This section aims to provide you with impartial, evidence-based information to help support you with breastfeeding your new baby. There is practical information and guidance as well as, some handy tips to help you should you find that breastfeeding is not going quite as smoothly as you had anticipated. We would like to reassure you that this section has been written in a context that fully respects and supports parents’ decisions about how they wish to feed their baby whilst being supportive of babies receiving breast milk whenever this is possible.
The health benefits of breastfeeding
Breastfeeding is important for many reasons not just for nutrition. ANY breastfeeding at all, even just one breastfeed soon after your baby’s birth, is incredibly valuable for their health and wellbeing.
For baby: Research studies show us that compared with those babies who are fully breastfed for four to six months, formula fed babies have increased risks of illness from:
- Gastroenteritis – formula fed babies have an increased incidence of hospital admissions because of diarrhoea or prolonged bouts of diarrhoea
- Respiratory (chest) infections – formula fed babies have an increased risk of having severe ‘wheezy’ illnesses and hospital admissions because of chest infections (respiratory disease)
- Atopic disease (allergies) – formula fed babies have an increased incidence of developing asthma or eczema if their family members have a history of allergies
- Otitis media (ear infection) – Formula fed babies have double the risk of developing an ear infection (eg glue ear) than babies who are breastfed
- Urinary tract infections (urine/’wee’ infections) – Formula fed babies are at greater risk of developing urinary tract infections (UTIs) than breastfed babies
- Necrotising enterocolitis (NEC) – Babies who are born prematurely (preterm) and formula fed have a substantially increased risk of developing NEC, compared with breast fed babies who are born prematurely
- Breastfeeding has been shown to protect babies against high blood pressure and raised cholesterol levels in their adult life. Both of these conditions have implications for longer term cardiovascular (heart and blood circulation) health
- Breastfeeding has been shown to protect children against obesity; research has shown that formula fed babies are more likely to become obese (overweight) as children and adolescents
- Formula fed babies have a reduced ability to produce antibodies to help fight off infections. Research has shown that formula fed babies have a poorer general immune system than breastfed babies
- Breastfed babies have been found to have better eyesight compared with formula fed babies who have been found to have poorer visual acuity (ie stereoscopic vision)
- Research has found that breastfed babies have higher developmental performance and educational achievement (intelligence/IQ scores) than formula fed babies
- The risk of Sudden Infant Death Syndrome (SIDS) (also called ‘Cot Death’) appears to be higher amongst formula fed babies, although the findings of research studies are inconsistent
- Studies have found that formula feeds are often incorrectly prepared, being made too concentrated or too diluted with serious implications for the baby’s health and wellbeing. Similarly, formula feeds can be overheated (particularly when microwave ovens are used), which can cause burns to the baby’s mouth and throat. The Department of Health and Food Standards Agency has issued guidance on the correct and safe preparation of infant formula feeds. You are likely to have been provided with a copy of this leaflet by your midwife or Health Visitor; if you have not, they will be able to provide you with one.
For mother: Research studies show us that breastfeeding confers significant health benefits on mothers too. Women who breastfeed have been found to be significantly less likely to develop:
- Breast cancer
- Cancer of the ovaries (ovarian cancer)
- Breastfeeding women are at reduced risk of osteoporosis (thinning of the bones) and post-menopausal hip fractures.
- They may also have a reduced risk of developing type 2 diabetes.
- Breastfeeding burns off an extra 500 calories a day, so breastfeeding mothers tend to lose some of the weight gained during pregnancy more quickly; it also helps the womb to return to its pre-pregnant size (in the pelvis) sooner!
Breastfeeding is a skill
The first thing to remember is that breastfeeding is actually a ‘skill’ that needs to be acquired. It is often nowhere near as easy as the books make out. It is natural in so much as women have mammary glands (breasts) which lactate (produce milk) and babies, born around their due date, have a ‘sucking reflex’. This means that if you introduce the pad of a small finger tip into the roof of your baby’s mouth, they will begin sucking on it. However, breastfeeding actually takes around five weeks to establish and both you and your baby will be on a steep learning curve together. Your baby needs to learn to get a sufficient mouthful of your breast so that they can suckle and work for your breast milk. Whereas, for mothers, it’s all about dexterity and learning to cope with just the one pair of hands! The important thing is to ask your midwife, health visitor or local breastfeeding counsellor for help… remember there are no silly questions – the only silly question is the one you never ask!
How does breastfeeding work?
The whole breast, not just the nipple, is involved in breastfeeding. We have included a diagram which shows a cross-section of the human breast to help explain this (See Diagram 1). Your breast milk is made in the acini cells and the myoepithelial cells then squeeze the breast milk out of the acini cells and into the milk ducts. Breastfeeding your baby as frequently as possible will help to ensure that your acini cells are primed to set up a good milk supply in the longer term. Therefore, your midwives will encourage you to breastfeed your baby whenever they want to feed throughout the day and the night.
There are two major hormones that regulate breastfeeding; these are ‘prolactin’ and ‘oxytocin’ and their combined action is described as the ‘endocrine effect’.
Prolactin – This hormone stimulates your breasts to produce breast milk; however, its action is inhibited by the pregnancy hormones circulating around your body in pregnancy. Once your placenta (after birth) has been delivered, your pregnancy hormone levels begin to fall and this enables your breasts to start lactating.
Oxytocin – This hormone stimulates the ‘myoepithelial cells’ to contract and transport the milk from the ‘acini cells’ into the milk ducts, where the baby can then remove it by suckling. When your baby is breastfeeding this action stimulates the release of oxytocin which causes the ‘let down reflex’ or ‘milk ejection reflex’ to occur so that your baby can receive your breast milk. Oxytocin levels are higher when mother and baby remain close to each other and when new mums feel relaxed and safe. However, if you and your baby are separated because, for example, your baby needs to be cared for on the Neonatal Unit, you will be encouraged to express your breast milk for them. Expressing your milk by hand or by using a breast pump can seem artificial compared with having your baby feed from the breast. There are however, strategies that can help – looking at a photograph of your baby, or holding an item of their clothing can help to make you feel physically closer to your baby and will help stimulate the ‘let down reflex’.
NB. Some mothers can find the ‘let down reflex quite uncomfortable, describing it as a burning-type or sharp pain; however, this is a very individual sensation and others will not feel anything. Similarly, as your body becomes used to nursing your new baby, this sensations tends to subside and/or becomes less noticeable. Oxytocin is also the hormone that stimulates uterine (womb) contractions during labour and afterwards; this is why mothers often experience ‘after pains’ while they are breastfeeding their baby. After pains help mothers’ bodies to return to their pre-pregnancy state a lot quicker! (See our section on ‘Coping with After Pains’).
Will I be able to produce enough milk for my baby?
Unlike Perspex feeding bottles, women’s breasts are not transparent and consequently new mums often worry that their baby isn’t getting sufficient milk. This is particularly so, during the first three days post birth when the first milk – ‘colostrum’ is present. It can be helpful to remember that 98% of women are able to breastfeed successfully, so please do have confidence in your body’s abilities. Breastfeeding also works on the basis of ‘supply’ and ‘demand’. This means that your breasts will produce all the milk that your baby needs. The composition of your breast milk will also alter to meet your baby’s changing nutritional needs. Breast milk is designed specifically for babies and is very easily absorbed, so it is the ideal food to support your baby’s growth and development. It contains all the nutrients that your new baby needs and in the right amounts.
Breastfeeding is often described as being ‘responsive feeding’. This means breastfeeding is baby-led ie the baby feeds whenever they want to, for as long as they want to. This encourages the relationship between the new mother and her baby (called ‘attachment’ and ‘bonding’) and also encourages intuitive feeding. Responsive feeding involves offering your baby the breast for comfort as well as for food. It encourages mothers to feed their baby when their baby is demonstrating early ‘feeding cues’:
The following are all feeding cues:
- your baby moves their eyes rapidly in their sleep (R.E.M visible under their eyelids)
- puts their fingers into their mouth
- sucking on their fingers/blankets/anything!
- your baby starts ‘rooting’ (opens their mouth as if to breastfeed)
- they start to poke their tongue out and/or lick their lips
- becomes generally restless
- your baby makes soft cooing noises.
NB. When your baby is crying this is almost ‘too late’; this is because it is more difficult to breastfeed a distressed baby. Keeping your baby close to you helps you to recognise your baby’s feeding cues much earlier. This is why the maternity staff on hospital postnatal wards will always encourage mothers to keep their babies with them at all times. Responsive breastfeeding also encourages new mothers to breastfeed their baby when their baby is distressed, feeling lonely and wanting a cuddle, and when the mother’s breasts are feeling full of milk.
How long should a good breastfeed last?
A breastfeed can be anything from 10 minutes to over 40 minutes – your baby may want a quick snack or drink (remember breast milk is both a food and a fluid!), or they may want a three-course dinner! When your baby has had enough they usually fall asleep, often with your nipple still in their mouth or they may push the nipple out of their mouth; or may make small fluttering sucks.
Remember: It is impossible to over-breastfeed your baby, so don’t be afraid to offer a feed whenever they seem interested in suckling at the breast. Thirty years ago it was common practice to restrict the amount of time that a baby breastfed, but research has shown us that this is not good for you or your baby. Breastfeeding needs to be baby-led and it is perfectly normal and healthy for a breastfed baby to have a more varied feeding pattern. Similarly, if breastfeeding is restricted, this will have a negative impact on the mother’s milk supply, or could result in breast engorgement – this is where the breasts become over full with milk. (See our section on ‘Common breastfeeding problems’).
The first few days
Immediately after your baby has been born they are often very alert and keen to feed. The midwives will encourage you to cuddle your baby skin-to-skin as soon as possible post birth to encourage this. During the first 24 hours your baby’s feeding is likely to be quite erratic with infrequent breastfeeds; however, during the next 24 hours after that, they begin to feed a lot more frequently in order to set up a good milk supply. A lot of new mothers often mistake a wakeful night with lengthy breastfeeds as meaning they do not have sufficient milk for their baby; however, this is not the case at all.
Breast milk is designed specifically for newborn babies and is very easily absorbed into the digestive tract, so there is very little wastage. This is why breastfed babies don’t have their bowels open as often (‘poo’) as much as formula fed (bottle fed) babies. Similarly, your baby’s stomach is actually very small – around the size of a very small marble.
The first breast milk – Colostrum
‘Colostrum’ is rather like ‘the cream at the top of the milk’ – it is very concentrated and often a ‘yellow’ colour. It is very concentrated, so there isn’t very much of it, but it provides your baby with all the nutrition they need until the milk comes in. Colostrum is also full of antibodies that strengthen your baby’s ability to fight off any infections! Your baby will want to feed for long periods at a time; however, each time they breastfeed, it is encouraging your milk to come in. Most mothers’ find that their breast milk comes in around day three to four post birth; however, this can be delayed a little if you have had a caesarean birth or are anaemic.
Once your breast milk comes in, you will find that your baby feeds for a shorter length of time at the breast, but they will be getting a larger volume of breast milk each time. Breast milk is a lot thinner than colostrum. You may hear your baby gulping down the breast milk!
You may also begin to notice that a feeding pattern starts to emerge – there will be times when your baby wants to feed more frequently (often this is in the evenings) and there will be other times when your baby wants to feed less often. However, you should expect your baby to want to breastfeed at least 6-8 times during each 24 hour period, although they may well want to feed more frequently. Don’t panic if you notice that the length of time your baby feeds at the breast varies quite a lot. Breast milk is a food and a fluid, so there will be times when your baby wants a drink or a quick snack and will feed for only a few minutes, and there will be other times when they are hungry and will want to feed for much longer. Don’t forget that breastfeeding also provides warmth, comfort and precious time to bond/attach with your baby.
Don’t lose confidence in your body – 98% of women are able to breastfeed. Your body will produce all the milk that your baby needs!
How do I know that my baby is feeding well?
The midwives will show you how to position and attach your baby at the breast. There are lots of different positions to try and you will soon find which one(s) you feel most comfortable using. The important things to look out for are that:
- Your baby should be facing towards the breast with their nose level with your nipple; this enable them to get a good mouthful of breast from under the nipple
- Baby’s head and body should be in a straight line, so they can swallow easily
- Holding your baby close to you; support your baby’s neck, shoulders and back
- Babies attach to the breast asymmetrically and need to be able to tilt their head backwards
- Allow the nipple to brush your baby’s top lip
- When your baby opens their mouth wide, you should bring them swiftly to the breast, aiming to get as much of the breast into the roof of their mouth. You should not try to put your breast into your baby’s mouth
There are other signs to look out for which indicate your baby is feeding well:
- Your baby has a large mouthful of your breast
- If you can see your areola (the dark skin around the nipple), you should see more of the areola above your baby’s top lip than below their bottom lip
- Your baby’s chin is in contact with/resting against your breast
- It doesn’t hurt when the baby is breastfeeding, although the first few sucks can feel uncomfortable because they are strong
- Your baby’s cheek stays full and round while they are feeding; there is no dimpling of their cheeks or audible sucking/clicking noises while baby feeds. You will also see a strong jaw action with each suckle
- Your baby takes long rhythmical sucks and swallows. Because baby’s nose breathe it is perfectly normal for them to pause occasionally during a feed
- Your baby should decide when they have had enough breast milk and come off the breast of their own accord. Sometimes your baby will fall asleep with the nipple in their mouth; other times, your baby may push the nipple out of their mouth.
You will know that your baby is receiving adequate milk because they will be content and satisfied after most feeds. Sometimes they will want to feed more often, so let them do so – there is no need to give formula milk supplements unless this is advised by a paediatrician (baby doctor). If you do give your baby other food or drink, this can adversely affect your milk supply because your baby will not want to breastfeed so often.
After the first few days, your baby should be having at least six wet nappies each day, and, once the first stool (meconium) has been passed (usually after day four post birth) your baby should have at least two yellow-coloured stools (poos) each day.
It is not uncommon for breast milk to leak from your nipples in response to your baby’s cries, or when you are feeding your baby. To stop the flow, you can try applying firm pressure by squeezing your nipple between your finger tips. This tends to stop the flow of breast milk quite quickly. Alternatively, you may prefer to wear breast pads – if so, you will need to change them at each feed. We advise that you avoid plastic-backed breast pads as these can get quite soggy. If you plan to breast feed for a while, you may wish to wear breast shells in your bra which can collect breast milk to store for use at a later time.
The more often you breastfeed your baby, the more your breasts will be stimulated to produce milk. When your baby comes off the first breast, offer them the second breast. You don’t need to worry if your baby is not interested in feeding from the second side, or if they feed for longer or just decide to ‘snack’! Just remember that if your baby feeds from the second side, you will need to offer this side first at the next feed.
Try to avoid using a dummy/pacifier for the first five weeks as your baby may find it difficult to remember how to attach to the breast. Breast feeding is like sucking your forearm with a wide-open mouth, whereas sucking on a dummy or bottle teat is like sucking your thumb. Sucking on a dummy may also result in your baby not feeding when they need to.
Think about what clothes are more conducive to breastfeeding – loose fitting tops that give easy access to the breast are ideal. Avoid wearing close fitting garments or outfits with a front button fastening – a loose-fitting top will allow you to breastfeed discreetly wherever you happen to be!
Your breastfed baby will get used to a variety of different flavours from the foods that you eat because these are passed into your breast milk. The colour of your breast milk may also be affected by what you eat and drink. For example, we have noticed that women who have drunk blue-coloured isotonic drinks sometimes produce green-coloured milk or colostrum. However, these affect the colour of the breast milk only, so you do not need to discard your breast milk.
When your baby is reluctant to feed
Sleepy babies – Birth can be just as exhausting for your baby as it is for you, so it is not uncommon for newborn babies to be quite sleepy during the first 24 hours post birth. Analgesia (pain–relieving drugs) given during labour can also make your baby sleepy post birth and so feeding patterns can often be quite erratic.
If your baby is sleepy and seems uninterested in feeding, it is important that you wake them up and offer breastfeeds. Watch out for early feeding cues (as above); if your baby isn’t waking up and it has been six hours since their last feed, and/or your breasts are feeling full, wake your baby up. You will need to stimulate them, so a nappy change, talking to them, and stripping your baby off to place them skin-to-skin can help your baby to wake and become more interested in feeding. If you are at all concerned about your baby being sleepy and reluctant to feed, it is important that you speak with your midwife, health visitor or GP without delay.
If your baby was born prematurely, is jaundiced or has been unwell, the paediatrician (baby doctor) and midwives will usually advise that you feed your baby more regularly – this can be three to four hourly depending on the circumstances. The maternity staff will advise and support you to ensure that breastfeeding is going well before you are discharged home.
Mucousy babies – Babies will often swallow the amniotic fluid (liquor/waters) around them as they are born; this is particularly common when a baby is born by Caesarean section. You may hear the midwives describe your baby as being ‘mucousy’ (see our section on ‘Mucousy babies’). This fluid tends to sit in their tummy, which can make them feel quite sick and uninterested in breastfeeding. You may also hear your baby’s tummy making gurgling noises. However, it is important that you try and get your baby to take a feed as the milk will sit on top of the fluid and mucous and encourages your baby to vomit it up. Your baby will then be a lot more interested in feeding!
If your baby is not interested in breastfeeding, the midwives/maternity support workers (MSW) will show you how to hand express your breast milk, which can then be given to the baby via a special feeding syringe. These syringes are a purple colour and very different from the syringes used to give injections. They allow for the collection of small amounts of colostrum which can then be instilled into the baby’s mouth. See our section on ‘Hand expressing’.
Cautions regarding breastfeeding
Breast milk can become contaminated by different substances including alcohol, medications (drugs) and certain viral infections. Most medication that a breastfeeding mother is taking will pass into her breast milk, so wherever possible, your doctor will ensure that any medications that need to be prescribed are safe to take while breastfeeding. There are some very informative textbooks available which give guidance on the safety of various medications for women who are breastfeeding (Briggs et al 2005, Hale 2006).
Hepatitis B or C infection – breastfeeding is not contraindicated for women who are hepatitis B or C positive. However, women who carry these viruses should receive expert medical advice on immunisation of their baby post birth
Active tuberculosis – breastfeeding is contraindicated for women who have active untreated tuberculosis. However, where the woman and/or her baby are receiving anti-tuberculosis treatment, breastfeeding is safe and can be continued
HIV (Human immunodeficiency virus) – breastfeeding increases the risk of the baby acquiring the HIV infection through its mother’s breast milk by 10-15% more than by the HIV virus crossing the placenta (transplacental), infection during labour (intrapartum) or other post birth contact with the HIV virus. The WHO advises that when replacement feeding is feasible, affordable, sustainable, safe and acceptable, the avoidance of all breastfeeding by HIV-infected mothers is recommended. However, other research has challenged this and suggests exclusive breastfeeding for six months and then stopped.
Your doctor and midwife should have discussed the various options with you during your pregnancy.
Breastfeeding in the longer term
The World Health Organization (WHO) recommends that mothers exclusively breastfeed for the first six months of their baby’s life, and continue breastfeeding for two years or more (WHO & UNICEF 2003, MIDIRS 2008). How long you choose to feed your baby is a very individual decision and will depend on any plans you have to return to work, as well as the needs of the wider family and other siblings.
When breastfeeding doesn’t work out
Given the considerable health benefits that breastfeeding confers to both mother and baby, there is widespread promotion of breastfeeding within UK maternity services. Various initiatives have been implemented that promote and protect breastfeeding, and raise awareness of women’s need for information and support within NHS maternity services and the wider community. These initiatives include the Breastfeeding Manifesto and the WHO/UNICEF Baby Friendly Initiative (BFI) (MIDIRS 2008). Even with the very best of intentions however, some women will find that breastfeeding isn’t what they expected and may make an informed decision to change their preferred method of infant feeding from breast to formula milk. While your maternity health professionals will be advocates of breastfeeding, they should respect your decision and support you in your choice. Parents Powwow firmly believes that women should not be coerced into choosing their preferred method of infant feeding. You need to do what feels right for you and your family.