Introduction

Breastfeeding provides optimum nutrition to the infant during the early months of life. But it is very important that breastfeeding should be done properly, the technique is as important as the breastfeeding itself. Breastfeeding helps boost immunity in the infant as it is rich in antibodies. Some studies suggest that children who are exclusively breastfed for first six months of life are healthier than children who are not breastfed at all.

Benefits to the infant

It enhances maternal involvement, interaction and bonding with the child; provides species-specific nutrients to support normal infant growth; provides non-nutrient growth factors, immune factors, hormones, and other bioactive components that can act as biological signals which can decrease the incidence and severity of infectious diseases and chronic illnesses along with enhanced neurodevelopment.

Benefits to the mother

Breastfeeding is beneficial for the mother's health as well as it increases maternal metabolism; has maternal contraceptive effects and is associated with a decreased incidence of maternal premenopausal breast cancer and osteoporosis.

General principles of breastfeeding

1. Exclusive breastfeeding for the first 6 months (Recommended by WHO)
2. When direct breastfeeding is not possible, expressed breast milk should be provided
3. Place infant skin-to-skin with the mother immediately after birth and encourage frequent feedings (8 to 12 feeds/24 hours)
4. Supplements (i.e. water or formula) and pacifiers should not be given unless medically indicated
5. Complementary foods should be introduced around 6 months with continued breastfeeding up to and beyond the first year
6. Oral vitamin D drops (100 IU/daily) should be given to the infant beginning at 2 months
7. Supplemental fluoride should not be provided during the first 6 months of life
8. Proper personal hygiene

Technique of breastfeeding

Breastfeeding can be started after delivery as soon as both mother and infant are stable. Correct positioning and breast-feeding technique is necessary to ensure effective nipple stimulation and optimal breast emptying with minimal nipple discomfort.

1. The infant should be elevated to the height of the breast and turned completely to face the mother, so that their abdomens touch.
2. The mother's arms supporting the infant should be held tightly at her side, bringing the infant's head in line with her breast.
3. The breast should be supported by the lower fingers of her free hand, with the nipple compressed between the thumb and index fingers to make it more protractile. The infant's initial licking and mouthing of the nipple helps make it more erect.
4. When the infant opens its mouth, the mother should rapidly insert as much nipple and areola as possible. Enough of the areola should be in the infant's mouth to permit the tongue to compress the areola against the hard palate. This provides a good seal and proper emptying or milking of the collecting ducts.
5. After suckling at the first breast, the infant is repositioned on the second breast. It is appropriate to alternate the side used to initiate the feeding and to equalize the time spent at each breast in a day's feedings.
6. The duration of feeding is 5 minutes per breast at each feeding the first day, 10 minutes on each side at each feeding the second day and 10-15 minutes per side thereafter. A vigorous infant can obtain most of the available milk in 5-7 minutes, but additional sucking time ensures breast emptying, promotes milk production and satisfies the infant's sucking urge. The mother may break suction gently after nursing by inserting her finger between the infant's gums.
7. A normal infant is alert and attentive and should root, grasp, and suckle well. But some infants may not demand feed in the first few days; parents should be instructed to wake these infants for feedings.
8. In the first weeks, infants should go no longer than 4 hours between feedings.

Signs of successful breastfeeding

1. At 3 to 5 days post-delivery, the mother should experience some breast fullness, and notice some dripping of milk from opposite breast during breastfeeding; demonstrate ability to latch infant to breast; understand infant signs of hunger and satiety; understand expectations and treatment of minor breast/nipple conditions
2. Expect a return to birth weight by 12-14 days of age and a continued rate of growth of at least 1/2 ounce per day during the first month.

Assessment of adequacy of milk intake

In the first few weeks after birth, an infant is adequately nourished if at least 8 to 12 feedings are received every 24 hours and the infant sleeps contentedly between feedings. The adequacy of milk intake can be assessed daily by counting the number of wet diapers, the number and quantity of stools, and weight gain (body weight loss of more than 7% should be avoided). In the first 24 hours after birth, the infant should have at least one wet diaper and one stool. On day 3, breastfed infants usually have three to four wet diapers and one to two stools that no longer look like meconium but are beginning to appear yellow. Later in the first week after birth, there should be six pale yellow diapers per day and a yellow stool with each feeding. Later in the month, the stool frequency may diminish to three per day.

All breastfeeding infants should be seen by a paediatrician or other health care provider at 3 to 5 days of age.

Breast changes and care

Sore, tender nipples

Most mothers will experience some degree of nipple soreness most likely a result of increased surface tension caused by the infant's sucking action. A common description of this soreness includes an intense onset at the initial latch-on with a rapid subsiding of discomfort as milk flow increases. Nipple tenderness should diminish during the first few weeks until no discomfort is experienced during breastfeeding.

Management

Purified lanolin and/or expressed breast milk applied sparingly to the nipples following feedings

Traumatized, painful nipples

Possible causes include: ineffective, poor latch-on to breast, improper infant sucking technique, removing infant from breast without first breaking suction, underlying nipple condition or infection (i.e., yeast, eczema). It may include bleeding, blisters or cracks.

Management

1. Ensure proper positioning technique and relief with adjusted latch-on.
2. Diagnose any underlying nipple condition and take appropriate treatment
3. In cases of severely traumatized nipples, temporary cessation of breastfeeding to allow for healing. The mother should maintain lactation with mechanical/hand expression until direct breastfeeding is resumed.

Engorgement

It usually presents on day 3-5 postpartum signalling the onset of copious milk production resulting in swollen, hard breasts that are warm to the touch. The infant may have difficulty latching to the breast until the engorgement is resolved.

Management

1. Application of warm, moist heat to the breast alternating with cold compression to relieve oedema of the breast tissue
2. Gentle hand-expression of milk to soften areola to facilitate infant attachment to the breast
3. Gentle massage of the breast during feeding and/or milk expression
4. Mild analgesic or anti-inflammatory

Plugged ducts

This appears as a palpable lump or area of the breast that does not soften during a feeding or pumping session. It may be the result of an ill-fitting bra, tight, constricting clothing, or a missed or delayed feeding/pumping.

Management

1. Frequent feedings or pumping sessions beginning with the affected breast
2. Application of moist heat and breast massage before and during feeding
3. Positioning infant during feeding to locate the chin toward the affected area to allow for maximum application of suction pressure to facilitate breast emptying.

Mastitis

It is an inflammatory and/or infectious breast condition—usually affecting only one breast characterized by rapid onset of fatigue, body aches, headache, fever and tender, reddened breast area.

Management

1. Immediate bed rest concurrent with continued breastfeeding
2. Frequent and efficient milk removal—using an electric breast pump when necessary
3. Appropriate antibiotics for a sufficient period (10-14 days)
4. Comfort measures to relieve breast discomfort and general malaise (i.e., analgesics, moist heat/massage to breast).

Lactation failure

Lactation failure is inadequate intake of breast milk due to irregular intervals of breastfeeding (poor lactation performance) or giving water and glucose supplements to a healthy infant. This can precipitate jaundice because of unconjugated hyperbilirubinemia during the first week and beyond the first week of age. It is related to inadequate milk intake and poor lactation performance. The treatment is aimed at increasing milk intake through an increase in the frequency of breastfeeding. In extreme circumstances, usually when the serum bilirubin concentration exceeds 20 mg/dL, the hyperbilirubinemia can be reduced by interrupting breastfeeding for 2 to 4 days. If this course is chosen, the mother must be encouraged to maintain her milk supply with a manual or mechanical method while the infant receives formula. When breastfeeding resumes, the serum bilirubin may rise slightly, but once the cycle is interrupted, recurrence of the jaundice is unlikely.

Breastfeeding and medications

A number of drugs may be secreted into human milk, but only a few are considered problematic for the breastfeeding infant and/or mother. These include:

1. Chemotherapeutic agents
2. Radioactive isotopes
3. Anticonvulsants
4. Antihistamines
5. Sulfa drugs
6. Salicylates
7. Caffeine (caffeine-containing beverages- commonly tea and coffee) (TAKE ONLY 2-3 per day)
8. Alcohol (may affect infant behaviour adversely)
9. Cigarette smoking (may affect milk volume)

The mother should discuss any medication with her physician, and the physician should substitute potentially problematic medications with those acknowledged to have better safety profiles.

Contraindications to breastfeeding

1. An infant with galactosemia will be unable to breastfeed or receive breast milk.
2. A mother with active tuberculosis will be isolated from her newborn for initial treatment. She can express her milk to initiate and maintain her milk volume during this period and once it is deemed safe for her to have contact with her infant she can begin breastfeeding.
3. Women who test positive for human immunodeficiency virus (HIV) strictly avoid breastfeeding.
4. Women on medications contraindicated during breastfeeding.
5. Breast Cancer

Conditions that are not contraindications to breastfeeding

1. Hepatitis B surface antigen positive mothers (hepatitis B immunoglobulin and hepatitis B vaccine to infant to eliminate risk of transmission)
2. Hepatitis C virus positive mothers.
3. Cytomegalovirus (CMV) positive mothers.

Care and handling of expressed breast milk

When possible, direct breastfeeding provides the greatest benefit for mother and infant, especially in terms of provision of specific human milk components and maternal-infant interaction. However, when direct breastfeeding is not possible, expressed breast milk should be encouraged with special attention to milk expression and storage techniques. Mothers separated from their infants immediately following delivery due to infant prematurity or illness must initiate lactation by mechanical milk expression.

Breast milk expression, collection and storage

1. Milk expression within the first few hours following delivery with a hospital-grade electric breast pump
2. 8 to 10 times daily for 10-15 minutes per session during the first 2 weeks following birth
3. A target daily milk volume of 800 to 1,000 mL at the end of the second week following delivery

Note:

1. Wash hands and scrub under fingernails before each milk expression
2. All milk collection equipment coming in contact with the breast and breast milk should be thoroughly cleaned before and following each use
3. Sterilizing milk collection equipment once a day
4. Collect milk in sterile glass or hard plastic containers
5. Label each milk container with date and time of milk expression
6. Refrigerate milk immediately following expression when the infant will be fed within 48 hours
7. Freeze milk when infant is not being fed within 24 hours of expression
8. Do not refreeze

Breast milk substitutes

Breast milk alternatives are given when lactation is contraindicated. The alternative to breast milk is commercially prepared infant formula. Based on the protein content of infant formulas, there are three main groups:

1. Cow milk protein (most common)
2. Soy protein
3. Hydrolysed casein protein.

There are many other specialized formulas available, such as amino acid-based formulas and formulas made specifically for certain inborn errors of metabolism. Perinatal hospital routines and early pediatric care have a great influence on the successful initiation of breastfeeding by promoting prenatal and postpartum education, frequent mother-infant contact after delivery, one-on-one advice about breastfeeding technique, demand feeding, rooming-in, avoidance of bottle supplements, early follow-up after delivery, maternal confidence, family support, adequate maternity leave, and advice about common problems such as sore nipples.

References

1. Current Pediatric Therapy, Eighteenth Edition. Fredric D. Burg, Julie R. Ingelfinger, Richard A. Polin, Anne A. Gershon. Elsevier Inc. ISBN-13: 978-0-7216-0549-4.
2. Current Diagnosis & Treatment: Pediatrics, Nineteenth Edition. William W. Hay, Jr.,Myron J. Levin, Judith M. Sondheimer,Robin R.Deterding. The McGraw-Hill Companies, Inc. ISBN 978-0-07-154433-7.
3. Manual of Clinical Problems in Pediatrics, Fifth Edition. Kenneth B. Roberts, Lippincott Williams & Wilkin
4. Manual of Neonatal Care, Sixth Edition. John P. Cloherty, Eric C. Eichenwald, Ann R. Stark, Lippincott Williams & Wilkins.
5. Textbook of Pedodontics, Second Edition. Shobha Tandon, Paras Medical Publisher, ISBN 978-81-8191-241-1.