Breastfeeding: questions & answers

Paediatrician and lactation consultant Abby Baskett offers answers to frequently asked questions on breastfeeding.

Breastfeeding may be nature's answer for feeding our babies, but for many women, it raises more than a few questions. Our newest recruit to the OHbaby! team of experts, Dr Abby Baskett, sheds some light based on her experience as a paediatrician and lactation consultant. 

Is there any way I can prepare my body for breastfeeding while I am still pregnant?
While your baby is growing, your breasts are preparing for milk production, and as such, most women notice their breasts enlarge during pregnancy. Hormones are acting on your breasts to develop the ducts and other structures in breast tissue so they are ready to make milk. All this will happen without any extra input from you!

The best way to prepare is to talk to women who have successfully breastfed about their experiences and talk with your midwife or LMC about how to initiate breastfeeding after birth.

Skin-to-skin contact with your baby after birth is very important to establish breastfeeding and facilitate bonding. It is also important to spend the first few days after birth focussed on your baby and breastfeeding. Try to keep visitors to a minimum and accept offers of food and help. The most important task at this stage is to develop a strong breastfeeding relationship with your baby.

If you had problems with establishing a good breast milk supply with your last baby, consider seeing a lactation consultant before your baby is born. They may suggest a plan to maximize your supply before delivery.

Does breast size have an effect on breastfeeding?
While breast size is not an indication of milk supply, breastfeeding can be harder with very large breasts, due to difficulties attaching and positioning the baby.

Why is breastfeeding painful for some women and not for others?
Pain can be caused by different issues because breastfeeding is affected by many factors: the shape of your nipples, the shape of baby’s tongue and mouth, the muscle tone and developmental stage of your baby, the amount of milk produced and the speed of milk letdown, to name a few.

Why is a baby’s latch so important to breastfeeding success?
A baby’s latch determines the position of the nipple inside baby’s mouth. Generally speaking, a deep latch is more comfortable for mum and allows the baby to transfer milk efficiently. This means the baby takes the nipple as far back in their mouth as possible, so that the sensitive nipple is against the soft palate at the back of the baby’s mouth.

How do I know if my baby is getting enough milk?
There are many signs of a satisfied baby:
✔ A well-fed baby is generally content and sleepy after a feed
✔ A new baby should have wet nappies after most feeds and several dirty nappies a day.
✔ Dirty nappies should transition from dark greeny black to mustard yellow over about five to seven days.
✔ Baby’s weight should return to birth weight (or higher) by two weeks.

Trust your body and your baby. A baby who is vigorous and demands feeds regularly, is contented after a feed, and is having lots of wet and dirty nappies, is likely to be getting enough milk.

How long should my baby feed for?
Newborn babies feed for different lengths of time. Some babies will be finished after 20 minutes and other babies take up to an hour. If your baby is consistently taking longer than this, you should check with your LMC or doctor.

Should I feed from both breasts each time my baby nurses?
This is different for different women and depends on milk supply. In the early days, feed from both breasts until your supply is established. In general, women with a very large supply should feed from one breast each feed, and women with a lower supply should feed from both.

Can I enhance my milk supply?
Breast milk works on a ‘supply and demand’ system: the more your baby stimulates and empties your breasts, the more milk is produced. If this cycle is interrupted, for example, by offering formula (which results in baby sleeping for a long time and not stimulating the breasts),then production of milk will decrease.

Breast milk supply can be increased in most women with a combination of demand feeding (with good latching technique) and regular pumping.  In rare cases medications can be used to increase milk supply.

Can oversupply of milk be harmful for baby?
Some babies whose mothers have a large supply can be very fussy and hard to settle. The problem can be compounded because an upset baby is often put to the breast again. The unsettled behaviour is probably caused by large volumes of milk (often watery fore-milk) being digested rapidly in the gut causing gas and discomfort. 

Often these babies gain weight rapidly, and have large greenish/mucousy nappies with most feeds.

How does a tongue tie affect breastfeeding?
A tongue tie is an unusually tight frenulum (band of tissue which normally attaches the tongue to the base of the mouth). A tongue tie restricts the movement of the tongue due to the 'anchoring' effect of the tie. Baby's tongue movement is very important in breastfeeding to get the nipple in the right position and also to effectively extract milk.

If baby's tongue cannot move properly, this may cause nipple pain (due to a poor position of the nipple in the baby’s mouth), ineffective milk transfer, excessive wind and other problems.

How do inverted nipples affect breastfeeding?
Inverted nipples make it harder for the baby to latch effectively at the breast. Depending on the degree of inversion, this can be overcome by improved latching techniques or the use of nipple shields or other equipment.

How should I deal with engorgement?
Engorgement is common in the first three to six days after birth. Demand feeding your baby, gentle massage of the breasts and using your hand to express small amounts of milk may relieve the discomfort. Some women find cold compresses or chilled cabbage leaves (worn inside your nursing bra) are also helpful. Engorgement usually passes in a few days.

What is mastitis and how do I treat it?
Mastitis is inflammation leading to infection in the breast tissues, usually caused by incomplete emptying of the breast or a blockage. Infection may enter the breast via a damaged raw area on a nipple. In the early stages, women may notice a painful red area on one breast and then a fever and increased pain may develop. The usual treatment is a combination of anti-inflammatories, antibiotics and feeding as much as possible from the affected side (to promote good emptying of the problem area). Feeding from your affected breast will not harm your baby in any way, but please see your midwife or doctor early if you are concerned.

Why is breastfeeding promoted as so important for baby?
Breast milk is made up of living cells and hundreds of different components including hormones, immunological factors and different proteins. Breast milk differs according to the age and even the gender of your baby. A breastfeeding mother exposed to infection produces immunoglobulins specific to that particular bacteria or virus, which are then passed into her milk in order to protect her baby. In a nutshell, breast milk is part of the newborn baby’s immune system and formula can never replicate human milk. 

Infant formula was developed over the first part of the 1900s. Initially infants were just given cows' milk if breast milk was not available. These infants did not thrive and had marked developmental delay and other health problems.

In the 1950s and '60s, new infant formulas were developed. These were aggressively marketed with devastating consequences to breastfeeding rates, especially in developing countries.

By the 1970s, 85% of babies in the USA were bottle-fed. Formula companies became powerful multi-nationals with influence on policy and regulatory bodies.   Formula feeding was now the new norm and it became unusual for women in the USA and other western countries to exclusively breastfeed. 

By the late 1970s and '80s, the negative impact of artificial infant milk (or formula) was being increasingly recognised and by the 1980s there was a strong movement against formula feeding. In 1981, legislation was developed to limit formula advertising, especially in postnatal hospitals. 

Over the last decade, the risks of formula feeding have become increasingly evident and research has shown higher rates of many common childhood and even adult diseases in formula-fed infants (see references for more details).

Many postnatal hospitals in New Zealand now follow a 'baby friendly' policy based on the World Health Organization code to promote breastfeeding and limit both the marketing of formula and its use on postnatal wards.

Many large international centres are moving to human milk banking as an alternative to cows' milk-based formula for babies whose mothers are unable to breastfeed. Unfortunately, banked human milk is not available in most parts of New Zealand, and babies who are unable to breastfeed remain reliant on formula. 

Dr Abby Baskett (FRACP, IBCLC) is a paediatrician and lactation consultant working at Starship Children’s Hospital and also at Kidzhealth in Newmarket. Abby has a special interest in infant health, particularly feeding issues, and also performs tongue-tie assessment and divisions.

References
• Breastfeeding and the Use of Human Milk, from the American Academy of Pediatrics Policy Statement, Section on Breastfeeding, Pediatrics, 2012.
• Breastfeeding: More Than Just Good Nutrition, Lawrence et al, Pediatrics In Review, 2011.
• The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis, Melissa Bartick and Arnold Reinhold, Pediatrics, 2010.