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Settling on the right method for breast-feeding

Dr Helen Offman draws on her own experience to offer practical advice on technique – and problems with the lactating breast

In my first days of motherhood I quickly realised I knew very little about breast-feeding. After experiencing many of the difficulties common to new mothers, I learned first-hand the techniques – and some of the pathology – associated with breast-feeding, knowledge I now use regularly in my practice and which gives me great satisfaction.

In addition to the fulfilling emotional experience, research has consistently shown the marked advantages: for the mother a reduction in breast cancer risk, for the baby a reduction in respiratory and gastrointestinal infections, atopy and allergies, advantages which are maintained after the cessation of breast-feeding. Breast milk may have an analgesic effect; some studies have even suggested a positive influence on intelligence.

Poor technique is responsible for many of the difficulties faced by new mothers, who may present with an underweight or irritable infant, painful nipples or recurrent episodes of mastitis. A GP with a thorough understanding of breast-feeding skills can do much to ensure the successful resolution of these problems and to prevent the unnecessary introduction of formula feeds.

Getting started

Breast-feeding for the first time is often a source of anxiety. Simple advice on correct latching-on and positioning may make the difference between success and failure.

The mother should have a comfortable chair with good back support. The baby, positioned so that the nose and umbilicus are facing in the same direction, should be brought to the breast.

If correctly latched on the baby's lips should be rolled back, chin touching the breast and the majority of the areola, not just the nipple, drawn into its mouth.

Timing feeds

The optimal way to establish a sufficient milk supply is feeding on demand, rather than 'trying to get the baby on a schedule'.

Every baby has its own feeding pattern: some will be satisfied after five minutes, others after 20: not all feeds will be the same length. Breastmilk is absorbed rapidly so that feeding intervals may be as little as 90 minutes.

The breast produces milk in response to demand, so removing the baby after a predetermined time, or prolonging intervals between feeds to fit the clock, is likely to result in an inadequate supply.

Growth spurts and patterns

At three-four, five-six and 10-12 weeks babies undergo growth spurts that are often characterised by incessant feeding for a few days. Advance warning or reassurance that this is quite normal is very helpful. These periods are followed by a greatly increased milk supply and obvious weight gain in the baby.

A breast-fed baby may take up to two weeks to return to the original birthweight. Weight gain tends to be less consistent than in bottle-fed babies, varying from week to week.

Is the baby getting enough?

Five or six wet nappies each day usually indicates adequate milk supply. Stools, however, may appear only once a fortnight. As weight gain is variable it should be assessed over a number of weeks. Test feeding (weighing the baby before and after feeds) is a potent source of anxiety, itself an inhibitor of milk production.

Problems in the lactating breast

lEngorgement

Commonly arising on the third day after birth it can be partly relieved by a firm supportive bra, ice packs or refrigerated whole cabbage leaves, and analgesia.

lPainful, fissured nipples

Very common in the first weeks – poor positioning or incorrect latching on is usually the cause if this persists. A fissure may act as a portal of entry for bacteria. Silicon nipple shields can be used for a few days to protect the nipples and allow them to heal. Vitamin E cream applied after feeds is also useful.

lPainful breasts

Nipple and breast pain occurring during, and persisting after feeding – often described as 'shooting' or 'stabbing' – is usually due to candidal infection. The telltale white patches may be seen in the baby's mouth. Mother and baby need simultaneous treatment for about two weeks. The mother should keep the nipples dry after feeds, avoiding the use of breast pads. Miconazole cream should be applied to the nipple after each feed, and rinsed off before the next.

Similarly, miconazole oral gel should be applied to the baby's mouth after feeding.

lA red patch

Blockage in one of the milk ducts results in breast milk leaking into the breast tissue, causing an inflammatory reaction. On examination a red, indurated patch is usually evident.

The block may sometimes be relieved by applying a warm compress over the area and massaging from above the site of the block down towards the nipple during a feed: the mother should be advised to continue feeding from the affected side.

Repositioning the baby to ensure more adequate emptying of the affected duct may be necessary. Failure to relieve the block results in mastitis.

lMastitis

Mastitis occurs as a result of an unrelieved blocked duct, or the entry of bacteria through a fissured nipple. The usual pathogen is staphylococcus aureus. The appearance of an erythematous, indurated painful wedge-shaped area on the breast is usually preceded by fever and flu-like symptoms. It is extremely important to continue feeding from the affected breast, to reduce the risk of abscess formation. Rest, adequate fluid intake and a 10-day course of co-amoxiclav are indicated.

lBreast abscess

Continuing pain after mastitis, brawny swelling and a lump are suggestive of breast abscess warranting surgical referral.

lGalactocoele

A firm, rounded swelling, usually decreasing in size after a feed, is characteristic of galactocoele. The diagnosis is confirmed by needle aspiration of milk followed by a reduction in the size of the lump.

lLactating adenoma

A rapidly enlarging, firm, often multilobular swelling in the lactating breast suggests this diagnosis. Fibroadenomas and even carcinomas may also be found in the lactating breast: all lumps should be referred for surgical evaluation.

Helen Offman trained in Liverpool and qualified in 1987 – after a stint as a GP in London she moved to Israel to a neighborhood where the average family has seven-eight children

Useful websites

La Leche League at

www.lalecheleague.org

National Childbirth Trust at www.nctpregnancyandbabycare.com

American Academy of Paediatrics at www.aap.org/family

(see new mother's guide to breast-feeding)

Reference

The Year After Childbirth

by Sheila Kitzinger has an excellent chapter on breast-feeding

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