteritis, otitis media and respiratory infection.(4) As breastmilk is always at the correct temperature and concentration, breastfeeding also eliminates the risk of contamination by bacterial pathogens or from over- and underfeeding from incorrectly prepared formula feeds.
Increasing evidence suggests that the benefits extend beyond the breastfeeding period into later life. For example, breastfed infants appear less likely to become obese or to develop other cardiovascular risk factors such as insulin resistance, an abnormal lipid profile or hypertension.(5,6) Although further research is needed, it is also likely that breastfeeding may protect against some immune-related diseases later in life, such as type 1 diabetes, coeliac disease, inflammatory bowel diseases and perhaps cancer and potentially improve bone development.(7,8) Possible protection from allergic disease has also been suggested, although findings have been very inconsistent.
There has been a lot of interest in the link between breastfeeding and cognitive development. Improved intelligence was originally noted in breastfed compared with formula-fed preterm infants, but the same has been demonstrated in term infants.(9,10) This effect has been attributed to the long-chain polyunsaturated fatty acids in breastmilk (docosahexaenoic acid and arachidonic acid), which until recently were absent from most formula milks. These fatty acids are known to be important structural components of the brain.
Health gains for breastfeeding mothers include more rapid return of postpartum uterine tone, postpartum weight loss and enhanced bonding between the mother and the infant. Breastfeeding is also associated with a decreased risk of breast and ovarian cancer in the premenopausal period and of hip fractures and osteoporosis in the postmenopausal period.(7) From an economic perspective, breastfeeding is less expensive than formula feeding.

Recognised barriers to breastfeeding
Despite general awareness that breastfeeding is best for babies, most women in the UK don't breastfeed beyond a few weeks. Factors that are known to be associated with success include:

  • Correct positioning of the baby on the breast.
  • Realistic expectations about breastfeeding.
  • Support from family and friends.
  • Consistent advice from health professionals.

Commonly reported reasons for giving up often revolve around physical factors such as:

  • Perceived insufficient milk supply.
  • Sore and cracked nipples.
  • The baby rejecting the breast.
  • A lack of confidence in breastfeeding.

[[NIP30_box1_66]]

Many of these problems can be overcome by good antenatal education, supportive healthcare facilities (including "baby-friendly" hospitals), training for all healthcare professionals who come into contact with mothers and babies, and better lactational support for mothers.
A number of social barriers are also frequently cited as reasons for early termination of breastfeeding, such as:

  • Inconvenience.
  • Perceived restriction of freedom and independence.
  • The need to work in an unsupportive work environment.
  • Embarrassment, particularly about breastfeeding in public.
  • Lack of opportunities to breastfeed comfortably.

Work needs to be done to enhance this aspect of motherhood so that breastfeeding is seen as a normal part of everyday life and mothers are free to breastfeed in public, without anyone thinking it is remarkable.(11)
In 2004, a survey of 1,000 women, carried out on behalf of the Department of Health, highlighted many of the current myths about breastfeeding:(12)

  • Nearly all believed that breastfeeding came naturally to some but not to all, and that some women are unable to produce enough milk to breastfeed successfully.
  • Two-thirds felt that breastfeeding in public is considered to be socially unacceptable.
  • Twenty percent of those aged 16-24 years thought that breastfeeding would have detrimental effects on their breasts and body shape. 

Clearly these myths need to be dispelled if we are to improve initiation and duration rates in the UK.

[[NIP30_table1_68]]

The role of nurses
Midwives, health visitors and other healthcare professionals strongly influence mothers' views on infant feeding and therefore play a central role in providing the education, supervision and support that women need. All new mothers must have accurate information about breastfeeding and get practical advice to overcome the recognised barriers to its implementation and continuation (see Table 1). In particular, women need to know that breastmilk does offer short- and long-term benefits over formula milk and that more and more establishments are welcoming breastfeeding mothers and providing suitable facilities. Healthcare professionals need to target women who are less likely to breastfeed and address their specific questions and concerns - for example, by informing young people about the potential benefits of breastfeeding for weight loss and health for the mother as well as the child, and reassuring them that it will not have a negative impact on their body shape. All who come into contact with mothers and babies should be equipped with up-to-date, evidence-based information to ensure that they provide consistent advice, as well as appropriate training to have the right skills to support breastfeeding. 

Conclusion
Breastfeeding is undoubtedly the best nutritional start in life for infants, offering both short- and long-term health benefits. It also confers important benefits to mothers. The "breast is best" message is not getting across to all women, particularly to younger women and those from disadvantaged communities. Lack of appropriate education and support also appears to be leading to avoidable termination of breastfeeding. Nurses have an important role in highlighting the nutritional benefits, dispelling many of the myths concerning breastfeeding and ensuring that women receive the necessary support to establish the skills and confidence to make breastfeeding a positive experience for both the mother and the baby.

References

  1. Hamlyn B, et al. Infant feeding 2000. London: TSO; 2002. Available from: http://www.dh.gov.uk/asset-Root/04/05/97/63/04059763.pdf
  2. Buttriss J, Wynne A, Stanner S. Nutrition -  a handbook for community nurses. London: Whurr Publishers; 2001.
  3. Mennella JA, et al. Acute alcohol consumption disrupts the hormonal milieu of lactating women. J Clin Endocrinol Metab 2005; 90:1979-85.
  4. Harrod-Wild K. Breastfeeding - benefits for the infant. Complete Nutrition 2006;6:9-11.
  5. Owen CG, et al. Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics 2005; 115:1367-77.
  6. Singhal A. Early nutrition and long-term cardiovascular health. Nutr Rev 2006;64:44-9.
  7. Schack-Nielsen L, et al. Long term effects of breastfeeding on the infant and mother. Adv Exp Med Biol 2005;569:16-23.
  8. Jones G, Riley M, Dwyer T. Breastfeeding in early life and bone mass in prepubertal children: a longitudinal study. Osteoporos Int 2000;11:146-52.
  9. Lucas A, Morley R, Cole TJ. Randomised trial of early diet in preterm babies and later intelligence quotient. BMJ 1998;317:1481-7.
  10. Oddy WH, et al. Breastfeeding and cognitive development in childhood: a prospective birth cohort study. Paediatr Perinat Epidemiol 2003;17:81-90.
  11. Department of Health. Good practice and innovation in breastfeeding. London: DH; 2004. Available from: http://www.breastfeeding.nhs.uk/
    pdfs/FINAL_Breastfeeding_Guide.pdf
  12. Hyman S, Stanner S. Dispelling popular myths that discourage breastfeeding. Nutr Bull 2004;3:180-2.