Breastfeeding Basics

Iampassionateabouthelpingwomenachievetheirbreastfeedinggoals,andhelpingthemover-comedifficultyduringtheirjourney.Everyone’sexperienceisveryuniqueandreflectsthevastdiversityofbothboobsandbabies!Itendtofindgeneralknowledgeofhowthebreastworksisnotwellunderstood–notjustbymothers,butevenbyhealthcareprofessionals.Irecentlywroteanarticleforthe“AustralianDoctor”(aresourceforGP’s)onthebasicsofbreastfeeding,andthoughtasummaryofthiswouldbehelpfulforallbreastfeedingmothersormothers-to-be.

AnatomyandPhysiologyoftheLactatingBreast

Thebreastismostlymadeupoftwodifferenttypesoftissue:fatandglandulartissues.Milkismadeandstoredintheglandulartissue.Surprisingly,65%oftheglandulartissueislocatedwithin3cmfromthenipple.iMilkismadeinalveoliandbunchesofalveoliformmilklobules.Thesethenconnecttomilkducts,whichtransportthemilktothenipple.

Surroundingthealveoliaremusclecellscalledmyoepithelialcells.Whenthesecontractaroundthealveoli,itpushesthemilkintothemilkductsandoutofthenipple.Thisiscalledaletdown.Letdownsaretriggeredbythereleaseofahormonecalledoxytocinwhichisreleasedbythebrain.Oxytocinisour“lovehormone”.Itistriggeredbysuckling/stimulationofthenippleandthinkingaboutthebaby.ii

Duringpregnancy,thebreastundergoesgrowthtoprepareforbreastfeeding,undertheinfluenceofourhormones.Prolactinisourmilk-makinghormone.Thiscontinuestoincreaseduringourpregnancy,butwedon’tmakemuchmilkuntiltheplacentaisdelivered.Thisisbecausetheplacentamakesanotherhormonecalledprogesterone,whichstopstheeffectofprolactin.Ourbreastscanmakecolostrumduringourpregnancythough.

Milkusually“comesin”betweendays2-8.Thisiswherethebreastsstarttomakeamuchlargervolumeofmilk,ratherthanjustthecolostrum.Itisthedropinprogesteroneafterdeliveryoftheplacentathattriggersthischange.Fromthere,milkproductionswitchesto“supplyanddemand”(autocrinecontrol):themoremilkthatisremovedfromthebreast,themoremilkthebreastwillmake.Andconversely,whenbreastsarepoorlyemptied,thiswillreducemilkproduction.

BreastMilkCompositionandVolume

Breastmilkcompositionisuniquelytailoredtotheindividualbabyandvariesthroughoutafeed,theday,andthespectrumofthefeedingjourney.Insummary,itcontains:fats(accountingforaroundhalfofitscalories);ahugearrayofproteins(tohelpabsorbnutrientsandassisttheimmunesystem);antibodies(secretoryIgAisparticularlyimportanttofightawiderangeofvirusesandbacteriawhilethebaby’sownimmunesystemismaturing);carbohydrates(mostlylactose);andhumanmilkoligosaccharides(prebioticsthatpreventgutandrespiratoryillnesses)iii.Theideaoffore-milkandhind-milkisnowout-dated;ratherthefatcontentishigherwhenthebreastisemptier;whichisnotjusttowardstheendofafeed,butalsoduringthelaterpartoftheday.ivThereisalwaysfatinmilk,evenatthestartofthefeed.

Breastfeeding Basics

The24-hourvolumeofmilkintakeisquitestablefromtheageof1-6months,althoughthisvolumevariessignificantlybetweenindividualbabies.Theaverageisaround800mlsin24hours,butcanrangefrom480mltoover1.3litres.vMilkvolumeproductionappearstomostlybedrivenbythebaby.Ultrasoundstudieshaveshownnolinkbetweentheamountofglandulartissueandmilkproduction,orstoragecapacity.vi

ExtractionofMilk

Thebabyattachestothebreast,creatingasealwithitsfacearoundthenipple,areolaandsurroundingbreasttissue.Thelipsarenotsoimportantforbreastfeeding.UltrasoundandMRIstudiesofbreastfeedingpairshaveshownthatthelipsusuallysitina“neutral”positionvii(highlightingthattheideaofthelipsneedingtoflangeisout-dated;asistheneedforthe“SpecialK”lips).(REFERENCE).Thebaby’slowerfaceagainstthebreastgeneratesabaselinevacuum.Bydroppingitsjawandtongueasoneunit,itincreasesthevacuumandmilkflowsintotheoralcavity,withthehelpofaletdown.Positioningthebabywithadeepface-breastbury,allowscontinueddrawing-upofthebreasttissueintothebaby’smouth.This,andensuringtheeliminationofanybreasttissuedragbyplacingthefacesymmetricallyaroundthenipple/areola,willleadtoeffectivemilkremoval.Unfortunately,theout-dated“strippingmodel”ofmilkremoval(wherethetongueliftsupandmassagesthebreastusingaperistalticaction),isstillwidelytaught.Throughultrasoundstudies,itisclearthemilkflowswhenthejawandtonguearedown,notup.Theanteriortongueonlyneedstomove3mmforeffectivemilkremoval.viii

PuttingThisAllTogether

Thefirstfewdaysareessentialforsettingupagoodbreastfeedingjourney.Thehormoneprolactinisreleasedinresponsetosuckling,andprolactiniswhatstartsmilkproductionix.Forthisreason,itisreallyimportantthenewbornisfedoften(ideally3hourlyormoreoften).Thiswillalsoprotectagainstlowbloodsugar,excessiveearlyweightlossandjaundiceinthebaby.Frequentfeedingwillalsobringinmum’smilkmorequickly.

Everywomanwillhavedifferentvolumesofstoragecapacity;ratesofmilkproduction;sensitivitytoafullbreast;andtimesformilkletdowntotakeeffect.However,successfulbreastfeedingandmilkproductionismostlydependentonthebabysucklingwellandoftenandregulatedbythebaby’sappetite.xTherecannotbea“onesizefitsallapproach”.Itisnormalforababytofeedbetween8-12timesin24hours.Nightfeedingisnormalandcontributestothe24-hourcalorieneed.xi Eachbabywillfeedforauniquelengthoftime,whichgetsshorterastheygetolder.Somemotherswillonlyneedtoofferonebreastperfeedwhereasotherswillalwaysneedtoofferbothandmostwillhaveamixedpicture(somefeedsthebabywillonlytakeonebreast,andotherfeedsthebabywillneedboth).xiiToensureappropriateongoingmilkproduction,itisessentialthemothercuesintoherbaby’ssucksandswallows.Ababysuckingbutnotswallowingisnottransferringmilk.Ifshehasagenerousmilksupply,advisethemothertoreallysoftenonebreastbeforeofferingthesecond.Ifshehasalowersupply,offering4-6breastsinafeedmaybemoreappropriate.Switchtotheothersidewhenthebabyisnotswallowingoften,orissleepyatthebreast.Thereisnobenefitin

Breastfeeding Basics

extendingthetimebetweenfeedsasthiscanbedetrimentaltosomebreastfeedingpairs.Instead,motherscanofferthebreastfrequentlyandflexiblywheneverthebabyiscueingforit,ratherthanwatchingtheclock.Youcannotoverfeedabreastfedbaby.Inessence,thereisno“normal”patterntobreastfeedingaseachmother-babypairissounique.

iDTRamsay,JCKent,RAHartmann,PEHartmann.“Anatomyofthelactatinghumanbreastredefinedwithultrasoundimaging.”JAnat.2005Jun;206(6);525-534iiLawrenceR&LawrenceR.“Breastfeeding:AGuidefortheMedicalProfessional”.EighthEdition.2016pg352iiiAndresN,KampmannB,MehringLe-DoareK.“Humanbreastmilk:Areviewonitscompostionandbioactivity”.EarlyHumanDevelopment91(2015)629-635ivKentJ,MitoulasL,CreganM,RamsayD,DohertyD,HartmannP.“VolumeandFrequencyofBreastfeedingsandFatContentofBreastMilkThroughouttheDay.”PediatricsVol117,Number3,March2006.e387-e395vKentJ,HepworthA,SherriffJ,CoxD,MitoulasL,HartmannP.“LongitudinalChangesinBreastfeedingPatternsfrom1to6monthsofLactation.”BreastfeedingMedicine.2013August,8(4):401-407viRamsayD,KentJ,HartmannR,HartmannP.“Anatomyofthelactatinghumanbreastredefinedwithultrasoundimaging.”JAnat.2005Jun;206(6);525-534.viiMillsNetal.“Imagingthebreastfeedingswallowing:Pilotstudyusingreal-timeMRI”.LaryngoscopeInvestigativeOtolaryngology.Vol5,Issue3,June2020pages572-579.viiiDoulgasP,GeddesD.“Practice-basedinterpretationofultrasoundstudiesleadsthewaytomoreeffectiveclinicalsupportandlesspharmaceuticalandsurgicalinterventionforbreastfeedinginfants”.Midwifery58(2018)145-155.ixLawrenceR,LawrenceR.“Breastfeeding:AguidefortheMedicalProfession”.Eighthedition.2016.Pg63-71.xRamsayD,KentJ,HartmannR,HartmannP.“Anatomyofthelactatinghumanbreastredefinedwithultrasoundimaging.”JAnat.2005Jun;206(6);525-534.xiKentJC,MitoulasLR,CreganM,RamsayDT,DohertyDA,HarmannPE.“Volumeandfrequencyofbreastfeedingsandfatcontentofbreastmilkthroughouttheday”.Paediatrics.2006Mar;117(3);e387-95.xiiKentJC,MitoulasLR,CreganM,RamsayDT,DohertyDA,HarmannPE.“Volumeandfrequencyofbreastfeedingsandfatcontentofbreastmilkthroughouttheday”.Paediatrics.2006Mar;117(3);e387-95.