T&Cs of Breastfeeding
If breastfeeding is the continuum of pregnancy and babies are born to breastfeed then breastfeeding should be easy and trouble free, right? How many of you read the fine print at the end of almost every contract or service offered? It is said that the biggest lie on the internet is ‘I have read and agree to the terms and conditions'....
Remember during your normal healthy pregnancy the things that happened to you as a result of your pregnancy? Possibly nausea, bladder pressure, getting up 6x at night to pee, possibly having to eat 5x a day cause eating a big meal results in heartburn, having to eat healthy to grow a healthy baby, growing uterus - thus having to “adjust” your clothing, uncomfortable at night, needing help to get out of bed in the morning (I remember from about 35 weeks I had to ask my husband to roll my out of bed!).... normal things very few people see as unnecessary, maybe unexpected but they see it as a normal part of pregnancy. Well the T&Cs doesn't go away with the birth of your baby. Mind you; life has T&Cs. (Topic for another day).
Now, since the fine print of breastfeeding is not readily available to help you prepare for what is actually normal, what follows are some T&Cs parents shared during a recent talk on the T&Cs of breastfeeding, on normal things that happened to them as a health breastfeeding family, mother, baby; and some precautions they needed to take.
Here are some of those T&Cs:
We may need help: Breastfeeding used to be easy and natural from the start but (apart from building the breastfeeding relationship – more about that later) nowadays we also need to learn about breastfeeding. I believe for two reasons: (a) Because breastfeeding is invisible. We do not know what it looks like anymore – we don’t know what is normal and (b) because we interfere with nature, for example: ¤the birth process, (with inductions, augmentation of labour, vacuum & forceps deliveries, Caesarean births, pain relief medications), ¤mom & baby separation after birth and after that ¤not rooming-in, ¤baby oral insult (which is vicious suctioning of airways, dummies, supplements, the list goes on) and then we end up with possible consequences like a delayed onset of breastfeeding (which means it takes longer for breastfeeding to establish), baby developing a disorganized suck or having a diminished early suckling response (and THIS could have an influence on the exclusivity and duration of breastfeeding) and as a result, a delayed Lactogenesis2, which means it takes longer for the milk to “come in”). SO we need to know what is normal and when to seek help.
Normal birth “sets the stage” for a best start: Getting breastfeeding off to the best possible start means choosing normal birth and selecting caregivers and places of birth that promote, protect, and support normal birth (like a Baby Friendly Hospital). Though you might have had many interventions during labour and yet baby managed to breastfeed just fine, normal, natural birth “sets the stage” for problem-free breastfeeding (what nature intended), while a complicated, intervention-intensive labour and birth “set the stage” for problems(1). This is why we have IBCLCs (International Board Certified Lactation Consultants), to help babies overcome the possible results of our interference with nature. Good news is nature wants us to succeed. Lactation is not as fragile as many people think – otherwise the human race would never have survived!
“Successful” breastfeeding consists of a few elements: Lots of milk + confident mother + good latch from baby + all in a basket of support = successful breastfeeding. Mothers need to make sure they have a support network ready to support them in breastfeeding. If breastfeeding is difficult, especially during the 1st weeks, prompt and reliable assessment by an IBCLC is vital!
There will be a 40-day adjustment period: When NASA launches a spacecraft, it uses about 90% of its fuel breaking free of the Earth’s atmosphere. After it clears the pull of this gravitational force, considerably less fuel is required, allowing it to travel great distances while expending far less energy. Breastfeeding during the early weeks is HARD work, a major activity, but after the “adjustment” period (about 40 days – remember in the Bible, it rained for 40 days and then the sun came out?), breastfeeding becomes a minor activity. We enter the “reward” period. Milk supply has established, breastfeeding is established and breastfeeding becomes easy and natural, as it is supposed to be.
Breastfeeding is a relationship: Breastfeeding is a relationship and like any relationship, it takes WORK(2) to “work” and has its ups and downs. Like mastering any other new skill, it takes a lot to hang in there and muddle through the demanding times. The required effort is often great and the challenge can be daunting, leading many to conclude that it’s not worth it or that they don’t have the stamina and perseverance to work forever at this level. SO some degree of effort and agony is inevitable in most relationships but it doesn’t have to last forever; it is generally a temporary condition. You may find after you make it “over the hump," the amount of effort and energy required to sustain and nurture the relationship is greatly reduced. Most parents find the experience of nurturing the relationship no longer feels like effort or work, but literally becomes a labor of love that feels more like a gift, a joyful opportunity for which we feel grateful and blessed. Two qualities are needed to hang in there long enough to get to the "gold" that committed partnerships offer—perseverance and trust. Perseverance has to do with the willingness to make the sustained, necessary effort to confront the challenges inherent in the process, particularly in the face of discouragement or pain. Trust pertains to the confidence that there is light at the end of the tunnel, whether we can currently see it or not, the understanding that persevering is worth the effort(3). In their book “Breastfeeding Made Simple: Seven Natural Laws for Nursing Mothers”(4), Nancy Mohrbacher and Kathleen Kendall-Tackett also say breastfeeding is a relationship. They say instead of thinking about breastfeeding as a skill to master, (or a measure of your worth as a mother), instead think of breastfeeding as primarily a relationship. As mothers hold their babies (and a lot of holding is encouraged as skin-to-skin contact is our first step towards successful breastfeeding(2)), baby will be more comfortable in seeking the breast and breastfeeding will flow naturally out of this affectionate relationship.
Breastfeeding is not just food: The function of lactation is: Optimizing baby’s innate immune protection, Nutrition and The basis for baby’s psychological development(5)
Room in if at all possible: This means let your baby sleep in your room 24/7 – this facilitates breastfeeding and is associated with a shorter time to effective latch, increased milk supply and longer duration of the breastfeeding relationship
Latch and feeding need to be effective: Apart from the breastfeeding relationship the basis of breastmilkfeeding is a baby who latches on and removes the milk effectively (without causing his/her mother any pain). A baby who latches on ineffectively has more difficulty getting milk s/he needs and when a baby is latching on ineffectively s/he may also cause the mother nipple-pain & or trauma, which might lead to a decrease in milk supply, baby not gaining weight and eventually premature weaning. Suspect a problem if breastfeeding is painful, if you have to make space for baby’s nose when s/he feeds, if you have any nipple damage, if the shape of your nipples changes as it comes out of baby’s mouth. How to prevent problems? By starting to breastfeed as soon as possible after birth and staying in skin-to-skin contact with baby until breastfeeding is going well. If things are not working; get help from an IBCLC ASAP.
Engorgement happens: Around 30-72 hours after birth, when milk supply increases dramatically (milk “comes in”), a mother may experience breast swelling, tenderness, warmth, redness, pain, low-grade fever, and flattening / disappearing of the nipple in breast. This is called Engorgement. The mammary glands and surrounding tissue swell, compressing milk ducts. There is also pressure on the lymph system and fluids can’t drain away. Blood flow decreases, causing warm and red breasts. Gentle massage to get the milk flowing, expressing some milk to soften areola or RPS to help baby latch (hard to latch on something pumped up to 3Bar), a cool compress after feeds, frequent feeding, making sure baby latches effectively can all help relieve engorgement, which usually resolves within a day or 2.
Nipple stretching pain can happen: During the first two to four days after birth, the mother's nipples may feel tender at the beginning of a feeding as the baby's early suckling stretches her nipple and areolar tissue far back into her/his mouth, called a nipple-stretching-pain. If a baby is positioned effectively at the breast, this temporary tenderness usually diminishes once the milk lets down (or maybe within 20 seconds or so), and disappears completely within a week or two.
Sore or cracked nipples can happen: Two of the most common reasons why women stop breastfeeding in the first days or weeks are sore and cracked nipples. It can happen due to: ineffective latch (mother and baby know what they are doing but the mother perhaps fell asleep during a feed and baby slipped to the tip of the nipple); or a fungal infection, or a bacterial infection, or eczema / dermatitis (e.g. allergic reaction to ointment or breast pad), or vasospasm (Raynaud’s phenomenon), or a milk blister / blep, or washing breast with soap and / or antiseptics, or baby’s tongue function or oral anatomy. First line or treatment is to get the latch checked, applying drops of breastmilk to nipples (and pure lanolin or hydrogel pads), not use soap on nipples (to protect the natural oils on your nipples), have baby’s tongue & mouth checked and talking with a breastfeeding specialist to pinpoint the reason for sore or cracked nipples.
Perceived Insufficient milk supply happens: A mother may feel she does not have enough milk because her breasts feels soft and or her baby is dissatisfied (frustrated and crying). Make sure baby is positioned and attached to the breast effectively. Feed baby on demand (cue), day and night. Stop the use of dummies. Wake a newborn baby up to feed if baby sleeps for too long (feed minimum 8x per 24 hours). Know you are able to produce sufficient milk, regardless of breast size, understand growth spurts, about every 2 weeks, let baby finish one breast first, before offering the second breast, check how many dirty / pooh nappies baby has in 24 hours (3 or more). Weight gain is the “acid test” of enough milk, thus if baby is gaining weight well, you know you have enough milk.
Making enough milk needs output: “The single most important factor in establishing successful breastfeeding is the volume of milk produced in the first one to two weeks postpartum”. So doing everything one can to make breastfeeding work well in the early weeks is important to breastfeeding success. For lots of milk (a good milk production) we need = sufficient glandular tissue + intact nerve pathways & ducts (your breast anatomy plays a role here) + adequate hormones & hormone receptors (your physiology plays a role here) + adequate frequent, effective milk removal & stimulation (here mom & baby are role-players).
Breastfeeding takes time: During the early days baby will be feeding a lot to help transition from constant feeding in the womb to intermitted feeding in the outside world. A baby is born with a small stomach, s/he gets small amounts of colostrum, that digests quickly, so for many babies this = very frequent, sometimes non-stop, breastfeeding. During the first few weeks, a lot of babies will probably not feed on any kind of regular schedule either. Most babies bunch their feeding together at certain times (called cluster feedings), and go longer between feedings at other times. Baby could feed 8 - 12 -15 times in a 24-hour period.
Blocked ducts happens: Sometimes tight clothing and brassieres, or pressure on the ducts in the breasts from laying on affected area, too hard a hug, infrequent feeds, a milk blep, or strenuous upper body exercise can cause a blocked duct resulting in a lump/segmented swelling in the breast. The area may also be warm, very tender and red. A mother can use different feeding position to help milk flow from all the ducts. It is very important that the milk be DRAINED from the breast. While baby is feeding, gently massage the area, put baby on affected breast first and make sure bra fits well (no under-wire bras). Try the potato protocol (applying raw potato slices to the breast may reduce pain, swelling and redness associated the mastitis. Cut +-6 washed raw potatoes lengthwise into thin slices. Places in a bowl of water at room temperature and leave for 15-20 minutes. Apply the wet potato slices to the affected area and leave for 15-20 minutes, remove and discard and apply new slices from the bowl. Repeat process two more times, so you have applied potato slices 3 times in an hour. Take a break for 20-30 minutes and repeat the procedure). There is a fine line between blocked ducts and breast inflammation (mastitis without infection). (When germs get into the backed-up milk, the result will be infections mastitis). If a mother experiences symptoms like fever (39 ˚C) and other flu-like symptoms like achy joints and general malaise, hot, hard and red breast, painful when pressure is applied on affected she needs to contact her care giver who may prescribe an anti-inflammatory and antibiotics to prevent affected area from developing an abscess. She needs to rest and drain the breast.
Food rules: Among women exclusively breastfeeding their infants, the energy demands of lactation exceed pre-pregnancy demands by approximately 640 kcal/day during the first 6 months post-partum compared with 300 kcal/day during the last two trimesters of pregnancy(6). The number of calories you might need depends upon how much body fat you have and how active you are. While women are often advised to consume about 500 extra calories daily while they are breastfeeding, research(7) now indicates that this could be too much for some women, while for others it could be insufficient. So no need to count calories (who has time for that anyway!); eat a healthy well-balanced diet like you did during pregnancy and you will be fine! At present time, there is lack of evidence that maternal dietary restrictions during pregnancy and breastfeeding play a significant role in the prevention of atopic disease in infants. How nice would it have been if fussiness and spots were due to what we ate? Because then we could control fussiness and spots by what we eat! Between 2 and 3 weeks of age, noticeable developmental change takes place: the “baby-moon” is over, babies feed more often, are awake for a little longer, and cry more. Many parents interpret this as cramps and due to what the mother ate. PLEASE, babies are little individuals, not everything baby does is because of you (or what you ate)!! The role of mom’s diet has been exaggerated and many mothers are given a list of “forbidden foods”. The percentage of babies who are truly sensitive to specific foods is pretty small, most mothers can eat a healthy, balanced diet and nothing is forbidden. Use common sense and eat moderate portions of everything you like. Mantra: anything goes but moderation is key. Providing “rules” about diet during lactation without considering maternal nutrition status and dietary preference can undermine breastfeeding and should be avoided(8). A mother with healthy eating habits does not usually need to change her diet while she is breastfeeding. Although exceptions exist, most breastfeeding mothers can eat anything they like in moderation – including chocolate and spicy food- without any effect on their baby. Health Professionals should keep diet information simple. Perceiving nutrition information as complicated may convince a mother not to breastfeed(9). A Study done by Jeong G, et al. on Maternal food restrictions during breastfeeding, published in the Korean J Pediatr 2017; 60(3):70-76; concluded that “most mothers restricted certain foods unnecessarily. Literature review identified no foods that mothers should absolutely avoid during breastfeeding unless the infant reacts negatively to the food. Nursing mothers should be educated on proper diet practices while being warned about unscientific approaches to diet restriction”. If a food allergy is suspected as the basis for colicky behavior in newborns and infants, they should be assessed by a medical professional like a pediatrician. Maternal elimination diets should be done under the guidance of a registered dietician.(10)
Beer or champagne (and other alcoholic drinks) do NOT increase your supply: Bear in mind that two standard drinks or more at a time can impair your judgment and functioning, and contribute to depression and fatigue (not something you need now!). Also daily consumption of alcohol has been shown in the research to increase the risk for slow weight gain in the infant and is associated with a decrease in baby’s gross-motor-development(11). Be careful if people suggest alcohol to increase your milk supply. Alcohol can inhibited the “let down reflex”(12), and reduce the volume of milk baby is receiving per feed by as much as 23%(13). It may be the barley that is the prolactin-stimulating component of beer, not the alcohol that helps. Non-alcoholic beer would probably have the same effect(14). Alcohol does not accumulate in breastmilk; it passes easily into breastmilk by simple diffusion, reaching levels almost equal to that in the mother’s blood stream. The Molecular weight of alcohol is 46 Dalton and anything lower than 500Da enters milk easily. It also leaves the milk easily. Thus no need to pump and dump milk after drinking alcohol, other than for comfort, because pumping and dumping does not speed the elimination of alcohol from the milk, it is not "trapped" in breastmilk, it returns to your bloodstream when your blood alcohol level drops. Alcohol peaks in mom's blood and milk approximately ½ -1 hour after drinking (but there is considerable variation from person to person, depending upon how much food was eaten in the same time period, mom's body weight and percentage of body fat, etc.). Thomas W. Hale, R.Ph. Ph.D. (author of Medications and Mothers' Milk) says: "mothers who ingest alcohol in moderate amounts can generally return to breastfeeding as soon as they feel neurologically normal.” Still unsure? If you drank alcohol, do not breastfeed until you are completely sober. Again, moderation is KEY.
Hold off with dummies and bottles: Nipple confusion happens when a baby is given artificial nipples or pacifiers (dummies) and “forgets” how to breastfeed. Baby may start to root for the breast but either can’t latch or doesn’t move her/his tongue correctly when s/he does latch. When baby arch, cry, scream or actively push away or simply turn away in disinterest after exposure to bottles, it may be due to a flow preference. Once baby has become accustomed to the instant gratification of a bottle that flows immediately and never stops until its empty, it can be harder for the breast to compete. Nipple preference can happen when there is a significant mismatch between mom’s nipple shape and the shape of the artificial nipple. E.g. when mom has a small nipple that protrude only slightly and the artificial nipple is large and long and easier to grasp, now baby gets confused between the prominent artificial nipple and the soft breast and small nipples (which was perfect to start off with). About half of all babies have trouble going back and forth between breast and bottle. Possible problems that may develop includes: breast refusal, ineffective suckling and suckling changes that cause sore nipples. Babies are not born with labels, so you will not know if your baby is susceptible to these kinds of problems until after they occur. Baby’s suckling action on the breast is also completely different to that on a bottle or dummy; a different set of muscles is used. In order to understand the difference between the way a baby uses a bottle nipple and a human nipple, here is a vivid demonstration: put your index finger in your mouth, closing your lips on the first knuckle. Begin sucking. Feel how your tongue flattens your fingertip up to the roof of your mouth. Now feel how your lips close around your finger very tightly. Feel the strength of your jaw and how your teeth make contact with your finger. This simulates the way a baby sucks from most artificial nipples. It is also the same way a baby sucks when s/he is latched shallowly on the breast. Now, put your finger in your mouth to the second knuckle. Notice that the tip of your finger almost touches the back of your soft palate. Begin sucking and feel the motion of your tongue, which is now elongated, curved around your finger, and massaging it. Feel the way your lips are slightly open and completely relaxed. Feel the way your jaw is more open and relaxed. Feel the way your teeth on your finger are now barely or not at all touching. This sucking technique approximates the way a baby sucks when s/he is latched deeply and effectively on the breast. Very different to the first-knuckle-finger sucking, don’t you think? Breastfeeding directly also supports the normal development of a baby’s jaw, teeth, face, and speech. The activity of breastfeeding helps exercise the facial muscles and promotes the development of a strong jaw and symmetric facial structure. Several studies have shown breastfeeding to enhance speech development and speech clarity. An increased duration of breastfeeding is associated with a decreased risk of the later need for braces or other orthodontic treatment and the rate of misaligned teeth (malocclusion) requiring orthodontia could be cut in half if infants were breastfed for one year(15). A word of caution: dummies are not remote-controls to put in baby’s mouth as soon as s/he says “eeee”, and you feel good, because it shut her/him up? Breastfeeding takes a few weeks to establish and breastmilk supply takes a few weeks to establish and dummies are sugarless gum for babies, it is an imitation of what a baby really needs. You already have two of the real thing! Dummies masks baby’s feeding cues and throws off his unique feeding rhythm. If used often enough, dummies can reduce the number of feedings per day during a time baby is working to set your milk supply. So during the first month to 40 days it is best to put away the dummy. Also think about it: baby’s tongue fills her/his whole mouth. The shape of baby’s palate is influenced in utero and after birth by the pressure of the tongue as it rests against the palate in the closed mouth. So where does the tongue go when we put a bottle or dummy in baby’s mouth? It is the bone that will eventually move not the muscle, causing the malocclusion mentioned above. Are you worried about baby not taking a bottle when you have to go back to work? Researches(16) have found that most babies will take the bottle easily whether started at 1, 2 or 3-6 months. When preparing to return to the work-force; speak to your lactation consultant on how to bottle-feed your breastfed baby, using the “paced-bottle feeding” method(17).
Take care of YOU: Good FOOD, good REST and good SUPPORT. William Sears reports that many mothers say: “My baby needs me so much that I don’t even have time to take a shower.” He says it is natural to put a baby’s needs first, yet that does not mean you always put your needs last. You cannot parent a draining baby if you are drained. Dr Sears says next time you are on an airplane, notice how the flight attendant demonstrates the proper use of oxygen: “Put on your oxygen mask first before putting on your child’s.” If you are suffocating, you are no good to your child. When you “pass out”, who will look after your child?? Moral of the story is to take care of you! How? “Don’t do it alone”. Don’t be afraid to reach out and ask for assistance, ask for help, and ask for company, every day. Listen to the African proverb that says: “it takes a village to raise a child”.
For breastfeeding support, information and education talk to someone who has TRAINING in the management of breastfeeding (not just personal experience): You will find that someone with breastfeeding training will not give you advice but counsel you. The word counseling is not new but it can be difficult to translate. Some languages use the same word as advising. However, counseling is different from simple advising. When someone advises you, you will find the person tells you what they think you should do. When someone counsels you, you will find the person does not tell what to do. They help you decide what is best for you, you make the decisions. S/he listens to you, and try to understand how you feel. They help you to develop confidence, so that you remain in control of your situation and you do not become depended on them for all your decisions!
Each mother-baby breastfeeding pair is unique: one cannot really compare a breastfeeding experience you had with your friend’s experience or even a breastfeeding experience you had with one of your children to the next; since each baby has his or her own unique breastfeeding personality and each pregnancy grows a new ductal system in the breasts for breastfeeding the yet unborn baby.
Breastfeeding should be easy and trouble free. SO if breastfeeding is difficult, especially during the 1st weeks, prompt and reliable assessment is vital! Breastfeeding families can get reliable help from an IBCLC*. If you have more T&Cs to add (and we are sure there are more T&Cs to be added!) please share your ideas with us here: contact us
*IBCLCs (International Board Certified Lactation Consultants) have passed a rigorous examination that demonstrates their ability to provide competent, comprehensive lactation and breastfeeding care. IBCLCs may have different areas of expertise, so you might have to seek further help if you needs are not met. See www.lacsa.org.za for trained breastfeeding help in your area.
Linda J. Smith, BSE, IBCLC. Impact of Birthing Practices on the Breastfeeding Dyad. J Midwifery Womens Health 2007;52:621–630).
That work is about committed listening, letting go of control, practicing vulnerability, overcoming resistance to change, being honest, even in the face of fear, and focusing on your own work rather than trying to change your partner.
Linda Bloom, L.C.S.W., and Charlie Bloom, M.S.W. Secrets of Great Marriages: Real Truths from Real Couples About Lasting Love. 2010.
Nancy Mohrbacher, IBCLC, FILCA & Kathleen Kendall-Tackett, PhD, IBCLC. (2005) Breastfeeding Made Simple: Seven Natural Laws for Nursing Mothers. Oakland: New Harbinger Publications, Inc.
Hale, T & Hartmann, P. et al. Textbook of Human Lactation. Amarillo, TX, USA: Hale Publishing, 2007.
Institute of Medicine (US) Committee on Nutritional Status During Pregnancy and Lactation. (1991). Nutrition During Lactation. Washington (DC): National Academies Press (US)
Sheri Lyn Parpia Khan. Maternal Nutrition during Breastfeeding. NEW BEGINNINGS, Vol. 21 No. 2, March-April 2004, p. 44
Hale, T & Hartmann, P. et al. Textbook of Human Lactation. Amarillo, TX, USA: Hale Publishing, 2007; p378
Mohrbacher, N. Breastfeeding Answers Made Simple: A Guide for Helping Mothers. Amarillo, TX, USA: Hale Publishing, 2010; p513, 516
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Jack Newman M.D. & Teresa Pitman. (2006). The Ultimate Breastfeeding Book of Answers: The Most Comprehensive Problem-Solving Guide to Breastfeeding from the Foremost Expert in North America, Revised & Updated. New York: Three Rivers Press
Palmer, B. (2008). The Influence of Breastfeeding on the Development of the Oral Cavity: A Commentary. Journal of Human Lactation, 14(2), 93-98)
Kearney, M. H. and Cronenwett , L. (1991) “Breastfeeding and employment”, Journal of Obstetric- Gynecologic and Neonatal Nursing, Vol. 20, No. 6, pp.471-480
Dee Kassing, Bottle-Feeding as a Tool to Reinforce Breastfeeding, J Hum Lact. 2002 Feb18(1):56-60