This year’s World Breastfeeding Week (Aug 1-7, 2022) had the theme “Step Up for Breastfeeding: Educate and Support” to elevate public awareness and importance.
Breastfeeding, one of the most significant bodily functions, has sadly been stigmatised or deprioritised throughout history due to its nature.
According to the World Health Organization (WHO) and United Nations Children’s Fund (Unicef), exclusive breastfeeding for the first six months of life, and complementary food introduction with continuous breastfeeding until at least two years of age, is recommended.
However, many children in infancy are deprived of this optimal feeding method.
Globally, only 44% of infants were exclusively breastfed up to six months for the period of 2015 to 2020.
In Malaysia, the rate of exclusive breastfeeding was 47.1% for the first six months of life, according to the latest national data.
The lives of over 820,000 children under five years of age could be saved worldwide every year if they were optimally breastfed from 0 to 23 months of age.
Benefiting mother and child
Breast milk is the optimal source of nutrition naturally designed to suit an infant’s need.
It provides the newborn with antibodies, micro- and macronutrients, and growth factors, to enhance immunity against infections and promote the proper growth and development of the newborn.
Studies have shown that there is less likelihood of childhood infections related to the digestive tract, respiratory tract and ear in breastfed infants.
Furthermore, breastfeeding offers protection against allergic conditions of the respiratory tract and skin (atopic dermatitis).
Based on recent studies, other potential benefits include lowered risk of childhood blood cancer (leukaemia), high blood pressure (hypertension), childhood obesity and sudden infant death syndrome (SIDS).
The protective effect also extends to adulthood as a prolonged duration of breastfeeding can reduce the risk of adult obesity and diabetes.
Following childbirth, early initiation of breastfeeding (within the first hour) helps in decreasing maternal blood loss as it stimulates the release of a hormone that triggers the uterus to contract and revert to normal.
The most crucial benefit is that it facilitates bonding of the mother and her newborn with skin-to-skin contact, and promotes psychological well-being by reducing maternal anxiety and depression.
There are two major hormones that play a crucial role in breastfeeding: prolactin and oxytocin.
Both hormones are secreted by the brain in response to breast stimulation via infant suckling or expressing the milk manually or via a breast pump.
Prolactin is mainly responsible for milk production by the mammary glands, while oxytocin helps the ejection/release of milk from the mammary glands to the milk ducts (let-down or milk ejection reflex).
The more the breast is stimulated by frequent feeds or pumping, the more is the milk production.
This will help with establishing lactation.
Prolactin also makes mother feel relaxed and sleepy, so that she can usually rest well even if she breastfeeds at night.
Oxytocin is also known as the mothering, bonding, love or anti-stress hormone, and is a powerful mood enhancer in reducing stress and making mother feel good.
Other than suckling, oxytocin can also be conditioned to be released from seeing, touching, smelling, hearing and thinking about the baby, as well as the sight, sound and smell of the breast pump if mother pumps regularly.
However, stress, illness, pain, anxiety, fatigue, smoking and drinking alcohol can inhibit oxytocin release and interfere with milk letdown.
The dual hormones work as a team to regulate breastfeeding and uplift the mental health of mother despite the sleep deprivation related to nighttime feeding.
Exclusive breastfeeding also causes cessation of the menses (lactational amenorrhoea) and confers a contraceptive effect during the first six months.
In addition, it aids in losing excess maternal weight gained during pregnancy.
In the long run, breastfeeding reduces the risk of breast cancer, ovarian cancer, obesity, diabetes, high blood pressure, lipid abnormalities (hyperlipidaemia) and heart disease.
Not drinking enough milk
Although exclusive breastfeeding is recommended for the first six months of the baby’s life, there are many problems that can interfere with, and stop, breastfeeding.
These obstacles can be overcome with proper guidance and support to encourage continuous breastfeeding for a longer period.
One common concern is inadequate milk intake.
This can be identified if baby does not gain weight or has signs of dehydration.
Inadequate intake can be due to inadequate milk production or poor milk extraction.
Inadequate milk production is mostly caused by infrequent breastfeeding, or if the child is also formula-fed.
Rare causes include breast reduction surgery or radiation, hormonal imbalance, or medications that interfere with milk production.
However, breast augmentation surgery or breast implants usually do not affect milk production.
Poor milk extraction is common in premature babies or babies with medical conditions like Down syndrome, tongue-tie (ankyloglossia) or mouth abnormalities.
Inadequate milk intake can be assessed through a proper evaluation of mother and baby with detailed medical history, physical examination and observation of breastfeeding.
A mother’s milk production can be improved by proper education to breastfeed frequently, or to empty the breast manually or by pumping.
This stimulates the breasts to produce more milk.
The role of medications (galactagogues) or herbal supplements to increase milk production is unclear as safety or efficacy is not well studied.
Children with a tongue-tie may need a surgical procedure in order to allow them to latch onto the nipple effectively and to prevent nipple injury, which can worsen milk intake.
Preventing nipple pain
The common causes of nipple pain are incorrect breastfeeding technique, flat or inverted nipples, the baby having a tongue-tie or other mouth anomalies, infections, and blood vessel constriction (vasospasm).
The infant should first be examined for tongue-tie and mouth anomalies that may affect latching onto the breast.
The mother’s nipples and breasts should be examined for signs of injury, infection (e.g. cellulitis, mastitis and breast abscess), skin problems (e.g. dermatitis and fungal infection) or engorgement (where the breast is overly enlarged due to storing too much milk).
The LATCH (latch, audible swallowing, type of nipple, comfort of mother, help required) score is used to assess an adequate latch.
An adequate latch can be achieved with an optimised breastfeeding technique (i.e. comfortable maternal position and proper infant position).
It will also reduce breastfeeding pain.
This can be demonstrated by healthcare providers using videos and simulation.
Aside from using correct breastfeeding techniques, nipple injury can also be prevented by:
- Keeping nipples dry and allowing them to air-dry after breastfeeding.
- Avoiding harsh soaps or cleansers on the breasts, which can irritate the skin.
- Proper positioning of baby to avoid biting.
For mothers with cracked nipples, the application of lanolin on the affected area can aid with healing.
These mothers should start breastfeeding with the normal breast first, then wipe off the cream on the cracked nipple before commencing feeding with that breast.
An inflamed breast
Mastitis is an inflammation of the breast that presents with pain, redness, warmth and swelling.
It can also cause fever, chills and flu-like symptoms.
Infective mastitis is commonly caused by the bacteria Staphylococcus sp.
However, mastitis is not always caused by an infection.
Mastitis can occur at any time in two to 10% of lactating mothers.
However, it is most common in the first six weeks after birth.
The following are the risk factors for mastitis:
- Infrequent feeding
- Unrelieved engorgement of breasts
- Oversupply of milk
- Poor latching
- Ineffective suckling (usually with a premature baby)
- Plugged mammary ducts
- Blocked nipple pore
- Cracked or damaged nipple, and
- Pressure on the breast that restricts milk flow (e.g. tight bras or clothing).
Frequent feeding to empty the breasts is advised.
If baby is unable to feed, then a breast pump can be used.
The blocked area should be massaged towards the nipple.
Application of warm compresses can facilitate milk let-down.
Feeding should be started on the affected breast first.
If it is too painful, then start on the unaffected breast and switch to affected breast once milk let-down occurs.
Application of cold compresses or ice packs after breastfeeding can help relieve pain.
Pain medications like acetaminophen or ibuprofen can also be prescribed.
If there is no improvement after 24 hours, antibiotics should be started.
Apart from this, lactating mothers should have adequate rest, plenty of fluids and a well-balanced diet.
Partners and other family members have a significant role in helping with household chores and in reducing stress.
Other possible issues
Bloody nipple discharge can occur during the first few days of lactation and is more common with the first pregnancy.
It is due to increased blood flow to the breasts and ducts when milk production starts.
The colour varies from pink to red or brown.
It usually clears by the first week after birth and is called rusty pipe syndrome.
Rarely, a milk-filled cyst (galactocele) can be caused by blocked milk ducts.
It is painless unless infected and may need to be drained.
If there is a persistent breast lump, further assessment is needed to exclude breast cancer, which can also develop during lactation.
Challenges for working mothers
Mothers who are full-time staff usually have paid maternity leave for three months.
After that, they often find it challenging to continue breastfeeding with their work commitments.
However, this depends on the attitude and knowledge of the mother towards breastfeeding, previous breastfeeding experience, and support by their partner, family, employer and healthcare team.
Manual expression and pumping are almost as good as breastfeeding and are an excellent alternative option when mother has to return to work, if baby is separated from mother (because they are preterm or sick), or if mother needs to take a break from breastfeeding.
Workplace related barriers vary by occupation.
Professional women have greater success in breastfeeding because of more autonomy, privacy and freedom, compared to non-professional women.
Research has shown that working mothers experience three main challenges in continuing breastfeeding:
- Insufficient milk
- Nipple or breast pain during breastfeeding, and
- Inverted nipples.
The perception of inadequate milk can be overcome by education, support and reassurance.
Flexible working hours, facilities for breast milk pumping and appropriate storage, practical lactational support, and encouragement by society, all have a positive impact on the breastfeeding practices of working mothers.
Stress due to work-life imbalance (e.g. workplace conflict, household chores, care of other children, role of wife) has negative influence on the breastfeeding hormones and can affect both mother and baby.
Sleep deprivation can lead to tiredness during the day, and problems in concentrating and decision-making, especially in working mothers.
Excessively stressful situations might trigger depression unless appropriate guidance and support is in place.
Partner/family support is vital to fight stress by sharing infant care (e.g. expressed milk feeding, burping, bathing, diaper changing, carrying); helping with house chores, including the caring of other children; being patient and accepting mother’s hormonal and emotional changes; and ensuring she gets enough rest and eats healthily.
Promoting breastfeeding
Below are some of the strategies that help promote the initiation and continuation of breastfeeding:
- Breastfeeding awareness and education during antenatal clinics
- Involvement of the partner in breastfeeding practice sessions
- Mother-baby skin-to-skin contact at birth
- Early initiation of breastfeeding
- Rooming-in
- Lactation support
- The Baby Friendly Hospital Initiative (BFHI)
- Professional face-to-face support
- New policies for breastfeeding support at the workplace, and
- Investment in breastfeeding promotion.
These interventions pave the foundation for the child’s future health and well-being.
WHO and Unicef emphasise that breastfeeding plays a critical role in achieving many of the Sustainable Development Goals (SDGs), advocating that it improves nutrition (SDG2), prevents child death and decreases the risk of non-communicable diseases (SDG3), and supports cognitive development and education (SDG4).
ALSO READ: Is Malaysia on track to achieving the third Sustainable Development Goal?
Breastfeeding also contributes towards ending poverty, promoting economic growth and reducing gender inequalities.
In a nutshell, breastfeeding is the smartest global investment families, communities and countries can make in improving the health of women, children and adolescents.
Dr Anitha Ponnupillai is a senior lecturer of obstetrics and gynaecology at Taylor’s University’s School of Medicine. For more information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only, and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this article. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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