Breasts and Breastfeeding

The Breast

The breast is made up of fifteen to twenty segments – imagine an orange cut in half. The cells which make the milk, alveoli, lie at the back of the segments and have ducts leading down to the nipple. Just before the ducts open on to the nipple they enlarge slightly to form a reservoir. These reservoirs are at the point where the normal skin of the breast darkens into the pigmented ring around the nipple, the areola. Small glands in the areola called ‘Montgomery’s tubercles’ produce a fluid that keeps the skin of the nipples and the areola soft and supple. The nipple has not just one opening, but several, which vary in number according to the number of segments and ducts of the breast. The size of breast does not dictate its ability to produce milk – small ones can be just as efficient as large ones.

During pregnancy breasts become much larger as they prepare to make milk because of an increase in the milk-producing cells and ducts and a greater blood supply, but they do not actually begin to make milk until stimulated by a complex hormone reaction after birth.

Colostrum is the creamy, yellowish substance that is made before the breasts begin to manufacture mature milk. Unlike milk, this is made during pregnancy, and from about the fifth month and towards the end of pregnancy may leak from the nipple a little – it is not significant whether this does or does not happen. Giving your baby colostrum at the start of his life is important. Even if you do nothing more than breastfeed for those first two or three days you will still have given him something valuable that cannot be artificially reproduced. Colostrum is uniquely designed for the transition your baby makes from placental feeding, when the nourishment he needs is carried in the blood supply through the umbilical cord, to digesting food himself. Colostrum is lower in sugar and fat than mature milk, so it is easier for a baby’s immature digestive system to cope with as it gently begins working. It also contains more protein than mature milk and has higher levels of antibodies. These protect the baby from bacterial infection, and this is perhaps the most valuable role of colostrum. It will also give protection from illnesses the mother has had or been immunised against. Colostrum goes on being produced for about ten days after the birth, but after about three days it begins to be mixed with mature milk which makes the milk seem creamier. Once the colostrum stops, breast milk on its own seems thinner and watery but do not think your own milk has become ‘poorer’ because this is its natural consistency.

Mature milk is usually present in the breast around the third day after the birth. Although the breasts have been ready to make milk since about the middle of pregnancy, it is actually the birth itself which acts as the trigger to milk production and this happens whether you plan to breastfeed or not. A drop in the hormones progesterone and oestrogen takes the brake off, as it were, and causes more of the main hormone which controls the milk supply to be produced (prolactin). It is this hormone which starts the milk-producing cells working, although it takes a couple of days for the first milk to appear. This mechanism also operates in the case of miscarriage or stillbirth because your body has no way of knowing there is no baby to feed, and can be very distressing, especially if a woman is not warned in advance. In the case of a live birth, it is the baby sucking at the breast which stimulates more prolactin and so ‘orders up’ more milk for the next feed.

Breast milk changes during a feed, from day to day and as the baby grows (the advantages of brest feeding). Your health, what you eat and drink, and even your feelings can also change the composition and quantity of milk. As mentioned, early colostrum and milk is higher in protein and antibodies than mature milk, but we still do not know all the ingredients of breast milk nor exactly how the composition changes as the baby grows.

Suckling after delivery has been shown to be a key factor in successful breastfeeding. Women who are able to put their baby to the breast within twelve hours of the birth and, even better, within four hours or as close to delivery as possible, are more likely to be able to breastfeed successfully and to continue longer. But if, for some reason, you cannot do this, it does not mean you won’t be able to feed (Caesarean mothers). The emotional and physical aspects of suckling after the birth are closely interwoven since milk production and the release of the milk are governed by hormones which are, in turn, affected by our emotions. The baby’s suckling stimulates the nerve endings in the nipple. This sends messages to the brain to produce the hormones oxytocin and prolactin. These hormones make the uterus contract back to its normal size and get the milk-making cells in the breast working.

Supply and demand is the basic principle of successful breastfeeding. The more the baby sucks at the breast, the more milk the breast makes. In the beginning there may be too much milk and the baby’s pattern of feeding will be erratic, but after two or three weeks this will settle down and as the baby grows your body will be able to match his needs by making just the right amount of milk, provided you let him feed whenever he is hungry.

Putting the Baby To the breast

‘I think men might imagine it’s a natural instinct and you know exactly what to do. In fact I felt rather self-conscious and hadn’t a clue how to get the baby fixed on. I was deeply grateful for a very helpful midwife who sat down and showed me exactly how. I was absolutely thrilled when my baby actually latched on and sucked. At first I still couldn’t believe I was a mother and now here was this enormous, perfect baby, doing just what babies are supposed to do!’

If you can sit up, make yourself comfortable with pillows and hold the baby so his head is level with your breast; you can put pillows under him as well to support his weight. If you can’t sit up you can still feed lying down and slightly turned to the side with the baby on the bed beside you (Caesarean mothers). To help the baby suck properly without making you sore, put the whole nipple and part of the areola into his mouth with his tongue underneath so that the pressure of his jaws as he sucks is on the areola, not the nipple itself. The baby’s father or a midwife can support the baby’s head close to your breast and gently guide him into the right position. Touch your nipple or stroke your finger against the baby’s cheek, and he will turn his head towards the breast – this is called ‘rooting’ – and open his mouth to take the nipple. If he does not open his mouth, touch your nipple against his bottom lip and then top lip – at this point you will need your helper to guide his head so that he takes the nipple fully deep into his mouth. If he is fixed on properly, the tops of his ears will wiggle slightly as he sucks. If this does not happen, and you can see his cheeks going in and out as he sucks, or it hurts, put the tip of your little finger gently into the corner of his mouth to break the suction and try again. Make sure when you are feeding your baby that he is able to breathe clearly through his nose. If you support your breast from underneath with the flat of your free hand against your ribs, this will direct your nipple and breast upwards into an easy feeding position for him.

A few hospitals may still recommend starting with two minutes each side and building up, but breastfeeding specialists now think this is not long enough to stimulate the let-down reflex. Instead they suggest following your and your baby’s preference from the start. A rough guide is that a feed takes about twenty minutes, approximately ten minutes each side, although as a baby gets older and sucks more efficiently, he will take less time. You can tell when your baby begins to suck less vigorously and lose interest that it is time to swap him to the other breast. Babies are individuals and feed at different rates and your body responds differently too, but if each feed is taking much longer it is pretty certain that your baby is just enjoying comfort sucking, rather than feeding.

Taking the Baby Off the Breast

Doing this the right way is just as important as fixing him on properly. Always break the suction first before withdrawing the nipple by sliding a finger-tip into the corner of his mouth – do not drag the nipple from his mouth while he is still sucking as this can cause soreness.

Babies Who Will Not Suck

A baby who will not suck may simply need a little time and patience to get the idea. Loosen any wrappings while still keeping him warm and enjoy stroking his limbs, talking to him and generally discovering the delights of your new baby. Usually babies have a very alert, aware period immediately after the birth and they have a lot of new sensations to take in. Try him at the breast again when you feel like it and be relaxed about the whole business. If you have been expressing colostrum you can try putting a drop on his lips. If he seems very sleepy, let him sleep and try him again when he next wakes. If you had pethidine close to the time of delivery it can make your baby drowsy too and you may have to wait for the effects to wear off. Babies who are jaundiced are also sometimes slow to suck and fall asleep during feeds. Premature babies may not have had time to develop the sucking reflex of babies born at full term. Babies who have swallowed a lot of mucus during the birth may also be reluctant to feed. They may be sick, which will make them feel better: sometimes feeding water on a spoon or with a bottle can help them to bring up the mucus.

The paediatrician who gives your baby a full examination, usually the day after the birth, will ask about feeding so seek advice about any problems.

After Pains

These are caused by the womb contracting back to its pre-pregnancy size; they often happen during breastfeeding because this stimulates the hormone oxytocin which in turn causes the contractions. If they are very severe in the first days, take a painkiller half an hour before feeding.

Which Side First?

Start on the breast you finished with at the last feed so that each side gets equal stimulation from your baby’s stronger sucking at the beginning of a feed. When you change breasts sit your baby upright, supporting him with a hand behind his neck and thumb under his chin, and gently rub his back with your free hand to encourage him to bring up any wind. A muslin nappy is a good precaution as babies often bring up a little milk when they burp because the muscle that closes off the stomach is not yet very strong. If your baby does not bring up any wind, do not spend ages thumping him on the back, but carry on feeding.

Feed Your Baby Whenever He Seems Interested

If he wants to suck, you can be sure you are doing the right thing. He may wake and cry or just start to root around or make sucking movements with his mouth – you will quickly recognise the signs. At times this may be only half an hour after you last fed him, while at other times he may sleep deeply for much longer. Most babies gradually settle to a recognisable routine, and forcing a routine on them will only mean several hours with a miserable, crying baby.

When the Milk Comes In

This is often the most difficult time because it usually causes some degree of engorgement and may coincide with a particularly emotional, weepy feeling around the third day. Signs are hard, swollen, hot breasts, with taut shiny skin and even some feverishness. ‘I woke up with two rock-hard, aching boulders where my breasts should be – no one told me it would be like this,’ is how one mother described it.

Don’t panic if you do get very engorged because it really is a passing phase which never lasts more than twenty-four to forty-eight hours. The rest of breastfeeding is not at all like this. Engorgement at this stage is caused by a greatly increased supply of blood to the breast and it is thought that frequent suckling from birth can help to minimise this. The remedy is to feed the baby little and often to empty the breasts, and apply cold compresses or ice packs or spray the breasts with cold water to make the blood vessels contract and reduce swelling. Alternatively, try sitting in a warm bath and expressing the milk by hand.

Remember this does not last long and after this it all gets better! At some point, usually after about six weeks, your breasts will become smaller and softer – this is not a sign that you have no milk, rather that milk production has now settled down and is being made by the milk-producing cells but not filling the breasts until the baby starts to feed and stimulates the let-down reflex.

The Let-Down Reflex

This is stimulated by the hormone oxytocin and causes muscles to contract, squeezing milk out of the milk-producing cells into the ducts leading to the nipple. In fact the process will have been working before the milk came in, but is rarely felt. Once the milk comes in it is very important because although the baby can get what is called ‘foremilk’, which is present in the ducts of the breast, by sucking, two-thirds of the feed is contained in what is called ‘hindmilk’, which is only released by the let-down. The hindmilk has more fat in it and is therefore much richer in calories which your baby needs for growing.

The sensation of the let-down reflex varies, but is usually described as a tingling or slight ache and is always accompanied by a rush of milk. Usually milk begins to leak out of the non-feeding breast and you can see the rhythm of the baby’s jaw action change as he begins to take deep swallows and does not have to suck so hard.

Problems with the let-down reflex are a common cause of babies not gaining weight and mothers of premature babies with a poor suck may be especially prone to difficulties. Anxiety, tension and stress can all inhibit the reflex so the circle gets worse. Try to relax and don’t limit the baby’s time at the breast, but continue to feed frequently. Bathing with hot water and expressing milk by hand can sometimes stimulate the let-down. You can also ask your GP or the hospital for a nasal spray of oxytocin which can be used effectively to prompt let-down – once the reflex has been experienced a few times the let-down will become easier.

Complementary Bottles

Complementary bottles can spell the beginning of the end of breastfeeding if you start giving them instead of letting the baby suck at the breast, or are too prompt to offer one as a ‘top-up’ without giving the baby enough time at the breast, because your supply will then decrease further. On the other hand, if the baby is driving you mad and won’t settle and you feel completely shattered at the end of a day of apparently non-stop breastfeeding, then handing him over to your partner for the occasional bottle while you take time off to rest and relax can be a real life-saver. It is also useful to have a baby who will take a bottle if necessary to enable you to leave him sometimes. If you do not want to risk formula feed because of the possibility of allergy, you can express and freeze your own milk for bottle-feeds (expressing and storing milk). Some babies accept breast or bottle equally well, others will take only the breast, or get used to bottle-feeding in hospital and will not switch easily to breastfeeding. ‘Natural’ nipple-shaped teats are available and have been suggested as more suitable for breastfed babies when they have the occasional bottle.

Cutting out complementary bottles can be done, but you need to be determined and prepared to accept a more unsettled feeding pattern for a few days. Aim to build up your milk supply as described on expressing and storing milk by putting the baby to the breast often and letting him suck as long as he wants. At the same time, try to get extra rest, take in plenty of fluids and eat well. Give the bottle after breastfeeds. Decrease the bottle-feed by 15g (H oz) per feed per day until you have dropped all the complementary feeds. Alternatively, leave out the bottle at the feed when you have most milk, usually first thing in the morning. Continue to feed often during the rest of the day, but two days later drop the next bottle. Allow a week to make the change-over if you have been giving a top-up bottle at every feed. Alternatively, if you have been giving only one or two extra bottle-feeds you can try setting two days aside for nothing but feeding whenever your baby seems hungry and abandon bottles straight away – your milk supply will quickly catch up with your baby’s demands in about forty-eight hours.

Food Requirements of Breastfeeding Mothers

Breastfeeding mothers need extra food and should eat regularly, with nutritious snacks between meals. During pregnancy stores of fat are especially laid down to be used to produce milk and in the early weeks you also need about 500 extra calories a day to offset the 600 or 800 calories a day your baby may be taking. Your appetite will usually be the best guide because breastfeeding invariably makes you hungry as well as thirsty – it is advisable to have a glass of water or fruit juice on hand while breastfeeding as some women get an overwhelming thirst then.

Examples of 500 calories are: a meal of meat, potatoes and vegetables; scrambled egg on two slices of toast with butter or margarine plus a rasher of bacon; one round of ham, or peanut butter or cheese sandwiches plus a yoghurt; a large slice of cake with a glass of milk. Breastfeeding is often a time when you can get away with the occasional indulgence in the cream cake or chocolate line, but do not rely too heavily on sugary and fatty foods to provide the extra calories as they have little nutritional value. As feeding is established, your body uses up fewer extra calories so you can gradually go back to normal eating, but still beware of going for long periods without food: this will affect your milk supply. What you should aim for is small amounts of nourishing food at regular intervals.

Not Having Enough Milk

This is a common worry among breastfeeding mothers. There are three rules to follow to build up your supply: feed your baby more frequently and let him suck as long as he wants; make sure you are eating and drinking enough through the day; take things easy so that the extra calories can be used for making milk. Usually forty-eight hours on this regime will summon up the necessary extra milk. You could try giving a couple of days or a weekend over completely to trying to boost your milk supply.

Babies often go through a growth spurt at around six weeks and will need more milk. If your baby is suddenly hungry a couple of hours after a feed increase your milk supply in the same way.

Take Advice

Talk to your GP or health visitor about feeding if the following signs occur in your baby: