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Breastfeeding--Starting Out Right
by Jack Newman, MD, FRCPC
Breastfeeding is the natural and normal way of feeding infants and young children, and human milk is the milk made specifically for human infants. A good start helps to ensure breastfeeding is a happy experience for both mother and baby; Breastfeeding should be easy and trouble free for most mothers.
The vast majority of mothers are perfectly capable of breastfeeding their babies exclusively for about six months. In fact, most mothers produce more than enough milk. Unfortunately, outdated hospital policies and routines based on bottle feeding still predominate in too many health care institutions and make breastfeeding difficult, even impossible, for too many mothers and babies. For breastfeeding to be well and properly established, a good start in the early few days can be crucial. Admittedly, even with a terrible start, many mothers and babies manage.
The trick to breastfeeding is getting the baby to latch on well. A baby who latches on well gets milk well. A baby who latches on poorly has more difficulty getting milk, especially if the supply is low. A poor latch is similar to giving a baby a bottle with a nipple hole that is too small-the bottle is full of milk, but the baby will not get much. When a baby is latching on poorly, he may also cause the mother nipple pain. And if he does not get milk well, he will usually stay on the breast for long periods, thus aggravating the pain. Unfortunately anyone can say that the baby is latched on well, even if he isn't. Because of mixed messages about breastfeeding from everything a mother reads to numerous publications and too little education, many people just don't know what a good latch is, and so breastfeeding can get off to a poor start. Here are a few ways breastfeeding can be made easy:
- The baby should be at the breast immediately after birth. The vast majority of newborns can be at the breast within minutes of birth. Indeed, research has shown that, given the chance, many babies only minutes old will crawl up to the breast from the mother's abdomen, latch on, and start breastfeeding all by themselves. This process may take up to an hour or longer, but the mother and baby should be given this time together to start learning about each other. Babies who "self-attach" run into far fewer breastfeeding problems. This process does not take any effort on the mother's part, and the excuse that it cannot be done because the mother is tired after labour is nonsense, pure and simple.
- The baby should be kept skin to skin with mother as much as possible immediately after birth and for as long as possible in the first few weeks of life. Incidentally, studies have also shown that skin-to-skin contact between mothers and babies keeps the baby as warm as an incubator (see section on skin to skin contact). It is true that many babies do not latch on and breastfeed during this time but generally, this is not a problem, and there is no harm in waiting for the baby to start breastfeeding. The skin to skin contact is good and critically important for the baby and the mother even if the baby does not latch on.
- The Skin to Skin contact helps to regulate many important things for baby: breathing rate, heart rate, oxygen saturation, body temperature, and blood sugar. Furthermore, there seems to be some good evidence to support that that the more babies are kept skin to skin in the first few days and weeks of life (not just during the feedings) the more brain development they will have. A proper latch is crucial to success. This is the key to successful breastfeeding. Unfortunately, too many mothers are being "helped" by people who don't know what a proper latch is. If you are being told your two-day old baby's latch is good despite your having very sore nipples, be sceptical, and ask for help from someone else who knows. Before you leave the hospital, you should be shown that your baby is latched on properly, and that he is actually getting milk from the breast and that you know how to know he is getting milk from the breast (open mouth wide-pause-close mouth type of suck). See also the website www.drjacknewman.com for videos on how to latch a baby on (as well as other videos). If you and the baby are leaving hospital not knowing this, get experienced help quickly (see handout When Latching). Mothers are often told that if the breastfeeding is painful, the latch is not good (usually true), so that the mother should take the baby off and latch him on again. This is not a good idea. Instead of delatching and relatching, fix the latch that you have as best you can; the pain usually settles regardless. Then, the latch should be fixed on the other side or at the next feeding. Taking the baby off the breast and latching him on again and again only multiplies the pain and the damage.
- The mother and baby should room in together. There is absolutely no medical reason for healthy mothers and babies to be separated from each other, even for short periods, even after caesarean section.
- Observation: Health facilities that have routine separations of mothers and babies after birth are not current with the evidence. Often, unreasonable excuses are given why baby should be separated from the mother. One example is that the baby passed meconium before birth. A baby who passes meconium and is fine a few minutes after birth will be fine and does not need to be in an incubator for several hours' "observation".
- Separation: There is no evidence that mothers who are separated from their babies are better rested. On the contrary, they are more rested and less stressed when they are with their babies. Mothers and babies learn how to sleep in the same rhythm. Thus, when the baby starts waking for a feed, the mother is also starting to wake up naturally. This is not as tiring for the mother as being awakened from deep sleep, as she often is if the baby is elsewhere when he wakes up. If the mother is shown how to feed the baby while both are lying down side by side, the mother is better rested.
- Feeding cues: The baby shows long before he starts crying that he is ready to feed. His breathing may change, for example. Or he may start to stretch. The mother, being in light sleep, will awaken, her milk will start to flow and the calm baby will be content to breastfeed. A baby who has been crying for some time before being tried on the breast may refuse to take the breast even if he is ravenous. Mothers and babies should be encouraged to sleep side by side in hospital. This is a great way for mothers to rest while the baby breastfeeds. Breastfeeding should be relaxing, not tiring.
- Bathing: Bathing the baby should be delayed for as long as possible after birth, and at least until the mother and the baby have had a chance to get breastfeeding well started, with baby coming to the breast and latching easily.
- Artificial nipples should not be given to the baby. TThere seems to be some controversy about whether "nipple confusion" exists. Babies will take whatever gives them a rapid flow of fluid and may refuse anything else. Thus, in the first few days, when the mother is normally producing only a little milk (as nature intended), and the baby gets a bottle (as nature intended?) from which he gets rapid flow, the baby will tend to prefer the rapid flow method. You don't have to be a rocket scientist to figure that one out. Note, it is not the baby who is confused. Nipple confusion includes a range of problems, including the baby not taking the breast as well as he could and thus not getting milk well and/or the mother getting sore nipples. Just because a baby will "take both" does not mean that the bottle is not having a negative effect. Since there are now alternatives available if the baby needs to be supplemented (see handout Using a Lactation Aid and handout Finger and Cup Feeding), why use an artificial nipple?
- No restriction on length or frequency of breastfeedings. A baby who drinks well will not be on the breast for hours at a time. Thus, if he is, it is usually because he is not latching on well and not getting the milk that is available. Get help to fix the baby's latch, and use compression to get the baby more milk (See handout on Breast Compression). Compression works very well in the first few days to get the colostrum flowing well. Do note, babies often cluster feed in the first few days of life-this is normal and temporary. Latching a baby well, using compressions, and maintaining skin to skin contact between mother and baby helps this transitional period to go smoothly.
- Supplements of water, sugar water, or formula are rarely needed. Most supplements could be avoided by getting the baby to take the breast properly and thus get the milk that is available. If you are being told you need to supplement without someone having observed you breastfeeding, ask for someone to help who knows what they are doing. There are rare indications for supplementation, but often supplements are suggested for "convenience" or due to outdated hospital policies. If supplements are required, they should be given by lactation aid at the breast (see handout Lactation Aid), not cup, finger feeding, syringe or bottle. The best supplement is your own colostrum. It can be mixed with 5% sugar water to extend the colostrum you have if you are not able to express much at first. Formula is hardly ever necessary in the first few days.
- Free formula samples and formula company literature are not gifts. There is only one purpose for these "gifts" and that is to get you to use formula. It is very effective, and it is unethical marketing. If you get any from any health professional, you should be wondering about his/her knowledge of breastfeeding and his/her commitment to breastfeeding. "But I need formula because the baby is not getting enough!" Maybe, but, more likely, you weren't given good help and the baby is simply not getting the milk that is available. Even if you need formula, nobody should be suggesting a particular brand and giving you free samples. Get good help. Formula samples are not help.
Under some circumstances, it may be impossible to start breastfeeding early. However, most "medical reasons" (maternal medication, for example) are not true reasons for stopping or delaying breastfeeding, and you are getting misinformation. Get good help. Premature babies can start breastfeeding much, much earlier than they do in many health facilities. In fact, studies are now quite definite that it is less stressful for a premature baby to breastfeed than to bottle feed. Unfortunately, too many health professionals dealing with premature babies do not seem to be aware of this
Not latching/Not breastfeeding: If for some reason baby is not taking the breast, then hand expression should be started within 6 hours or so after birth, or as soon as it becomes apparent baby will not be feeding at the breast.
Questions? see my book Dr. Jack Newman's Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA)
Handout #1. BreastfeedingStarting Out Right. Revised May 2008
Written and Revised by Jack Newman, MD, FRCPC 1995-2005
Revised by Edith Kernerman, IBCLC, and Jack Newman, MD, FRCPC © 2008
May be copied and distributed without further permission on the condition that it is not used in any context in which the WHO code on the marketing of breastmilk substitutes is violated.
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