Breastmilk engorgement is a common breastfeeding problem. In the time leading up to birth, a pregnant…
What is breastfeeding?
When a baby is born, the mother's body produces breastmilk (a process known as lactation). Breastmilk provides your baby with all of its nutritional requirements for the first months of life. When all goes well, breastfeeding is a rewarding activity for all concerned.
Breastmilk also contains numerous components that are important for your baby's health. They guide your baby's development, protect your baby from infections and help to develop a robust immune system. In addition, the act of breastfeeding itself can have beneficial physical and emotional effects for you and your baby.
Breastmilk is the recommended form of baby nutrition throughout the world. The evidence shows that breastfed babies enjoy better health outcomes than babies who are fed with alternative foodstuffs, such as formula.
Breastfeeding is a natural act, practised for over 200 million years by all mammals. However, it is also a learned skill. Problems with breastfeeding are not uncommon and many new mothers can benefit from expert guidance.
Breastfeeding can sometimes be a controversial topic. Common debates revolve around questions such as how much, how often and for how long a mother should breastfeed, how to handle difficulties in breastfeeding, or how breastfeeding should fit into a modern woman's home and work life. In addition to the medical context, breastfeeding is debated in its emotional, political, economic and ethical aspects.
Benefits of breastfeeding
It is perhaps incorrect to discuss 'benefits' of breastfeeding, as it is the default option for mother and child. It might be more correct to have breastfeeding as the benchmark and speak instead of the disadvantages of not breastfeeding. To be on the safe side, it may simply be said that breastfeeding is good for the child and good for the mother.
Good for the child
Children who breastfeed enjoy, on average:
- A lowered risk of sudden infant death syndrome (SIDS);
- Better digestion;
- A lowered risk of inflammatory bowel disease;
- Increased protection from gastroenteritis;
- Less diarrhoea;
- Fewer allergies in later life;
- Reduced rates of asthma;
- A lowered risk of diabetes;
- A lowered risk of childhood cancers, including leukaemia and lymphoma;
- Fewer ear and chest infections;
- Fewer urinary tract infections (UTIs);
- Higher intelligence, and;
- Less likelihood of obesity in later life.
These benefits 'increase by dose' - any amount of breastfeeding is beneficial and more is better.
Good for the mother
Breastfeeding can also help the mother, both in the short and long-term. Breastfeeding:
- Helps contract the uterus just after birth, which minimises postpartum bleeding;
- Reduces maternal response to stress;
- Reduces the likelihood of postpartum depression;
- Is free, readily available, requires no container, requires less equipment and preparation;
- Reduces the likelihood of ovarian cancer, uterine cancer and breast cancer;
- Reduces the likelihood of type 2 diabetes;
- Reduces the likelihood of osteoporosis;
- Reduces the likelihood of cardiovascular disease;
- Is a form of birth control;
- Helps with loss of 'baby weight' and maintaining a healthy weight after birth;
- Helps you bond with your baby;
- Helps baby sleep better (less fuss when feeding at night), and;
- Helps baby calm down in stressful situations (such as plane flights).
Preparing for breastfeeding before birth
You can prepare yourself for breastfeeding by learning about the topic, planning any lifestyle changes you choose to make and arranging support and guidance. These steps could save you time and effort in the first hours and days after birth, an intense time for families.
While lactation itself normally begins shortly after birth, your body will start preparing for it several weeks and months beforehand. In the lead-up to birth, hormones in your body will begin making changes in your body. Immune cells migrate to the breasts and milk production begins.
Breastmilk is a living, changing entity, composed of thousands of different substances. Its individual composition will change:
- Throughout each feed;
- Between different feeds in the course of the day;
- Throughout your child's development until you stop breastfeeding;
- According to your diet;
- Between breasts, and;
- In response to cues from your child and from the environment.
Breastmilk performs several different roles. It is a source of nutrition, protection and communication between your baby and yourself.
Colostrum, also known as 'first milk', is particularly suited for newborns. Your body produces colostrum during late pregnancy, so it is ready for your baby immediately after birth. Colostrum is yellowish in colour and is rich in immune components, growth factors and protein. Your baby will feed on colostrum for the first few days, until the breastmilk appears.
Breastmilk meets all the nutritional needs of your baby for the first months of life. It is globally recommended that a healthy mother breastfeed exclusively (with no additional nutritional supplements other than vitamin D) for the first six months of a baby's life.
After six months, it is recommended that mothers continue breastfeeding until the baby is 12 months or older, while gradually introducing other food ('solids') for the baby to experience.
In addition to nutritional components, breastfeeding has an important role in promoting healthy intestinal microbiota (microorganisms in your baby's gut that are important for healthy digestion throughout life).
Growth and development
Breastmilk contains components that guide your baby's healthy growth and development. These include:
- Growth factors (epidermal growth factor, insulin-like growth factor, neuron growth factor, erythropoietin, vascular endothelial growth factor);
- Hormones (calcitonin, somatostatin, adiponectin, leptin, gherlin), and;
- Cytokines and chemokines.
Recent studies have found that breastmilk contains pluripotent stem cells. These cells can develop into any type of body cell. Their function in breastmilk is still unknown.
Immunity and disease prevention
Breastmilk provides your baby with a large variety of cells and substances that protect them from infection and help develop a healthy immune system. Immune components of breastmilk include:
Breastmilk contains several kinds of protective antibodies. Prominent among these are 'secretory IgA' antibodies, whose unique composition enables them to avoid being digested in your baby's stomach. These antibodies protect your baby against intestinal pathogens and promote the establishment of 'good' intestinal bacteria in your baby's stomach.
Your body's immune system recognises harmful pathogens in your immediate surroundings and the antibodies it produces are also passed on in breastmilk. Thus, your body functions as an active 'early warning system' that protects your baby against the infections it is most likely to encounter at any time.
Breastfeeding also avoids the danger of your baby being infected with waterborne pathogens or toxic substances that can be found in water used for preparing infant formula.
Breastmilk also contains immune cells (white blood cells) that fight infection and may promote your baby's immune system development. During the first few weeks of breastfeeding, your breastmilk produces billions of these cells per day. The number of immune cells tapers off during the next six months. They are then mostly produced to compensate for the baby's underdeveloped immune system just after birth.
If you or your baby are infected, your body will respond by delivering more of these infection-fighting immune cells to your baby via breastmilk.
Other immune components
Breastmilk also contains antimicrobial components. Some of these are lactoferrin, mucins, bifidus factor, B12 binding protein, lysozyme, Interferon, fibronectin, lactahedrin, oligosaccharides, glycans and others. There may well be other immune components of breastmilk that are yet to be identified.
Diseases passing in breastmilk
A mother infected with certain diseases, particularly those caused by viruses that infect immune cells, such as HIV/AIDS, can transfer the infection to their child via breastfeeding. In developed countries, mothers with HIV should avoid breastfeeding when there are safe alternatives.
For certain infectious diseases such as hepatitis B and hepatitis C, an infected mother can safely breastfeed her child. For other conditions, such as chickenpox, the advice is more tailored. In the case of chickenpox, an infected mother cannot infect her baby through her breastmilk. However, if there are blisters around her nipple, direct contact with these blisters by the baby can result in the baby becoming infected. Therefore, it is recommended to avoid directly breastfeeding while there are blisters present. Expressing the breastmilk and then bottle-feeding the baby is a safer alternative.
If you have an infectious disease and are preparing for breastfeeding, discuss your options with your doctor.
Breastfeeding is about more than the milk. The feeding act itself is a significant element of the mother-child relationship in the first months and years of life.
Although breastfeeding is a natural act, it is also a learned skill. While some mothers and babies enter easily into breastfeeding, others can have trouble and can benefit from advice from experienced healthcare professionals such as doctors, midwives, nurses and lactation consultants. In many countries, national breastfeeding phone helplines are also available.
The first feed
Breastfeeding normally begins in the first few hours after birth. Your baby will often not want to feed immediately after birth. Rather, your baby will have a period of rest and recuperation that can last from 20 minutes to an hour, after which they will want to feed.
Preterm babies and breastfeeding
Babies born prematurely receive significant benefits from breastmilk. The mother's own milk or milk from a donor is often used when available. However, preterm babies often require supplements to their nutrition until they are ready to begin exclusive breastfeeding.
Breastfeeding after a caesarean section
A large number of babies are born through caesarean section (C-section). After such a birth, both mother and baby will usually need a longer time to recover from the procedure and the anaesthesia involved.
In preparation for breastfeeding your baby after a C-section, you can ask that your baby is kept by or on your body in 'skin-to-skin' contact whenever possible, with as little handling by other people as necessary, and to have quiet time alone with your baby. You and your baby can start trying to feed as early as you both feel is good for you.
Attachment of the baby to the breast is a crucial part of breastfeeding. A well-attached baby will suckle easily, ensuring a good milk flow. For the mother, good attachment prevents problems such as sore or cracked nipples, mastitis and blocked milk ducts.
Recognising and enabling good attachment
- Attachment is easiest when your baby is calm, especially during the first days;
- There is no one 'right' way to hold your baby when breastfeeding - every mother and child settle into the position that suits them;
- Your baby should not have to strain, stretch, or turn its head to suckle;
- Skin-to-skin contact calms your baby and encourages milk release and feeding;
- Baby's head will be tilted slightly backwards when feeding, with the chin digging into the breast. When the nipple brushes against the baby's upper lip, the baby will open its mouth wide and close it around the nipple and some of the breast around it. When feeding, the nipple is near the back of baby's mouth;
- A baby who is well attached to the breast will look calm and content. You will hear swallowing sounds, not sucking sounds;
- Your nipples should not be painful after feeding;
- If you need to stop your baby feeding, break the suction by inserting your little finger gently between the corner of your baby's mouth and the breast, and;
- Nipple shields, when used correctly, can help a baby attach the right way in some cases where attachment is a problem.
'Baby-led attachment' is the technique of allowing your baby to follow its instincts and find the correct position for feeding. Some babies latch onto the breast quickly, while others take more time to find their ideal position.
Healthy newborn babies will display 'feeding cues' when they are ready to feed. They will 'search' for the breast, moving their heads, sticking out their tongues and putting their hands to their mouth.
'Mother-led attachment' is a more active way for the mother to facilitate breastfeeding. The mother leads the baby to the breast and brushes the nose and upper lip against the nipple, causing the baby to open the mouth wide. At that point the mother inserts the nipple into baby's mouth.
Milk production, milk flow and the let-down reflex
Breasts are milk factories, not milk containers and match their supply to your baby's needs.
When your baby breastfeeds, your body feels the suckling and responds by producing more milk and releasing the milk that is already there. This is known as the 'let-down reflex' or 'milk ejection reflex'. Different hormones released during breastfeeding encourage milk production (prolactin) and milk flow (oxytocin).
Steps to facilitate breastfeeding
Things that can help you start and continue breastfeeding include:
- Access to skilled guidance;
- Support from your partner, family and environment;
- Starting shortly after birth rather than waiting;
- Skin-to-skin contact;
- Avoiding smoking and excessive alcohol;
- Avoiding dummies (pacifiers), and;
- Avoiding bottles and formula.
How much? How often? For how long? How to stop?
Different babies have different feeding patterns. In recent years, expert recommendations have shifted from feeding infants at regular intervals to feeding 'on demand', which is feeding when the baby signals that it is hungry and ready to feed.
After comparing babies fed using this method, it is clear that some newborn babies are naturally comfortable with feeding every two or three hours, while others require feeding on an hourly basis. A healthy baby is the best judge of its own needs and will let you know when it is time to feed and when it has had enough.
As your baby grows, its stomach will also grow and be able to contain more milk and feeds will become less frequent. Your baby will also become better at feeding and its body will digest the milk better.
Ideally, babies should be given the option to breastfeed until they wean themselves naturally. This is also a highly individual process; some babies are 'done' after less than a year, while others will breastfeed on occasion until quite advanced ages - even to school age - if given the option.
Of course, what is best for the baby is not always best for everyone else; many mothers will want (or need) at some point to encourage their child to wean off breastfeeding and onto an adult diet. You can help your child wean by distracting them from nursing - offering other foods, letting your child play with the food and to feed themselves.
Weaning is a gradual process and can take days or weeks. It is often easier to 'drop' day feeds while leaving night-time and early morning breastfeeds, as these have an added comfort value for your child.
When not to breastfeed
In certain cases, breastfeeding may not be advisable. These can include:
- When the infant has special dietary problems such as galactosaemia, a genetic allergy to galactose (a type of sugar found in breastmilk);
- When the mother is infected with certain diseases that can pass in breastmilk, as noted above;
- When the mother is undergoing chemotherapy or radiotherapy as treatment for cancer, and;
- When the mother is using certain medications or illicit drugs that may harm the baby.
It should be noted that for some mothers in some situations, including mothers who are HIV-positive or using drugs, the benefits of breastfeeding (such as protection from infection in areas where infectious diseases are common) can outweigh the risks. Consult your doctor for specific advice.
In many cases, a mother is not able to breastfeed her child any time they wish. In these cases, expressing breastmilk - pumping it out of the breast into a bottle or container - is a good alternative. Breastmilk can be expressed manually (by squeezing the nipple with fingers) or with an automatic breast pump.
Common breastfeeding problems
Even under ideal circumstances, breastfeeding does not always go smoothly. All mothers experience problems in breastfeeding at one point or another. These problems can cause distress to the mother, baby and family and may not always have fast or easy solutions.
Common problems for breastfeeding can include:
'No milk' or 'not enough milk'
Many mothers believe they naturally do not have enough milk to feed their babies. This is only true in quite rare cases. It is much more common that feeding starts off slower than usual or not correctly. This situation can often be fixed with help and guidance.
In addition, a mother's belief that she has 'dried up' or has 'no milk' may affect her oxytocin production and may cause her to produce less milk.
Blocked ducts and mastitis
Milk ducts in the breast can become blocked, often as a result of incorrect attachment of the baby to the breast. Blocked ducts can cause soreness and pain and may lead to inflammation of the nipple (mastitis). Continuing to breastfeed (with correct attachment) can help relieve blocked ducts and mastitis.
If mastitis does not clear up within a day or so, it might be the result of an infection. In this case, it is best to consult a healthcare professional.
Sore or cracked nipples
These are commonly the result of incorrect attachment. If breastfeeding is painful, it is a sign that something is wrong. It is recommended that you stop your baby feeding, relieve your pain with a few drops of breastmilk, or a soothing ointment such as paraffin and let your nipples dry.
Healthcare professionals can help you improve your attachment so you can continue breastfeeding.
In breastfeeding women, breasts grow larger, fuller and often tender to the touch. In some cases, breasts are too full and may be painful. This is known as engorgement.
Common solutions to this problem include feeding more often from the affected breast, hand-expressing a little milk before feeding to soften the breast, massages and cold compresses. Consult your healthcare professional for specific advice.
Breastfeeding and society
Breastfeeding practices vary widely between societies. The attitudes and perceptions towards breastfeeding have significant impact on the practice of breastfeeding.
Breastfeeding has a significant economic impact. Studies have shown that healthcare costs due to premature weaning amount to billions of dollars per year in the US and elsewhere.
Resistance to breastfeeding
In some societies, some people may hold negative attitudes toward breastfeeding and breastfeeding mothers. Breastfeeding may be considered unnecessary, too difficult, immodest, or not suitable for certain lifestyles and careers.
Whether and for how long to breastfeed is ultimately the choice of the individual mother. The people around her and the society she lives in can support breastfeeding by:
- Providing encouragement and guidance;
- Not voicing judgemental opinions;
- Providing appropriate facilities for breastfeeding and expressing breastmilk (in workplaces and public areas), and;
- Giving a mother who chooses to breastfeed the ability to do so without suffering economically or socially.
Misconceptions about breastfeeding
There are many misconceptions about breastfeeding. Some of the more common ones include:
- 'No milk' (see above);
- 'Formula is just as good' - as noted above, breastmilk is a changing, living entity. Even the most advanced forms of infant formula cannot compete with breastmilk for its nutritional qualities. In addition, infant formula does not have the numerous living cells and biological components found in breastmilk and thus cannot give immune protection and developmental assistance;
- 'Bigger breast means more milk' - breast size is not connected to milk production. Small breasts can produce enough milk for even the hungriest of infants;
- 'Breastfeeding makes breasts sag' - there is no connection between breastfeeding and subsequent breast shape, and;
- 'You cannot have sex when breastfeeding' - birth and breastfeeding affect a woman's body, emotional state and hormonal balance. These may change her sexual life, especially during the first weeks and months after birth. However, breastfeeding women can and do enjoy sex - though it may need some preparation and patience on the part of the woman and her partner.