Written by: Dr Jennifer Johnstone MRCGP DRCOG DFSRH Whether you are currently breastfeeding or are wanting to breastfeed then this article aims to give you accurate, evidence-based advice from a qualified health professional. Disclosure: The recommendations in this article are UK based and we would recommend for people to consult their own national health guidelines for localised recommendations. We support all parents and their choices, whether that’s breast, bottle or mixed feeding. Breastfeeding: Benefits, Nutrition and General Advice Breastfeeding can be a truly wonderful experience, and breastmilk provides the most ideal nutrition, as well as having many other benefits for your developing baby. Breastfeeding can also be very challenging, and most certainly requires good support to be successful and enjoyable for both mum and baby. This article aims to provide key information about: Breastmilk composition and why it is so unique Issues which mums can face, particularly in the early days of breastfeeding Some practical tips from professional and personal experience Advice on when and who to ask for help. How do we produce milk? The process of making milk is called lactogenesis and involves the maturation of cells in the breast. It is under the influence of hormones in the body which change through pregnancy and after delivery of the baby. Lactogenesis takes place in two stages, the first of which is called secretory initiation. This occurs during the second half of your pregnancy and is the reason why some women can produce small amounts of milk in pregnancy. Many women will take advantage of this and perform colostrum harvesting whereby you hand express tiny amounts of colostrum (first milk) from the breast and store this in syringes for when the baby is born. This is particularly useful if there are any issues with being able to breastfeed immediately, and is especially important for use in premature babies. The second stage of lactogenesis is called secretory activation and is triggered by hormonal changes after the placenta is delivered. This is when milk starts to be secreted. Why is breast milk so important to my baby? Breastfeeding has significant long-lasting benefits for both baby and for mum. Breastfed babies are at lower risk of infections, in particular, gastroenteritis, respiratory infections, and ear infections. For premature or sick babies, breastmilk is extremely important in preventing infections and a serious gastrointestinal condition called necrotising enterocolitis which carries a high mortality rate. Breastfeeding can also be protective against sudden infant death syndrome. Breastmilk contains the perfect balance of vitamins, proteins and fats that are very easily digested by babies. Importantly for newborn babies who are very susceptible to illness, it contains antibodies from the mother which help babies to fight off infection. In addition, it contains many other cells which help to develop a child’s immune system (immunoglobulins, white blood cells, lactoferrin) and a healthy gut microbiome (oligosaccharides). It contains stem cells, enzymes and growth factors, and it also contains hormones. Most notable of the hormones are leptin and oxytocin. Leptin is a hormone which tells your baby when he or she is full and therefore prevents overeating. Oxytocin is the key hormone involved in milk ejection or the “let down” reflex, and it brings about feelings of relaxation in both mum and baby. It may also enhance feelings of love between mum and baby and strengthen bonding with your baby. Breastmilk is a very dynamic fluid and the composition of it changes throughout the day, the night, the months and the years to meet your child’s needs. Its composition also varies between mothers and is tailor-made for your baby in response to what they specifically need. What are the benefits of breastfeeding for a mother? For a breastfeeding mother, there is a reduced risk of breast cancer and ovarian cancer, and some studies suggest a reduced risk of developing type 2 diabetes, obesity and cardiovascular disease. In the shorter term, breastfeeding helps with weight loss as breastfeeding burns on average an extra 500 calories a day. Breastfeeding also acts as a contraceptive. It is 98% effective at preventing pregnancy for the first 6 months after giving birth – known as the lactational amenorrhoea method. How long should I breastfeed for? The World Health Organization recommends that babies should be exclusively breastfed until approximately six months of age and weaning from breastfeeding after the age of two years. This has often been interpreted as breast milk having less or no benefits over the age of six months. However, breast milk adapts as children grow and develop and so not only does breastmilk continue to provide increased immune protection to the child, but the calorie content per feed increases and so they need feeding less frequently.Please do remember that any length of time you can breastfeed your baby for is fantastic and of great benefit to them. Recognising what works best overall for you, your baby and your life is what matters most, so try not to put too much pressure on yourself. Changes to your milk postpartum The first milk produced by the breasts is called colostrum. This is a thick sticky golden colour and is often referred to as “liquid gold”, not just because of its colour, but because of how important it is for a newborn baby in terms of its nutrients and protective factors. Colostrum is produced in very small volumes, but this is all that is needed for a newborn baby as their stomachs are only the size of a marble at this stage. Colostrum contains the same ingredients which later milk has, but the proportion of ingredients is different. The main difference is that colostrum has a high proportion of antibodies. This is so your baby receives what is sometimes called “natural vaccination” to protect them from infections and disease after they have left the protective environment of your womb. It also has higher concentrations of certain vitamins and proteins compared with mature breast milk. After two or three days postpartum, most women will experience swelling of the breasts due to the onset of copious milk production. This time is referred to as your milk “coming in” and is when the milk in your breasts is changing from small volume colostrum to higher volume mature milk. This can be quite an uncomfortable experience and there are a lot of old and new remedies which can provide some relief during this stage. One of the traditional methods, which I think is still a good one, is cabbage leaf compresses. Cool compresses before feeding and gentle breast massage can also be helpful. This discomfort tends to be short-lived, usually subsiding within 24 hours. How often should I breastfeed my baby? Lactation (the secretion of milk) is maintained through stimulation of the nipple and regular removal of milk, which is why it is important to offer frequent feeds to your baby. Breastfeeding “on-demand” (feeding your baby when they give cues they want to be fed) is one of the best ways to breastfeed, but do ensure that in the early days you don’t go longer than 3-4 hours between feeds. You should be feeding at least 8 times a day in the early days of breastfeeding. There are many apps now available which allow you to track your feeds (frequency and duration of feed) which can be really helpful when you first start breastfeeding as it can often be difficult to remember when you last fed, which breast was used etc. Once lactation is established and maintained, production is regulated by a supply and demand interaction. If milk is not removed, a protein builds up which inhibits lactation and reduces the production of milk. Conversely, if breastmilk is removed, the inhibitor is also removed and milk secretion will resume. The role of this inhibitor is to regulate the amount of milk produced. This is determined by how much the baby takes, and therefore by how much the baby needs. All babies feed differently – some feed more frequently than others, some feed for longer or shorter periods. Every woman is different in terms of their breast supply and the storage in each breast. Some women will need to feed more frequently than others, some babies will feed from both breasts, some from only ever one breast. Allowing your baby to feed when they need to will ensure your supply of breastmilk is tailored exactly to how they need it to be for them. How to make sure your breast milk production remains good Now we’ve covered the science part of breastmilk production, let’s now focus on the basic but essential things which are needed for you as a mum to ensure your milk production remains good. Eat a healthy balanced diet The production of milk is a big process in the body and burns a lot of calories in doing so – on average, around 500 calories a day! This means that you need to eat well whilst you’re breastfeeding in order to continue producing milk for your baby. Focus on trying to maintain a balanced diet but increase the amount of healthy fats as much as you can. Stay hydrated Hydration is also very important whilst breastfeeding. It’s likely you will often feel very thirsty whilst you’re breastfeeding. This is because you are losing a lot of fluid from your body via your breastmilk. If you don’t keep yourself well-hydrated, your body will struggle to produce a good volume of breastmilk which will then impact on what your baby receives. In the early days (when I was most thirsty!) I would always have glasses or bottles of water to hand, and I would take two or three bottles of water to bed with me at night. Overnight feeding was particularly thirsty work! Sleep, sleep, sleep The final important thing to help with milk production is to get as much rest as possible. Tired mums can struggle to keep up their milk supply. You really have to look after your body to be able to look after your baby, so as hard as it can be, do try and nap at any time possible. Unfortunately, the caveat here is that it is advisable to feed your baby at least once overnight because this is when the hormone prolactin is at its highest, and prolactin is the hormone responsible for milk production. What if my baby is struggling to feed? Bearing in mind what we’ve covered in terms of the factors involved in breastmilk production and maintaining supply, if you need to protect your milk supply (if baby is struggling to feed) or increase your supply then you have to consider each of these points in turn. Firstly, you need to continue removing milk from the breasts. If your baby is not doing it for whatever reason, then you will need to use a breast pump to remove the milk in order to encourage more production of milk. You may need to pump after you have breastfed to ensure all the milk has been removed after that feed. How do I increase my supply? You may also need to pump in between breastfeeds if you are wanting to increase your supply. Increasing your fluid intake (hydration status) and the amount of food you are consuming is important, as is getting as much rest as possible. Oats and fennel tea are good for increasing your supply, with the latter also being useful to treat colic in babies. Lactation cookies are not something I personally recommend because there isn’t a huge amount of evidence that these work. Oat based ones can be good because oats, in general, do help with your milk supply. My advice would be to have a nice bowl of porridge with your favourite toppings instead! The final bit of advice I have to increase your supply is to do lots and lots of skin-to-skin. This causes hormonal releases in mum which in turn stimulates milk production. What you must try to do throughout breastfeeding is trust your supply as much as possible. It’s very easy to worry you’re not producing enough milk for your baby. Some people may suggest in this instance that you give a bottle (of either previously expressed breastmilk or formula milk) to your baby to “top them up”, but this can, unfortunately, cause a number of issues. The things which can reassure you that your supply is, in fact, adequate are feeling full before a feed and flat or empty after it, leaking breasts; and in baby, you’re looking for them to be gaining weight and having frequent wet nappies. The problem with supplementing feeds when you don’t need to is that this doesn’t send the signal to your breasts that you need more milk for your baby, and in fact what will happen is that you start producing less milk. If you do give a bottle of milk in place of a feed for whatever reason, you should ideally pump during that feed to maintain your supply. What is a cluster feed? The time when most women worry most about their supply is in the early days of breastfeeding when babies cluster feed. Baby will be on and off the breast frequently for sometimes a few hours during the evening. This is normal behaviour and is your baby’s way of increasing your milk supply. It doesn’t mean your baby is starving and needs additional milk. As mentioned previously, if you fall into the trap of instead giving alternative milk you risk perpetuating a cycle of lower milk production by the breasts. What are the benefits of expressing milk? Expressing your milk can be a really useful thing to do for many reasons: Expressing can help to boost your milk supply. Conversely, you may need to express some milk if you are struggling with engorgement from oversupply of milk (more on this later). Having stores of expressed breast milk is great to have the option of you or somebody else giving a bottle of your milk so you can have a break or get some much-needed rest. It’s also very useful for if you’re not available for whatever reason, or if you’re unwell at any point. General advice from health visitors is not to pump for 6 weeks postpartum. This stems from concern that whilst you’re trying to get your breast milk supply established, pumping runs the risk of stimulating too much supply (which can lead to engorgement and other issues). In addition, there is a worry that giving bottles of milk whilst starting up breastfeeding will cause confusion for the newborn between the nipple of the breast and the teat of the bottle and can result in them not breastfeeding well. The risk with waiting too long before you give expressed milk in a bottle (if this is what you want to do) is that the baby might not take the bottle as they’re by then so used to the nipple. Some suggest that two weeks postpartum is enough time to minimise the risk of nipple/teat confusion but to ensure baby will take a bottle when you want or need them to. How can I express milk? There are many ways to express your milk: You can hand express Use a silicone let down pump (haakaa or naturebond are the most famous of these) Use a manual pump Use one of the many electronic pumps available on the market. With the electronic pumps you have the option of single (one breast at a time) or double (both breasts) pumps, some are mains powered, some are battery-powered. Some pumps allow you to express directly into a bag (for storage) or a bottle (to then give to baby later). Before you buy, it’s worth doing a little bit of research into what you think might work best for you and your lifestyle because some pumps can be very expensive. Where can I store breast milk? All breast pump manufacturers tend to have their own guidance on how to pump, store milk, sterilise bottles and reheat your milk. It’s really important that you follow the instructions carefully to avoid getting bacteria into your milk. A rule of thumb with storing breast milk is that it can be stored at room temperature (freshly expressed) for up to 6 hours, in the refrigerator for up to 6 days, and in the freezer for up to 6 months. Who can help if I am struggling with breastfeeding? At the start of this article, I made reference to the fact that breastfeeding can be challenging for many reasons. If you are ever struggling with breastfeeding, I would really urge you to get some help from a healthcare professional experienced in breastfeeding support. If you give birth in hospital, before you leave, try to ensure that somebody watches you doing a full feed with your baby and if you have any concerns at all, keep asking for support before you’re discharged. Your hospital should have a nurse or midwife available who is trained to support women with breastfeeding. At home, if there are any concerns you can speak to your health visitor, your family doctor (although be mindful they may not have had a lot of training in breastfeeding support), a lactational consultant, or a la leche league counsellor. What are the most common problems with breastfeeding? The most common problems with breastfeeding, particularly in the early days are to do with the baby having a good latch and good positioning. A poor latch can cause terrible nipple pain for mum, can lead to blocked milk ducts and mastitis, and can mean that baby struggles to get a full supply of milk resulting in poor weight gain. How do I get my baby to latch properly? A “good latch” is a way of describing the optimum way the baby attaches his or her mouth onto the breast. A good latch is when the baby takes a big mouthful of the breast as well as the nipple into the mouth as this allows for the nipple to fall deeper into the baby’s mouth and not rub against the roof of their mouth or their tongue. If you have a good latch your nipple should look maybe just a little longer after a feed, but shouldn’t be abnormal in shape e.g. a lipstick shape. The “flipple technique” is worth looking up if you feel you are continuing to have latch issues as this shows an exaggerated version of what a normal latch should be like. Remember that if you are struggling with latch difficulties, it is really important to express your milk regularly in order to maintain your milk supply. Breastfeeding is a new skill for both you and baby and so it can take a bit of practice to get baby latching correctly and to feel comfortable with breastfeeding. This is why if you have the opportunity for somebody experienced to watch your baby latch on and feed then please take it. Medical conditions and how they affect breastfeeding A medical condition which can really hinder the chance of your baby having a good latch is if they have a tongue or lip tie. Tongue-tie (ankyloglossia), is characterised by a tight lingual frenulum, the piece of tissue that anchors the tongue to the bottom of the mouth. A lip tie is an unusually tight labial frenulum, the piece of tissue that keeps the upper lip tethered close to the gum line. Tongue and lip can often occur together. Some babies with tongue or lip ties are still able to feed well, but for others, it causes poor latch and consequently nipple pain for mum, and poor weight gain in baby because of reduced milk intake. Ties can be treated by a relatively straightforward procedure which involves cutting the tight piece of tissue that is causing the restriction. It is, however, worth me stressing here that there are lots of causes for nipple pain and for poor latching, so again, do ask for help if you are struggling with these issues so that the correct diagnosis can be made to give you the best support. Tips for feeding Ensure when you are feeding that you’re in a good position which allows you to hold your baby comfortably, as feeding can take some time. There are many ways of holding your baby to feed. The commonest is a cradle or cross-cradle hold, but there is also laid back breastfeeding, rugby or football hold, and side-lying hold. Some positions lend themselves to particular situations. For instance, laid back feeding (or even just leaning back whilst you feed) can help if you have a fast let-down of milk. A fast let-down can make feeding difficult for your baby as they struggle with the fast flow of milk and might start coughing and spluttering with it. Another tip for fast let-down is to hand express some milk off before you feed, or allow some of the milk to flow into a muslin before you let baby take the milk. Side-lying hold is good for feeding in the middle of the night as you can remain lying down in bed whilst baby feeds. As long as breastfeeding feels comfortable and your baby is feeding well, it doesn’t matter which position you prefer to choose. Some women can experience a delay with their milk coming in. There are lots of reasons why this might be, but it is more often seen in those who have had a complicated birth or other issues whereby mother and baby are not together and feeding frequently. A lot of hospitals now have staff available (nursery nurses/NICU nurses) who are trained in breastfeeding support and should be accessible to help in situations where a mother wants to breastfeed but there are these difficulties. Do ensure you get this support and don’t allow anybody to suggest that your only option is to formula feed. Another issue you might encounter in the first few weeks of breastfeeding is giving baby too much foremilk. Breastmilk is made up of foremilk (first part of the feed) and hindmilk (received towards the end of the feed). If you have a high supply of milk (over-supply) it will eventually adjust over time to meet the needs of your baby better. Whilst this adjustment is happening, your baby might take an excess of foremilk. This is called foremilk-hindmilk imbalance. Foremilk has a lot of lactose within it which can be difficult for babies to digest. This can sometimes cause the baby to be a bit fussy and uncomfortable, and cause green frothy nappies. The other time this imbalance can happen is if you continually take your baby off the breast before they have finished their feed as they will only receive the first parts of the milk (foremilk). Please note that green nappies and fussiness in your baby can also be possible signs of other intolerances so it is always worth seeking advice. Nipple pain when breastfeeding We’ve discussed a poor latch as a cause of nipple pain, but there are other causes of this which are worth considering. First of all, I must make it clear that you should have some expectation that your nipples will be sore for at least the first few weeks of breastfeeding. Even with the most perfect latch, there will be discomfort. It’s very unlikely that your nipples have ever had a little suction device on them at least 8 times a day for up to 40 minutes at a time, so this new experience will not be comfortable and it will take time for your nipples to get used to this. That said, it is not normal to have cracked or bleeding nipples. It is also not normal to have intense nipple pain which persists throughout a feed, as opposed to just at the start of the feed. This can indicate nipple thrush or other infections which requires treatment. Milk blisters or blebs are another cause for nipple pain. A milk blister is when one of the tiny openings on your nipple gets blocked with thickened milk or a layer of skin. This can be really uncomfortable and it can often be difficult to see the blister clearly. It tends to look like a very small white spot. You can treat this by applying lanolin or some olive oil on a cotton pad to try and soften the area, then frequent feeding and/or pumping can help. Sometimes you might need to deroof the blister with a sterile needle. If you think you have any of these nipple issues then please do speak with your family doctor or health visitor. My advice from day 1 of breastfeeding is to use all the lanolin you can get your hands on! A nice thin layer after every feed will give some protection to your nipples. There are also nipple compresses which you can place over the nipples and wear for short periods which are a more intense treatment to soothe the nipples. Healing cups (silverette) and gel discs (hydrogel or jelonet) are available too. If you have ongoing difficulties, there are nipple shields which can help to allow you to continue feeding your baby and many women successfully use these. Blocked milk ducts and mastitis Your milk ducts can become blocked if your baby is not fully emptying the ducts when feeding or if you aren’t feeding frequently enough. The blocked duct means that milk builds up in that area and this causes a lot of pressure and discomfort. The blocked duct area of the breast may feel quite hard. It is important to clear duct blockages as soon as possible as leaving them risks the development of mastitis. Mastitis is a painful inflammatory condition of the breast which may or may not be accompanied by infection. It is usually extremely painful and can cause you to feel quite unwell in yourself generally. It can lead to breast abscesses and sepsis and is, therefore, something you should see a doctor about immediately. To clear a blocked duct there are lots of different things you can do. Try to massage the area which feels firm (from the outer edge of the area massaging towards the nipple), apply heat to the area before massaging and before feeding, try to get your baby to feed more frequently and aim their chin towards the area of blockage whilst feeding. Pumping can also help clear the blockage, as can holding an electric toothbrush over the firm area. Lecithin capsules are a good option if you have recurrent blocked ducts. Mastitis requires all of the above manual treatment options, but in certain circumstances may require antibiotic treatment and this is why seeing your doctor is important. It is also worthwhile taking simple analgesia (paracetamol and ibuprofen) to help reduce discomfort and inflammation. Do breastfed babies sleep worse compared to formula-fed babies? The last focus of this article is regarding the myth that breastfed babies don’t sleep very well compared to formula-fed babies, and that breastfed babies don’t sleep through the night. Although the total number of awakenings may differ, studies have shown that there is, in fact, no difference in the total amount of sleep duration between breastfed and formula-fed babies. Similarly, despite experiencing a greater number of awakenings, research suggests that breastfeeding mothers get the same amount of sleep or more sleep overall compared to formula-feeding mothers. There has been however a difference in the reported amount of sleep by parents, with formula-fed parents overestimating the amount of sleep their babies were having. A study in 2011 concluded that breastfeeding mothers, in fact, report longer total sleep time, more daily energy and better physical health than those mothers mixed or formula feeding. Many people suggest that formula feeding, or even just a bottle of formula milk before bed will help your baby sleep better through the night. There is not any evidence to support this claim, but there might be some truth in a bottle of milk (breastmilk or formula) helping babies to sleep a little longer at night. The reason behind this is that in the evenings of cluster feeding and when you’re feeling tired, you are unlikely to be producing large volumes of milk. In addition, a tired baby won't be sucking as hard to take the milk. Some find that a bottle of expressed milk has a good effect because you can potentially give a higher volume of milk and baby can take this easier later at night. To finish, I wanted to share with you some of my favourite websites, which have an abundance of information about everything to do with breastfeeding: https://www.kellymom.com https://breastfeeding.support https://www.breastfeedingnetwork.org.uk http://www.human-milk.com/natural.html ------------- Bibliography 1. Victora, C.G. et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet Volume 387 Issue 10017, pages 475-490 (2016) 2. Riskin, A. et al. Changes in immunomodulatory constituents of human milk in response to active infection in the nursing infant. Pediatric Research Volume 71, pages 220–225 (2012) 3. Pillay J, Davis TJ. Physiology, Lactation. (2018). In: StatPearls [Internet]. Pubmed. https://www.ncbi.nlm.nih.gov/books/NBK499981/ 4. Kendall-Tackett, K. et al. The Effect of Feeding Method on Sleep Duration, Maternal Well-being, and Postpartum Depression. Clinical Lactation Vol 2 Issue 2, pages 22-26 5. Rudzik, A. et al. Discrepancies in maternal reports of infant sleep vs. actigraphy by mode of feeding. Sleep medicine Vol 49, pages 90-98 (2018) 6. Gay, C. et al. Sleep Patterns and Fatigue in New Mothers and Fathers. Biological research for nursing. Apr; 5(4): pages 311-318 (2004) 7. Doan, T. et al. Nighttime breastfeeding behavior is associated with more nocturnal sleep among first-time mothers at one month postpartum. Journal of Clinical Sleep Medicine; 10(3): pages 313-319 (2014) --------------- About the Author: Dr Jennifer Johnstone MRCGP DRCOG DFSRH Jennifer is a salaried GP in London with a keen interest in both women’s health and sexual health. She had her first child in January of this year and has been navigating the ups and downs of motherhood ever since. She feels that becoming a mum and truly understanding first hand some of the many challenges with breastfeeding and raising a child has really enhanced the medical knowledge she had before starting her journey into motherhood.
