Written for the Doula, Midwifery Apprentice and Home Health Aide
Currently the American Pediatric Association recommends all mothers breastfeed their infants for a minimum of one year. Breastfeeding stimulates brain development, protects the gastrointestinal tract, and strengthens the immune system of newborns and infants. It is the finest food available for babies.
Relaxation, adequate rest and a good diet will bring the greatest success in nourishing a baby through breastfeeding. Nursing mothers need to consume more calories than they did when they were pregnant. Nursing moms need to drink quarts of fluid daily. Always have a beverage near the mother's bed and/or chair. Typically, nursing mothers will be very hungry until their milk supply is well-established (by about 6-8 weeks postpartum). Mothers need to have easy-to-access, high calorie, complex carbohydrate foods available at all times. Even something as simple as boiled potatoes with olive oil and nutritional yeast can stimulate production of breastmilk.
Essential components of a good nursing diet are: green salads (spinach, romaine and darker leaf lettuces, arugula, endive, sprouts, watercress, chickweed, parsley), fresh raw vegetables, broccoli, dark leafy steamed greens (kale, swiss chard, beet greens, turnip greens, mustard greens, collards, bok choy, spinach), nutritional yeast, acidophilus yogurt, and lots of liquids (herb teas, high quality orange, grape, and apple juices, soy milk, dairy milk, seed milk, grain milk, coconut water, spring water, etc).
To provide the increased calories needed to breastfeed, good food suggestions for families include fresh fruits and vegetables in season, tofu, tempeh, cottage cheese, hard cheese, eggs, wheat germ, fish or poultry, pasta, whole grain breads and crackers, honey, agave, lentils and beans, winter squash, nut butters, molasses, dried fruit, brown rice and other whole grains, olive oil, wholesome salad dressings, whole wheat pancake mix, and sauces the family enjoys. With the above foods a wonderful array of nourishing well-balanced meals can be created that will stimulate breastmilk production.
Occasionally a mother will feel that her baby is fussy due to something she ate that is passing through her breastmilk. There are no particular food items to universally avoid due to gas causing properties, as babies worldwide tolerate many different types of foods eaten by breastfeeding mothers. Some infants, however, are sensitive to some foods, and a mother may be encouraged to eliminate the suspect food from her diet for two weeks to see if there is improvement in the baby's gastric comfort.
My first recommedation for a food type to remove is all dairy products. Many babies get relief from gastric discomfort this way. If they do, it does not mean they will be lactose intolerant as children. The gastrointestinal tract of infants is less able to adjust to some food components, but it will mature and digest food types better as the baby grows. The second food category that may cause some upset in a baby are the brassicas. If eliminating dairy for two weeks offers no improvement of colic, try eliminating the cruciferous brassicas (broccoli, brussel sprouts, cabbage, bok choy, cauliflower, etc) .
With each home visit be sure to observe the newborn suckling at the mother's breast. Pay close attention to how well the baby is latched onto the nipple and areola. Observe the baby's sense of satisfaction while s/he nurses. Gently squeeze up the skin on the baby's forearm. If it falls back in place immediately, the skin has good "turgor "and the baby is adequately hydrated. If the skin stands up for 2 or 3 seconds (returns back in place slowly) the infant is dehydrated and the health care provider should be informed immediately. To be well hydrated, a newborn needs to nurse at least every 4 hours and wet through at least 6-8 diapers a day after the milk comes in. Breastmilk is usually present by postpartum days 2-4. Babies nurse between 6 and 20 times a day. Most infants will want to nurse at variable times and this should be encouraged. Before the milk comes in, for the first few days after birth, babies moisten about four diapers a day, since colostrum is less abundant. This is totally normal. Healthy babies do not need additional water as newborns.
A latched-on baby is fairly difficult to remove from the breast. Releasing latch requires placing a finger near the infant's mouth and pressing against the breast to release the suction. A baby without effective latch-on will not be getting adequate nutrition and could suffer from failure to thrive if the problem is not identified; or the mother may abandon nursing because she determines that her infant is not satisfied with breastfeeding. Some babies have very urgent, demanding personalities around feeding and other infants may be less apt to insist on adequate feeding, so determine the baby's sleeping and eating patterns. With poor latch, a mother will usually express that the nipple is excessivley painful beyond about six days postpartum, and/or the nipple shows signs of cracking or bleeding. The baby needs to be assisted to flange the lower and upper lips outward in most situations. Correct positioning is very helpful for adequate latch.
A baby cannot be spoiled with attention. Rather a baby is most content and well nurtured if s/he remains in close contact with the mother, and is fed on demand. Remind the mother to wash her hands frequently and to keep her fingernails clean to eliminate potential bacteria. Bacteria can be introduced to the baby and to the breast if sanitation is marginal. Also encourage siblings to wash their hands before handling the new infant. Sometimes normal bacteria present on the skin or in the body becomes overgrown, causing a breast infection. This issue is addressed below.
Burping the infant can be accomplished several different ways. If mom is lying in bed nursing, she can simply place the newborn on its back, raise it to a sitting position next to her and gently rub up and down on the baby's spine to get a burp up. This is a handy technique if it is winter and the family relies on wood heat. The baby can be fed and burped without getting out from under the warmth of the blankets. Another technique is the over-the-shoulder position with the baby facing backward over your shoulder and patting or rubbing his/her back to bring up the air bubble. It is also effective to sit the baby upright on the lap after a feed and gently pat or rub-up a burp this way. First-time moms generally need a little assistance with burping in the first few days after birth. If the baby is fussy, always try burping the him/her first.
Exposing the breasts to the air daily is helpful in maintaining nipple suppleness and helps to prevent cracking of the glandular surface. If there is a way to expose the nipples to sunshine (even if it is through a window pane), do so regularly.
Anhydrous lanolin can be applied to the nipples if there is any pain, cracking, or fissures appearing there. Mother's own milk can be massaged into nipple and areola after each nursing to promote healing. Lansinoh ointment is a natural lanolin product that is safe and effective without needing to be washed off for nursing. Aloe vera can also be applied if available, but the smell and taste may delay latch-on, so have mom gently wash her nipples off with warm water before nursing.
If the breasts become engorged the mother needs to be encouraged to continue to nurse regularly. Protecting the engorged breast from infant suckling will make the problem of engorgement much worse. Have the mother take her temperature twice daily if she is experiencing engorgement. Observe her breasts, looking for signs of infection (mastitis). If an infection is present, her temperature will rise to over 100.4 degrees and the veins of the affected breast will appear very reddened and distended. Have her notify her health care provider immediately. Then treat her topically for mastitis. Very warm poultices of simmered ginger root and/or plantain leaf can be applied to the breasts with great success (alternately, not combined). A good reference article for using herbal remedies for mastitis is "Postpartum Herbal Care" , also written by Linda Lieberman, published in Midwifery Today, No. 25 Spring 1993. Women who suffer regular breast infections when nursing need to push a gallon of water daily; their tendency to mastitis will resolve when pushing this much water, in most cases.
Breastfeeding suppresses the hormones that trigger the body to ovulate. Although breastfeeding should never be relied upon totally as a method of birth control, it is wise to encourage women to note the indicators of ovulation during the breastfeeding cycle. If hormonal methods of birth control are used postpartum, or gel/foam spermicide, indicators of return to fertility will be masked.
One of the first noticeable indicators that a woman is about to ovulate is the appearance of cervical mucus. Postpartum women continue to have lochial discharge for 4-8 weeks after birth, but then, during the months of breastfeeding, cervical mucus is minimal, or noticeably absent. Then one day it returns again, maybe at 8 weeks postpartum, maybe at 18 months postpartum. Advise women to observe this change in their body rhythms to better identify their return to fertility.
Suppressing ovulation with breastfeeding is done most effectively by nursing an infant or toddler every 3 hours or less, around the clock. If at any time a nursing is replaced or substituted with a bottle of fluid, or solid food of any type, it breaks the biological clockwork and ovulation can happen. Some women report around-the-clock nursing of this type and still start their menstrual cycle when their infant is quite young. To avoid an unexpected pregnancy while nursing an infant, a highly effective method of birth control is recommended.
Because breastfeeding is extremely beneficial to the health and wellbeing of an infant, great care must be taken to encourage women to see their breasts as beautiful, productive, and life-giving. Some women dislike feeling top heavy, feeling milk drip from their breasts uncontrollably, or feeling the intense sensation as the baby latches onto the nerve-sensitive nipple. Many women see their maternal shape as cumbersome and less desirable because American society has placed greater emphasis on the young, slender, and shapely female body. Remind women that being a mother involves being full of life as well as full of body.
Although breastfeeding has been recognized as a superior way to nourish a newborn baby through the first year of life, many cultural practices and beliefs remain extremely detrimental to a woman's comfort with breastfeeding. In the 1990's we saw about 50% of newly birthed mothers choosing to breastfeed. Of this group, more than 25% abandoned breastfeeding after 4-12 weeks, due to physical or psychological barriers. Data for 2000-2009 breastfeeding statistics for U.S. children from birth to 12 months can be found here http://www.cdc.gov/breastfeeding/data/nis_data/
Notably, it has been necessary to pass state laws stating that breastfeeding in public is not an infringement of decency. Some business establishments view breastfeeding in public as inappropriate, immodest, and bad for business. Some women are very strong in their beliefs that breastfeeding is one of the most important provisions for their babies, and are comfortable feeding their infants on demand in any location, regardless of public opinion.
It is more common, however, for women to conform to the existing ethics of society. They may choose to stay home to breastfeed, going out only for short periods of time, or they may introduce bottle feedings to avoid embarrassment or stares in public. Some women are more comfortable nursing in public by placing a baby blanket over baby and breast to hide the nursing activity. There are several clothing companies which specialize in nursing fashions now, allowing nursing mothers to be discreet when nursing an infant openly in public.
Oregon is one of the leading states in the nation in the amount of women breastfeeding exclusively for 3 and 6 months, at over 56% and 26% respectively. Only 25% of mothers in the U.S. continue to breastfeed their children for an entire year, although in Oregon almost 50% are still breastfeeding at 12 months. Oregonians tend to embrace a more natural, outdoorsy lifestyle, which lends itself to feeding children in the most natural and heatlhy manner. Below is a statistical link of interest. http://www.statehealthfacts.org/profileind.jsp?rgn=39&ind=501
Encouraging a woman to follow her heart will be most beneficial in helping her choose the appropriate time and place to nurse her baby. Her milk let-down can be inhibited if her comfort level is compromised. Feeling relaxed during breastfeeding is of utmost importance for continued success.
There is clear scientific evidence now that women who breastfeed their children have a substantially reduced risk of breast cancer both before and after menopause. The more months a woman breastfeeds, the greater the opportunity for mammary health as she ages. Well-designed studies have shown that the protective effect of breastfeeding on breast cancer prevention depends upon nursing an infant more than 6 months. Breastfeeding also reduces a woman's chances of developing ovarian cancer and osteoporosis.