41. Principles of infant nutrition
breastfeeding
CHAPTER CONTENTS
Understanding lactation293
Feeding cues295
Expected feeding patterns in the newborn295
Assessing effective feeding295
Problem solving296
Role and responsibilities of the midwife297
Summary297
Self-assessment exercises297
References297
LEARNING OUTCOMES
Having read this chapter the reader should be able to:
• briefly describe the anatomy of the breast and the physiology of lactation
• describe how to facilitate correct attachment at the breast using: (1) the traditional approach; and (2) the concept of biological nurturing
• compare and contrast the traditional and biological nurturing practices
• discuss the recognition and significance of feeding cues, feeding patterns and effective attachment
• discuss correct expressing and storage of breast milk.
There can be no doubt as to the suitability of human milk for human infants. However, the 2005 Infant Feeding Survey (Bolling et al 2007) suggested that only 21% of babies were being exclusively breastfed at 6 weeks of age in the UK. Colson (2005a) questions the advice and care given to breastfeeding women over the last few decades and suggests that the relationship of particular maternal/child positions stimulate innate breastfeeding behaviours and so significantly aid the initiation of breastfeeding (Colson 2007b). Colson (2007b) terms this new approach to breastfeeding initiation as biological nurturing. This will be reviewed in this chapter as well as the traditional approach to breastfeeding practice. Also discussed are basic breast anatomy, feeding cues and patterns, assessing for effective feeding and problem solving. The chapter ends by discussing the safe expressing and storage of breast milk.
Understanding lactation
Each breast functions independently. Each has a rich blood, nerve and lymphatic supply and is comprised of glandular tissue and fat. Support is provided from ligaments. The proportions of fat and glandular tissue vary for each woman, glandular tissue increases in pregnancy under hormonal influences in preparation for lactation. In some women the proportion of glandular tissue to fat is 2 : 1.
The glandular tissue is an extensive convoluted ductal network separated into lobes. These are subdivided into lobules; within each lobule are alveoli, each of which is a cavity lined with acini cells surrounded by myoepithelial cells. Under the influence of prolactin milk is produced in the acini cells. When the infant suckles (under the influence of oxytocin) the milk is propelled into the network of ducts by the muscular contraction of the myoepithelial cells. The lactiferous ducts branch to join other larger ducts, eventually opening out onto the surface of the nipple. Recent research (Geddes 2009) suggests that there are 4–18 ducts opening onto the nipple, the average being 9. The network of ducts has been identified much nearer to the surface of the breast than originally thought and the milk collecting areas (lactiferous sinuses) were not visualised, suggesting that milk is transported freshly through the ducts on demand.
Colostrum is present from about the sixteenth week of pregnancy but it is the loss of placental hormones that initiates the rise in oxytocin and prolactin and therefore the availability of increasing volumes of milk for the newborn infant. Colson, 2007a and Colson, 2008 suggests that practice should protect and encourage the mechanisms that stimulate breastfeeding hormones in order to ensure effective transfer of nutrition from mother to child. These include prolonged cuddling and baby holding, skin-to-skin contact, privacy, feeding in biological nurturing positions (below) and maintaining the physical environment in a calm, warm, safe manner (minimal neocortical stimulation).
Milk is supplied according to demand, consequently it is the effective removal of milk from the breast according to the baby’s appetite that stimulates the milk supply. The milk is thought to change during the feed (and change over time as the infant grows) so that both the hunger and thirst are satisfied.
Successful attachment at the breast
There is no doubt in any part of the literature that an incorrect attachment at the breast potentially both damages the nipples and prevents effective transfer of milk. Mohrbacher & Stock (2003) suggest that correct attachment means that the nipple extends beyond the hard palate in the mouth (and therefore does not traumatise the tissue) whilst the ducts beneath the areola are compressed to eject the milk. The baby sucks initially with quick short sucks that soon change to slow deep ones. The mother may experience a ‘toe curling’ sensation initially as the nipple is drawn out, thereafter the feed should be painless (Mohrbacher & Stock 2003).
The traditional approach
Traditional practice encourages the mother to adopt an upright position, using pillows on her lap so that the baby is close to her (‘tummy to mummy’), the baby’s nose being level with the nipple. As the baby’s mouth opens with a wide gape (and natural extension of the head), the mother brings the baby swiftly onto the breast (Fig. 41.1). The baby is then supported across the shoulders and/or back.
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| Figure 41.1 • The wide gape. Note, too, the slightly extended head, proximity of top lip/nose to nipple, position of bottom lip and direction that nipple enters the mouth |
The biological approach
Biological nurturing first encourages the mother to adopt a comfortable, well-supported semi-recumbent position. Mother and baby are in skin-to-skin contact (or lightly dressed), the baby lies on the mother’s abdomen, ‘tummy on mummy’ and is fully supported by her body contours or (depending on position) the baby’s feet might be supported by the bed or pillows. The atmosphere should be relaxed and unhurried, with plenty of time for caressing and cuddling. These positional interactions release innate reflexes in the baby (Colson et al 2008) (including moderately preterm and small-for-gestational-age infants; Colson et al 2003), which encourage the baby, in his or her own time, to find the breast, self-attach and effectively feed. Babies often manoeuvre themselves into the optimal position. Colson (2005b) notes that if a baby has not self-attached successfully at the breast a modification in body lie (the direction of the baby’s position) can facilitate this. In her studies, babies adopted a similar lie for feeding to their in-utero position – longitudinal, transverse or oblique. Between feeds the baby may sleep in this position or in arms but Colson et al (2003)
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