Breastfeeding

Breast milk is the best choice for a baby. The American Academy of Pediatrics (APA) recommends that a baby be fed exclusively with breast milk for at least the first six months of life, with age-appropriate complementary foods introduced between 6 months and 1 year of age. After 1 year, breastfeeding continues for as long as the baby and mother desire, although after 1 year, breastfeeding should only supplement a complete diet with sufficient solid foods and liquids.

Breastfeeding is one of the most important factors in the adaptation of a newborn to the new conditions of extrauterine life.

Almost every woman is able to breastfeed her child for a long time. But to do this, you need to meet certain conditions, the main ones being:

• early, that is, in the first 30-60 minutes after birth, attachment of the newborn to the breast;
• frequent, active sucking, which is determined not by some schedule, but only by the individual requirements of the child and the degree of his satiety;
• correct feeding technique that ensures effective sucking;
• complete emptying of the mammary gland and receipt of milk by the baby;
• positive emotional state of a woman who is breastfeeding.

To ensure successful breastfeeding, clinicians should begin work on establishing lactation dominance before birth by communicating the benefits of breast milk to the infant (optimal composition to match the infant's gastrointestinal tract and provide all nutrient needs; optimal cognitive development; protection against infections, allergies, obesity, Crohn's disease, and diabetes) and the mother [decreased fertility during lactation; faster postpartum recovery (i.e., uterine involution, weight loss); protection against osteoporosis, obesity, ovarian cancer, and premenopausal breast cancer].

In primiparous women, lactation is fully established 72-96 hours after birth, in multiparous women - in a shorter time. At first, colostrum is produced, high-calorie, high-protein, yellowish in color, with high protective properties due to the content of antibodies, lymphocytes, macrophages, capable of stimulating the passage of meconium. Subsequent milk contains a large amount of lactose, which provides an easily accessible source of energy corresponding to the limited capabilities of the immature gastrointestinal tract of the newborn; contains large amounts of vitamin E, which can help prevent the development of anemia by increasing the lifespan of red blood cells, and is also an important antioxidant; has a calcium and phosphorus ratio of 2:1, which prevents the development of hypocalcemic seizures; causes favorable changes in stool pH and intestinal flora, thus protecting the child from bacterial diarrhea; transfers protective antibodies from mother to baby. Breast milk is also a source of -3 and -6 fatty acids. These fatty acids and their long-chain polyunsaturated derivatives (LCPUFA), arachidonic acid (ARA) and docosahexaenoic acid (DHA), are thought to provide better visual and cognitive abilities in breastfed children than in formula-fed children. Regardless of the mother's diet, breast milk also contains cholesterol and taurine, which are essential for brain development.

If the mother's diet is sufficiently varied, no diets or vitamin supplements are needed for either the mother or the baby if full-term, the only exception being vitamin D 200 IU once daily starting in the second month of life for all exclusively breastfed infants. Premature and dark-skinned infants, as well as infants with little sun exposure (living in northern regions), are at risk. Infants under 6 months do not need additional fluids due to the risk of hyponatremia.

[ 1 ], [ 2 ], [ 3 ]

Benefits of Breastfeeding

The benefits of breastfeeding are:

• Lower infant mortality (even in low-income populations).
• Putting the baby to the breast helps the uterus contract, which prevents postpartum bleeding.
• Direct contact between mother and child, eye to eye, establishes intimate contact between them and contributes to the further development of the maternal instinct, which is an emotional stimulus for the mother.
• Breastfeeding is a proven experience as a general stimulant of all five senses.
• Breastfeeding is cheap and breast milk is clean.
• It protects against infection, as milk contains IgA, macrophages, lymphocytes (carrying interferon) and lysozyme. Breast milk has an acidic reaction, which promotes the growth of beneficial lactobacilli in the baby's intestines. Gastroenteritis in a child fed with breast milk is always easier, as the mother can pass on antibodies to the child with milk (an immune dialogue between mother and child occurs).
• Breast milk contains less sodium, potassium and chloride than other milk sources, making it easier for the kidneys to establish homeostasis.

If dehydration does occur, the risk of fatal hypernatremia is much lower.

[ 4 ], [ 5 ], [ 6 ]

Factors that make it difficult to start breastfeeding

• In the maternity hospital, the mother and the newborn are in different rooms at night,
• Urbanization and its consequences - the mother must work, but there is no place to feed the baby at work.
• Young saleswomen dressed as nannies delivering food to newborns' homes.
• Influence of example: If older sisters do not breastfeed their newborn, it may be more difficult for younger sisters to begin breastfeeding later.

[ 7 ], [ 8 ], [ 9 ], [ 10 ]

Why should extended breastfeeding be promoted?

• This makes the baby happy and helps increase the mother's milk production.
• This reduces the number of problems with the mammary gland - inflammation, swelling, engorgement, development of abscesses.

Please note: sleep is much less likely to be interrupted if the baby shares the same bed with the mother at night.

Ten principles for successful breastfeeding

1. It is important to put the baby to the breast as early as possible. This should be done in the delivery room. Early breastfeeding is important for both the baby and the mother;
2. from the very beginning, bottle feeding and the use of pacifiers are excluded. Do not use a pacifier, a pacifier, or a bottle - this will help to avoid breastfeeding in the future, will provide a sufficient amount of milk and constant contact with the baby. Remember that the more often a mother breastfeeds, the more milk she will have;
3. Do not limit the duration of feeding and do not take the baby away from the breast before he lets go himself. For a baby, being near the breast is not only nutrition, it is a feeling of security, comfort and closeness to the mother;
4. Feed your baby at night. The baby grows quickly and cannot go long periods of time without feeding. Night feeding stimulates milk production the next day;
5. It is important for a child to be with his mother from the very beginning. Being together has many advantages, for example:
   1. the mother quickly learns to respond to the child's signals; this helps to establish strong emotional and psychological connections;
   2. the baby feels protected;
   3. the mother feeds the baby more confidently and can put him to the breast as soon as the baby wants (at least 8-12 times a day);
   4. when mother and child are kept together, the risk of developing infectious diseases is reduced;
6. The position of the baby near the breast is of great importance. This is the key to comfortable, effective feeding and, accordingly, successful lactation. When giving the breast, hold the baby very close, with his tummy towards you. Your nipple should be at the level of the baby's nose. Wait for the baby to open his mouth wide, and attach it so that he captures not only the nipple, but also most of the areola (the area of the breast around the nipple);
7. Do not give your child water, tea or other products under any circumstances until 6 months. This will protect your baby from infections, allergies and intestinal disorders and provide your child with adequate nutrition;
8. do not wash your breasts before and after feeding. Excessive washing with soap dries out the skin of the nipples, can lead to cracking, and also washes away the microflora that is beneficial for the baby from the mother's skin;
9. Do not express milk unless absolutely necessary. Expression is only necessary in cases of forced separation of mother and child or when the child cannot suckle;
10. In order for a baby to grow up healthy, as nature intended, WHO recommends breastfeeding a child for at least two years, the first six months of which should be exclusively breast milk.

Contraindications for breastfeeding

• Mother is HBsAg positive.
• The mother receives amiodarone.
• The mother is receiving antimetabolites.
• The mother is receiving opiates.

It should be considered a mistake to recommend that mothers infected with HIV switch to formula feeding, since if the infant has escaped infection in utero, it is unlikely that the infant will become infected from the mother, and the benefits of breastfeeding may outweigh the small additional risk of infection.

Read the full article: Contraindications to breastfeeding

[ 11 ], [ 12 ], [ 13 ], [ 14 ]

Breastfeeding technique

The mother can adopt any relaxed, comfortable position and should support the breast with her hand in such a way as to reduce trauma and to be sure that the nipple is at the level of the middle of the baby's mouth.

In this position, the nipple stimulates the receptors of the baby's lower lip, a search reflex is triggered and the mouth opens wide. It is necessary to ensure that the baby's lips are at a distance of 2.5-4 cm from the base of the nipple, thus maximally capturing the areola with the lips. The baby's tongue then presses the nipple to the hard palate. It will take at least 2 minutes for the milk flow reflex to occur.

The volume of milk increases with the growth of the child, as well as the stimulation of lactation during sucking. The duration of feeding is usually determined by the child himself. Some women need a breast pump to increase or maintain lactation; for most women, 90 minutes a day of pumping, divided into 6-8 approaches, allows you to get enough milk for the child.

The baby should suckle on one breast until the breast becomes soft and the baby slows down or stops. Before removing the baby from one breast and offering the other, the mother can interrupt the suckling with her finger. In the first few days after birth, the baby can only suckle on one breast at a time, in which case the mother should alternate breasts at each feeding. If the baby falls asleep before the required amount of milk is sucked, the mother can remove the baby when the suckling slows down, hold the baby upright to allow any swallowed air to escape, and offer the other breast. This method of feeding will keep the baby awake during feeding and will also stimulate milk production in both breasts.

Mothers should be advised of the benefits of feeding on demand or every 1.5 to 3 hours (8 to 12 feeds per day), with feeding frequency gradually decreasing over time; some infants under 2500 g may require more frequent feedings to prevent hypoglycemia. Newborns may need to be woken for feedings in the first few days. It is usually best for the infant and the family to establish a routine that allows the infant to sleep as much as possible at night.

Mothers who work outside the home can express milk while they are away from their baby to help maintain their milk supply. The frequency of expression may vary, but should roughly match the baby's schedule. Expressed breast milk should be refrigerated immediately if it is to be used within 48 hours, or frozen if stored longer. Milk that has been refrigerated for more than 96 hours should be discarded due to the high risk of bacterial contamination. Frozen milk should be defrosted in warm water; microwave use is not recommended.

If early attachment for some reason did not take place and the first feeding was postponed for some time, lactation in this case can also be successful and long-term. It is necessary to replace the sucking of the child with early regular expression of colostrum from the mammary glands every 3-3.5 hours. Even if the mammary glands are empty after birth, it is necessary to massage the nipple and areola, and then carefully express drops of colostrum, repeating this procedure regularly. The amount of milk will definitely increase and it will be enough for a day of feeding the child.

The frequency of putting the baby to the breast can reach 10-12 times a day. As the amount of milk increases, the frequency of feedings will decrease to 7-9. Night feedings are especially important in maintaining lactation.

With the correct feeding technique, the duration of feeding should not be limited. After actively sucking on one breast and emptying it, the baby should be offered the other breast. The next feeding should be started from the breast that was fed last. But it is important to remember that using two mammary glands for one feeding can lead to the baby not receiving the "back", the most energy-valuable milk. Therefore, in any case, you should not quickly mark the breast during feeding. As a rule, on the 6th-14th day with this feeding regime, sufficient lactation is established, the duration of sucking is on average 20-30 minutes, and the need to feed the baby from two breasts disappears.

Today it is well known that feeding a child on a strict schedule, with a night break, using a bottle with a nipple when supplementing with formula during the period of establishing lactation, that is, in the first days after birth, leads to a decrease in milk production and early loss of lactation in general.

Regardless of the position in which feeding is carried out (sitting or lying down), you need to adhere to the following basic rules:

• the baby's head and body should be in line;
• the baby's face should be facing the mother's breast, the nose should be opposite the nipple;
• the baby's body should be pressed against the mother's body (belly to belly);
• You should hold the baby's entire body from below with one hand.

Signs of correct attachment of the baby to the breast:

• the baby's chin touches the mother's breast;
• the baby's mouth is wide open;
• the lower lip is everted;
• cheeks are rounded;
• most of the areola is not visible (mainly its lower part);
• the mother does not feel pain even with prolonged sucking,
• You can hear the baby swallowing milk.

Signs of improper feeding of a child:

• the baby's body is not fully turned towards the mother;
• the chin does not touch the chest;
• the mouth is not wide open, the lower lip is pulled in, the cheeks are even sunken;
• most of the lower part of the areola remains outside the baby's mouth;
• sucking movements are quick and short, sometimes smacking sounds appear;
• a feeling of pain in the nipple area.

To ensure long-term and successful breastfeeding from the first days after returning home from the maternity hospital, you need to adhere to the following rules:

• feed the baby "on demand" and not "on schedule", that is, you need to give the baby the opportunity to feed as much as he wants. In the first weeks of life, this can be 8-10 and even 12 times a day. Such frequent feeding of a newborn is physiological and promotes good stimulation of your lactation. Gradually, usually in the 3-4th week of the baby's life, the frequency of feedings decreases and is 6-7 times a day; 
• do not avoid night feeding. If the baby wakes up at night and cries, do not give him water or a pacifier, but breastfeed. Remember that it is at night that intensive production of prolactin occurs, which is responsible for lactation;
• Breastfeeding should take place in a calm atmosphere. The mother's good mood, pleasant music, and comfort contribute to intensive milk production and easy release from the mammary gland;
• the duration of each feeding is usually 15-20 minutes. Most children suck out the required amount of milk during this time and fall asleep. If this does not cause you any unpleasant or painful sensations, then it is advisable not to take the baby away from the breast and give him the opportunity to fully satisfy his sucking reflex;
• A healthy child who receives sufficient amounts of breast milk does not need additional water, infusions or tea, even on hot days, since breast milk contains not only nutrients, but also the water that the child needs.

Exclusive breastfeeding is considered optimal during the first 4-5 months (the child receives only breast milk and no foreign food, not even water), since with sufficient lactation and a woman’s rational nutrition, mother’s milk fully meets the physiological needs of the child during the first 5 months of life.

[ 15 ], [ 16 ], [ 17 ], [ 18 ]

Complications of breastfeeding for the baby

The primary complication is underfeeding, which can lead to dehydration and hyperbilirubinemia. Risk factors for underfeeding include small or premature infants, primiparous mothers, maternal illnesses, difficult labor, and surgical intervention during labor. A rough estimate of the adequacy of feeding can be given by the number of diapers used; at the age of 5 days, a healthy newborn wets at least 6 diapers per day and soils 2-3 diapers per day; a smaller number of diapers may indicate hypohydration and underfeeding. Another parameter indicating underfeeding is the baby's weight; delayed weight gain may also indicate malnutrition. Constant restlessness before the age of 6 weeks, when colic may develop regardless of hunger or thirst, may also indicate underfeeding. Dehydration should be assumed when the intensity of crying and skin turgor decrease; Drowsiness and lethargy are serious signs of dehydration and prompt immediate determination of sodium levels due to the possibility of developing hypernatremia.

[ 19 ]

Complications of breastfeeding on the part of the mother

The most common maternal complications include breast engorgement, cracked nipples, blocked milk ducts, mastitis, and restlessness.

Engorgement that occurs early in lactation and lasts 24-48 hours can be minimized by early, frequent breastfeeding. A comfortable nursing bra worn 24 hours a day, a cool compress on the breast after feeding, and a mild analgesic (such as ibuprofen) can also help. Massage and a warm compress may also be helpful. Expressing a little milk before feeding will help the baby better latch onto the swollen areola. Expressing extra milk between feedings will help reduce engorgement; you do not need to express all the milk, but just enough to relieve discomfort.

To treat cracked nipples, check the baby's position during feeding; sometimes babies pull their lip inward and suck on it, which irritates the nipple. A woman can release the lip with her thumb. After feeding, squeeze out a few drops of milk and let them dry on the nipple. After feeding, a cool compress will reduce engorgement and ensure further comfort.

A blocked milk duct will appear as a tense, mildly painful area of the breast in a nursing woman, although she has no general signs of the disease. The lumps will appear in different places and are painless. Continuing to breastfeed will ensure that the breast is emptied. Warm compresses and massage of the affected area can help restore patency. A woman can also change her feeding position, as different areas of the breast are better emptied depending on the position of the baby. A comfortable bra can help, while regular bras with wire inserts and constricting straps can contribute to milk stagnation in the compressed areas.

Mastitis is quite common and manifests itself as a painful, hot, swollen, wedge-shaped area of the mammary gland. It develops against the background of engorgement of the mammary gland, blockage of the ducts; infection can occur secondarily, most often caused by penicillin-resistant strains of Staphylococcus aureus, less often - Streptococcus sp or Escherichia coli. Infection can cause fever (> 38.5 ° C), chills, flu-like condition. Diagnosis is based on the anamnesis and clinical data. The cell count (leukocytes> 106 / ml) and breast milk culture (bacteria> 103 / ml) will help to distinguish infectious from non-infectious mastitis. If symptoms are mild and last less than 24 hours, conservative treatment (emptying the breast by feeding or expressing, compresses, analgesics, a supportive bra, protective regimen) may be sufficient. If there is no improvement after 12-24 hours or the process is highly active, it is necessary to begin antibacterial therapy using drugs that are safe for the child and effective against S. aureus (for example, cephalexin 500 mg orally 4 times a day); the duration of therapy is 10-14 days. Complications of late initiation of therapy include relapse and abscess formation. Breastfeeding can be continued during treatment.

Maternal anxiety, frustration, and dissatisfaction may develop due to lack of breastfeeding experience, mechanical difficulties during feeding, fatigue, and difficulty in determining whether milk is sufficient, as well as postpartum physiological changes. These factors and emotions are the most common reasons why women stop breastfeeding. Early monitoring by a pediatrician or consultation with a lactation specialist are effective measures to prevent early termination of breastfeeding.

One of the decisive factors for successful lactation is ensuring the appropriate position of the baby near the breast and the correct breastfeeding technique. The consequences of incorrect breastfeeding may be:

• the formation of cracked nipples, pain during feeding, the appearance of fear regarding the occurrence of pain, inhibition of the milk ejection reflex;
• ineffective sucking of the baby at the breast, and consequently, dissatisfaction, weight loss;
• use of milk and a decrease in its production as a result of insufficient emptying of the breast;
• development of insufficient milk production, the so-called hypochalactia;
• sucking in a significant amount of air (aerophagia), which fills the stomach, stretches it and leads to regurgitation of milk;
• cracked nipples and milk stagnation, which subsequently leads to mastitis.

To make feeding pleasant and easy, you need to take a comfortable position (lying or sitting with back support). The child should be able to study the mother's face, especially her eyes. It is best to feed the child naked, so that the child has maximum contact with the mother's body. If the baby is swaddled tightly, then it is impossible to properly attach him to the breast. The child should move freely during sucking, show his emotions, reactions. Free swaddling, without restricting movement, promotes the correct development of the musculoskeletal system, joints, and forms the child's need for breast milk to renew energy.

[ 20 ], [ 21 ], [ 22 ]

Medicines and breastfeeding

Breastfeeding women should avoid medications whenever possible. If drug therapy is necessary, avoid medications and drugs that suppress lactation (bromocriptine, levodopa), choose the safest alternative, and take it immediately after breastfeeding or before the baby's longest sleep period; this is less appropriate for newborns who feed frequently and whose feeding schedule has not yet been established. Adverse effects of most medications are based on case reports or small studies. Some medications (eg, acetaminophen, ibuprofen, cephalosporins, insulin) have been shown to be safe in large studies, while others are considered safe only based on the absence of reports of adverse effects. Medications that have been used for a long time are generally safer than newer medications for which information is limited because of limited experience.

Weaning

Weaning usually occurs by mutual agreement between mother and child at any age over 12 months. More often, weaning occurs gradually over several weeks or months, while the child is offered new types of solid food; some babies wean immediately, without any problems, while others continue to breastfeed 1-2 times a day until 18-24 months or even longer.