The success of sustaining breastfeeding depends on priming the breast with early and frequent prolactin surges.
The current Department of Health recommendation is for women to exclusively breastfeed their babies for six months and to continue breastfeeding alongside appropriate complementary (‘solid’) foods. This means that when we support women, we need to make sure that we give them the information and support they need to achieve this.
The information women need to enable them to breastfeed should be given while they are pregnant. It should then be repeated and reinforced after the baby is born.
Most women are physically able to produce enough milk for their baby, as long as they receive appropriate advice and care. However, some women will have a more marginal physical capacity to produce milk. This means that they have the potential to produce enough, but that early interruptions in establishing breastfeeding are more likely to have negative consequences.
We have probably all known a woman who did not have early contact with her baby and did not feed frequently and who still managed to have a good milk supply and a baby who thrived.
However, as we cannot predict what any individual woman’s potential for milk production is, we need to give care and support to all women which will enable them to establish breastfeeding even if their potential is limited.
Fat content of breastmilk and ‘demand feeding’
The balance of nutrients and other elements in each mother’s milk is unique to her. In fact, it may differ for each baby she feeds and will vary at every feed, in response to the baby’s suckling. (This is one reason why infant formula can never really imitate human milk.)
Fat is an important element in milk that enables babies to grow at the astonishing rate which is normal in the early weeks. (Most full-term babies will double their birth weight within the first four months.) The proportion of fat in breastmilk varies during every individual feed and from feed to feed during the 24-hour day.
Many myths have grown up about ‘fore milk’ and ‘hind milk’. ‘Fore milk’ refers to the milk at the very start of a feed and ‘hind milk’ refers to the milk in the breast at the end of a feed. But these terms are not helpful in describing how the fat content changes during a feed.
As the baby feeds the volume of milk in the breast goes down and the fat content gradually rises. So the milk a baby receives early in the feed has a lower fat content than the milk later on. The highest fat content comes at the end of the feed. Only the baby knows the consistency of the milk he is getting at any point during the feed.
Babies need fat – not just to keep going but also to keep growing. However, they are able to regulate the amount they get as long as they are allowed to feed according to their appetite. A ‘demand-fed’ baby – one who is allowed to feed whenever he wants, for as long as he wants – is able to get what his body needs for growth and development.
Any artificial timing, such as rules about how often the baby should feed (e.g. ‘not more often than every 2 hours’ or ‘six feeds a day’) or about how long feeds should last (e.g. ‘only 10 minutes a side’ or ‘at least 10 minutes’) interferes with the baby’s ability to regulate his own appetite and his mother’s milk supply. As long as a baby is well attached to the breast, he should be allowed to feed as and when he wants.
Mothers should be encouraged to notice and respond to their baby’s feeding cues. Often women think that crying is the sign that their baby is ready for breastfeeding; this is a late sign. Earlier signs include the baby being restless and wakeful, making small noises or movements of his mouth, smacking his lips or sucking his fist, rooting, or turning toward the breast (if held).
If a mother notices these signs, this is an ideal time to offer the breast. A baby is likely to feed more effectively if he is relaxed and has not had to go as far as crying to demonstrate that he would like to breastfeed.
Of course, should a mother feel uncomfortably full, or want to feed sooner for convenience reasons, she is also allowed her share of ‘demands’. Breastfeeding, especially in the early weeks, is about the mother and baby getting into balance with one another. Mothers should be encouraged to find out what works for them and their babies. At a feed, some babies want to feed from both breasts while some are content after feeding from one. Some babies change from feed to feed.
After a baby has come off the first breast himself, he should be offered the second one. If he doesn’t want it, this is fine; if he does, this is also fine.
The traditional ‘good baby’ is one who does not ask for feeding frequently, who feeds for a certain length of time only and who is then content to be firmly wrapped up and put in cot or pram. Although mothers (and grandparents) still expect babies to behave like this, few babies actually follow this pattern. And this pattern of mother-baby interaction is likely to interfere with the physical establishment of breastfeeding.
It is useful to reinforce the ‘normality’ of frequent feeding and desire for contact from the baby when speaking with parents about breastfeeding.
Current delivery practices mean that many women receive analgesia during labour, so many babies are born sedated. This means that their normal biological drive to feed is somewhat dampened down in the first few days. It may be necessary to encourage mothers to offer the breast even if their baby does not show signs of interest. This can be very important in ‘waking babies up’ to the pleasure of feeding – and can help get breastfeeding going well.
Babies who are over 48 hours old are likely to want to feed at least eight times in 24 hours – with almost no upper limit. They will also want to feed during the night. Because this pattern is radically different from the culturally desirable pattern of a baby who gets into a routine easily and early, it is important that every professional who discusses feeding with a mother reinforces the normality of this feeding pattern.
Frequent feeding is very important during the early weeks, and especially in the first few days, to establish maximum milk production. The change from the early hormonal control (described above) to a more automatic, reflex control of breastfeeding may take several weeks, during which mother and baby are learning about each other and establishing their own way of doing things. Once mothers and babies have established breastfeeding together, babies will not necessarily feed quite as often. The frequency of feeding will depend on the storage capacity of the mother’s breasts. This is something which cannot be estimated from looking at the breasts.
A woman’s two breasts may also have different storage capacities. This may be one reason some babies have a marked preference for feeding from one side.
Babies, if allowed to regulate their own feeding, will settle into a pattern of feeds which is suitable to the individual physiology of themselves and their mothers.
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