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Breastfeeding Basics

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“If breastfeeding did not already exist, someone who invented it today would deserve a dual Nobel Prize in medicine and economics… Breastfeeding is a child’s first inoculation against death, disease, and poverty, but also their most enduring investment in physical, cognitive, and social capacity.”

The benefits to children, mothers, society, and the environment breastfeeding brings are not to be underestimated. It is the most effective and cost-effective public health strategy known. Yet, we are still constantly failing mothers, with insufficient education and lactation support, allowing the formula industry to have excessive influence over parents’ feeding choices and providing inadequate societal and financial structures to support families.

The World Health Organisation has set a global target for all mothers too, where medically possible, breastfeed exclusively for the first six months of life and continue feeding (with the addition of complementary foods) until at least two years of age. Unfortunately, all nations, including Australia, fall drastically short of these minimum targets.

It’s a complex area, often needing specialist input. However, knowing some basics, including how women can access help, goes a long way to supporting mothers and infants in their breastfeeding journeys. Therefore, we will cover a few basic points about breastfeeding to make those less familiar with this incredible process more comfortable with the topic.

Creativity in breastfeeding

Jenny is a new mum struggling with breastfeeding her 3-week-old baby, Lily. She has painful, cracked nipples, and her finances are tight, so she’ll have to return to work much sooner than expected. She wants to continue breastfeeding, but it’s all quite overwhelming now, and she doesn’t know what to do next.

Whilst direct breastfeeding (infant mouth directly onto nipple) is ideal for several reasons, there are plenty of other ways to deliver breastmilk, which can provide some much-needed flexibility (and relief!) for mums and alternatives for babies who struggle with direct feeding for any reason.

  • Nipple shields are flexible plastic covers that can be placed over the nipple to reduce discomfort and improve milk transfer for babies otherwise struggling. An experienced midwife or lactation consultant is usually needed to support mums in using these effectively. They can be purchased from pharmacies or supplied by hospitals.
  • Expressed breastmilk bottle feeds – The Australian Breastfeeding Association website has clear guidelines on how to pump, store and administer expressed milk, which is a time-consuming but often popular choice to improve maternal flexibility, especially when returning to the workplace. Frozen and reheated milk may lose some nutritional value, but it’s still a great choice.
  • Supply lines – This is another great choice, particularly for women with supply issues. A couple of commercial setups are available: a container, which mum fills with milk and wears around her neck, and a thin tube placed in bub’s mouth during direct breastfeeding. As the baby sucks on the nipple, additional milk is drawn into the mouth through the tube. This method works well as it rewards sucking and encourages the baby to stay on the breast longer, which helps build up supply. Babies with poor suck due to prematurity or other issues will also get more bang for their buck.
  • Mixed feeding – Although exclusive breastfeeding is the gold standard, adding formula bottles into the feeding regime is perfectly reasonable (and sometimes medically necessary). However, mixed feeding can affect maternal supply and can sometimes affect an infant’s willingness to suckle at a breast, so a relevant health professional should be involved to monitor things. It’s ideal to wait until breastfeeding is established (e.g. around six weeks of age) before introducing formula feeds.

Support crew

If you’re not a lactation expert, you’ll need to find immediate and ongoing support for Jenny. The options for getting help generally depend on location, although quality telehealth services may be available in many remote and regional areas.

  • Lactation Consultant (LC): A lactation consultant is a health professional, typically a midwife or General Practitioner, with extensive additional training in lactation medicine, holding an expert qualification as an International Board Certified Lactation Consultant (IBCLC). Private lactation consultants are often available for home visits, and community health centres and hospitals frequently have at least one on staff, which families may be able to access.
  • Midwife: Midwives can be accessed in maternity units and through some community programs, with varying (but usually high!) levels of experience and skill in breastfeeding support.
  • Child Health Nurse: Nurses with specialist early childhood and/or midwifery training are available through local community health centres. However, again, there will be variability in each individual’s skill and experience in breastfeeding support. In addition, many community health centres offer free breastfeeding drop-in clinics supported by midwives, child health nurses, and/or lactation consultants.
  • Australian Breastfeeding Association (ABA): The ABA offers a 24/7 hotline to provide breastfeeding advice and support. The website is also excellent.
  • General Practitioner (GP): GPs will again have varying skill in breastfeeding support, but many are brilliant at this and are an ideal resource for troubleshooting many breastfeeding issues. They also play a vital role in managing the various medical problems which may arise during the breastfeeding journey, such as mastitis, thrush, and various infant pathologies.
  • Paediatrician: Paediatricians can be used when GPs require additional support to manage problems in infants, such as poor growth, excessive vomiting, suspected allergies, and so forth, which may be associated with breastfeeding.

General Troubleshooting

Here is a very basic guide for approaching some of the more common issues arising during a breastfeeding journey.

Problem

Approach

Uncertainty about supply

If baby is alert, pink, warm, and moist, with clear urine and a soft stool here and there, intake is likely to be ok for the moment. Monitor growth over time (frequency depends on the situation) to ensure caloric intake is sufficient for baby to progress steadily along growth centiles. Please note, pumped volumes have no correlation with actual supply. Weighing baby before and after a feed can be helpful in some cases but is usually unnecessary. Most maternal/infant health professionals can assess this situation and refer as needed.

Painful feeding and nipple trauma

Support from a lactation consultant is ideal in this situation, as the causes are myriad. In the acute setting (such as ED), with limited specialist lactation support on hand, the mother could try nipple shields (if already trained to use these) or pumping and bottle feeding temporarily to allow the nipple(s) to heal. Lots of products are available to help soothe and support healing. Babies can drink milk which is contaminated with maternal blood due to nipple trauma (except where the mother has an infectious blood-borne illness, such as hepatitis C), although sometimes it causes a few pink-stained vomits.

Tongue Ties

See Tessa’s fantastic article on this controversial topic. As a general rule, a lactation consultant should be involved before considering intervention.

Blocked ducts and mastitis

The general rule is to keep feeding when possible. Massage, heat, adjusting positions, and antibiotics may all be needed. GPs, midwives and LCs may all need to be involved.

Maternal medical issues

Some medications may not be suitable for lactating mothers. There’s rarely a problem with mums feeding straight after anaesthetic, but check with the anaesthetist.

Suspected infant allergies

This should be managed under an experienced GP, paediatrician or allergy specialist, usually with dietician support. Mothers should never be starting elimination diets or stopping breastfeeding altogether without specialist advice and monitoring.

Suspected GORD/colic/other infant concerns

As above, these issues should always be managed by experts, often requiring paediatrician or specialist GP involvement. Stopping breastfeeding is rarely required, and should only be done on specialist advice.

Suspected lactose overload

Frothy, explosive stools, and a gassy, unhappy, seemingly hungry baby, might suggest lactose overload. Try block feeding – feeding on one breast only over a 4-hour period, then swapping to the other side. See the ABA website for more detail and suggestions.

Nipple and oral thrush

This can be very painful for mums, and often tricky to detect, as there’s often no surface signs on the breasts. A more obvious clue is seeing a thick white coating in the baby’s mouth, and/or a refractory, nasty nappy rash. A GP is usually best placed to diagnose and manage mum and baby. Both will need treating if detected.

Additional nutritional needs

Breast milk contains very little vitamin D or iron, so some babies, such as those born prematurely, may need supplementation. Mothers with certain dietary restrictions may also lack specific components in their breastmilk (such as B12 in vegan mums). A GP, paediatrician, or dietician should usually advise individual families. All pregnant and breastfeeding women should take iodine supplementation.

Can you freeze breastmilk?

Freezing breast milk – whether you’ve seen it done during your NICU time or done it yourself as a parent, it’s probably something we’ve all had to consider. General advice is that it’s ok to freeze your breast milk for 6-9 months. But is that true, or does freezing damage breast milk?

A study published in the Journal of Pediatrics assesses whether or not freezing breast milk is safe. Do we have to change our practice?

Ahrabi AF, Handa D, Codipilly CN, Shah S, Williams JE, McGuire MA, Potak D, Aharon GG, Schanler RJ. Effects of extended freezer storage on the integrity of human milk. The Journal of pediatrics. 2016 Oct 1;177:140-3.

Why freeze breast milk?

In NICU, breastfeeding of premature infants is encouraged, and breast milk is frequently frozen for an extended period. Similarly, at home, mums often express and freeze milk for later use, particularly as they return to work. The idea is that even though the mum cannot breastfeed her child herself, the child will still get all the benefits of breast milk.

What are the current guidelines for safe milk storage?

The American Academy of Pediatrics recommends that breast milk be refrigerated for 24 hours and then frozen, and then can be stored for 3-6 months if it remains at -20oC. The NHMRC Infant Feeding Guidelines recommends refrigerating and then freezing within 72 hours, and then can be stored for up to 12 months if it remains at -20o

What were the aims of the study?

This study aimed to measure the qualities of the milk after freezing – including pH, bacterial counts, and nutrients.

Who were the participants?

The study included 40 mothers with infants in NICU. Only those with excess milk supply were included.

Mothers were excluded if they showed signs of a breast infection or had received antibiotics in the previous seven days.

Each mother expressed 100ml breast milk and this was split into 9 x 10ml volumes. 4 of these were refridgerated (4oC) for 72 hours and then frozen (-20oC) and 4 were frozen immediately (-20oC). One of each was thawed at 1, 3, 6, and 9 months and analyzed.

One 10ml sample was used as a control and was frozen immediately to -80o

How did they analyse the thawed breast milk samples?

The authors tested for pH, total bacterial colony count, gram-positive and gram-negative colony count, lipids, osmolality, and concentrations of protein, lactoferrin, and secretory IgA.

What were the findings?

Milk pH declined, and fatty acid concentration increased over nine months and was not affected by prior refrigeration.

Bacterial count decreases during the time when milk is frozen too, and this decline happens more rapidly in milk that was refridgerated prior to freezing.

Concentrations of protein, lactoferrin and secretory IgA were unaffected.

What does the declining bacterial count mean?

The significance of the bacterial count isn’t clear. The authors suggest that the decline over time means the milk is still biologically active, which is good. However, reducing to zero bacteria may remove some of the benefits of breast milk. As refrigerating the milk first seems to accelerate the decline of bacteria, this should be considered when storing breast milk for pre-term infants, where we know that bacteria can benefit neonatal health.

In conclusion, milk’s nutritional content does not change with freezing. The bacterial count does decline, but the significance of this seems less certain.

Freezing breast milk – whether you’ve seen it done during your NICU time, or done it yourself as a parent, it’s probably something that we’ve all had to consider. General advice is that it’s ok to freeze your breast milk for 6-9 months. But is that really true, or does freezing damage breast milk?

A study published online this month in the Journal of Pediatrics, assesses whether or not freezing breast milk is safe. Do we have to change our practice?

Ahrabi AF, Handa D, Codipilly CN, Shah S, Williams JE, McGuire MA, Potak D, Aharon GG, Schanler RJ. Effects of extended freezer storage on the integrity of human milk. The Journal of pediatrics. 2016 Oct 1;177:140-3.

Why freeze breast milk?

In NICU, breastfeeding of premature infants is encouraged, and breast milk is frequently frozen for an extended period. Similarly, at home, mums often express and freeze milk for later use, particularly as they return to work. The idea is that even though the mum cannot breastfeed her child herself, the child will still get all the benefits of breast milk.

What are the current guidelines for safe milk storage?

The American Academy of Pediatrics recommends that breast milk be refrigerated for 24 hours and then frozen, and then can be stored for 3-6 months if it remains at -20oC. The NHMRC Infant Feeding Guidelines recommends refrigerating and then freezing within 72 hours, and then can be stored for up to 12 months if it remains at -20o

What were the aims of the study?

This study aimed to measure the qualities of the milk after freezing – including pH, bacterial counts, and nutrients.

Who were the participants?

The study included 40 mothers with infants in NICU. Only those with excess milk supply were included.

Mothers were excluded if they showed signs of a breast infection or had received antibiotics in the previous seven days.

Each mother expressed 100ml breast milk and this was split into 9 x 10ml volumes. 4 of these were refridgerated (4oC) for 72 hours and then frozen (-20oC) and 4 were frozen immediately (-20oC). One of each was thawed at 1, 3, 6, and 9 months and analyzed.

One 10ml sample was used as a control and was frozen immediately to -80o

How did they analyse the thawed breast milk samples?

The authors tested for pH, total bacterial colony count, gram-positive and gram-negative colony count, lipids, osmolality, and concentrations of protein, lactoferrin, and secretory IgA.

What were the findings?

Milk pH declined, and fatty acid concentration increased over nine months and was not affected by prior refrigeration.

Bacterial count decreases during the time when milk is frozen too, and this decline happens more rapidly in milk that was refridgerated prior to freezing.

Concentrations of protein, lactoferrin and secretory IgA were unaffected.

What does the declining bacterial count mean?

The significance of the bacterial count isn’t made clear. The authors suggest that the decline over time means that the milk is still biologically active, which is good. However, reducing to zero bacteria may remove some of the benefits of breast milk. As refrigerating the milk first seems to accelerate the decline of bacteria, this should be considered when storing breast milk for pre-term infants, where we know that bacteria can benefit neonatal health.

Milk’s nutritional content does not change with freezing. The bacterial count does decline, but the significance of this seems less certain. It’s probably okay to store it in the freezer for up to nine months.

Can you donate breast milk?

You are a junior doctor working in ED. A 4-month-old girl, Lisa, is brought in by her parents with suspected bronchiolitis. On reviewing her history, her Dads tell you that Lisa is adopted, and is being fed donor breastmilk (and formula when they can’t access sufficient volumes). You’ve never encountered a baby on donor breastmilk, so you aren’t sure of the implications. You ask your friendly paediatric registrar about it…

Given that human milk is vastly superior to formula, it stands to reason that if a baby can’t be fed milk by their mother, donor breastmilk should be the next step. Families wishing to access such milk must use either formal milk banks, wet nurses, or private donor arrangements. The use of wet nurses (direct feeding of an infant by a lactating woman other than the infant’s mother) is very unusual, though it still occurs in some cultures.

Charles et Henri Beaubrun anciennement attribué à Anonyme France XVIIe siècle Title Français : Louis XIV et la Dame Longuet de La Giraudière

Milk Banks

Formal ‘milk banks’ were quite prevalent a few decades ago until HIV fears in the 1980s shut many facilities down. With new protocols for screening and techniques for pasteurisation available, a resurgence in milk banking is being seen across the globe. A small handful of milk banks exist across Australia, predominantly to provide donor milk to vulnerable premature and low birth weight infants in Neonatal Intensive Care Units.

Formal milk banks cost a lot of money to set up (AUD$200,000-$250,000) and to run (AUD$150,000-$250,000 per year). Donors are screened similarly to blood donors, with questionnaires and blood tests, and the milk is pasteurized to remove bacteria and viruses. Some live breastmilk components are denatured in this process, but many important immunological and nutritional features remain. NICU infants are prime donor milk recipients, given they require so little compared to their older counterparts. Human milk has been shown to reduce rates of necrotising enterocolitis and sepsis (compared with formula).

Private sharing of breastmilk

For the rest of the Australian community, accessing milk banks is almost impossible, so many families requiring a breastmilk alternative use social media and other community networks to find donors. These are entirely unregulated, although some web pages provide collection, handling, home pasteurisation, and breastmilk storage guidelines. Donors will sometimes sell their milk, which is considered highly unethical, although reimbursement of a donor’s costs may be acceptable.

The Australia Breastfeeding Association does not endorse private exchanges of breastmilk supplies, as there can be no safety guarantees for infants. However, it does provide web links to sites with guidelines for private milk sharing in case members are interested in this route so that families (and donors) can be appropriately educated.

Ideally, formal human milk banks should be accessible to all families who, for whatever reason, require a safe alternative to maternal breast milk. However, given the high set-up and running costs and that most mothers should be able to feed their infants if given adequate support, perhaps any funds would be better spent for now on improving health sector lactation support, maternity leave financial support and breastfeeding infrastructure.

Informal exchange of breastmilk is hard to endorse, given the inherent risks; however, if families are well educated and guidelines are adhered to, the risks can likely be significantly reduced. Additionally, given the myriad health benefits of using human milk over formula, many families will consider these risks acceptable and will continue using human donor milk where available. 

In Lisa’s case, her dads explain that they are sourcing the milk from three altruistic donors who are all long-term friends of the family. They are all healthy women, and all have been strictly following the advice provided on the ‘eats on feets’ and ABA websites to ensure the milk is managed safely.

The paediatric registrar has discussed this with the parents and reminded them about the risks of viral and bacterial transmission even with all due care, but as Lisa is otherwise a thriving baby, with just a mild case of bronchiolitis, there appears to be no cause for further investigation or cessation of the current feeding regimen.

Overall, the most important thing for us as health professionals working with infants and breastfeeding mums is to be educated enough on the topic to provide good general advice (just knowing your local resources is a brilliant start), and to celebrate every mother’s efforts to care for her child in the best way she can.

Selected references

Australian Government. Department of Health | Breastfeeding [Internet]. Www1.health.gov.au. 2019. Available from: https://www1.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-brfeed-index.htm

Hansen K. Breastfeeding: a smart investment in people and in economies. The Lancet. 2016;387(10017):416.

WHO | Exclusive breastfeeding for six months best for babies everywhere [Internet]. Who.int. 2011. Available from: https://www.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/

Author

  • Annabel Smith is a General Paediatrician based on the Central Coast of New South Wales, with interests in public health, the environment, and doctor's wellbeing. She is passionate about breastfeeding, good sleep practices, physical exercise, excellent nutrition, and building family resilience and cohesion to promote long term health and wellbeing for all children.

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