The art and science of breastfeeding

Dr Abby Baskett explains the art and science of breastfeeding to new and expectant mothers.

It’s incredible what our bodies are designed to do and how they do things at just the right moment, often without any conscious direction. When it comes to breastfeeding, however, an understanding of what’s going on with your body (and your baby’s) will prove helpful. There are so many firsts to grapple with in the early days of a baby’s life, so it’s definitely worthwhile learning what you can about the art and science of breastfeeding before you’re faced with a hungry baby and you need to put all the theory into practice.

IN THE BEGINNING...

Breasts develop during puberty and then again during pregnancy. This is called mammogenesis and is driven by different hormones at these stages of life. During pregnancy most women notice an increase in breast size, darkening of the skin over the areola (pink area around the nipple), and increased tenderness and sensitivity in the nipple area. This is because, during pregnancy, breasts are developing all the structures needed to produce a good milk supply once a baby is born. Another name for this process is lactogenesis 1. By about half way through pregnancy, breasts are capable of producing colostrum and some women may notice a slight discharge from the nipples towards the end of their pregnancy.

COLOSTRUM: RICH AND POWERFUL

Early milk is mainly colostrum. Colostrum appears thicker and oilier than later milk. It is rich in immunoglobulins – a fun word to get your mouth around – which protect the newborn against potential germs in the environment, and is very calorie-dense.

On day one a newborn’s stomach capacity is around 5 ml (only a teaspoonful!), so healthy babies are designed to survive on only a trickle of colostrum for the first day or two. During this time they feel thirsty and want to feed constantly, and the stimulation at the breast also promotes production of milk. Colostrum is thought to have many health benefits and to impact on health outcomes in later life. Bovine colostrum is marketed widely as a health supplement.

WHY YOUR CUP RUNNETH OVER

The delivery of the baby and placenta causes an abrupt drop in some of the pregnancy hormones that had been inhibiting milk production. Milk production, or milk ‘coming in’, in the first few days is driven by hormonal change and occurs even in mothers whose baby is not feeding from them. At the onset of lactogenesis 2, or ‘coming in’, most women notice swelling and tightness of the breasts, which can be painful or uncomfortable for some. With good latching and the baby consistently draining milk from the breasts, symptoms usually resolve over a day or two.

MASTERING THE LATCH

It is important to establish a good comfortable latch early on. Your midwife or lactation consultant will help with this. A comfortable latch is more likely if your baby has a good mouthful of areola – the dark area around your nipple – and baby’s body is nicely lined up, ear to shoulder to hip. If there is pain or a pinching feeling, or baby looks twisted or uncomfortable, take baby off the breast carefully – gently inserting your little finger into the corner of their mouth breaks the seal – and try again, or ask an expert for help.

Even if the latch looks right and feels comfortable around the nipple, don’t forget to attend to other parts of your body, such as your shoulders, back, arms and wrists. Sometimes after the concentration of latching your baby, your shoulders may be tense or you may be holding tension somewhere else in your upper body.  Once baby is comfortable, remember to check your own body for any areas of tension. Breastfeeding is a long process in newborn babies, and holding muscle tension will result in pain.

Some nipple pain and trauma is common in the first few days after birth and usually clears up over a few days with proper latching. Some women find using a cream or ointment, such as coconut oil, lanolin or simply rubbing breast milk into the sore area, to be helpful.

SUPPLY AND DEMAND

Around week two to three, milk transitions to mature milk and is largely produced via a supply and demand (or autocrine) system. (In medical terms this process is lactogenesis 3). The emptier your breasts are, the harder they will work to produce more milk the next time. If your breasts are producing too much milk and are consistently full, production will decrease over time. Interrupting the ‘supply-demand’ system, eg by separating from your baby for a period with no breast stimulation, or offering formula and not feeding your baby for a few hours, will reduce milk supply over the next day or so. The good news is that supply can be increased again just by increasing stimulation at the breast, either by allowing the baby to feed continuously for a day or so, or pumping and feeding.

Mature milk content varies according to time of day, gender of your baby and what you are exposed to in the environment. Milk has less fat content in the morning when breasts are fuller. As they empty during the day, the milk has a higher fat content. The fat content in emptier breasts in the afternoon and evening is more sustaining for babies and (theoretically) allows them to sleep longer periods overnight. Fuller breasts in the morning quickly satiate a baby’s thirst after a longer night sleep. 

LIQUID GOLD

Breast milk is known as a ‘live milk’ as it contains living cells and many, many different hormones and proteins. More components of breast milk are being discovered all the time. Special immunogloblulins – or protective proteins – are expressed in breast milk after the mother’s exposure to various viruses or bacteria. These immunoglobulins protect babies against diseases in the environment that their mother has been exposed to. In fact, breast milk is an important part of a new baby’s immune system.

Tiny amounts of some of the proteins that you eat are transferred into milk giving the baby a tiny exposure to some of the tastes that their mother is eating.

Artificial milk (formula) can closely approximate human milk in terms of electrolytes, sugar content and some minerals and vitamins, but does not contain the long list of hormones, living cells and immunoglobulins present in breast milk. 

IDENTIFYING PROBLEMS AND FINDING SOLUTIONS

In other mammals, and in many human cultures where breastfeeding is the norm, problems with feeding are uncommon. In developed countries, formula feeding became the new normal in the 1960s following intensive marketing by the formula companies in the 1950s and 1960s. Consequently, generational knowledge around breastfeeding was lost and many women giving birth today were not breastfed themselves. This trend is slowly improving, and according to Plunket statistics, today 21% of infants are exclusively breastfed to six months.

Unfortunately, in New Zealand, problems with breastfeeding are common in women, and support can be difficult to find. Two of the most frequent concerns are around painful latch, and worry about milk supply. If nipple pain is an ongoing issue, it is worth seeing a breastfeeding expert, such as a midwife or lactation consultant, who should do a thorough examination of your baby’s mouth, your nipples and breasts, and also watch your baby feeding. Nipple pain has many causes, most of which are easily treated  once the underlying problem is identified.

Parents (or grandparents!) often attribute unsettled behaviour or persistent crying to hunger due to undersupply of breast milk. However, there are many reasons why a baby may be unsettled. If your baby is growing well and your midwife has not expressed any concerns about your baby’s weight, then it is likely that baby is getting enough milk and is crying for another reason.

True undersupply of milk is uncommon. Hormonal factors influencing milk supply are still being studied but it is thought that thyroid problems, polycystic ovarian syndrome and diabetes can affect milk supply in some cases. Work in this area is ongoing.

Correcting a baby’s latch and improving their transfer of milk at the breast can often improve milk supply. Anything that impedes baby’s ability to suck efficiently – such as a tongue tie – will affect proper drainage at the breast, thus interrupting the supply-demand equation and reducing milk supply.

Breastfeeding is a combination of many different factors: baby’s mouth and tongue, nipple shape and size, milk supply, baby’s muscle tone and coordination, and mother’s prior experience and knowledge. Not every piece of the puzzle needs to be perfectly in place for the breastfeeding to work, but sometimes making a small change to one or two of these factors can make all the difference for a successful breastfeeding experience. 

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