by Brian Symon copyright permission granted.
Food, feeding and breast care
A child at birth has been growing rapidly in the womb. The newborn will continue to grow rapidly. The source of nutrition for growth varies with the child’s age and the mother’s circumstances. There is no debate that the best source of nutrition for the newborn baby is breast milk from a healthy mother. The complexity of breast milk will never be equalled by an artificial feed. This is partly because breast milk varies according to changes in the environment of the family. A mother in contact with a virus will develop antibodies and pass a degree of immunity on to her child. Such a development is impossible with artificial feeds.
If breast milk is available then the next requirements for the baby to achieve good growth are quantity and quality.
BREAST MILK QUANTITY
Quantity of milk relates to the volume of milk that the breast is able to produce. Later in this chapter we will discuss quality. Please note that when breast feeding a baby both these issues are interconnected.
Most women in our society are able to eat well. Their bodies are presented with enough calories and nutrients to allow the breasts to produce milk. What needs to be made clear is that each woman is unique. Her ability to produce breast milk varies. Some women are so well supplied with milk from their breasts that they could feed twins easily. Other women are unable to produce useful volumes of milk despite their best efforts. This variation is due to normal differences between individuals. Some of us are tall, some short, some produce much breast milk, others produce a little.
Breast milk is the best feed as long as there is enough of it. The volume of milk being delivered to the baby can be checked quite easily and in a number of different ways.
CHECKING QUANTITY BY OBSERVATION OF THE BABY
There are a number of observations of infants which give an indication as to the adequacy of milk supply. The following small sections break these observations into useful headings.
The normal, adequately fed baby passes urine as often as every fifteen minutes. Despite the mother’s best efforts, which may include nappy changes as often as 12 or more times per day, the baby is ‘always wet’. This indicates that the child is probably receiving an adequate volume of milk.
If the bowel is being presented with adequate volumes of milk it will produce a soft, yellow, non offensive bowel action at least once per day and often more frequently. If the bowel action is hard, small and difficult to pass, this suggests that the total volume of milk may be inadequate.
A baby receiving enough nutrition becomes ’rounded’ and chubby. Thick cheek pads form and the arms and legs fill out.
The baby’s behaviour is an excellent indicator of the adequacy of milk supply. If the child is well enough to suck and swallow vigorously, becomes settled and ’sedated’ by the feed, settles to sleep quickly, sleeps for say three to five hours and then awakens to feed vigorously again, then milk supply is probably adequate.
Conversely the baby’s behaviour may suggest that milk supply is inadequate. If the child is irritable at the breast, unwilling or too tired to drink, sleeps before the feed is finished or fails to settle within 15 minutes of the end of the feed, sleeps for only 1-2 hours, then milk supply may be inadequate. I will enlarge on the above by dividing babies into two groups.
a) Underfed but coping
This baby is going to give you a hard time. He or she is not getting enough and plans to do something about it. The baby demands the feed vigorously, sucks hard, may continue to demand after the feed, settles poorly and awakens early demanding the next feed. If measured, weight gain is often less than 20 gm per day.
b) Underfed and not coping
This is a very dangerous situation. The child demands weakly or not at all. The feed is poor and is interrupted by episodes of ‘waking’ the baby. The child sleeps quickly and sleeps through the next feed time. Production of urine decreases, bowel actions tend to be small, irregular and difficult to pass. If measured weight gain is low or negative eg: less than 10 gm/day or even losing weight.
This problem needs to be recognised and treated with additional feeding.
Check on milk quantity by weighing
If in doubt about milk volume, measure it. The answer is important to the mother and baby. If the question of the amount of the supply arises it can be so easily answered by weighing. If the volume is inadequate then that information needs to be available so that remedial action can be taken. At the same time the information that the milk supply is excellent will cause no harm and must boost the confidence of the mother.
a) Baby’s weight
If the baby is gaining adequate weight on a daily or weekly basis then the milk volume is adequate. I set as a base line, weight gain of at least, 30 gm per day. So if over several days the average weight gain is 30 gm/day or more then the mother can be reassured that her milk supply is adequate. Weight gain over 30 gm/day varies greatly. Thirty, 40, 50, 60 gm/day or occasionally even more may be quite normal for that child.
If the weight is less than 30 gm/day over several days then the milk supply may be inadequate. A weight gain of 15 gm per day or less is almost always inadequate and requires remedial action. Having said this I note that very occasionally a child from parents with small body size may be quite happy and thriving at a weight gain of 15 gm per day.
b) Test weight
While in hospital the baby can be weighed before and after a feed giving the weight of milk ingested. The required volume varies with the baby’s weight and the number of days after birth. Test weighs done over 24 hours rapidly answer the question ‘Do I have enough milk?’.
BREAST MILK QUALITY
Milk quality relates to energy density or the ability of milk to deliver calories to the baby.
Occasionally the breasts will produce adequate milk volume but of poor energy density. This tends to be determined by genetic factors in the mother and can not be altered no matter how she tries. It is important to point out that the woman is not responsible for this. It is similar to the woman’s height or hair colour. It reflects the complex genetic factors inherited from her parents. If the genetic pattern determines that breast milk energy density is low then it can’t be improved by trying hard any more than we can change our height by working out in the gym.
Sometimes for no easily defined reason a women will have a ‘poor’ lactation. With the next child the milk production may be very different. I have certainly cared for women where one lactation was difficult but another was quite successful.
Occasionally a woman is attempting to lose weight and may be drinking only water to decrease her total calorie intake. In this setting the baby is feeding well, has ample urine and bowel actions but is not settled and has poor weight gain. Dieting is rarely required in the breast feeding mother as her body’s allocation of energy to the production of milk and the other tasks associated with a new infant usually means that she is often losing weight anyway.
WHAT TO DO ABOUT INADEQUATE MILK SUPPLY
We have diagnosed one way or another that the milk supply is low. What do we do about it?
It is difficult to exaggerate how busy a mother is. The amount of work increases with every child. Once a mother has two or three children, a partner, a house, a social circle and perhaps some employment responsibilities she has become so busy that she is really being asked to do the work of more than one person.
Our culture is not set up to meet the needs of these women. In some cultures the mother’s responsibilities will be spread amongst other members of the group while she is given some months to concentrate on feeding and caring for her newborn. Our society does not provide that luxury.
The human body has a given number of ‘energy units’ to spend each day. Some of those ‘energy units’ will be used in the breast feeding mother for milk production. If the total number of ‘energy units’ available to the body is inadequate milk production will suffer.
Milk supply may be inadequate for one or more of three reasons:
a) inadequate energy or fluid intake
b) excess energy expenditure
c) genetic factors which determine a low breast milk output.
INADEQUATE ENERGY INTAKE
A breast feeding mother should eat three meals per day. These should contain contributions from the five basic food groups. Protein, vegetables, dairy products, cereals and fat. The volume should give adequate calories to fill her energy needs. When choosing fluids she should choose those which give energy as well as water. Milo, milk, ice-cream, milkshakes, egg nog all give calorie value as well as fluid volume. I recommend at least a litre of milk-based fluid per day. If you do not like milk then cheese, yogurt or ice-cream can act as alternatives. If you are not thirsty enough to drink a litre per day then salted nuts will help create a thirst and at the same time provide energy.
A woman who is breast feeding well and eating adequately will often still lose weight. I generally request that a woman defer dieting until the baby is gaining weight well, started on solids and sleeping at least 10 hours per night.
EXCESS ENERGY EXPENDITURE
A mother is busy to a level which is difficult to exaggerate. How many mothers say to each other ‘What did I do with my time before I had children?’ The work of caring for children, house, partner and possibly employment uses energy. Assuming that the diet is providing adequate calories and nutrients, the milk supply can still be impaired by an excessive work load. The single most helpful strategy when life is too busy is sleep. For the first few weeks of her baby’s life mother will have disturbed sleep as there are feeds every three to four hours. If at all possible then the mother should join the baby in a day time sleep. Two hours sleep in the early afternoon can be a very ‘humanising’ event. As the number of family members increases an afternoon sleep becomes both more necessary and at the same time less possible. When it is impossible, then going to bed at the same time as the children can be helpful until the baby is sleeping at least eight hours at night.
GENETIC FACTORS AFFECTING MILK PRODUCTION
Being female, having a baby and having breasts does not mean that all women can produce milk. Humans vary in their abilities for every measurable parameter. Some are tall, others short. Some are dark, others light. The ability to produce breast milk and its energy density are biological parameters which will vary from woman to woman. Therefore it is not surprising that some women produce more and others less. There is no rule which makes it possible to predict milk supply. Despite this there are some guidelines which experience tells me are often, although not always, valuable. Often a bigger breast before the lactation produces less milk and the smaller breast more. A women of 120 Kgm with pendulous breasts may have little milk supply despite her best efforts. A woman of 60 Kgm with small breasts can often blossom in this area and to her own surprise be an excellent breast feeder.
Measuring baby’s weight gain and test weighing feeds can help inform a women of her breasts ability to produce milk. If there is little intrinsic milk production then she should be informed so that an alternative can be used. Nothing can be more cruel than insisting that a mother attempt breast feeding when her breasts just do not produce an adequate volume of milk in any circumstances. She feels frustration and a sense of failure, the baby fails to grow and is unsettled. The family becomes unhappy. There is no guilt in not producing breast milk. No more guilt than in being 150 cm or 190 cm tall or having black hair. If low milk production is the woman’s norm, in this pregnancy, then so be it. Alternatives need to be found. This does not mean that breast feeding must fail completely, it may still be partly successful if supported. In addition, inadequate milk supply in one pregnancy does not always mean that there will be an inadequate supply in the next pregnancy.
ALTERNATIVE STRATEGIES FOR BREAST FEEDING
As mentioned above the ability to produce milk varies up and down the scale. Let us assume that an imaginary healthy, happy, growing baby requires 100 units of milk per day. If we measured the milk production of 100 women we would find that some could produce 200 units of milk. Some would produce very little. There would be a large majority whose production was near the 100 units required. There will be a significant minority who under ideal circumstances produce less than 100 units which our imaginary baby needs. These women are producing breast milk. It is of good quality and is beneficial to the baby. However, there is not quite enough. I have never understood why feeding should be seen as only fully breast or only fully bottle. If a woman is producing good quality breast milk but in slightly inadequate volumes, why not compliment it with an alternative feed? There are many good milk substitutes on the market. They are not as perfect as human milk but they can be a very adequate supplement and if necessary can be the basis for total feeding. Some mothers will find that if they supplement from the bottle immediately following the breast feed the baby settles well, sleeps deeply and awakens to feed efficiently at the next ‘meal’ time.
This pattern can be made a little more specific. The supply of breast milk tends to decrease in the late afternoon. While feeds in the morning may be adequate for the baby’s needs, by late afternoon the milk supply may be inadequate to supply the baby’s whole requirement. Tea time can become less than the ideal family event. Baby has fed but is unsatisfied and crying. The children from school are tired, demanding and hungry. You are tired having been up once or twice overnight. It is a fun time!! The sort of time of day when being alone in the Simpson desert seems the easy option. One step in improving this time of day can be complementary feeding at the baby’s ‘evening meal’. If the baby has settled after an adequate feed it becomes easier to concentrate on the needs of the rest of the family. So the suggestion here is to give a breast feed before starting to commence preparation of the evening meal. Follow the breast feed with a complimentary bottle feed to the volume which the baby desires. It might be 20 ml or it might be 100 ml. The correct volume is the one which allows the infant to settle and returns sanity to the family.
A development upon this idea is for those babies where weight gain is a little inadequate. In this setting a top up for all p.m. feeds, that is between 12 noon and 12 midnight can support the milk supply through that part of the day when it is at its lowest ebb. The baby receives normal breast feeds overnight and in the morning. This is the time when mother is most rested and has the best milk supply. From 12 noon onwards, when her milk production may be starting to decrease, offer a complimentary or top up bottle after the breast feed.
Breast feeding should be a pleasant, relaxing time. Enormous satisfaction can be gained watching a baby suckle contentedly and then sleep soundly in a relaxed pose. It is a time when love blossoms, life’s worries retreat and you just know that this is what you want to be doing at this particular time in your life. If you are tearful, upset or in pain things need to change. If baby is unhappy, angry, or unsettled there is a problem.
Breast feeding can be sore if the nipple becomes ‘cracked’. The pain is most severe as the baby attaches to the nipple. If left untreated feeding can become impossible. Nipple care is best carried out before the problem develops. In those years that I provided hospital care, the time that a baby was allowed to suck increased from a starting point of about three minutes per side on the first day. This increased by about 2 minutes per side per day until the feeds were approximately 10 by 10. This allows the skin of the nipples time to adjust to the new requirements being placed upon them.
Anyone who has suffered from dry cracked lips as a consequence of excessive licking knows that it removes moisturising oils from the skin. Once the skin is not ‘oily’ it becomes brittle and prone to cracking. The underlying cause of this is that the loss of ‘oil’ from the skin allows it to evaporate more water and dry out. Application of an oily substance to the nipple can avoid painful cracking. The skin covering the nipple is thinner than skin in most parts of the body. Because it is so thin it is very prone to water loss and then cracking. Many agents are used in different institutions for keeping the skin of the nipples moist and oily. Wool fat, lanolin, moisturiser. I have had the best success with a proprietary product containing a local anaesthetic and an anti-inflammatory in an ointment base. For more specific advice please see your health care provider.
If you are frustrated by breast feeding perhaps you should review why you are doing it. Occasionally a woman finds that it is an unattractive and unpleasant event. Perhaps a sense of obligation is not the best motivation for breast feeding. More commonly a mother wishes to breast feed but has a sense of frustration because it is not working for the baby.
Very, very few babies will fail to display a sucking reflex. Even the most immature babies born before the reflex develops will at the appropriate time begin to suck. This reflex will be reinforced by the satisfaction of swallowing milk making the behaviour pattern stronger.
It is not uncommon to see a mother whose baby is getting angry at the breasts. Mother is upset because despite her best efforts, feeding times have become a time of dispute between her and the baby. The common scene is that the baby comes to the breast hungry. Initially there is strong sucking but after one or two minutes the baby comes off the nipple and starts to cry. After some persuasion he or she re-attaches but after a short time comes off and cries vigorously. Further attempts at re-attaching are not very successful and the baby turns away from the nipple. If the other breast is offered, after a short interval the same performance is repeated. The mother can often see milk on the nipples and in the baby’s mouth and believes the supply is adequate. The most common causes in this setting are inadequate milk volume a slow let-down of milk or an overtired baby. Another problem which can exist is flat nipples. These can make it very difficult for the baby to attach and medical assistance may be required. Diagnosing these problems and their treatment are dealt with specifically in other areas. The easiest diagnostic step is to offer a bottle. If the baby feeds well, then the problem is probably a slightly decreased milk supply compared with the baby’s needs.