BREASTFEEDING: On the Path to Health

Elaine Christian, MSN, CNM

One quiet, gray morning last December, I took my turn as the on-call midwife at Marin General Hospital. Having completed rounds on the new mothers, and experiencing a lull between the labors and births, I was able to enjoy the Winter 2013 edition of Marin Medicine. The edition was dedicated to children’s health and included compelling information about the illnesses and lifestyle choices that undermine the well-being of today’s children. I learned a great deal from the articles, and they left me wondering if there wasn’t something else we could be doing to protect these young patients.

And then I remembered that there is something that has been proven to help get infants and children off to a better start: breastfeeding. Not only is breastmilk the ideal nutrition for most infants, including preemies, but it also provides many certain or potential health benefits for young children.[1,2]

There is much scrutiny of the benefits of breastfeeding. The research findings can be particularly difficult to tease apart because it is impossible and unethical to randomize babies to breast versus formula; there are also many confounding variables that influence their health from infancy into adulthood. That being said, giving babies a head start on wellness with the best nutrition, a boost to their immune system, better cognitive development, and the possibility of diminishing their risk for asthma and obesity, is prudent in this era.[3-5]

The Academy of Breastfeeding Medicine is so solidly convinced that babies should be breastfed that they have issued a position statement urging that all physicians, regardless of their discipline, should acquire the current, evidence-based training they need to effectively support breastfeeding mothers and babies. The American Academy of Pediatrics, the American College of Nurse Midwives, the American Academy of Obstetricians and Gynecologists, and many other professional organizations have similar policy statements. They have all responded to the overwhelming body of evidence on the benefits of breastfeeding and to the 1990 World Health Organization/UNICEF pledge to improve infant well-being globally by helping babies have regular and sustained access to breastmilk.

To its credit, Marin General Hospital is able to report that 98% of its babies have access to breastfeeding before discharge.[6] Improved public awareness about the value of breastmilk, the inclusion of this topic at prenatal visits, and our collaborative efforts during and after hospital birth have made a difference we can be proud of.

Unfortunately, in spite of our remarkable breastfeeding initiation rates, Marin County’s rate of any amount of breastfeeding at six months (just 42%) lags behind the average in California, and our rate at one year (only 19%) is dismal. The results are clear. Marin County’s babies are getting a good start at breastfeeding, but too many of them are stopping in the early weeks and months after hospital discharge.

Although babies benefit from even the littlest bit of colostrum, the best health outcomes are associated with exclusive breastfeeding--nothing but mother’s milk for at least six months. Acknowledging that other benefits of breastfeeding extend well beyond those first six months, the American Academy of Pediatrics (AAP) encourages breastfeeding continuation “for one year or longer, as is mutually desired by mother and infant.”[7] This respectful phrasing is appropriate because each mother, child and family has unique reasons and timing for weaning. Like the AAP, the Cochrane Pregnancy and Childbirth Group also found that “the available evidence demonstrates no apparent risks in recommending, as a general policy, exclusive breastfeeding for the first six months of life in both developing and developed-country settings.”[8]

Responding to the dire needs of children around the globe, the World Health Organization and UNICEF have proclaimed that access to breastmilk for two years or more is beneficial. In the populations I care for at MGH, I have heard reports of breastfeeding for up to 2.5 years, and I know there are toddlers out there who are getting even more.

To get babies off to a good start with breastfeeding, they need access to mother’s milk in the first hour after birth. The simple task of bringing babies to mother’s chest after birth has been strongly associated with more effective suckling and the long-term goal of sustained nursing.[9,10] In past eras, it was customary to separate the newborn from the mother so that routine admission procedures could be executed. This is no longer the case in hospitals, such as MGH, that favor babies’ needs over non-urgent tasks.

MGH Lactation Consultant Julie Moxley notes that the pivotal decision to delay the newborn’s first bath has made it easier for babies to carry out their innate desire to nurse. Bonding time was previously interrupted by the first bath and the additional time it took to warm the iatrogenically chilled newborn. When newborns are placed in close, “skin to skin” proximity to their mother’s chest, they are better able to regulate their temperature and respirations and to figure out the nuances of their new job of eating and growing--which begins with nuzzling and suckling at the breast.

Breastfeeding studies have also shown that it is best to keep mothers and babies together throughout their hospital stay. During this time families get to know their child, learn the hunger cues and request assistance with any nursing challenges that may develop. We also encourage “nesting time” at home for the first few weeks for the same reason: so that breastfeeding mothers and babies can get in sync.

Although the vast majority of nursing mothers and babies do well with just a little kindness and some help around the house, there are many mothers who struggle. Whether they plan to breastfeed for six months or two years, they often need our help to get past the first few days and weeks. If they don’t receive support in a timely manner they may conclude that they have no other option but to abandon breastfeeding. You may encounter these women and their babies in the emergency room, office or clinic. Knowing how to recognize and respond to early breastfeeding problems is our collective responsibility.

Common reasons that women give for discontinuing breastfeeding include nipple pain, perceived milk insufficiency and lack of support. These factors and their cures are addressed in the mini-primer below. My hope is that the primer will help you tend to the mothers and babies in your practice who are at risk for unnecessary cessation of breastfeeding.

As health care providers who are mindful of preventive medicine and the Healthy People 2020 goals, we strive to teach our at-risk patients about the benefits of portion control, good nutrition, and exercise. We know that it is important to advocate for the removal of poor-quality foods from school lunches, for the use of car seats and bicycle helmets, and for early intervention in mental illness or abuse.

We should add basic breastfeeding education and support to these advocacy efforts. Families who are inspired to make one positive decision or change for their children are often compelled to make another. By the same token, families who begin infant care with breastmilk may be more inclined to offer nutritious food to their toddlers and school-age children. As effective promoters and supporters of long-term breastfeeding, we can guide them on the path to health.

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Ms. Christian is a certified nurse midwife with the Prima Medical Group’s Midwives of Marin.

Email: emariec@comcast.net

A First Responder’s Primer for Early Breastfeeding Problems

Early and often

Putting babies to breast in the first hour after birth is linked to better and longer breastfeeding. Letting babies nurse as often as they desire will help mom make the right amount of milk.

Keeping mom and baby together

Mothers and babies need each other. Rooming in, baby wearing and sleeping in close proximity all help babies have the regular access they need to feed well and grow. Mom’s milk production is also in better sync when her baby is nearby.

Belly to belly

The goal is to position the baby so that its head and body are in line with the mother’s body. By approaching the breast directly rather than with its head turned towards the side, the baby is better able to get a good grasp of the areola for optimal milk transfer. This is easier to do if the baby is “skin to skin” or minimally wrapped so that mother and baby’s clothing do not create additional distance between the breast and mouth. Go ahead and gently rotate the baby so that it is facing the nipple. Easy and important!

A good latch

Babies are born to suck. With a proper latch at the breast, they can extract the right amount of milk, and mother should not feel any pain. The nipple should be deep in the mouth with the lips flanged out around the areola. You should be able to see--and may even hear--rhythmic sucking and swallowing.

Squished nose breathing is fine

Resist the urge to create an unnecessary “breathing space” between mother’s breast and baby’s nose. Gently dissuade the mother from doing the same. Babies can breathe just fine with their faces pressed into the breast, and this up-close connection helps them effectively remove milk. Using a finger to compress the breast will cause the baby’s mouth to slip to the tip of the nipple. This is painful for the mother and leads to an underfed, fussy baby. Complaints of nipple pain and unsatisfied babies are common reasons for premature cessation of breastfeeding.

Sleeping like a baby

Mothers who know what is normal about infant sleep patterns (irregular and sometimes short!) are better able to accept that frequent night-time waking and feeding is okay. Help them to understand that the term infant’s body clock doesn’t mature until 6-12 months. Therefore mothers should sleep when the baby sleeps (especially during the day or any long stretch), as this may save her sanity. Baby’s daytime naps are not a time to catch up on household chores. Mom should give those jobs to anyone who is willing.

Time to nurse

Babies have personalities, and just like us some are rapid gobblers, while others slowly graze. It is recommended that they nurse at both breasts each session to help stimulate milk production. Over time the baby will teach the mother how long this is going to take.

Once mom and baby have mastered the basics, 15-20 minutes per breast is typical. It is not uncommon for one nursing session to end just as the next one begins; this is called “cluster feeding.” The good news is that these back-to-back sessions just might lead to a lovely, long nap. You can usually recommend that the mother “follow the leader” (her baby) when it comes to length and frequency of feeds.

Frequency

Breastfeeding infants should nurse 8-12 times in 24 hours. This isn’t a schedule--it’s a guide. Every baby is unique. This nursing guide doesn’t begin until after the first 24 hours. It is perfectly okay and normal for the term, well baby to have a peaceful, long sleep after birth and then wake up feeling hungry the next day.

Don’t interrupt

Breastfeeding is a big job for a little brain, and babies need to focus. Extra noise and activity can be a distraction. Once mom and baby have finally achieved a functional latch, they shouldn’t be interrupted.

Stop confusing the mother

Imagine how you would respond if everyone you encountered gave conflicting advice about the right way to do your new job. Add fatigue, pain and a dose of self-doubt, and it would be even more daunting. No wonder new mothers “turn to the bottle” when we offer incorrect or confusing advice. Collaborate with your lactation consultants and colleagues and make sure everyone has the same script.

Happy baby

Everyone wants the baby to be happy and healthy. Include the grandparents, aunties, friends and visitors when you are teaching. It takes a village, and good news spreads! Extol the virtues of breastfeeding, acknowledge the mother’s labor of love, and praise the baby for being smart enough to know how to nurse!

Feeding the mother

Everyone wants to feed the baby--but that leads to missed sessions at the breast that can derail milk production in the early weeks. The best advice is to feed the mother instead. The people in her support system can do this by preparing meals, caring for her children, performing household chores, running errands and doing anything else she needs. This extra help will allow the mother to eat well and rest more, which will boost her milk production.

Compassion

Breast milk is more easily released when the mother is relaxed. Your kind words and gentle assistance go a long way with this patient.

Call the lactation consultant

If the tips and tricks above don’t get the desired results, you can call the lactation consultant. Busy ER doctors, surgeons or anyone caring for a breastfeeding mother or baby should have the  consultant’s number at the ready. At Marin General Hospital, it’s 415-925-7522.

For more information

Visit the La Leche League website at www.llli.org.

References

1. McVeagh P, “Human milk--there’s no other quite like it,” Pacific Health Dialog, 1:43-51 (1994).

2. Wall G, “Outcomes of Breastfeeding,” Evergreen Perinatal Ed, www.llli.org (2013).

3. Bernard JY, et al, “Breastfeeding duration and cognitive development at 2 and 3 years of age in the EDEN mother-child cohort,” J Pediatrics (Jan. 14, 2013).

4. Scholtens S, et al, “Breastfeeding, parental allergy and asthma in children followed for 8 years,” Thorax, 64:604-609 (2009).

5. U.S. Breastfeeding Committee, “Preventing obesity begins at birth through breastfeeding,” press release (Feb. 11, 2010).

6. MGH Lactation Center, www.maringeneral.org (2013).

7. AAP Policy Statement, “Breastfeeding and the use of human milk”, www.pediatrics.aappublications.org (2012).

8. Kramer MS, Kakuma R. “Optimal duration of exclusive breastfeeding,” www.onlinelibrary.wiley.com (2012).

9. Alade R, “Effect of delivery room routines on success of first breastfeed,” Lancet, 336:1105-7 (1990).

10. Mikiel-Kostyra K, et al, “Effect of early skin-to-skin contact after delivery on duration of breastfeeding,” Acta Paed, 91:1301-6 (2002).