Sr Audrey Voges from the Breast Feeding Association of South Africa answers some frequently asked questions.
In your opinion, why is breast best?
Breast is best because it is human milk made for human babies.
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It contains all the nutrients that a baby requires; and the mother’s body has the ability to change breast milk as the baby grows and his needs change.
There is no such thing as weak milk or strong milk. It is always correct for the baby, at the right temperature too.
The antibodies in breast milk enhance the baby’s immune system and protect him from infections. There are antibodies present to everything that the mother has ever suffered herself, to everything against which she was immunized and also to everything to which she is exposed. Within 12 hours of exposure of the mother to a particular bacteria/virus the antibodies are present in the milk.
Breast milk is a convenient and economical choice. It is the ONLY free consumer product.
It should never run out or dry up. As long as the baby is prepared to suck, breast milk will be produced.
Breast milk is always available – especially in the middle of the night!
Can you recommend a couple of tips for breastfeeding success?
Ensure that the baby is correctly latched onto the breast. Avoid artificial teats and nipple shields. They are meant for women with inverted nipples not for assisting in getting the baby onto the nipple easier.
Relax and enjoy the feeding time as much as possible. Make a cup of tea. Do not be afraid of chatting to your baby during a feed and stroking and loving your baby.
Try to follow a pattern of feeding that suits you and your baby. The important factor to remember is to ensure that your baby has at least six to eight feeds in a 24 hour period. If necessary wake him to achieve this goal.
Try to rest but be practical about it. Do not do a “spring clean” of the home in the first week at home. Be realistic. Certain chores need to be done but accept all offers of help from friends and family. Remember you are resting of necessity during a feed. It is difficult to breast feed “on the trot”!
Do not be embarrassed to ask questions. Consult a professional person with whom you are comfortable. Well meaning friends and family can offer confusing advice which can make mom unnecessarily anxious.
Breastfeeding is a natural process. Keep it so as much as possible. Do not be governed by the clocks and time or by any preconceived ideas. Each mom and baby is an individual and needs time to find their own pattern which is comfortable for each of them.
What can be done about inverted nipples? Can you still nurse?
Yes, you can still nurse. There are special exercises that can be done ante-natally to release the adhesions which is the possible cause of inverted nipples. The exercise regime can begin at about 28-30 week gestation. Twice a day mom is to apply some moisturising cream to each index finger. Standing in front of a mirror and visualising the nipple as the face of a clock mom must place her index fingers on opposite sides of the nipple e.g 3 o’clock and 9 o’clock and stroke and gently pull her nipple and areola from the centre of the nipple outwards. She should proceed around the nipple gradually moving the position of her index fingers. There is no need to be vigorous and it should not hurt. I suggest that such exercises be done morning and evening. Once the baby is offered the nipple, he will do the best job of all in getting the nipple to protrude slightly. Each successful feed makes the next one so much easier!
Is it advisable to avoid certain foods during breastfeeding? If so, what do you recommend?
It is unwise to avoid certain foodstuffs during breastfeeding. Mom should have a balanced intake of the foods which are enjoyable to her. She may eat whatever she fancies, whenever she fancies but in moderate quantities. Stress variety in the diet. Strong flavours are inclined to flavour the milk but even this is very acceptable to the baby. If, however, the baby shows signs of intolerance consult a professional lactation consultant for advice. It is VERY seldom that a mother is on an exclusion diet during lactation. Baby’s restlessness can be ascribed to many things other than mother’s food intake.
Insufficient milk supply – is it inherited and what can be done about it?
Insufficient milk supply is not inherited. If your mother/sister could not nurse there is no reason at all that the same lot should befall you. If mother feels positive about her desire to nurse and she has support from her partner she can be successful. Basically mother needs sufficient nipple stimulation from the baby or in the case of a premature infant, maybe a breast pump, to produce milk. The golden rule of breastfeeding is that the more frequently the baby feeds, the more milk will be produced.
If a mother suspects that the milk supply may be a little low she is encouraged to feed more frequently e.g. every 1½ -2 hours, relax and take in adequate fluids. It is extremely difficult for mom herself to estimate her milk production because a crying baby is not necessarily a hungry baby. Other things can be bothering the baby.
Consult a lactation consultant. Breast milk is totally digestible, so if the baby is passing regular stools it is quite possible that his intake is sufficient.
Should you schedule your baby’s feeds and limit the time he spends on the breast?
I prefer not to schedule the baby’s feeds initially. Each baby has his own “programme” and I prefer that mom gets to know that “programme” rather than become time orientated. A baby needs six to eight feeds in 24 hours or maybe more. Allow him to show the way but do not let him have his daytime feeds further than 3½-4 hours apart. If necessary, wake him. At night it is possible to allow the baby to sleep slightly longer as long as he is thriving and gaining weight. Timing a feed is difficult. We are feeding a baby and not a clock! Sucking time is important for the baby.
On average a feed could be of 5 minute duration or up to about 30 minute duration. I am uncomfortable removing a baby who is well latched from the breast after a particular time. Baby has no concept of time and he requires sucking to help with digestion, help with peristalsis and as a great comfort - the nipple is his greatest comfort. A second or subsequent baby might require some scheduling to fit in with the family requirements. If a sibling for example needs to be at school at a particular time the feeds need to be scheduled around such events. It needs to be a give and take situation.
Can you comment on the suggestion that a baby should be on the breast for a particular time each side?
Sucking time is important for a baby, therefore it is preferable not to limit the time on a breast. If the baby is correctly attached to the breast, and he is stimulated to suck well, he will not cause sore nipples. The “time” concept evolved a long time ago when soreness of the nipples was equated to time on the nipples. This is not the case.
Sore nipples are caused by incorrect latching, not by extra sucking time. If a baby is forcibly removed from a nipple he can cause extreme pain and damage. It is preferable to allow the baby to release the nipple himself. It is important to offer both breasts at each feed but not to strive for equal time on each breast and also not to force the second breast, if the baby indicates that he is satisfied on one.
What are some cues as to when the baby is ready to feed?
This is a little difficult to put down on paper because each baby is such an individual. Each mother will very quickly begin to read her baby’s signs. Generally speaking the baby will wake fairly slowly and restfully with some eye movement flutters. Then he will make specific noises that act as a trigger for his mother. It could be quite a while before he starts to cry – basically if his trigger sounds were not answered. It would also probably be two to three hours from the previous feed.
In your opinion, does nursing increase the mother’s libido?
No, it does not increase mom’s libido. It also does not decrease mom’s libido. Breastfeeding can, however, give a little sexual discomfort. Oestrogen levels are lower when prolactin levels increase and this change in hormone levels can result in a dryness of the vagina. This problem can easily be overcome by the use of lubricants. Mom is at times physically tired as she gets used to her new role as a parent and the sleep disturbances that are inevitable with a new baby. This physical tiredness may reduce her libido. It is temporary.
Do you have any advice to offer on feeding twins?
It is a very good idea to breastfeed twins. Mom may feel that she needs as many hands as an octopus but twins are very adaptable! It is advisable to feed twins together. Feeding time can thus be halved. I suggest that the “football” feeding position is used. That is – a baby positioned under each arm, their heads together and their feet towards mom’s back. The one can help the other along. Mom will get a simultaneous release of milk from both breasts. The babies are also aware of each other and “communicate” with each other in this way.
Mother will often be most comfortable sitting on the floor supported by a nest of cushions. The fear of the babies falling is thus alleviated. Initially mom may need help to position and latch the babies but before too long the babies “help themselves” and it gets easier. Economically it is also a very good idea to breastfeed twins. Formula is expensive and breastfed babies are healthier babies.
Is it possible for adoptive moms to nurse? If so, what can be done to help this?
Yes, it is possible to nurse your adoptive baby. It is important to get the baby to the breast as soon as possible. However, with adoptive babies this may only be possible after a couple of weeks. Mom can manually stimulate her breasts before the baby is placed with her. She needs to with her fingers gently squeeze the areola area between her thumb and index finger while massaging the breast with the other hand. Once the baby is with her, the Golden Rule of Breastfeeding applies – put the baby on the breast as often as possible but at least every two to three hours. Or allow mom and baby a day or two in bed together so that the baby has continual access to the breast.
It may be necessary to offer him a little formula feed after one or two evening breastfeeds initially but once the baby starts to gain weight and the evidence of breast milk is visible the formula feeds can be reduced or stopped. This procedure should be attempted with the support of her partner and a lactation consultant. Serious counselling is usually necessary.
When is your baby ready for solids?
Solids are not necessary before four to six months. It is inadvisable to introduce solids before that time. The baby’s development has not reached a point where his body is able to cope with solids too early. The signs to watch for after four months are:
The baby requires more than seven breastfeeds/milk feeds in 24 hours.
He changes his regular sleep pattern and wakes more frequently at night for three to four consecutive nights.
He no longer has the thrust reflex with his tongue.
He does not gag when things (toys, spoon etc.) are put into his mouth.
If he is older than four months and mom is anxious, despite all advice, to proceed to the next stage!
If a mom wishes to go back to work in two months’ time, what would be the recommended path for weaning the baby onto the bottle?
Firstly there are a number of options for a mother returning to work.
She could elect to express her breast milk while at work and allow the day mother to offer this milk to the baby in a bottle or by cup. She would need to express twice during her working day e.g. at morning tea time and during her lunch time. Whatever was expressed on Monday at work would be offered to the baby on Tuesday. She would need to hand express or to have a breast pump at her disposal. The breast pump should be sterilised at home and kept in a closed container at work when she is not using it. It is not necessary to refrigerate the breast pump or the expressed milk until she gets home. Using this method, mom will be able to fully breastfeed her infant over weekends and holidays, and mornings and evenings of the working week because she has had adequate stimulation and is still producing milk regularly.
She may elect not to express but to still breastfeed in the morning before work and in the evenings. This baby would then need to be weaned from at least two feeds a day in the week to ten days before mom returns to work. She would replace a breast feed with a formula every five to seven days. E.g offer a formula bottle midmorning for five to seven days then offer a formula bottle midmorning and mid-afternoon. She would need to continue in this pattern of mixed feeding over weekends and holidays. This may present a problem in that the baby might prefer the formula bottle to the breast milk and thus continue with the weaning process. The mother should consult a lactation consultant or her clinic sister for advice on the formula and the quantities to be offered.
She may decide that she wishes to completely wean from the breast and offer the baby only formula. A slow wean is recommended. The process in (2) is followed but continued until all the breast feeds are replaced by formula feeds. Again advice on the formula and the quantities should be sought.
It is very definitely mother and father’s personal choice how long they are going to breastfeed their baby. In the weaning process it should be repeatedly emphasized how well mom has done and the consultant should ascertain that mom is happy with her choice.
Is it true that breast milk given in conjunction with formula may cause problems for the baby?
No, it is not true. The baby will be able to cope with both methods of feeding. Problems can, however, be caused if mom herself offers both breast and formula to the baby. It can cause confusion.
It is seldom necessary for a breastfed baby to have formula except when mom is unavailable as in a work situation or a social occasion or even a shopping expedition. In such circumstances the caregiver would offer a formula feed to the baby with no confusion or adverse effects. The baby associates mom with the breastfeed and the caregiver with the formula.
It can also be applied when daddy decides to allow his wife a good night’s rest by once a week offering a formula feed or an expressed milk feed during the night. Mom needs to leave dad and baby to their own devices and just “sleep on”!
Is breast pain normal while nursing? Please explain.
Breast pain is not generally experienced while nursing. There is, however, a sensation felt with the baby on the breast, usually a pleasant sensation.
Between day two to six post delivery when “the milk comes in” the breast may be uncomfortable and heavy but again it should not be painful.
If mastitis occurs at any time during the lactation period, the affected lobe can be painful, red and swollen. Mastitis must be adequately treated by continuing to breastfeed mainly on the affected breast, using an antipyretic like paracetamol and if possible getting ultrasound treatment with a qualified physiotherapist.
In your opinion, when should you call a lactation consultant?
A lactation consultant is there to help you in any situation which causes you stress or anxiety concerning your own health or the health, feeding and behaviour of your infant. A lactation consultant is someone who has herself breastfed a baby and can identify with your anxieties, listen to you and offer constructive suggestions to overcome your problems. No question is a stupid question with your most precious possession. Call a lactation consultant whenever you need reassurance.
Visit your clinic on a regular basis and get to know your lactation consultant in a happy, friendly environment. Then you know she will be there for you in your time of need. Advice from different sources, however well meaning it may be, can be confusing for a new mother. If she cultures a relationship with a consultant with whom she is comfortable, such a consultant can become an important support for her to enable her to fully enjoy each day with her baby.
There is a lot of debate regarding the best positions for breastfeeding. Can you recommend any?
The important aspect to understand with breastfeeding is that mother should be comfortable. There is no one position that is better than another and a different position can be adopted with each feed as mom and baby experiment and get to know one another. The comfort aspect will depend largely on the type of delivery that mother experienced, thus her comfortable sitting or lying position. The most commonly used position is the “Madonna” position, with mother sitting in a comfortable chair and the baby positioned across her lap.
An adaptation of this is the “football” position which also has mother sitting but the baby is positioned under her arm and lying against the side of mom’s body. Mother can also lie on her side with the baby on his side, facing mother. It is possible for mom to lie on her back with two to three cushions behind her head and allow the baby to lie on his tummy across mom’s tummy. This position is often used when the flow of milk is rather fast for the baby to cope with. The important points to remember is:
Mother should be comfortable.
Baby should be positioned against mom so that his chin, chest and knees are against mother’s body.
Experience as much skin contact as possible between mom and baby.
What are the basics with regard to expressing milk?
Always work with extreme care and optimal hygiene when expressing milk. Mother’s hands must be thoroughly washed before beginning. Any utensils e.g. breast pumps or bottles that are used must be adequately washed and sterilised. The containers in which the milk is to be stored should also be washed and sterilised. All breast pumps are for individual use only. Never borrow a breast pump from a friend or buy a second hand breast pump.
Express milk only for use when mom and baby are separated. You cannot “prove” how much milk you are producing by expressing. With the very best intentions you will usually only manage to express about one quarter of the quantity that the baby would be able to drink if he were on the breast. Milk expressed may be stored for 48 hours in the refrigerator or for three months in the freezer so long as it is stored in sterilised sealed containers with the date of expressing clearly marked on the container. The oldest milk must be used first.
To hand express:
Mother must wash her hands
Use a sterilised wide neck bottle in which to express
Gently massage her breast in the direction of the nipple
Support her breast with a cupped hand and gently squeeze the areola area (the brown area behind the nipple) between thumb and forefinger
It helps to lean forward slightly
Mother must not bruise or hurt herself
She will be aided by warming her breasts with warm water or cloths
Be patient. Practice makes perfect!
Is it recommended to prepare my nipples in any way before breastfeeding?
It is unnecessary to prepare nipples prior to breastfeeding. Please DO NOT rub or scrub nipples or apply all sorts of creams or lotions.
The only nipples which require some attention prior to feeding are genuinely inverted nipples. Special exercises named Hoffman’s exercises are recommended to release the adhesions which frequently cause inverted nipples. These exercises should not be painful at all. Consult your doctor or lactation counselor for further guidance.
Does the size of your nipple affect your ability to breastfeed?
The size of your nipple is irrelevant to breastfeeding. Your baby has no comparisons to make and is usually perfectly happy with the pair of nipples he is presented with!
I have heard that active/career women don’t lactate for more than a few weeks, at which stage should eglonyl be introduced if this is the case. How should eglonyl be used and what is it’s dual role in post-partum depression? Active career women should be encouraged to breastfeed as long as possible. Feeding patterns can be adapted to allow feeding only at night and initially the mother can “express” during the day. Eglonyl is not an anti-depressant and should not be used as treatment for post partum depression. It is useful to stimulate lactation and as adjunct is a mild mood elevator.
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