(The same article is also available in Nepali and Hindi)

        Breast milk is ideal for all newborns. It is the best gift a mother can give to her child. It contains all the nutrients that the baby needs till 6 months of life. As such, exclusive breastfeeding till 6 months of age till is the standard of care. Breastfeeding is now accepted as a human right, a right of the baby as well as the mother.

       As per the World health organization’s (WHO) estimates exclusive breastfeeding till 6 months of age can save the lives of 800,000 children and US$ 300 billion every year. This is more than the population of more than 120 countries. It may is inappropriate to compare lives with money but this amount is more than the GDP of 140 countries and if the healthcare budget of India remains the same as of 2020, with 300 billion, it can last for 33 years! Also, note that one in 6 people in the world is in India.

Benefits of breastfeeding- Why should you breastfeed your baby?

  1. Nutritional superiority Breast milk contains all the nutrients the baby needs for optimal growth and development in an optimum proportion and in a form that is easily digested and absorbed.
  2. Tailor-made nutrition- The composition of breast milk changes over time. To meet the changing needs of the baby. If the baby is born premature, the composition alters by itself to meet the needs of the preterm baby. Even during a single feed, initial milk (foremilk) and later part (hindmilk) are different. The foremilk is rich in proteins, sugar, vitamins, minerals, and water that quenches the baby’s thirst. The hindmilk is richer in fat that provides more energy and gives a sense of satiety. Such customization is impossible with any formula or animal milk.
  3. Prevention against infection Breast milk is sterile (does not contain any bacteria) whereas bacterial contamination is highly likely in the case of animal milk or formula. Furthermore, breast milk contains antibodies other protective factors that fight infection. Breast milk prevents diarrhea, pneumonia, ear, mouth, and teeth infections. If they do occur, they are milder in breastfed babies..
  4. Prevention against other illnesses Breast milk prevents future allergy, asthma, diabetes, obesity heart disease, and even some cancers (lymphoma) when the child becomes older.
  5. Mental growth Breast milk contains many substances like DHA (,docosahexaenoic acid) which help in brain growth (many infant formulae have been trying to copy and incorporate this albeit poorly). Studies have shown that children who were breastfed had higher IQs than formula-fed. It is well said that breast milk is for brain growth and cow’s milk for body growth (it is obesogenic). Breastfeeding releases the “love hormone” oxytocin, which increases emotional bonding between the mother and the child.
  6. Benefits to mother When started immediately after birth, oxytocin released during breastfeeding causes involution (reduction in size) of the womb thereby decreasing bleeding. Breastfeeding is the most effective method of shedding extra weight gained during pregnancy. It also reduces the risk of cancer of the breast and ovary. Lastly breastfeeding is convenient, economic, and time-saving. You need not carry or prepare anything to provide it.

The steps for successful breastfeeding

PreparationBreastfeeding preparation

      During the pregnancy itself, you can request the gynecologist (or your local midwife or ASHA) to have your breast examined. So that any possible obstacle to successful breastfeeding (like inverted nipples) can be tackled before the birth of the baby. You can take your husband or mother-in-law for the examination. This will increase their breastfeeding support.

Initiation

     Baby must be put to the breast within half an hour after normal delivery and within four hours after cesarean births. Many cultures give gold rubbed in water, honey, distilled water, glucose, etc. before initiating breastfeeding. These items will satisfy the thirst and will reduce the vigor to suck and may lead to diarrhea and worm infection. These greatly reduce the success of initiating breastfeeding.

      A small amount of milk, called colostrum is produced in the first few days. Its small volume is enough for the baby in the initial days. In certain cultures, colostrum is discarded. However, giving it is extremely important because it contains proteins and antibodies which help in fighting infection

Maintenance

  1. The baby should be exclusively breastfed till 6 months of age. Nothing else (except medicines when needed) should be given, not even water. Breast milk contains sufficient water to satisfy the thirst of the baby. Continue breastfeeding for 2 years and beyond along with complementary feeds.
  2. The two hormones which are important in breastfeeding are prolactin and oxytocin (the same love hormone as described above). Prolactin is responsible for milk production and oxytocin for the release of the milk from the breast. The body functions in such a way that more baby sucks at the breast more of both the hormones are produced and hence more milk is released. Hence it is important to start breastfeeding early, feed frequently, and empty the breasts in each feeding session. Oxytocin production is better when the mother is confident and reduced when she is stressed.
  3. It is better to feed on one breast completely and then switching to the other side so that the baby gets the benefits of both fore and hindmilk.
  4. Exclusive demand feeding is the ideal schedule to follow. There is no ‘tailor-made schedule’, as milk production, sucking habits, stomach capacity etc., vary from baby to baby. Practice frequent breastfeeding initially and allow ‘self-regulation’ by the baby. The mother can soon find out the average time interval the baby will rest after a feed. She can adjust her rest period in between.
  5. Babies tend to take in a lot of air during feeding. This will lead to abdominal distension, pain (colic) and spitting or vomiting out milk. To get rid of this, the mother has to do ‘winding’ or burping.
  6. Breastfeeding should be continued when the mother or the baby is ill. It can be given during infections like common cold, fever, diarrhea, asthma, etc. It is the most easily digestible food for the ill baby. It will be the best pacifier to the sick baby and it often acts as a life saviour to many babies.
  7. All the medicines taken by mother can go to the baby through milk. Although many of them are safe, I recommend that you consult your pediatrician if you are taking (or need to take) any of them.

The technique of breastfeeding

       With the correct technique, breastfeeding is a natural and pleasurable experience for the mother. However, many many require substantial assistance to learn it. In many hospitals, a lactational counselor is available to help mothers for the same.

Positioning

Position of the mother

        The mother can assume any position which is comfortable to her and the baby. She can sit or lie down. Her back should be well supported and she should not be leaning on her baby.Breastfeeding Position of the mother-Lying downBreastfeeding Position of the mother-sitting

Position of the baby

Make sure that the baby is kept warm by wrapping on a cloth.

1. Support the whole body not just neck or shoulders

2. The head and the body should be in one line without any twist in the neck

3. Body of the baby should be turned towards the mother. The abdomens of the baby and the mother should be touching each other.

4. Baby’s nose should be at the level of the nipple.

Attachment

       The baby should be attached well to the breast so that breastfeeding is efficient and any injury is avoided. Good attachment is indicated by

1. Baby’s mouth is wide open

2. The baby’s mouth covers most of the nipple and areola (the black part of the breast surrounding the nipple). The baby should suck at the areola, not the nipple.

3. Baby’s chin is touching the breast.

4. Lower lip is everted

Problems of breastfeeding

1. Low milk output

      This is the most common complaint of the breastfeeding mother. In around 80 to 90% of mothers, it is “perceived” low output. My professor used to say “humans are the only animals who needs to formula feed their offspring because we are the only one who can think that breast milk is insufficient”.

         The baby is crying is a poor indicator that milk output is less (even if the baby stops crying after feeding). Most babies will stop crying if something is put in his or her mouth, regardless of the cause of crying. This is how a pacifier works. In fact, in hospitals, we put sugar-containing gauges in the baby’s mouth while taking a blood sample. This reduces crying (and also has been shown to reduce their pain).

If the following are there it means the baby is getting sufficient milk.

1. Baby is gaining weight (barring weight loss in the first 10 days) as described in the article “,,Ten findings in newborn which parents feel are abnormal (but are normal)”

2. Passing urine 6 to 8 times per day. It is difficult to know the exact number of times the baby passed urine if he or she is wearing a diaper. But if you have to change the diaper 3 or more times per day, urine output is good.

3. Baby sleeps 2 to 3 hours after feeding

4. When awake the baby is playful and not crying for some time at least.

     In short, crying does not indicate that the baby is getting insufficient milk, even if giving formula milk to the baby to stops it. What it does show that baby maybe (not must be) in distress. The only way a baby can communicate with parents is by crying. They cannot speak out loud saying “I am feeling hot, cold, tired (by handling by many people) or my back is itching, or the diaper is wet or too tight”. They just cry out. Holding the baby upright on the shoulder and rocking quietens most babies.

If the above conditions are not fulfilled and milk production is really insufficient, it can be due to

1. Again the perception that the milk output is less. As described above, oxytocin production (and hence milk output) is increased when the mother is confident and reduced by any stress.

2. Use of dummies, pacifiers, and feeding bottles. Furthermore, these predispose the baby to diarrhea.

3. Giving supplements like sugar water, gripe water (Yes gripe water is harmful! and devoid of any benefit), honey, formula milk either before initiation or along with breastfeeding. Honey can cause serious botulinum infection if given to child less than 1 year.

4. Painful conditions of the breast like sore nipples

5. Lack of night feeding (prolactin production is highest at night).

6. Inadequate emptying of the breast such as when the baby is sick or small or when the baby feeds less frequently.

7. Poor nutrition in the mother.

     Also, milk output is less in the first 3 to 4 days (when colostrum is secreted), only 30 to 40 ml. This is however sufficient for the first few days. I recommend mothers to show to the pediatrician in any case they feel they have low milk output, before trying formula. Finally, milk output is not dependent on the size of the breast. Mothers with small breasts produce the same amount of milk as others

2. Working mother

        In most Indian states 6-month maternity leave is provided to facilitate exclusive breastfeeding for 6-month. If however, your employer does not provide it, take as much maternity leave as long as possible. Try to complete at least 4 months of exclusive feeding directly from the breast.

       When you join work, take the baby with you if the daycare center or creche (or any other arrangement) is available. If this is also not possible, breastfeed immediately before and after work. Wake up if the baby is sleeping. Try to come home and feed during lunch hours if possible. Feed during nights and holidays. Express the milk (take out the milk and store it in a bowl) for the time you are away from the baby, taking care of the hygiene.

        Milk can be expressed by hands or by using pumps. Pumps are more efficient. Both manual and electric pumps are available in the market. Electric pumps are user friendly and can express more milk in shorter time. The expressed milk should be fed using a paladi (better) or spoon and not a bottle.no-bottle-feeding

       Bottle feeding increases the risk of infection and prevents successful breastfeeding by nipple confusion. Since bottle feeding is a passive process in contrast to breastfeeding or paladi/spoon feeding when the baby needs to put effort. With bottle-feeding, the baby tends to become lazy and may refuse to breastfeed. It is similar to us becoming lazy to walk even a short distance after buying a vehicle.

       While feeding directly through the breast or paladi or spoon, the baby can regulate the amount of milk to take in contrast to bottle-feeding, which prevents vomiting and milk going into the lungs (which can cause pneumonia). Many would argue that they have bottle-fed all their children and no adverse event happened. But this argument is as valid as a drunk driver claiming he can drive safely as no accidents happened in past.

     Expressing milk might sound strange to some mothers, it is widely practiced in all the hospitals for babies who are sick and weak to put effort feed directly from mothers breast. Other than these two there may be other obstacles to successful breastfeeding like nipple sore or infection, breast swelling, inverted nipples. For all these my advice is to show to a doctor.

Diet for the mother

      Healthy nutritious diet which is usually taken by the family can be taken. You need not avoid anything (yes!). You need not even avoid turmeric (Haldi) when the baby is jaundiced. Your turmeric intake is not causing jaundice. If you are planning to spend some money on infant foods (like nan, lactogen, cerelac, etc.), rather spend the same amount on your diet. This will increase milk output. Also, you must drink plenty of water

The following are links to breast milk pumps. The first one is electric, second is manual

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