Starting Out Right - Dr Newman

Let me start by saying: there are no benefits to breastfeeding. Breastfeeding is the natural, physiologic way of feeding infants and young children, and human milk is the milk made specifically for human infants. There are, however, RISKS to not breastfeeding. Formulas made from cow’s milk or soybeans (most formulas, even “designer formulas” and formulas with DHA and other components added) are only superficially similar to human milk, and advertising which states otherwise is misleading.

The slogan “Babies are born to be breastfed” is true in more ways than one. Babies are biologically designed to be ready to feed at the breast and breastfeeding should be easy and trouble free for most mothers. A good start helps to ensure breastfeeding is a happy experience for both mother and baby.

Unfortunately, outdated hospital routines based on bottle feeding still predominate in too many health care institutions and make breastfeeding difficult, even impossible, for too many mothers and babies. For breastfeeding to be well and properly established, a good start in the first few days can be crucial. Admittedly, even with a terrible start, many mothers and babies manage to overcome the initial challenges and continue to breastfeed – but others will not be able to, or will become discouraged and wean.

The trick to breastfeeding is getting the baby to latch on well. A baby who latches on well gets milk without difficulty. A good latch is comfortable for the mother and effective in transferring milk to the baby. A baby who latches on poorly has more difficulty getting milk, especially if the supply is low. A poor latch is similar to giving a baby a bottle with a nipple hole that 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. Unfortunately, anyone can say that the baby is latched on well, even if he isn’t. Too many people who should know better just don’t know what a good latch is.

So how do you get breastfeeding off to a good start? It begins with the birth.

1.     Minimize medication during labour and birth. While most pain-relieving medications used during labor are recommended to parents as having no long-term effects on the baby, research shows that, in fact, these medications do affect the baby’s ability to coordinate sucking at the breast and, therefore, they may make it harder for the mother to establish breastfeeding. Researchers looking at epidural anesthesia’s effect on the baby’s breastfeeding skills clearly showed that medication during birth did negatively affect babies’ ability to suckle normally during the first 12 hours, and that combining medications increased the effect. Demerol and fentanyl were especially harmful to the baby's suckling ability.

It’s clear that, particularly with good help, many mothers and babies are able to overcome this difficult start to breastfeeding. But where other problems are also present, the baby’s uncoordinated sucking in the first day or so may be “the final straw.”

We also know that when mothers are given intravenous fluids during labour (as they are, for example, when an epidural is given), they may experience oedema of the breast tissue (and particularly the areola) and that can interact with the fullness caused by the milk increasing in quantity in the breasts. Usually, the oedema begins fairly soon after the baby is born while the increase in milk production happens two or three days after the birth, but they can certainly overlap and cause real difficulties in breastfeeding.  Women are often then advised to pump to relieve the pain, only to find that pumping simply pulls more fluid into the breasts and makes the situation worse. Avoiding  medications such as the epidural which require IV fluids can help reduce this problem as well.

Here’s how to do it: Put your thumbs or forefingers one on either side of the nipple, near the base of the nipple. Press gently but firmly straight back towards your ribcage. Keep that pressure there for a full 60 seconds. Move your fingers a quarter way around the nipple, and apply pressure again.

“Your goal is to create a ring of dimples around the nipple,” Cotterman says.

This pushes the excess fluid in the breast tissue temporarily back into the deeper part of the breast, so that the baby can more easily latch onto the nipple. It also presses on the milk sinuses around the nipple, and if they are overly full some milk may be expressed.

With the breast softer around the nipple, helping the baby latch on well should be easier. Cotterman recommends that mothers use breast compression while the baby is nursing – massaging or pressing on the breast to help the baby get more milk quickly.

If the baby is not able to come to the breast, perhaps because she is ill or premature, Cotterman suggests hand expressing milk rather than pumping.

1. The baby should be at the breast immediately after birth. The vast majority of newborns can be at the breast within minutes of birth. Indeed, research has shown that, given the chance, many babies only minutes old will crawl up to the breast from the mother’s abdomen, latch on and start breastfeeding all by themselves. The baby will move to the breast and may start by licking or mouthing the nipple. Usually, he then begins to bob his head as he orients to the nipple and latches on. 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. The baby can be examined while lying on the mother and other routines can be delayed until after the baby has had time to initiate breastfeeding.

Babies who “self-attach” run into far fewer breastfeeding problems. It also helps the mother feel confident about the breastfeeding process – even if she’s not sure how to breastfeed, she can see for herself that her baby is ready and knows what to do.

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. All she has to do is lie there and relax while the baby goes to the breast. Incidentally, studies have also shown that skin-to-skin contact between mothers and babies keeps the baby as warm as an incubator, and reduces any potential drop in blood sugar. Incidentally, it is normal for the blood sugar to drop during the first hour or so after birth so that those postpartum units that do a blood sugar immediately after birth and then an hour or two after and treat a “dropping blood sugar” are treating something that is normal and expected.

Caption: A just born baby skin to skin with his mother.  One can see how tiring this is for the mother and the baby.

Some babies do not latch on and begin breastfeeding during this time. Generally, this is not a problem, and there is no harm in waiting for the baby to start breastfeeding when he or she is ready. Simply keep the mother and baby together and be patient  The skin to skin contact is good for the baby and the mother even if the baby does not latch on.

By the way, this applies to babies born by Caesarean as well. With a capable person to assist the mother, the baby can be helped to latch on even as the mother’s incision is being closed.

Caption.  A baby skin to skin with the mother while her incision for a caesarean section is being sewn up.

If the baby does not self-attach and/or the mother would like to help the baby latch on, it’s essential to be sure that a knowledgeable person is there to provide guidance. Nipple damage can begin with this very first feeding if the baby does not latch on well. The mother may need extra help in finding a comfortable position right after birth, especially if she’s had a Caesarean or stitches from a tear or episiotomy. It’s important to have someone with the mother who knows how to help a baby breastfeed in a variety of positions.

3. The mother and baby should room in together. There is absolutely no medical reason for healthy mothers and babies to be separated from each other, even for short periods.

• Health facilities that 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 that 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’ “observation.” Parents make very dedicated observers of their own babies – they will notice every little snort and snuffle. Another common reason for separation is that the mother has a fever and therefore may have an infection which could be passed on to the baby. However, the fever may actually be the result of the epidural she was given in labor – another reason to minimize the use of medication in labor.   
• 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 are biologically designed to respond to subtle cues from each other and to sleep in the same rhythm. Thus, when the baby starts waking for a feed, the mother is also starting to wake up naturally. Even when asleep, she is in tune with his quiet noises and is aware of the change in his breathing and the sounds he makes as he gets ready to nurse. 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.  If the mother is shown how to feed the baby while both are lying down side by side, the mother is better rested.
• 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, whose sleep cycles are synchronized with her baby, will be in light sleep, so these small signals will wake her, her milk will start to flow and the calm baby will be easier to nurse. A baby who has been crying for some time in a room down the hall from his

Caption: Feeding lying down immediately after birth.

mother before being brought to her and tried on the breast may refuse to take the breast even though he is ravenous. If she does get him on the breast, he may only nurse for a short time before he falls asleep from exhaustion. Mothers and babies should be encouraged to nurse lying down. This is a great way for mothers to rest while the baby nurses. Breastfeeding should be relaxing, not tiring.

1. Artificial nipples should not be given to the baby. There seems to be some controversy about whether “nipple confusion” exists. Certainly, it is clear that some babies will show clear preferences for a particular nipple. We all hear about bottle fed babies, for example, who only like one particular brand. Babies are biologically geared to eat, gain weight and grow. So they will take whatever gives them a rapid flow of fluid and may refuse other nipples that do not. Thus, in the first few days, when the mother is normally producing only a little milk (as nature intended), if the baby is given a bottle (NOT as nature intended) from which he gets a rapid flow of milk, the baby will tend to prefer the rapid flow method. You don’t have to be a rocket scientist to figure that one out. Note, it is not the baby who is confused. Nipple confusion includes a range of problems, including 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 – the baby may not be latching on as well as he could be at the breast. Since there are now alternatives available to bottles if the baby truly needs to be supplemented, why use an artificial nipple?

I think it is important when discussing this with mothers not to call it “nipple preference.” Mothers tend to react emotionally to this description, believing that it means the baby prefers the bottle over them. It’s more helpful to the mother to explain that we have confused the baby by giving him the fast-flowing bottles, but that her baby really does want to breastfeed.

While pacifiers don’t provide milk either rapidly or slowly, there are a number of studies showing that pacifiers reduce the duration of breastfeeding and some suggesting they may also cause latch difficulties. It may be that giving a pacifier means the mother misses some of those early feeding cues described above, so she may feed the baby less often or may end up waiting until the baby is crying with hunger and doesn’t feed as well. I’ve noticed that babies who take pacifiers tend to have more problems with biting down on their mother’s nipples as they get older and are teething. They discover that biting on the pacifier is comforting to their sore gums and seem to think they can do the same thing at the breast. (This is not to say that babies who don’t get pacifiers never bite – they sometimes do. But the problem seems to be more persistent with babies who get pacifiers.)

5. No restriction on length or frequency of breastfeedings. 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 that is available. The first step is to fix the latch, and use breast compression to get the baby more milk. Compression works very well in the first few days to get the colostrum flowing well.  Restricting the length or frequency of feedings will not help this problem. It will also not help the problem of sore nipples, which are most often caused by latch problems.

It is said that a newborn will nurse an average of 8 to 12 times a day (I disagree with this and I don’t think it should be a “recommendation”). This does not mean that the baby who nurses 13 or 14 or 15 times a day is in trouble or doing something wrong or needs to be supplemented, as some medical professionals have suggested. We know that in tribal societies, where true unrestricted breastfeeding is practiced, babies nurse an average of 30 or 40 times a day, for a few minutes each time, and this may be biologically more normal behavior for infants.  As their babies grow, some mothers will want to work towards a more predictable schedule, but at least in the beginning, there should be no restrictions on how often or how long the baby nurses.

6. 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 thus get the milk that is available. Before considering supplementation, observe at least one feeding at the breast. Work first on improving the baby’s latch. This does not mean that the baby should be pulled off and relatched over and over again, as this will just make nipple soreness intolerable for many mothers.  Five painful latches cause 5 times as much pain and 5 times as much damage as one.  The baby also becomes frustrated as does the mother.  A sequence of events occurs that too often results in the baby being fed off the breast often with supplements, to give the “nipples a rest”, and too many mothers never overcome this terrible start.  The nipples may heal, but often the baby refuses the breast after that.  And the latch has not been corrected, so that pain starts again.  If the latch hurts, the pain usually diminishes.  So leave the mother be, and fix the latch on the other side or the next feeding. If supplements are required, they should be given by lactation aid at the breast, not cup, finger feeding, syringe or bottle. The best supplement is the mother’s own colostrum, expressed by hand. (Because the volume of colostrum is small, hand-expression often works best in the first few days.) If there is not much colostrum, it can be mixed with 5% sugar water to be given to the baby. By giving it to the baby at the breast, the baby not only receives the extra fluids (the issue is fluid, not calories, at least not most of the time) but is encouraged and rewarded for nursing at the breast. Formula is hardly ever necessary in the first few days.

7. Be aware that many “contraindications to breastfeeding” are not valid.

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. Consult the current issue of “Medications and Mother’s Milk” by Dr. Thomas Hale for detailed discussions of the safety of maternal medications – you will find that, in fact, the vast majority are safe while breastfeeding and, in many other cases, safe alternatives are available.

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 less stressful for a premature baby to breastfeed than to bottle feed. Kangaroo Mother Care should be the standard of care for a stable premature baby, and this facilitates breastfeeding as well.

A good start makes breastfeeding easy and comfortable for mother and baby, and it is worth taking the time to help because so many future problems can be prevented.

The Importance of Skin to Skin Contact

We now have a multitude of studies that show that mothers and babies should be together, skin to skin (baby naked, not wrapped in a blanket) the baby’s neck extended slightly so his head is in “sniffing position” immediately after birth, and spend as much time together skin to skin as possible in the days that follow.  The baby is happier, the baby’s temperature is more stable and more normal, the baby’s heart and breathing rates are more stable and more normal, and the baby’s blood sugar levels are better.  Not only that, skin to skin contact immediately after birth allows the baby to be colonized by the same bacteria as the mother.  This, plus breastfeeding, are thought to be important in the prevention of allergic diseases.  When a baby is put into an incubator, his skin and gut are often colonized by bacteria different from his mother’s and studies show that the baby is much more likely to adjust to his new world, metabolically speaking, when he is skin to skin with the mother than if he is in that incubator.

We now know that this is true not only for the baby born at term and in good health, but also for the premature baby.  Skin to skin contact and Kangaroo Mother Care can contribute much to the care of the premature baby.  Even babies on oxygen can be cared for skin to skin, and this helps reduce their needs for oxygen, and keeps them more stable in other ways as well.

From the point of view of breastfeeding, babies who are kept skin to skin with the mother immediately after birth for at least an hour, are more likely to latch on without any help, and they are more likely to latch on well, especially if the mother did not receive medication during labor or birth. Putting mother and baby skin to skin can also be a valuable first step in solving any breastfeeding difficulties they are having.

To recap, skin to skin contact immediately after birth, which lasts for at least an hour has the following positive effects on the baby.  These babies:

• Are more likely to latch on.
• Are more likely to latch on well.
• Have more stable and normal skin temperatures.
• Have more stable and normal heart rates and blood pressures.
• Have higher blood sugars.
• Are less likely to cry.
• Are more likely to breastfeed exclusively longer.

There is no reason that the vast majority of babies cannot be skin to skin with the mother immediately after birth for at least an hour.  Hospital routines, such as weighing the baby, should not take precedence.  Of course, there is also no reason a baby cannot be back skin to skin with the mother immediately after the hospital routines are done.

The baby should be dried off and put on the mother.  Nobody should be pushing the baby to do anything; nobody should be trying to help the baby latch on during this time.  The mother, of course, may make some attempts to help the baby, usually in response to the baby’s behaviors showing some interest in going to the breast, and this should not be discouraged.  The mother and baby should just be left in peace to enjoy each other’s company. (The mother and baby should not be left alone, however, especially if the mother has received medication, and it is important that not only the mother’s partner, but also a nurse, midwife, doula or physician stay with them—occasionally, some babies do need medical help and someone qualified should be there “just in case”). The eye drops and the injection of vitamin K can wait a couple of hours.  By the way, immediate skin to skin contact can also be done after cæsarean section, even while the mother is getting stitched up, unless there are medical reasons which prevent it.

Caption: Skin to skin contact while mother is having her incision for caesarean section sewn up.

Studies have shown that even premature babies, as small as 1200 g (2 lb 10 oz) are more stable metabolically (including the level of their blood sugars) and breathe better if they are skin to skin immediately after birth.  The need for an intravenous infusion, oxygen therapy or a nasogastric tube, for example, or all the preceding, does not preclude skin to skin contact. Skin to skin contact is quite compatible with other measures taken to keep the baby healthy.  Of course, if the baby is quite sick, the baby’s health must not be compromised, but any premature baby who is not suffering from respiratory distress syndrome can be skin to skin with the mother immediately after birth.  Indeed, in the premature baby, as in the full term baby, skin to skin contact may decrease rapid breathing into the normal range.

Even if the baby does not latch on during the first hour or two, skin to skin contact is still good and important for the baby and the mother for all the other reasons mentioned.

I have heard of a few cases where a mother had planned not to breastfeed, but was still urged by hospital staff to hold her baby skin to skin. After doing this for a short period of time, and seeing her baby gravitate to her breast, these mothers decided to breastfeed after all. The effects of this simple technique are powerful!  In fact, one could say that skin to skin contact is even more important if the mother does not breastfeed so that the mother and baby have this special opportunity to “fall in love with each other”.