Feeding Time

THE DECISION TO BREASTFEED can give your baby the best possible start in life. While that’s true, it’s still an intimate and personal choice—and there are many factors that can weigh on a mother’s decision. In healthcare, we can guide parents to recognize the benefits breastfeeding brings to both mother and child, but we must also respect and support women for whom breastfeeding is not possible or is not the best choice.

According to UNICEF, 24% of babies in Vietnam are breastfed (either exclusively or with formula feeding) up to the age of six months—higher than the overall global rate. The official recommendation from the WHO is that women are advised to breastfeed exclusively for the baby’s first six months of life, without the need for additional solid food or fluids, including water. Breastfeeding reduces the risk of many diseases that are a threat to infants, including Sudden Infant Death Syndrome (by 36%); middle ear

infection (otitis media), allergic rhinitis, and childhood leukemia (by about 18%).

There are also some studies that show children who are breastfed tend to have a higher IQ, and are less likely to be obese or overweight in adolescence and Adulthood.

The benefits to the mother include a reduced risk of pre- and postmenopausal Breast cancer (because of the reduced exposure to estrogen) And a reduced risk of ovarian cancer.

These benefits increase with longer periods of breastfeeding. It’s usually considered best for mother and baby to experience close skin contact immediately after birth to trigger a bond that also helps to stimulate the production of breast milk.

After giving birth, it takes about two or three days for the milk to come in to the breast. The first milk that comes in is something called colostrum, a creamy yellow liquid containing high levels of antibodies—which are proteins that fight infections and bacteria. Babies only drink about 5–10 mls of it, after which the breast milk begins to be produced in its normal form. Normally when a baby suckles, the first part of the milk taken will be more watered down. Milk with a higher fat and nutritive content comes in at the end. It’s often recommended that breastfeeding mothers should make sure that they are allowing their baby to stay on long enough to get what they need and not switch too early, so that the baby is getting the creamy fat content at the end.

It’s unfortunate that some mothers do experience significant challenges in feeding their babies that can be overwhelming, especially in the absence of professional help from a midwife or lactation consultant.

Around 30% of women will experience at least one breastfeeding problem in the first two weeks after delivery, and many of those will consult their doctor. The most common reasons for stopping breastfeeding in those early weeks is the baby not suckling or rejecting the breast, as well as painful breasts/nipples. After the first few weeks, the most common reason for stopping breastfeeding is reported as insufficient milk—which can include the perception of insufficient milk. Appropriate management and support for these problems is therefore key to achieving ongoing breastfeeding. Low milk supply is the most commonly reported cause of mothers choosing to stop breastfeeding.

However not all mothers who worry about low milk supply have an actual issue. Perception of low milk supply is a common problem, when parents misinterpret normal newborn behaviors—such as cluster feeding (prolonged periods of frequent brief feeds), growth spurts, and frequent feeding—or misunderstand how breastfeeding works, not appreciating that breasts may come to feel softer as the weeks go by; a baby’s swallowing pattern may change; or that response to a breast pump is not a measurement of milk supply. Milk production is a feedback mechanism—the more you feed, the more milk is produced, and the less you feed, the less milk is produced—so if the mother starts supplementing breast milk with bottle feeding, this may lead to an actual decrease in her milk production.

Sometimes there really is an issue with milk transfer, in that the milk isn't being effectively withdrawn from the breast by the baby. The most common cause of this isn't an illness—it's more to do with positioning and attachment of the baby at the breast. If the mother is not positioned correctly while breastfeeding or the baby is not attached to the breast well, feeding will become more painful and this will lead to ineffective milk transfer. The best indicators of low milk supply are the frequency of wet nappies and weight gain (after five weeks of age).

Rarely, in perhaps 2–5% of cases, there is an underlying medical problem. Issues such as retained placenta, hyperthyroidism, and heavy bleeding during delivery can affect the pituitary gland, which affects milk supply. One third of women who have polycystic ovarian syndrome will have problems with their milk supply—breast surgery can also be responsible for this situation, as can the effect of hormonal contraception.

Pain in breastfeeding can have a significant impact on the relationship and whether the mother chooses to continue breastfeeding her child. Cracked or sore nipples are common and are usually due to positioning and attachment issues. This is common in the early days of breastfeeding, and usually with practice and patience the issue resolves itself and the woman can carry on without needing to see a doctor. However, breastfeeding isn’t supposed to be painful, and if the problem continues for a long period it is advised for the mother to seek help from a medical or health professional.

If it does continue, it can cause fissures and acute pain—which will then affect breastfeeding. Applying a small amount of breast milk on the nipple can be very protective and restorative, as well as using purified lanolin (which is found in a lot of commercial nipple creams). Sometimes an antibacterial ointment is also necessary.

Cracked nipples are caused by attachment problems, when the baby is not attaching to the breast properly.

Usually, when a baby attaches to the breast, it will make a wide open mouth so the top lip is way above the nipple, and make strong sucking motions. But if the baby is latching onto the nipple only, this will eventually cause nipple pain. Sometimes when milk is not effectively removed from the breast, a painful condition called mastitis may arise, which presents as a wedge-shaped area of the breast that becomes painful, red, hard or firm, and hot. It may be accompanied by symptoms such as fever and chills, body aches, tiredness, nausea, and vomiting. It occurs when milk is held too long in the duct, causing distension—a blocked duct that then gives rise to mastitis. Blocked ducts are normally caused by poor positioning and attachment. When mastitis does occur, it is important to present to your doctor early to assess whether treatment is needed and to get advice on positioning and attachment to prevent the problem in the future.

POSITIONING AND ATTACHMENT TIPS MEDICAL COLUMN

Dr. Olivia Wyatt was born in South Africa and raised in Botswana, where she worked with HIV patients with Harvard Medical School and the Clinton Foundation. Now a mother of three—daughters Aggi Rose and Evie and son Louis—Dr. Olivia regularly

convenes FMP’s Saigon International Mother and Baby Association, a group supporting new and expecting mothers with parenting guidance and information, where she leads discussions on topics such as feeding, sleeping, development milestones, colds & coughs, and vaccinations over coffee, tea

• Sit comfortably with your back well-supported and your lap flat.
• Keep baby’s body in a straight line facing the breast.
• Support baby’s neck, shoulders and back so he/she can easily tilt back the head.
• Ensure baby’s lower lip and chin makes contact with the breast first.

SIGNS OF EFFECTIVE ATTACHMENT

Usually, if the nipple is brushed against a baby's top lip and nose, it will fully open its mouth. This is called rooting, and every suckling animal has the same instinctive response. It will latch on naturally when the nipple touches the top of the mouth, which draws in quite a large part of the breast rather than just the nipple. If the mother and baby are properly guided, the baby will get used to the correct rooting response, and the more frequently it will occur.

Trained healthcare professionals can support mothers and educate them about the best positions for the strongest attachments. A lactation consultant—or a midwife, or a nurse—can help to educate new mothers on how breastfeeding works, what to expect, what's normal, and what's not often talked about, especially in the early stages.

• Baby has a large mouthful of breast.
• Baby’s chin is firmly touching the breast.
• Baby’s mouth is wide open.
• Feeding doesn’t hurt.
• No change in shape or color of the nipple after feeds.
• Baby’s cheeks stay rounded while sucking.
• Baby takes long, rhythmic sucks and swallows with occasional pauses.
• Baby finishes feeding independently.

Baby should produce regular soaked/heavy nappies. Bowel motions should be soft and yellow from day 4/5 with two or more dirty nappies a day and poos at least the size of a large coin.