Other survival tip areas:
• Sleep and Settling Strategies
• Biting
• When your Baby (under 4 months) cries
• Toddler Behaviour
• Toddler Nutrition
• Tips for Introducing Solids (PDF)
• Toilet Training
• Postnatal Depression
• Wrapping your Baby

Breastfeeding:

For ease of reading the female gender has been used throughout this article.

The following information provides a brief guide to breastfeeding and gives you some suggestions for solving problems you might be experiencing. For further information and support please consult your Early Childhood Nurse, Lactation Consultant, General Practitioner or Karitane Careline on (02) 9794 1852 or 1800 677 961 outside the Sydney metropolitan area.

Breastfeeding is an art and skill which comes to some women more easily than others for a variety of reasons. In the past the art of breastfeeding was passed from generation to generation of women however these days the skill is often learned from a book.

There are many reasons for making the choice to breastfeed.

For baby

• It is the perfect food for the growth and development of your baby until she is 6 months of age
• Breast milk is conveniently packaged and is easily available at the correct temperature
• Breast milk provides your baby with valuable antibodies which help her to resist and fight infection
• Breastfeeding helps to strengthen the bonding and attachment process between mother and baby

For mother

• The hormone that stimulates milk ejection also acts on the uterus causing it to contract - this assists in the return to the pre-pregnant state
• Breastfeeding provides a measure of protection against breast and ovarian cancer
• Breast milk is free
• Breastfeeding can be an effective contraceptive but you will need to speak to your doctor regarding your choice of contraceptive method (To be an effective contraceptive method a woman needs to be totally breastfeeding, her baby who is under 6 months of age and her menses have not returned since the birth). There is still a 1.7% failure rate with this method.

The following information will explain how

• breast milk is produced
• to check that your baby is attached to the breast properly
• to be sure that your baby is getting enough nourishment
• to increase your milk supply
• to manage problems that may develop - engorgement, nipple pain, thrush and mastitis

How breast milk is produced

A woman's breast provides an excellent food source for babies, and the way in which it does this is fascinating. The following are the major components of your breast.

The Breast
	Coopers Ligament is connective tissues that supports the breast in bands and keeps it from sagging
	Areola is the pigmented skin that goes around the nipple. During pregnancy and shortly after this skin usually changes in colour and becomes darker
	Montgomery Glands are the raised areas on the areola which secrete an oily substance that protects the nipple and has antimicrobial properties. It is thus very important not to wash your breasts too frequently or to use nipple creams routinely.
	Alveoli are the milk-producing cells. They are clustered in groups of between 10 and 100. There are between 10,000 and 100,000 alveoli in the breast
	Ducts carry the breast milk from the alveoli to the collecting ducts under the areola
	Lobes there are 15 to 25 lobes in the breast. Each lobe contains a branch of alveoli and ducts that narrow to an opening in the nipple to form a nipple pore,
	Nipples are made up of smooth muscle and have openings at the tip to allow breast milk to be released. The smooth muscle contracts when stimulated by cold air or with sexual arousal, causing the nipple to become erect

Production of Milk

The hormone prolactin is stimulated and released by your baby's sucking, and in response to this release the secretory cells of the alveoli distend and produce milk. The alveoli is wrapped in layers of cells, which, in response to the hormone oxytocin, clamps down and squeezes the alveoli, pushing the milk out into the ducts and on to the collecting ducts. This is called the 'letdown reflex', and it responds to your emotional feelings. The process of let-down is observable by watching changes in you baby's sucking pattern.

The Let-down Reflex

Repeated spurts of the hormones oxytocin are released from the pituitary gland causing milk to gush in streams from the alveoli to your baby. This usually occurs within the first couple of minutes of sucking. In order for the reflex to work during breast feeding it is helpful to relax. This will be helpful for the let-down, which can be inhibited by pain, embarrassment, fear, tiredness and stress.

Signs of Let-down

Any or all of the following will signal that let-down is occurring:-

• You may be aware of a 'pins and needles' sensation in your breasts, although this sensation may not occur for the first 6 weeks or may not occur at all
• You will notice a change in your baby's sucking pattern -longer more drawing sucks - as the let - down occurs.
• You may experience an increase in thirst while feeding
• Baby will gulp, pull off your breast and the milk may spurt from the nipples
• You may leak
• Oxytocin causes the let-down reflex and helps contract the uterus, so you will most probably feel uterine contractions during breastfeeding especially in the first few days after the birth. This is more common for women who have had more than one baby
• A let-down may also be triggered by a baby's cry, the sight or even the thought of your baby

Your baby is attached properly to the breast

• When most of the areola is in her mouth - more areola will be evident above the baby's top lip than below her bottom lip
• The baby's bottom lip will be curled back
• Baby's tongue should be over the lower gum
• As baby sucks you will notice her jaw and ears moving up and down
• No clicking noises will be heard and your baby’s cheeks will appear full
• You should not have any pain. Pain is an indication that your baby may not be latched on properly - to remove your baby from the breast, place your little finger in the corner of her mouth and press lightly on her lower jaw. This will encourage her to open her mouth so that she will let go and you can re-attach her
• After an initial short burst of sucking, the rhythm will be slow and even with deep jaw movements. Swallowing sounds will be heard
• If your baby is attached properly she will remain on the breast. Most babies will take approximately 30-40 minutes to complete a feed but remember all babies are individuals so this time may vary enormously. As babies get older they also become more efficient at sucking at the breast.

Correct Attachment and Positioning of the Nipple
	a. At the beginning of each cycle, the jaws compress the collecting ducts, trapping the milk and the tongue swells up at the top b. The tongue moves in waves of compression moving the nipple further back c. The nipple is compressed against the hard palate and the milk is swept to the end of the nipple and d. swallowed

Is Baby getting enough nourishment ?

Some parents may have difficulty with the concept of breastfeeding because they do not know exactly how much milk the baby is drinking. It is important to know that it takes an average of 6 weeks for a woman's milk supply to stabilise. The composition of colostrum and breast milk is different and the composition of breast milk is different at various times during a feed.

Colostrum contains higher levels of antibodies and lower levels of fats and lactose than breast milk - the antibodies help prevent the baby getting infections and being concentrated means the colostrum does not overload the baby's kidneys. Colostrum also acts as a laxative thereby helping your baby to pass the meconium (the blackish-green bowel motion that a baby first passes).

Foremilk which the baby receives at the beginning of the feed tends to have a higher water content and is lower in fat than the hindmilk. Hindmilk is released as a result of the letdown reflex. Babies need both variations of breast milk - the former more as a thirst quencher and the latter to ensure adequate weight gain and growth.

It is a good idea to start each feed with a different breast. Always offer your baby both breasts at each feed.

Your baby is getting enough breast milk if

• She is alert and has good skin colour and muscle tone
• She is settled between feeds
• She has 6-8 wet nappies each day (provided she is only having breastfeeds)- the urine is clear and a pale yellow colour
• Bowel motions are soft - in the first 6-8 weeks bowels motions may occur several times each day. After this time bowel motions may be as infrequent as every 3-5 days
• The anterior fontanelle (soft spot on the top of her head) is not depressed
• Weight gains are within normal ranges - that is approximately 150 grams per week up to approximately 6 months of age

How to Increase your Milk Supply

There are many reasons why the breast milk supply may be low including poor positioning and attachment, a sleepy baby, stress, a premature baby, drug interactions and some hormonal contraceptives.

Supply will usually equal demand although sometimes it may take a day or so to catch up.

To improve a low milk supply consider the following strategies:-

Make sure your baby is positioned and attached to the breast correctly. Feed your baby more frequently for example every 2 - 2 .5 hours. Feel your breast before your baby starts to feed so that you have some idea of how full it is. Make sure your baby has drained the first breast before offering the second breast. Express each breast after each feed for 5-10 minutes. This will provide extra stimulation to your breasts and tells your body to increase the milk supply. Avoid giving your baby complementary feeds.

Look after yourself. Rest as much as possible - get family and friends to do the housework for you. Ensure that each meal is nutritious and try not to skip meals. Drink enough fluids to satisfy your thirst. Make feed times your opportunity to relax - put on your favourite music and ignore all other distractions. Maybe even take the phone off the hook.

Problem Management

Engorgement occurs most often during the first few weeks of lactation. It is the result of an oversupply of breast milk as your body attempts to adjust to the demands of your new baby. The alveoli become distended which in turn restricts the blood supply causing further distension and discomfort. Your breasts will become hard and large, the skin surface may appear shiny. This makes it difficult for your baby to latch on to the breast. Express enough breast milk prior to a feed to soften the areola and enable your baby to attach properly. Once your baby is attached to the first breast allow your other breast to flow with the 'let down' reflex (you will probably need to remove your bra to enable this to occur). Always make sure that the first breast is well drained before you attach your baby to the other breast.

Nipple Pain is not a usual part of breastfeeding. It may be caused by incorrect positioning and attachment, grazed or cracked nipples, engorgement (too much milk) or thrush. Pain may be worsened by conditions such as your baby having abnormalities of the mouth or palate or your nipples being flat or inverted. The best way to avoid nipple pain is to make sure your baby is positioned and attached correctly to the breast. If your breasts are engorged express enough breast milk prior to a feed to soften the areola and enable your baby to attach properly. Thrush requires specific treatment.

Thrush is often described as a 'shooting burning' pain like red hot needles which radiate from the nipple posteriorly into the breast. The pain is sometimes most noticeable during feeding despite the fact that your baby is latched onto the breast properly. The nipple may appear slightly pinker than usual, there may or may not be a rash on the nipple and areola. Sometimes the nipples are itchy.

Both you and your baby will need specific treatment for this condition - baby often also has thrush in her mouth. Your general practitioner will be able to diagnose your problem, prescribe and advise you regarding the use of a suitable medication. Keep your nipples dry by changing nursing pads frequently and air dry when possible. Make sure you wash your hands with soap and water before and after your baby's nappy change and before you breastfeed. If your baby has a pacifier this should be boiled for five (5) minutes several times through out the day and replaced after one week (NH & MRC, 1996).

Masititis is an inflammation of the breast tissue. It may be caused by either blocked milk ducts or situations where bacteria enter the breast for example when a woman has cracked nipples. It is possible for either a segment or the entire breast to become painful, swollen, red and hot to touch. You may also feel feverish and experience general aches and pains. You will need to contact you general practitioner immediately for antibiotics and/or management strategies.

If you have tried all the above or are worried anyway please do not hesitate to contact your Early Childhood Nurse, Lactation Consultant, General Practitioner or Karitane Careline.

The following websites may also be useful:
http://www.breastfeeding.asn.au
http://www.lalecheleague.org

References, further reading and viewing

Brodribb, W. (Ed.).(1997). Breastfeeding Management in Australia, Merrily Merrily Enterprises.

Lawrence, R. (1999). Breastfeeding: a Guide for the Medical Profession, Mosby, St. Louis.

Riordan, J. & Auerbach, K. (1998), Breastfeeding and Human Lactation, Jones & Bartlett Publishers, Toronto.

Walker, M. (2002). Core Curriculum for Lactation Consultant Practice, Jones and Bartlett Publishers, Massachusetts.

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Last modified: Tuesday, 17 June 2003