Breastfeeding is when the baby is feeding directly at the breast. While it is the biological norm, some mothers do not view breastfeeding as the sociological norm. Breastfeeding is promoted and supported by health professionals in the United Kingdom because of the weight of evidence of the health benefits for baby and mother. Care from health professionals needs to be based on the UNICEF Baby Friendly Initiative Standards (2012). Many maternity units, neonatal units, community services, children’s centres and universities training nurses, midwives and health visitors have undergone ‘Baby Friendly’ accreditation or are working towards it.

Breastmilk is a live substance made within the mother’s breast. It is immediately available to the baby at birth and undergoes changes in the first month of the baby’s life. The breastmilk changes are:

• colostrum – present prior to birth and first few days following birth. Present in small amounts, and packed with immunoglobulins. Colostrum is thick and creamy yellow, compared to mature milk, which is thin and bluish in colour.
  
• transitional milk – by 96 hours to 10–14 days post birth, the colostrum changes to transitional milk.
  
• mature milk – the type of mother’s milk available thereafter until feeding/expressing ceases.

Breastfeeding conveys a range of biological and psychological benefits for the baby and mother (UNICEF, 2015).

• Provides skin-to-skin contact between mother and baby.
  
• It keeps mother and baby close day and night.
  
• It is baby-led feeding – the mother must watch for feeding cues and respond.
  
• Mother should be sitting or lying comfortably so that her oxytocin will flow and feeding is sustainable.
  
• Effective positioning and attachment are required to enable the baby to feed from the breast in an efficient manner and for it to be a pleasant experience for the mother. The baby is positioned in relation to the angle and dangle of the breast to achieve alignment. This will aid a good latch.
  
• Let the baby finish the first breast before offering the second breast.
  
• The mother should seek help quickly if experiencing difficulties or is worried about baby not feeding.
  
• The mother should maintain her milk supply by frequent feeding of baby and by frequent eating and drinking.
  
• Do not clock-watch when breastfeeding. Keep calm and carry on.

Breastmilk production is a supply and demand issue. Feeding at the breast stimulates the release of prolactin from the brain to make the breastmilk and the release of oxytocin to release the milk from the breast. If the baby cannot breastfeed, then the mother needs to maintain her supply by expressing breastmilk using an electric breast pump. Expressing of both breasts simultaneously is more time-efficient.

A healthy baby will initially start feeding at the breast with fast shallow sucks and then change to longer deeper sucks as the milk starts flowing well. The longer, deeper sucking pattern indicates a good ‘let-down’. This is when oxytocin has caused the release of the milk from the breast. In the early stages of a feed, there will be short pauses but these will lengthen as the feed progresses and the baby becomes fuller. A sign that the baby may be about to finish the feed is the characteristic fluttering type suck. Many babies can take the majority of milk needed in the first 5–10 minutes of a feed. The feeding frequency will not remain constant. Events such as growth spurts are well recognized to increase feeding frequency while cluster feeding, especially in the evenings, can challenge some mothers. During such episodes it is important to reassure the mother that this is a normal event and to follow cues from the baby. Adjustments of daily life may be needed for maternal peace of mind.

• A contented baby who wakes to feed and settles between feeds.
  
• A happy mother.
  
• Baby having at least six wet nappies and multiple dirty nappies per day (once mature milk is in).
  
• Baby is growing.

• Try not to separate mother and baby if the baby is admitted to hospital.
  
• If separated for medical reasons, ensure the mother’s milk supply is maintained by pumping.
  
• If mother requires help with feeding, ensure she has access to a member of staff with additional training to support breastfeeding mothers and babies.
  
• Different positions to hold baby may help: cross-cradle or football/underarm.
  
• Is the baby’s body close to the mother’s body and in alignment with nose and knees pointing in the same direction?
  
• Is the baby’s head able to tilt back and thus help achieve a wide gape?
  
• Is the baby starting off nose to nipple?
  
• Once latched, is the angle of the open mouth on the breast the optimal 160 degrees?
  
• Is the chin tucked into the breast? There should be no space between chin and breast.
  
• Is the latch comfortable for the mother?
  
• Is the position sustainable for the mother for the duration of the feed? Mothers generally need to use both arms/hands to support the baby.
  
• Is the baby actually transferring milk? This is evident by seeing or hearing swallowing, weight gain, wet and dirty nappies.

HIV-positive mothers may transmit HIV to their infant during breastfeeding as HIV is found in breastmilk. Emerging evidence now shows that HIV-positive mothers should be encouraged to breastfeed and adhere to their anti-retroviral treatment.