BREASTFEEDING

Breastfeeding is the normal way of providing young infants with the nutrients they need for healthy growth and development. (WHO) Virtually all mothers can breastfeed, provided they have accurate information, and the support of their family, the health care system and society at large. Colostrum, the yellowish, sticky breast milk produced at the end of pregnancy, is recommended by WHO as the perfect food for the newborn, and feeding should be initiated within the first hour after birth. Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond. As health care providers, we are the prime people to teach women about the benefits of breastfeeding and provide anticipatory guidance for problems that may occur.

How milk is developed Breast milk is formed ion the acinar or alveolar cells of the mammary glands. With the delivery of the placenta, the level of progesterone in a mothers body falls dramatically, stimulating the production of prolactin, an anterior pituitary hormone. Prolactin acts on the acinar cells of the mammary glands to stimulate the production of milk. In addition, when an infant sucks at a breast, nerve impulses travel from the nipple to the hypothalamus to stimulate the production of prolactin-releasing factor. This factor stimulates further active production of prolactin. Other anterior pituitary hormones, such as adrenocorticotropic hormone, thyroid stimulating hormone and growth hormone, probably also play a role in growth of the mammary glands and their ability to secrete milk.

A. Advantages For Mothers

1. Serves a protection function in preventing breast and cervical cancer and

osteoporosis.
2. The release of oxytocin from the posterior pituitary gland aids in uterine

involution.
3. Successful breastfeeding can have an empowering effect, because it is a skill

only a woman can master.

4. Breastfeeding reduces the cost of feeding and preparation time. 5. Excellent opportunity for mother and child bonding.

6. Serves as a contraceptive technique because continuous breastfeeding may

cause delay in menstruation (lactational amenorrhea). But: 50% of women resume ovulating by the fourth week after the delivery.

For Babies

1. Due to the anti-infective properties of breastmilk, breastfed babies tend to have

less incidence of or less pronounced symptoms of ear infections, respiratory illness, allergies, diarrhea, and vomiting. Provides immunity for the baby. 2. Due to the digestibility of breastmilk, breastfed babies are rarely constipated. (BM is high in lactose, an easily digested sugar that provides ready glucose for rapid brain growth. The protein in the BM is also easily digested).
3. The stools of breastfed babies are mild-smelling. 4. Breastmilk is constantly changing in its composition to meet the changing needs

of the baby. It has the exact combination of protein, fats, vitamins, minerals, enzymes, and sugars needed for the human infant at various stages of his growth. B. Disadvantages
1. There can be discomfort involved with breastfeeding. When you first start breastfeeding, you may experience sore nipples. For the entirety of your breastfeeding endeavors, your breasts may feel swollen or engorged. 2. You may leak milk at times that are inconvenient or embarrassing. When the baby cries, you almost immediately start producing milk. If you arent prepared for this properly, it can be inconvenient or embarrassing. 3. Everything you consume is being passed on to your baby. Any food you eat, medication you use, or anything that you are applying to your skin can and most likely will be passed onto your baby through breastfeeding. 4. It may carry microorganisms such as Hepatitis B and cytomegalovirus, although

the risk to infants is small. HIV is carried at a high enough level in breastmilk that women who are HIV positive are advised not to breastfeed. C. Contraindications Breastfeeding is contraindicated in only a few circumstances, such as the following:

An infant with galactosemia (such infants cannot digest the lactose in the milk) Herpes lesions on a mothers lesions Maternal diet is nutrient restricted, preventing quality milk production Maternal medications (lithium, methotrexate) are inappropriate for breastfeeding Maternal exposure to radioactive compounds (during thyroid testing) Breast cancer

D. Positioning During Breastfeeding

The Cradle Hold The cradle hold is one of the most frequently seen breastfeeding positions for babies. It is great because it allows mom to hold the baby closely and support their little bodies, particularly when they are newborns and not quite able to hold themselves up in any way.

The Cross Cradle Hold

The baby is in the same position as the cradle hold, but here you can use your hands more effectively to help steer the baby's head, while the other hand maneuvers the breast. The forearm is used to support the baby's body.

The Football Hold

The football hold is a great position if you really need to see the breast. It works well for large breasted mothers as well as mothers who need to avoid the baby being on their abdomen, such as after a caesarean section. Be sure to use pillows with this position so that you can be sure that the baby is well supported. If the baby is longer than the space you have between you and where you are sitting, bend the legs upward, so that their bottom is against the back of the chair or bed. This prevents you from leaning out.

With this position you can also use the other hand to help better position the baby's mouth or your breast. It gives you a great look at the breast while nursing, so works well if you're having latch issues.

The Reclining Position

The goal is to keep your back and hips in a straight line. With your baby facing you, draw her close and cradle her head with the hand of your bottom arm. Or, cradle her head with your top arm, tucking your bottom arm under your head, out of the way.

E. Breastfeeding techniques
1. Keep the baby on you after birth until he/she shows signs of readiness to

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nurse. Unless the baby need immediate help or is having complications, research shows that babies who are left undisturbed on the mothers chest until they nurse breastfeed more effectively and latch better. Signs of readiness include rooting, sucking on fist or fingers, mouthing. Delay the newborn procedures until after baby had breastfed. Most newborn procedures (even eye ointment) can wait for at least an hour or more until baby has nursed. Often babies will show readiness signs 15-20 minutes after birth. Nurse baby as often as possible in the first few hours and days after birth. Mothers wonder why babies cry a lot and always seem hungry in the first week. This is how your body is coordinated with the baby's needs. Their demands to eat often will help your milk come in around day 2-5. To latch baby properly, turn baby toward you, stroke baby's lower lip lightly with your nipple and wait to nurse until baby has a very wide open mouth. For helpful photos on latching, see breastfeeding.com. Do not let the baby suck on the tip of your nipple. Typically this will feel very "pinchy" if your baby is not taking nearly the entire areola in her mouth. Allow baby to nurse as long as possible on the first side. Once the milk comes in, the consistency of the milk changes throughout the feeding. At the end of a feeding, the milk has a higher fat content (called "hindmilk") to help the baby gain weight. Limiting time on the breast may reduce the baby's ability to gain weight.

6. Try not to schedule feedings but watch the baby for signs of hunger. The

baby is your best gauge for feeding schedules, not the clock. Babies only hold about 1-2 ounces of milk in their tummies at a time. In somes cases, this means that they may be hungry again after only an hour, especially if they have had a dirty diaper. 7. Watch for at least 6-8 wet and frequent dirty diapers a day by the end of the first week. Listen for frequent swallowing during feedings and signs that the baby is content after feedings to know that your baby is getting enough. Most pediatricians look for the baby to gain back enough to reach his/her birth weight by two weeks to know that baby is on the right track with weight gain. Read signs that baby is getting enough for more information. 8. If breast soreness happens, review techniques for good latching, change positions frequently, use lanolin-based ointments or hygrogel pads. Be sure to consult with a lactation consultant if the breast soreness continues. 9. Avoid giving the baby a bottle or pacifier for at least 2 weeks after birth. Even then, baby should be latching on well, suppply of breastmilk should be wellestablished and everything going well before baby has any artificial nipples since they can confuse babies. 10. To make more breastmilk, nurse more frequently and for longer periods at each breast. Occasionally mothers can become concerned that they do not have enough milk, so the easiest way to increase milk is to increase the "demand" for breastmilk.
Breastfeeding is a learned skill for both mother and infant, requiring both time and patience.

When to start
Immediately after birth, your baby is eager, alert and ready to breastfeed. Place your baby skinto-skin immediately after birth and as often as possible during the first days of life. This will help your baby adjust to life outside of your body and to breastfeed better. Full-term infants display many different suckling behaviors or feeding cues, such as bringing their hands to their mouth, rooting, suckling, licking and nuzzling the nipple (a normal behavior). Your babys suckling reflex is greatest from 45 minutes to 2 hours after birth. The first several feedings have a lasting effect and are a positive and satisfying experience for you and your baby. Your babys initial alertness and eagerness is followed by an increasingly deeper sleep. About 20 24 hours of age, your baby will be awake more often and more interested in nursing. When awake, your baby may want to feed often and alternate between light sleep and quiet wakefulness. Your baby may nurse several times close together (cluster feedings) and sleep several hours without nursing. Normal, full-term, healthy newborns may breastfeed every hour or several times in one hour, usually in the evening, late night or early morning hours. Responding to your babys needs for cluster feedings should help your baby feel satisfied.

Breastfeeding after a cearean birth A Cesarean birth does not directly affect the breastfeeding process. However, discomfort, fatigue, and the medications used in surgery may present more of a challenge when you begin breastfeeding. Nurse your baby as soon after delivery as possible (8 to 12 times per 24 hour period). Once you begin regular feedings, your milk supply will increase. Your partner or support person can be very valuable in helping you lift and position your baby. You may be more comfortable using the football hold,side-lying, or cradle hold while cushioning your abdomen with a pillow.

The first few days of breastfeeding

Research shows that the critical days for breastfeeding success are the first six to seven days after delivery, and later near the babys sixth week. It is important to get the help you need during these times. Fatigue may play a large role in any doubts about continuing breastfeeding. If possible, get help with the household chores and infant care, allowing time for rest and comfort. Do not hesitate to accept help when offered. Simplify the chores as much as possible, such as using paper plates/cups or a grocery delivery service.

Create a peaceful comfortable nursing station and allow yourself to relax.

Find a comfortable position, such as in a chair with ample room on the sides and back for pillows to support your baby and your arms. Sitting with your legs up on a bed or using a footstool when in a chair will help you feel more comfortable. Unwrap your baby and check if his/her diaper needs to be changed. This will help arouse and stimulate your baby to nurse, especially if your baby is sleepy. If your baby is awake and ready to nurse, wait until after your baby finishes nursing on the first breast to change your babys diapers.

After the initial quiet alert state following birth, it is normal for babies to be sleepy for the next 24 hours. Breastfeed 8 to 12 times per 24 hour period.

Breastfeeding positions
Cradle hold (tummy-to-tummy) Cross cradle hold (tummy-to-tummy)

Football hold Side-lying position

Latching on
If your baby latches-on only to your nipple and not the areola, problems may develop, such as sore nipples and a poor milk supply for your baby. You may have to repeat these steps several times before your baby latches-on correctly

Sit tummy-to-tummy with your baby. Make sure your babys ear, shoulder and hip are in a straight line and the babys nose is level with the nipple.

Bring your baby close to your breast. Touch your nipple to your babys lips.

When your babys mouth opens wide, quickly pull your baby in to latch-on since the mouth will be open for only a few seconds. NOTE: Bring your baby to your breast, rather than bringing your breast to your babys mouth. Your baby will be able to breathe even though his/her nose may press into your breast. It is helpful in the first week to continue to support the weight of your breast throughout the nursing session. Support your babys head at the base of the neck as well. Look for the following after your baby is latched-on: Your babys mouth should be about one inch from the tip of your nipple around the areola.

Your babys lips should be turned outward against the breast. The motion of the suck is along the jaw, not in the cheeks. Your babys ears, shoulder and hip should be in a straight line.

Breastfeeding should not hurt. You should feel a strong rhythmic tug on your breast. A little bit of nipple tenderness within the first minute is normal during the learning period. However, sore, reddened, bleeding or cracked nipples are not normal. Taking your baby off the breast and burping
Taking your baby off the breast. Be sure to break the suction by slipping your little finger in the corner of your babys mouth between the gums. Do not remove your baby from your breast

until the suction is released, or you may develop sore nipples. The suction is quite strong, and it may require some effort to release your babys grip. Burping your baby. Not every breastfed baby needs to burp with every feeding. Generally, breastfed babies do not swallow as much air as bottle fed babies do. If your baby has been crying before the feeding, and is pulling on and off the breast, try burping then try breastfeeding again. Some babies do not burp right away, and you may need to try several positions. Helpful positions for burping your baby include:

Propped up with babys tummy against your shoulder Lying tummy-down across your lap

Sitting up, leaning forward with your hand on the left side of the babys body supporting the babys stomach and neck

BOTTLE FEEDING

The practice of feeding an infant a substitute for breastmilk. Pediatricians generally advise exclusively breastfeeding (that is, breastfeeding with no supplementary formula) for all full-term, healthy infants for the first 6 months of life. However, many infants are bottlefed today, at least in part.

A. Advantages

Bottle-fed babies need to be fed less frequently since it is more difficult to digest. If you are bottle feeding your baby, you know exactly how much milk your baby has had. Your baby may sleep longer in between feeds You do not need to be present each time the baby has to be fed; some other family member or friend can also feed the baby. Your social life does not need to be curtailed. You can resume your normal life.

B. Disadvantages

Babies who are bottle fed using formula milk are more likely to develop illnesses, such as diarrhoea, or a chest, ear, or urine infection. There is also an increased risk of premature babies who are bottle fed developing a

rare, but serious condition called necrotizing enterocolitis (NEC), where the intestines are damaged due to infection and a poor supply of blood. It does not offer the protective immune system antibodies available only in the breastmilk. When making formula milk, it is possible to get the mixture wrong and make it too strong, too weak, or too hot. There is also a lot of work involved in thoroughly washing and sterilising all of the equipment that is needed for bottle feeding, In studies carried out comparing babies who were breastfed with those who were bottle fed, bottle fed babies were found to have an increased risk of obesity at least until six years of age, Bottle feeding using formula milk can be expensive. Once you have decided not to breastfeed your baby it is difficult to reverse the decision and begin breastfeeding. Also, if you decide to combine bottle feeding with breastfeeding, you should not introduce bottle feeding during the first six weeks of life, because the difference between nipples can confuse the baby, causing feeding problems, and it can interfere with the establishment of breastfeeding.

C. Types of Formula Milk

Cow's milk-based formula uses cow's milk as the protein source and has been modified to be more like breast milk and appropriate for your baby. Cow's milk-based formula with DHA and ARA is cow's milk formula with the addition of 2 fatty acids docosahexaenoic acid (DHA) and arachidonic acid (ARA). These fatty acids occur naturally in breast milk and are associated with the development of your baby's brain and eyes. Low-lactose formula is a cow's milk based formula but the milk sugar called lactose has been removed and replaced with glucose polymers. This is used for infants who are sensitive to the lactose and are experiencing feeding problems like fussiness, crying, bloating, gas, or diarrhea. Soy-based formula uses isolated soy protein as an alternative to milk protein. It is appropriate for certain sensitivities and parent preferences. Protein hydrolystate formula and fat malabsorption formula are available for babies with protein allergies and fat absorption difficulties. The protein and fat in these formulas have been broken down for easier digestion, absorption, and utilization. Old fashioned homemade formulas made from canned milk, evaporated milk, or goat's milk and corn syrup may have nourished you or your mother, but they are nutritionally inferior to today's commercially prepared formulas and should not be used. Iron: Choose a formula with iron rather than low iron. The iron helps form hemoglobin that carries oxygen throughout the body. Iron is also important in

brain development and educational performance. Iron in formulas does not cause gas, spitting up, diarrhea or constipation. Forms of Infant Formula:

Ready-to-feed cans do not need to be diluted with water. The formula can be poured directly into a bottle and refrigerated until use. This formula is the most convenient because no mixing or measuring is necessary; however, it is also the most expensive. Liquid concentrate formula is mixed with an equal amount of water. Then it is poured into the bottles and refrigerated until use. Powdered infant formula is mixed with water. One level scoop (from can) of the formula is added to each 2 ounces of cold water in a baby bottle. Do not pack the formula into the scoop or tap the side of the can before leveling off the scoop. Shake the bottle well to mix. Refrigerate until ready to use. This type formula is the least expensive.

D. Techniques of Formula Feeding

1. Despite prevalent attitudes today, there's no shame in bottle-nursing. Choosing

whether to breastfeed or bottle-nurse is a personal decision and no one should be able to sway you from your decision. Stay positive about your decision to bottle nurse.
2. Hold your baby in the same positions you would if you were nursing her. Get

skin-to-skin as much as possible, as often as possible. Your baby needs to benefit from your warm skin, your breathing and your heartbeat. Be sure to include extra snuggling and skin-to-skin contact throughout the day when you're not feeding the baby.
3. Take your time and get comfortable with pillows or a Boppy, just as you would if

you were nursing. You can even prop a small baby comfortably on a pillow so she is facing you, and then you have a free hand to touch her. Let her play with your hands, your fingers, your face. Gently discourage her from playing with the hard, plastic bottle by offering your soft, warm skin.
4. Be sure to always hold the bottle at the right angle - every bottle system is

different, so follow the instructions that come with the bottles.

5. Don't rush things. Let the baby eat at his or her own pace. Sometimes you have

to take the nipple out a bit and let the baby "catch up" on swallowing, much like

during breastfeeding let-down. Don't force-feed the baby. S/he will start and stop on their own. Be patient. Your baby will let you know when s/he is done.
6. A good latch is just as important for bottle-feeding as it is for breastfeeding.

Breastfed babies develop their jaw, tongue and facial muscles and coordination through suckling, so ensure your bottle-fed baby has a good latch. Her lips should be everted (rolled outwards), and touching the nipple all the way around so no air gets in her mouth. Look at pictures of breastfeeding latches to learn more.
7. Each baby is unique and has his or her own suckling technique. You may need to

go through several styles of bottles and nipples before you find the one that's right for your baby. Pay attention to your baby's comfort level during eating - is it too slow? Too fast? Is the nipple too wide or too narrow? Is the baby taking in too much air (causing painful gas and fussiness)? Are they just chewing on the nipple and not able to suck effectively? (Also, remember your baby's suckling style will change as s/he grows.)
8. Gaze into your baby's eyes, talk to her, sing to her. Rock in a rocking chair or

glider. Curl up in bed. Dim the lights, shut out distractions, and focus entirely on your baby - because the bottle is between you and your baby, you'll need to go the extra mile to get close to the breastfeeding experience.
9. Always offer formula at near-body temperature. Some babies will take a room-

temperature or cold bottle, but remember, with bottle-feeding you need to compensate for having that bottle between you and your baby.
10. DO NOT BOTTLE-PROP. EVER. It is unsafe. Also, because you have the bottle

between you and your baby, you can compensate for any lack of physical bonding by dedicating yourself to bottle-nursing with love. Bottle-propping leads to feeding problems, possible choking, and dental problems, in addition to possibly creating detachment in both parent and baby.
11. When you bottle-feed in public, try the same things that breastfeeding mothers

do: Find a quiet place, get comfortable, and even cover your shoulder and the baby with a blanket so they can have a nice, cozy, non-distracting environment to eat in.
12. If you feel discouraged, remind yourself why you are doing this: To recreate the

nursing experience for both you and your baby.