Breastfeeding—Starting Out RightJack Newman, M.D., FRCPC
Breastfeeding is the natural, physiologic way of feeding infants and young children milk, and human milk is the milk made specifically for human infants. Formulas made from cow's milk or soy beans (most of them) are only superficially similar, and advertising which states otherwise is misleading. Breastfeeding should be easy and trouble free for most mothers. A good start helps to assure breastfeeding is a happy experience for both mother and baby.
The vast majority of mothers are perfectly capable of breastfeeding their babies exclusively for four to six months. In fact, most mothers produce more than enough milk. Unfortunately, outdated hospital routines based on bottle feeding still predominate in many health care institutions and make breastfeeding difficult, even impossible, for some mothers and babies. For breastfeeding to be well and properly established, a good early few days can be crucial. Admittedly, even with a terrible start, many mothers and babies manage.
The trick to breastfeeding is getting the baby to latch on well. A baby who latches on well, gets milk well. A baby who latches on poorly has difficulty getting milk, especially if the supply is low. A poor latch is similar to giving a baby a bottle with a nipple hole which is too small—the bottle is full of milk, but the baby will not get much. When a baby is latching on poorly, he may also cause the mother nipple pain. And if he does not get milk well, he will usually stay on the breast for long periods, thus aggravating the pain. Here are a few ways breastfeeding can be made easy: The baby should be at the breast immediately after birth. The vast majority of newborns can be put to breast within minutes of birth. Indeed, research has shown that, given the chance, babies only minutes old will often crawl up to the breast from the mother's abdomen, and start breastfeeding all by themselves. This process may take up to an hour or longer, but the mother and baby should be given this time together to start learning about each other. Babies who "self-attach" run into far fewer breastfeeding problems. This process does not take any effort on the mother's part, and the excuse that it cannot be done because the mother is tired after labor is nonsense, pure and simple. Incidentally, studies have also shown that skin to skin contact between mothers and babies keeps the baby as warm as an incubator. The mother and baby should room in together. There is absolutely no medial reason for healthy mothers and babies to be separated from each other, even for short periods.
Health facilities which have routine separations of mothers and babies after birth are years behind the times, and the reasons for the separation often have to do with letting parents know who is in control (the hospital) and who is not (the parents). Often bogus reasons are given for separations. One example is the baby passed meconium before birth. A baby who passes meconium and is fine a few minutes after birth will be fine and does not need to be in an incubator for several hours under "observation".
There is no evidence that mothers who are separated from their babies are better rested. On the contrary, they are more rested and less stressed when they are with their babies. Mothers and babies learn how to sleep in the same rhythm. Thus, when the baby starts waking for a feed, the mother is also starting to wake up naturally. This is not as tiring for the mother as being awakened from deep sleep, as she often is if the baby is elsewhere when he wakes up.
The baby shows long before he starts crying that he is ready to feed. His breathing may change, for example. Or he may start to stretch. The mother, being in light sleep, will awaken, her milk will start to flow and the calm baby will be content to nurse. A baby who has been crying for some time before being tried on the breast may refuse to take the breast even if he is ravenous.
Mothers and babies should be encouraged to sleep side by side in hospital. This is a great way for mothers to rest while the baby nurses. Breastfeeding should be relaxing, not tiring. Artificial nipples should not be given to the baby. There seems to be some controversy about whether "nipple confusion" exists. Babies will take whatever method gives them a rapid flow of fluid and may refuse others that do not. Thus, in the first few days, when the mother is producing only a little milk (as nature intended), and the baby gets a bottle (as nature intended?) from which he gets rapid flow, he will tend to prefer the rapid flow method. You don't have to be a rocket scientist to figure that one out, though many health professionals, who are supposed to be helping you, don't seem to be able to manage it.
Nipple confusion includes not just the baby refusing the breast, but also the baby not taking the breast as well as he could and thus not getting milk well and /or the mother getting sore nipples. Just because a baby will "take both" does not mean that the bottle is not having a negative effect. Since there are now alternatives available if the baby needs to be supplemented ,why use an artificial nipple? No restriction on length or frequency of feedings. A baby who drinks well will not be on the breast for hours at a time. Thus, if he is, it is usually because he is not latching on well and not getting the milk which is available. Get help to fix the baby's latch, and use compression to get the baby more milk. This, not a pacifier, not a bottle, not taking the baby to the nursery, will help.
Supplements of water, sugar water, or formula are rarely needed. Most supplements could be avoided by getting the baby to take the breast properly and get the milk that is available. If you are being told you need to supplement without someone having observed you breastfeeding, ask for someone to help who knows what they are doing. There are rare indications for supplementation, but usually supplements are suggested for the convenience of the hospital staff. If supplements are required, they should be given by lactation aid (see handout #5), not cup, finger feeding, syringe or bottle. The best supplement is your own colostrum. It can be mixed with sugar water if you are not able to express much at first. Formula is hardly ever necessary in the first few days. A proper latch is crucial to success. This is the key to successful breastfeeding. Unfortunately, too many mothers are being "helped" by people who don't know what a proper latch is. If you are being told your two day old's latch is good despite your having very sore nipples, be skeptical, and ask for help from someone who knows.
Before you leave the hospital, you should be shown that your baby is latched on properly, and that he is actually getting milk from the breast and that you know how to know he is getting milk from the breast (open—pause—close type of suck). If you and the baby are leaving hospital not knowing this, get help quickly.
Free formula samples and formula company literature are not gifts. There is only one purpose for these "gifts" and that is to get you to use formula. It is very effective, and very unethical, marketing. If you get any from any health professional, you should be wondering about his/her knowledge of breastfeeding and his/her commitment to breastfeeding. "But I need formula because the baby is not getting enough!". Maybe, but, more likely, you were not given good help and the baby is simply not getting your milk well. Get good help. Formula samples are not help.
Under some circumstances, it may be impossible to start breastfeeding early. However, most medical reasons (maternal medication, for example) are not true reasons for stopping or delaying breastfeeding, and you are getting misinformation. Get good help. Premature babies can start breastfeeding much, much earlier than they do in many health facilities. In fact, studies are now quite definite that it is easier for a premature baby to breastfeed than to bottle feed. Unfortunately, too many health professionals dealing with premature babies do not seem to be aware of this.Jack Newman, MD, FRCPC, is a Toronto pediatrician who has practiced medicine since 1970. He is a graduate of the University of Toronto medical school. In 1984 he established the first hospital-based breastfeeding clinic in Canada at Toronto's Hospital for Sick Children. He has practiced as a physician in Canada, New Zealand, and South Africa. He now holds breastfeeding clinics in several hospitals in the Toronto area. He is a consultant with UNICEF's Baby Friendly Hospital Initiative and is a popular speaker at breastfeeding conferences across North America and beyond. He is the father of three children, all breastfed.
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