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Priming the treasure chest: maximising early breastmilk supply

Alison Blenkinsop
Dip Midwifery Studies
International Board Certified Lactation Consultant (1999-2009);
Author of Fit to Bust - A Comic Treasure Chest

Breastfeeding promotion affects not only individual families, but also global health and wealth. How can we support the establishment of lactation in practical ways, ensuring that mothers have a real choice to maintain it? 

Over the last three decades, research has clearly shown that breastfeeding makes a big difference to the health of both babies and mothers. You may have observed that it is now embedded in health promotion targets, and is much discussed in parenting magazines, media articles and online forums.

Recent UK Infant Feeding Surveys show an increasing trend to start breastfeeding. But within weeks or even a few days, many women give up or introduce top-up bottles, mostly from unresolved problems rather than choice.1 Many readers will have personal and professional experiences of these problems.

You may also have noticed that studies into infant nutrition usually highlight the apparent benefits of natural feeding, rather than the risks of artificial milk. This idealisation of breastfeeding reinforces the perception that formula feeding is normal.2 When breastfeeding is depicted on television or discussed in magazines, the focus is usually on some negative aspect. Formula feeding provokes little comment, and is often recommended as the answer to any breastfeeding challenge. For example, in a recent episode of Coronation Street, Audrey advised Maria to give a bottle to her breastfed baby when problems arose.

It is not surprising that soap operas and newspaper articles often omit the reasons and practical solutions for such problems. Many health workers receive little or no education in lactation, and may not appreciate its importance, so what chance is there for the general public? Another factor is babymilk advertising, promoting it as a safe solution to breastfeeding challenges, or a simple matter of lifestyle choice. Government failure to protect infants by regulating the formula industry is a political matter.3 We need to understand the risks of artificial feeding and the importance of protecting breastfeeding, and enable mothers to have a real choice.

Breastfeeding is important for individual mothers and babies
For women, lactation is an inseparable part of their reproductive cycle. Even before their first missed period, many feel changes in their breasts as the mammary system prepares to nourish the newborn. Breastfeeding not only provides food, but also promotes calmness and loving attachment between mother and baby from the release of feel-good hormones. Frequent feeding delays menstruation, and is the only contraceptive available to many women in developing countries. There are good reasons to continue beyond weaning; for example, research shows that the risk of female breast cancer reduces by 4.3% for every year of breastfeeding.4

For infants, breastfeeding alone gives full nutrition and protection from infection for around six months, and remains important alongside appropriate complementary foods for many more months. The World Health Organization recommends a minimum of two years, as research shows that health risks worldwide increase with shorter or absent breastfeeding.5 This is not surprising, given breastmilk's antibody load and its many other protective factors. Also, toddlers enjoy it!

Breastfeeding is important for the world
No food has a lower environmental impact than breastmilk; given directly, it has the smallest carbon footprint and zero food miles. Raising breastfeeding rates is the most cost-effective health promotion activity in all countries, and directly addresses seven of the eight Millennium Development Goals.6 Continuance of breastfeeding throughout early childhood would minimise medical and dental costs, leaving more money for governments to spend on other disease prevention, education and development.

A copious supply is normal
Most mothers have the potential for a plentiful milk supply for many years. Exceptions include those with rare insufficiency of breast tissue, or a history of reduction surgery or trauma. But these conditions account for only a fraction of the women who discontinue or supplement breastfeeding because of concerns with low supply. The most common cause is inadequate stimulation in the early postnatal period, which is largely preventable. Later problems with milk volume, after a good start, are usually reversible.

Development of a full supply
Colostrum production starts in the second half of pregnancy. Conversion to a full milk supply may be compromised if pregnancy ends more than four weeks early, as the mammary system is still maturing.

Within 36 hours of birth, a decline in pregnancy hormones triggers the change from viscous, clear or golden yellow colostrum to runny, sweet milk. A full yield needs efficient removal within the first few days. Transitional milk is high in colostrum, so retains a creamy tinge. Within a month, the mature milk is pure white.

The first fortnight is crucial
Breastfeeding stimulates prolactin to generate milk, and oxytocin to release it. These hormones also make nursing enjoyable for both mother and baby, helping them communicate and relax. Complete attachment of baby to breast is essential to prevent soreness and promote good drainage of all mammary lobes. This reduces the risk of engorgement, which could jeopardise later production by damaging milk cells and impeding the development of prolactin receptors. If little or no milk is removed, further production is suppressed by a feedback inhibitor of lactation (FIL), strongly active in early lactation. FIL means that new mothers who choose artificial feeding lose their own milk within a week. Unfortunately, it may also severely reduce output in women who want to breastfeed, but are not encouraged or enabled to nurse frequently.

Continuation of lactation
In the first weeks, FIL reduces the supply to match the baby's needs. This suppressant then gradually declines, so milk takes longer to dry up if breastfeeding stops later on. However, a mother who had previously built up a good stock can usually resume feeding, as the mammary tissue is primed for relactation. This can be lifesaving in emergency situations.

Avoidance of unresolved problems
Good attachment to the breast is vital for happy breastfeeding. Problems are caused mainly by poor attachment and infrequent attachment. These causes may be linked; if feeding is difficult and painful, mothers may understandably be reluctant to offer the breast. Babies in discomfort from an instrumental birth, or not held close enough, may be unable to attach well. Skilled help is essential if there are anatomical hindrances such as inverted nipples and infant tongue-tie. Mothers may need encouragement to respond to feeding cues; babies need feeding frequently, day and night, for
many weeks.

Early recognition of problems, and extra support to overcome them, will help mothers to avoid pain, breast damage, and low supply. It will also protect their babies from inadequate intake and poor development of sucking skills.
 
Implications for birth practices and the first days
Easy breastfeeding is positively associated with normal, unmedicated birth, so mothers need information and support to encourage this. Labour medications and birth interventions may delay lactation from hormonal disruption. Afterwards, mothers and babies should be kept together as much as possible. Early and prolonged skin-to-skin contact between baby and mother, or her partner, reduces stress hormones in both and encourages early breastfeeding.

Maternity staff have a vital role in helping women to recognise adequate milk intake, shown by the baby's steady sucking pattern and changing colour of stools. Pain and anxiety may hamper milk let-down, in turn reducing supply. Mothers should be urged to seek immediate help for any nipple pain before damage occurs, and not have to struggle on alone. Discomfort is an important warning - breastfeeding should never hurt!

Steps to promote good lactation
1. Encourage early and frequent breastfeeds in comfortable positions, with baby in skin contact or lightly dressed. Colson's "biological nurturing" (BN) research shows that when the mother leans back with her baby on top of her, primitive neonatal reflexes are triggered to allow instinctive attachment. This may forestall any need for hands-on help, but if this is required, handle baby very gently to keep stress hormones low. BN also encourages high maternal oxytocin levels, which promote continuance of breastfeeding.7
2. Give premature babies' mothers extra support. Infant survival may depend on breastmilk, but expressing it is challenging for anxious mothers.
3. Watch out for difficulties in breast attachment, shown by pain and alteration of nipple shape after feeds. Nipple damage is preventable - refer for skilled support quickly!
4. Look for physiological causes of infant feeding difficulties. The baby may be in pain from an instrumental delivery, or have transient tachypnoea of the newborn (TTN) after a caesarean birth. Maintain skin-to-skin contact while waiting for a paediatric review for
analgesia or investigation of respiratory conditions, as this aids resolution of both pain and breathing problems. Refer to a breastfeeding specialist in good time if you suspect tongue-tie.
5. Check for breast swelling. In the first couple of days, there may be generalised oedema from a long labour, intravenous fluids, or pregnancy-induced hypertension. Breast engorgement may occur later, if the rate of milk production temporarily overtakes removal. Over-distension may flatten nipples or make any inversion more pronounced. "Reverse pressure softening" (RPS) around the areola resolves many attachment problems; instructions can be found online.8
6. Ensure the baby is getting enough milk. A baby who feeds vigorously, is content for an hour or so between feeds, has a change from black to yellow stools within the first five days, and regains birth weight by two weeks is well fed.
7. Assist milk expression if breastfeeding is inefficient, very painful or impossible. This helps the mother maintain her supply and avoid artificial supplements. Support her as follows:

  • Promote prolonged, close contact with her baby, and encourage her partner to join in.
  • Facilitate prompt and frequent expression of colostrum or milk:
    - Aim for every two to three hours, with no more than one longer gap for sleep.
    - Express by hand until colostrum increases and thins, thereafter by hospital-grade electric pump.
    - Use the machine's double-pumping facility, to increase volume and milk fat, and give the mother more cuddle time with her baby.
  • Consider using syringes and then cups to give the milk; prolonged use of artificial teats may affect the baby's ability to breastfeed later.
  • Offer ongoing encouragement.

Latch key (see also points 1-6 above)
L ean back comfortably (1)
A llow baby to rest on your body (1)
T ake off outer clothing (1)
C heck breast is soft for baby to grasp (5)
H elp baby very gently (1)
K eep asking for help if it hurts (3)
E xpress milk if necessary (6)
Y our nipples should look the same afterwards (3).9

Other practical points
Family support is strongly associated with maintenance of lactation. Increase oxytocin levels in both parents by paying attention to their needs:

  • Physical - maternal analgesia for post-birth pain, comfortable seating, good food and plenty to drink, avoiding alcohol and excess caffeine.
  • Emotional - privacy, close contact with their baby, loving attention and praise, humour.

With mechanical milk expression, ensure thorough breast drainage:

  • Use RPS to reduce localised oedema or engorgement first.
  • Then centre the nipple in a well-fitting funnel (high-grade machines have several sizes).
  • Start with fast cycles and low vacuum until milk flows, then use slower cycles and maximum comfortable vacuum.
  • Express for no more than 20 minutes, switching sides whenever the flow reduces; aim for at least eight times a day.

Pear-shaped situations
If you are unable to resolve problems easily, call quickly for specialist support from your local infant feeding adviser, lactation consultant or breastfeeding counsellor. The baby may need physiotherapy or cranial therapy for muscular problems such as jaw or neck stiffness from a difficult birth. If medical investigations are required, stay in touch to offer ongoing support.

Conclusion
Most women want to breastfeed their babies, and helping them to establish a full milk supply in good time gives them the choice to continue. Well-informed support for this process makes a positive impact on the health and wellbeing of individual families and the wider world.  

References
1. Bolling K, Grant C, Hamlyn B, Thornton K. Infant Feeding Survey 2005. London: The Information Centre; 2007.
2. Berry N, Gribble K. Breast is no longer best: promoting normal infant feeding. Matern Child Nutr 2007;4(1):74-9.
3. Palmer G. The Politics of Breastfeeding (3rd edition). London: Pinter & Martin; 2009.
4. The World Cancer Research Fund (WCRF). Food, Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective. Available from: www.dietandcancerreport.org
5. World Health Organization (WHO). Global strategy for infant and young child feeding. Geneva: WHO;2003:6.
6. Blenkinsop A. Breastfeeding saves mothers' lives. Midwives April/May 2009:46.
7. Colson S. Maternal breastfeeding positions: have we got it right? Pract Midwife 2005;8(10):24-7.
8. Cotterman KJ. Reverse pressure softening. Available from: www.breastfeedingonline.com/rps.shtml
9. Blenkinsop, A. Fit to Bust - a comic treasure chest. London: Pen Press; 2008.

Further reading and resources
Lothian J. The birth of a breastfeeding baby and mother. J Perinat Educ 2005;14(1):42-5.

For other useful information and contacts, visit:
W: www.realbabymilk.com

W: www.linkable.biz

Lothian, J. The Birth of a Breastfeeding Baby and Mother. J Perinat Educ. 2005;14(1): 42-45. Online at ncbi.nlm.nih.gov/pmc/articles/PMC1595228/  (accessed 9/01/2010)

For other useful information and contacts, visit realbabymilk.com/

Photos and images
Image A - 'ASB Tania & Anna' - this has a photograph of myself. Use at top of article by my name

Image B - '18 bus'
 
Image C - '12 Lappins'
 
Image D - ' Key'  (this needs to be put on the left side of the list of points in the text)

Image E - 'Fit2Bustcovernew'