KEY POINTS
- 1.
The female breast develops with chronologic maturation, during pregnancy, and with major physiologic/endocrine changes in preparation for lactation after delivery.
- 2.
Care providers need to begin preparing pregnant women for lactation during antenatal visits by providing information about the importance of breastfeeding and about early initiation of breastfeeding.
- 3.
After birth, skin-to-skin contact, initiation of feeding within the first hour, positioning, identification of the infant’s cues to start feedings, maintaining maternal-infant contact to promote bonding, and psychological support during the first hours can be helpful.
- 4.
Maternal-infant bonding, maternal motivation, and successful establishment of breastfeeding are important to form the necessary feed-forward cycle for feeding.
- 5.
For young mothers, education about posture, timing, and storage of milk and provision of information about the nutritional, immunologic, and other components is useful.
- 6.
There is increasing information that shows the universal impact of encouraging maternal feeding on infant health and survival.
Introduction
The female breast progressively develops with chronologic maturation. This process is further accelerated during pregnancy, when major physiologic/endocrine changes prepare the breast tissue for lactation after delivery ( Fig. 16.1 ). Hormones such as estrogen, progesterone, prolactin, and the placental lactogen augment proliferation and differentiation of the mammary glands ( Table 16.1 ). The first milk, the colostrum, is rich in energy and immunologic factors to prepare the newborn infant for independent existence. Over the next few days, the colostrum “matures” with increased volume and changes in various constituents. Colostrum contains factors that can protect the newborn infant against infections and many metabolic disorders. Increasing information suggests that it may be protective in disorders such as sudden infant death syndrome, which we are still trying to understand.
| Developmental Stage | Hormonal Regulation | Local Factors | Description |
|---|---|---|---|
| Embryogenesis | — | Fat pad necessary for ductal extension | Epithelial bud develops in fetus at 18–19 weeks, extending short distance into mammary fat pad with blind ducts that become canalized; some milk secretion may be present at birth |
| Mammogenesis | Anatomic development | ||
| Puberty | |||
| Before onset of menses | Estrogen, GH | IGF-I, hGF, TGF-β; others | Ductal extension into mammary fat pad; branching morphogenesis |
| After onset of menses | Estrogen, progesterone; PRL | Lobular development with formation of terminal duct lobular unit | |
| Pregnancy | Progesterone, PRL, hPL | HER; others | Alveolus formation; partial cellular differentiation |
| Lactogenesis | Progesterone withdrawal, PRL, glucocorticoid | Not known | Onset of milk secretion Stage I: midpregnancy Stage II: parturition |
| Lactation | PRL, oxytocin | FIL | Ongoing milk secretion |
| Involution | PRL withdrawal | Milk stasis; FIL | Alveolar epithelium undergoes apoptosis and remodeling; gland reverts to prepregnant state |
Preparation of the Mother for Breastfeeding
The care providers need to prepare the mother-infant dyad for lactation. , The effort starts during the antenatal visits, where the mother must be informed about the importance of breastfeeding and motivated for early initiation and various techniques to breastfeed. Maternal-infant bonding, maternal motivation, and successful establishment of breastfeeding forms a feed-forward cycle ( Fig. 16.2 ). Steps such as skin-to-skin contact ( Fig. 16.3 ), breast crawl, initiation of feeding as early as within the first hour, correct positioning, identification of the infant’s cues to start feedings, repeated opportunities for feedings, maintaining maternal-infant contact to promote bonding, monitoring for any difficulties in suckling, and psychological support during the first hours can be helpful. ,
To encourage active feedings, keeping the baby awake with skin-to-skin contact and gentle, affectionate stroking may be helpful. Mothers may also find it helpful to have some support in recognizing when to switch sides. The care providers can help the mother by ensuring adequate fluid intake. In this process, the fathers can contribute by arranging fluids of choice for the mother and by providing care to the baby when the mother begins to feel fatigued and needs rest. After a few attempts, both parents begin to recognize when the baby settles between feeds.
The infant should have 5 to 7 wet nappies in 24 hours. In the first few days, the stool color also changes from the darker meconium to a mustard-yellow appearance. It is not unusual for a baby to have 2 to 5 stools every day. It is usually an instance of great joy for the parents when the baby gains weight for the first time after the first few days.
Information That We Have Found Useful to Encourage Mothers
Most mothers find information on the physiologic benefits of lactation ( Fig. 16.4 ), healthy weight gain for the baby, and various nutritional and immunologic factors present in their milk to be very interesting and encouraging ( Table 16.2 ). Increasing information suggests that breast milk components, particularly specific types of fats, are ideal for the baby’s intellectual development. Mother’s milk may also be protective against the risk of chronic disorders including allergic disorders such as eczema, and in the longer term, diabetes and hypertension.
| Immune factors |
| Growth factors |
| Hormones |
| Enzymes |
| Nucleotides |
| Vitamins |
| Lipids |
| Mucins |
It is very comforting for the mother to know that her milk is all the nutrition the baby needs, including that needed to maintain hydration and to fulfill her/his needs for subcomponents of nutrition: proteins, fat, and carbohydrates. There is no need for any supplements.
Appropriate Postures for the Mother and Good Latch-on for the Baby
Information on the right posture should be provided, such as that the mother’s back is straight and well-supported and the lap and feet are flat; the mother can use a pillow to support her back and arms when she is raising baby to the level of her breasts. Some mothers, particularly when fatigued, at night, or those who have had to undergo a cesarean section, may find feeding easier while lying down. All these postures are shown in Fig. 16.5 . The consideration of posture(s) may be particularly important when feeding premature/critically ill infants who may be physically too weak to feed adequately. ,
The mother should try to hold the baby close to her, with her/his mouth facing the breast and close to the nipple and with the head, shoulders, and body in a straight line. The baby should be able to latch on to the breast with the mouth wide open and the nipple pointing toward the roof of this mouth. Her/his chin should be touching the breast. If the mother can see the areola, less should be visible below the bottom lip than the top one ( Fig. 16.6 ). When feeding premature infants, sometimes there may be a need to use devices such as nipple shields ( Fig. 16.7 ).
The sucking pattern should be with long, deep sucks with pauses. Feeding should not be painful. If it is, the mother may need to adjust the position of the baby. It is good to involve fathers. Most of the time, any discomfort felt by the mother is related to positioning while feeding or inadequate efforts to feed in terms of frequency. Babies differ in terms of their feeding patterns, and it may take a few days for the both the mothers and the baby to adjust. This is normal. The milk supply will also change to match the baby’s needs. If the baby looks hungry, the mother may just try to feed more frequently, and her body will adjust accordingly. Some of the difficult situations that may make lactation difficult and need supervision from a specialist are listed in Table 16.3 .
| Maternal chronic illness such as diabetes, cystic fibrosis, or sickle cell disease |
| Prior breast surgery |
| Obesity |
| Perinatal complications, cesarean section |
| Multiple births |
| Nipple injury, pain |
| Premature infants |
| Small-for-gestation infant |
| Large-for-gestation infant |
| Congenital anomalies in the infant, ranging from chromosomal errors to anatomic defects a |
| Infant with neurologic issues |
| Infants in the postoperative period for any reason |
| Infants recovering from birth asphyxia |
a One important, frequently encountered difficulty is in feeding infants with cleft lip/palate. These infants should be evaluated on an individual basis, based on the size and location of the baby’s clefts and the mother’s wishes and previous experience with breastfeeding ( Fig. 16.8 ). Most infants with cleft lip are able to generate at least some suction and may be able to feed successfully. Those with a cleft lip and palate may have difficulty generating enough suction. Some infants may be able to feed using a cup, spoon, or bottle, with the parents having to keep a close eye on the hydration and growth status of the infant. The families may be able to find some peer support from organizations such as Operation Smile. In some infants, modifications to breastfeeding positions may help.
Milk Expression
The mother may have to express milk using her hands or using a hand/electric pump (some of the equipment is shown in chapter 17 that is focused on milk storage). The mother may also consider doing so if the breast feels too full and engorged. Sometimes, there may also be a need to do so if she has to go back to work. She should just wash her hands, and also wash all the containers, bottles, and pump pieces in soapy water before use. In geographic regions or countries with warmer climates, it may be useful to sterilize the equipment with steam; the equipment is easily available.
To express milk, it may be easier to do so in quiet, private settings. , Some mothers find it easier to do so with a warm drink and with thoughts/pictures of the baby. Gently massaging the breast and rolling the nipples between the first finger and the thumb may help because it simulates the sensations that the baby would have provided during feeding. The nipple itself may be too sensitive, and it may be helpful to exert the pressure on the surrounding area. The milk may take a minute or two to flow. It may be useful to rotate the fingers around the nipple to ensure that all the sections can be emptied. After a few minutes, it may be easier to switch sides.
Some women find it more comfortable to use hand-held or electric breast pumps, particularly when the breasts are full. The pumps have a funnel that fits over the areola. These pumps may allow expressing milk from both sides at the same time and thus may add to the convenience. It may be useful to maintain a certain frequency, such as every 3 hours.
Milk Storage at Home
Milk can be stored at 2 to 4 degrees for up to 5 days. In warmer climate areas, some hospitals recommend freezing the milk if the mother needs to store it for more than 24 hours. , When freezing for occasional use at home, a plastic container can be used, although many authorities are now beginning to consider using a glass container because of the concerns with potentially soluble toxins in some plastic vessels. It may be useful to date and label each container.
Frozen milk should be thawed slowly by moving it to the refrigerator or to room temperature. Once thawed, it should be used immediately if possible; if the milk does not get used, it may be better to discard it. The use of a microwave to thaw milk is not recommended because of uneven heating, although there may not be major changes in the nutrient composition. It is also undesirable if the milk has been stored in plastic containers for the reasons mentioned above.
Nutritional Components in Human Milk
The nutrient composition of human milk is dynamic and changes within a feeding, during the course of a day, and throughout lactation and also differs between women. Components of human milk have multiple nutritional and immunologic functions. A reference tabulation of the composition of human milk comparing term and preterm milk 1 week after delivery is given in Table 16.4 . In the first few weeks after birth, milk from mothers who delivered prematurely contains more protein than does milk from those delivering at term, and the total protein content in both declines similarly to a plateau seen in “mature” milk. Milk protein content is not related to maternal diet but increases with maternal body mass index.
