2.THE PHYSIOLOGICAL BASIS OF BREASTFEEDING 11 FIGURE3 FIGURE4 Anatomy of the breast Prolactin Muscle cells 了Oxytocin makes them contract Sensory impulses Milk-secreting cells Prolactin makes from nipples L them secrete milk Prolactin Ducts in blood Larger ducts Nipple Baby suckling More prolactin secreted at night Areola Suppresses Montgomery 's glands ovulation Alveoli Supporting tissue and fat Secreted after feed to produce next feed 2.5 Hormonal control of milk production More prolactin is produced at night,so breastfeeding There are two hormones that directly affect breast- at night is especially helpful for keeping up the milk feeding:prolactin and oxytocin.A number of other supply.Prolactin seems to make a mother feel relaxed hormones,such as oestrogen,are involved indirectly in and sleepy,so she usually rests well even if she breast- lactation(2).Whena baby suckles at the breast,sensory feeds at night. impulses pass from the nipple to the brain.In response, Suckling affects the release of other pituitary hor- the anterior lobe of the pituitary gland secretes prolac- mones,including gonadotrophin releasing hormone tin and the posterior lobe secretes oxytocin. (GnRH),follicle stimulating hormone,andluteinising hormone,which results in suppression of ovulation Prolactin and menstruation.Therefore,frequent breastfeeding Prolactin is necessary for the secretion of milk by the can help to delay a new pregnancy(see Session 8 on cells of the alveoli.The level of prolactin in the blood Mother's Health).Breastfeeding at night is important increases markedly during pregnancy,and stimulates to ensure this effect. the growth and development of the mammary tissue, in preparation for the production of milk(19).How- Oxytocin ever,milk is not secreted then,because progesterone Oxytocin makes the myoepithelial cells around the and oestrogen,the hormones of pregnancy,block this alveoli contract.This makes the milk,which has col- action of prolactin.After delivery,levels of progester- lected in the alveoli,flow along and fill the ducts(21) one and oestrogen fall rapidly,prolactin is no longer (see Figure 5).Sometimes the milk is ejected in fine blocked,and milk secretion begins. streams. When a baby suckles,the level of prolactin in the FIGURE 5 blood increases,and stimulates production of milk Oxytocin by the alveoli(Figure 4).The prolactin level is highest about 30 minutes after the beginning of the feed,so its most important effect is to make milk for the next Sensory impulses feed(20).During the first few weeks,the more a baby from nipples suckles and stimulates the nipple,the more prolac- Oxytocin tin is produced,and the more milk is produced.This in blood effect is particularly important at the time when lac- tation is becoming established.Although prolactin is still necessary for milk production,after a few weeks Baby suckling there is not a close relationship between the amount Makes uterus contract of prolactin and the amount of milk produced.How- ever,if the mother stops breastfeeding,milk secretion may stop too-then the milk will dry up. Works before or during a feed to make the milk flow
2. The physiological basis of breastfeeding 11 2.5 Hormonal control of milk production There are two hormones that directly affect breastfeeding: prolactin and oxytocin. A number of other hormones, such as oestrogen, are involved indirectly in lactation (2). When a baby suckles at the breast, sensory impulses pass from the nipple to the brain. In response, the anterior lobe of the pituitary gland secretes prolactin and the posterior lobe secretes oxytocin. Prolactin Prolactin is necessary for the secretion of milk by the cells of the alveoli. The level of prolactin in the blood increases markedly during pregnancy, and stimulates the growth and development of the mammary tissue, in preparation for the production of milk (19). However, milk is not secreted then, because progesterone and oestrogen, the hormones of pregnancy, block this action of prolactin. After delivery, levels of progesterone and oestrogen fall rapidly, prolactin is no longer blocked, and milk secretion begins. When a baby suckles, the level of prolactin in the blood increases, and stimulates production of milk by the alveoli (Figure 4). The prolactin level is highest about 30 minutes after the beginning of the feed, so its most important effect is to make milk for the next feed (20). During the first few weeks, the more a baby suckles and stimulates the nipple, the more prolactin is produced, and the more milk is produced. This effect is particularly important at the time when lactation is becoming established. Although prolactin is still necessary for milk production, after a few weeks there is not a close relationship between the amount of prolactin and the amount of milk produced. However, if the mother stops breastfeeding, milk secretion may stop too – then the milk will dry up. More prolactin is produced at night, so breastfeeding at night is especially helpful for keeping up the milk supply. Prolactin seems to make a mother feel relaxed and sleepy, so she usually rests well even if she breastfeeds at night. Suckling affects the release of other pituitary hormones, including gonadotrophin releasing hormone (GnRH), follicle stimulating hormone, and luteinising hormone, which results in suppression of ovulation and menstruation. Therefore, frequent breastfeeding can help to delay a new pregnancy (see Session 8 on Mother’s Health). Breastfeeding at night is important to ensure this effect. Oxytocin Oxytocin makes the myoepithelial cells around the alveoli contract. This makes the milk, which has collected in the alveoli, flow along and fill the ducts (21) (see Figure 5). Sometimes the milk is ejected in fine streams. Figure 3 Anatomy of the breast Figure 4 Prolactin Secreted after feed to produce next feed Prolactin in blood Baby suckling Sensory impulses from nipples • More prolactin secreted at night • Suppresses ovulation Works before or during a feed to make the milk flow Figure 5 Oxytocin Oxytocin in blood Baby suckling Sensory impulses from nipples • Makes uterus contract
12 INFANT AND YOUNG CHILD FEEDING-MODEL CHAPTER FOR TEXTBOOKS The oxytocin reflex is also sometimes called the"let- Psychological effects of oxytocin down reflex'”or the“milk ejection reflex”.Oxytocin Oxytocin also has important psychological effects, is produced more quickly than prolactin.It makes the and is known to affect mothering behaviour in ani- milk that is already in the breast flow for the current mals.In humans,oxytocin induces a state of calm, feed,and helps the baby to get the milk easily. and reduces stress(22).It may enhance feelings of Oxytocin starts working when a mother expects a affection between mother and child,and promote feed as well as when the baby is suckling.The reflex bonding.Pleasant forms of touch stimulate the secre- becomes conditioned to the mother's sensations and tion of oxytocin,and also prolactin,and skin-to-skin feelings,such as touching,smelling or seeing her baby, contact between mother and baby after delivery helps or hearing her baby cry,or thinking lovingly about both breastfeeding and emotional bonding(23,24). him or her.If a mother is in severe pain or emotion- ally upset,the oxytocin reflex may become inhibited, 2.6 Feedback inhibitor of lactation and her milk may suddenly stop flowing well.If she Milk production is also controlled in the breast by a receives support,is helped to feel comfortable and lets substance called the feedback inhibitor of lactation,or the baby continue to breastfeed,the milk will flow FIL(a polypeptide),which is present in breast milk again. (25).Sometimes one breast stops making milk while Understanding the oxytocin reflex is important in the other breast continues,for example if a baby suck- practice,because it explains why it is important to les only on one side.This is because of the local con- keep a mother and baby together and for them to have trol of milk production independently within each skin-to-skin contact,to help the flow of milk. breast.If milk is not removed,the inhibitor collects and stops the cells from secreting any more,helping Oxytocin makes a mother's uterus contract after to protect the breast from the harmful effects of being delivery and helps to reduce bleeding.The contrac- too full.If breast milk is removed the inhibitor is also tions can cause severe uterine pain when a baby suck- removed,and secretion resumes.If the baby cannot les during the first few days. suckle,then milk must be removed by expression. Signs of an active oxytocin reflex FIL enables the amount of milk produced to be deter- mined by how much the baby takes,and therefore Mothers may notice signs that show that the oxytocin by how much the baby needs.This mechanism is reflex is active: particularly important for ongoing close regulation a tingling sensation in the breast before or during a after lactation is established.At this stage,prolactin feed; is needed to enable milk secretion to take place,but it milk flowing from her breasts when she thinks of does not control the amount of milk produced. the baby or hears him crying; 2.7 Reflexes in the baby milk flowing from the other breast when the baby The baby's reflexes are important for appropriate is suckling; breastfeeding.The main reflexes are rooting,suckling milk flowing from the breast in streams if suckling and swallowing.When something touches a baby's is interrupted; lips or cheek,the baby turns to find the stimulus,and slow deep sucks and swallowing by the baby,which opens his or her mouth,putting his or her tongue show that milk is flowing into his mouth; down and forward.This is the rooting reflex and is present from about the 32nd week of pregnancy. uterine pain or a flow of blood from the uterus; When something touches a baby's palate,he or she ■thirst during a feed. starts to suck it.This is the sucking reflex.When the baby's mouth fills with milk,he or she swallows.This If one or more of these signs are present,the reflex is the swallowing reflex.Preterm infants can grasp is working.However,if they are not present,it does the nipple from about 28 weeks gestational age,and not mean that the reflex is not active.The signs may they can suckle and remove some milk from about not be obvious,and the mother may not be aware of 31 weeks.Coordination of suckling,swallowing and them. breathing appears between 32 and 35 weeks of preg- nancy.Infants can only suckle for a short time at that
12 Infant and Young Child Feeding – Model Chapter for textbooks The oxytocin reflex is also sometimes called the “letdown reflex” or the “milk ejection reflex”. Oxytocin is produced more quickly than prolactin. It makes the milk that is already in the breast flow for the current feed, and helps the baby to get the milk easily. Oxytocin starts working when a mother expects a feed as well as when the baby is suckling. The reflex becomes conditioned to the mother’s sensations and feelings, such as touching, smelling or seeing her baby, or hearing her baby cry, or thinking lovingly about him or her. If a mother is in severe pain or emotionally upset, the oxytocin reflex may become inhibited, and her milk may suddenly stop flowing well. If she receives support, is helped to feel comfortable and lets the baby continue to breastfeed, the milk will flow again. Understanding the oxytocin reflex is important in practice, because it explains why it is important to keep a mother and baby together and for them to have skin-to-skin contact, to help the flow of milk. Oxytocin makes a mother’s uterus contract after delivery and helps to reduce bleeding. The contractions can cause severe uterine pain when a baby suckles during the first few days. Signs of an active oxytocin reflex Mothers may notice signs that show that the oxytocin reflex is active: K a tingling sensation in the breast before or during a feed; K milk flowing from her breasts when she thinks of the baby or hears him crying; K milk flowing from the other breast when the baby is suckling; K milk flowing from the breast in streams if suckling is interrupted; K slow deep sucks and swallowing by the baby, which show that milk is flowing into his mouth; K uterine pain or a flow of blood from the uterus; K thirst during a feed. If one or more of these signs are present, the reflex is working. However, if they are not present, it does not mean that the reflex is not active. The signs may not be obvious, and the mother may not be aware of them. Psychological effects of oxytocin Oxytocin also has important psychological effects, and is known to affect mothering behaviour in animals. In humans, oxytocin induces a state of calm, and reduces stress (22). It may enhance feelings of affection between mother and child, and promote bonding. Pleasant forms of touch stimulate the secretion of oxytocin, and also prolactin, and skin-to-skin contact between mother and baby after delivery helps both breastfeeding and emotional bonding (23,24). 2.6 Feedback inhibitor of lactation Milk production is also controlled in the breast by a substance called the feedback inhibitor of lactation, or FIL (a polypeptide), which is present in breast milk (25). Sometimes one breast stops making milk while the other breast continues, for example if a baby suckles only on one side. This is because of the local control of milk production independently within each breast. If milk is not removed, the inhibitor collects and stops the cells from secreting any more, helping to protect the breast from the harmful effects of being too full. If breast milk is removed the inhibitor is also removed, and secretion resumes. If the baby cannot suckle, then milk must be removed by expression. FIL enables the amount of milk produced to be determined by how much the baby takes, and therefore by how much the baby needs. This mechanism is particularly important for ongoing close regulation after lactation is established. At this stage, prolactin is needed to enable milk secretion to take place, but it does not control the amount of milk produced. 2.7 Reflexes in the baby The baby’s reflexes are important for appropriate breastfeeding. The main reflexes are rooting, suckling and swallowing. When something touches a baby’s lips or cheek, the baby turns to find the stimulus, and opens his or her mouth, putting his or her tongue down and forward. This is the rooting reflex and is present from about the 32nd week of pregnancy. When something touches a baby’s palate, he or she starts to suck it. This is the sucking reflex. When the baby’s mouth fills with milk, he or she swallows. This is the swallowing reflex. Preterm infants can grasp the nipple from about 28 weeks gestational age, and they can suckle and remove some milk from about 31 weeks. Coordination of suckling, swallowing and breathing appears between 32 and 35 weeks of pregnancy. Infants can only suckle for a short time at that
2.THE PHYSIOLOGICAL BASIS OF BREASTFEEDING 13 age,but they can take supplementary feeds by cup. the baby is suckling from the breast,not from the A majority of infants can breastfeed fully at a gesta- nipple. tional age of 36 weeks(26). As the baby suckles,a wave passes along the tongue When supporting a mother and baby to initiate and from front to back,pressing the teat against the hard establish exclusive breastfeeding,it is important to palate,and pressing milk out of the sinuses into the know about these reflexes,as their level of maturation baby's mouth from where he or she swallows it.The will guide whether an infant can breastfeed directly baby uses suction mainly to stretch out the breast tis- or temporarily requires another feeding method. sue and to hold it in his or her mouth.The oxytocin reflex makes the breast milk flow along the ducts, 2.8 How a baby attaches and suckles at the breast and the action of the baby's tongue presses the milk To stimulate the nipple and remove milk from the from the ducts into the baby's mouth.When a baby breast,and to ensure an adequate supply and a good is well attached his mouth and tongue do not rub or flow of milk,a baby needs to be well attached so traumatise the skin of the nipple and areola.Suckling that he or she can suckle effectively (27).Difficulties is comfortable and often pleasurable for the mother. often occur because a baby does not take the breast She does not feel pain. into his or her mouth properly,and so cannot suckle effectively. Poor attachment Figure 7 shows what happens in the mouth when a FIGURE6 baby is not well attached at the breast. Good attachment-inside the infant's mouth The points to notice are: only the nipple is in the baby's mouth,not the underlying breast tissue or ducts; the baby's tongue is back inside his or her mouth, and cannot reach the ducts to press on them. Suckling with poor attachment may be uncomfort- able or painful for the mother,and may damage the skin of the nipple and areola,causing sore nipples and fissures (or "cracks").Poor attachment is the com- monest and most important cause of sore nipples(see Session 7.6),and may result in inefficient removal of milk and apparent low supply. FIGURE 7 Good attachment Poor attachment-inside the infant's mouth Figure 6 shows how a baby takes the breast into his or her mouth to suckle effectively.This baby is well attached to the breast. The points to notice are: much of the areola and the tissues underneath it,including the larger ducts,are in the baby's mouth; the breast is stretched out to form a long 'teat',but the nipple only forms about one third of the'teat'; the baby's tongue is forward over the lower gums, beneath the milk ducts(the baby's tongue is in fact cupped around the sides of the'teat',but a drawing cannot show this);
13 age, but they can take supplementary feeds by cup. A majority of infants can breastfeed fully at a gestational age of 36 weeks (26). When supporting a mother and baby to initiate and establish exclusive breastfeeding, it is important to know about these reflexes, as their level of maturation will guide whether an infant can breastfeed directly or temporarily requires another feeding method. 2.8 How a baby attaches and suckles at the breast To stimulate the nipple and remove milk from the breast, and to ensure an adequate supply and a good flow of milk, a baby needs to be well attached so that he or she can suckle effectively (27). Difficulties often occur because a baby does not take the breast into his or her mouth properly, and so cannot suckle effectively. K the baby is suckling from the breast, not from the nipple. As the baby suckles, a wave passes along the tongue from front to back, pressing the teat against the hard palate, and pressing milk out of the sinuses into the baby’s mouth from where he or she swallows it. The baby uses suction mainly to stretch out the breast tissue and to hold it in his or her mouth. The oxytocin reflex makes the breast milk flow along the ducts, and the action of the baby’s tongue presses the milk from the ducts into the baby’s mouth. When a baby is well attached his mouth and tongue do not rub or traumatise the skin of the nipple and areola. Suckling is comfortable and often pleasurable for the mother. She does not feel pain. Poor attachment Figure 7 shows what happens in the mouth when a baby is not well attached at the breast. The points to notice are: K only the nipple is in the baby’s mouth, not the underlying breast tissue or ducts; K the baby’s tongue is back inside his or her mouth, and cannot reach the ducts to press on them. Suckling with poor attachment may be uncomfortable or painful for the mother, and may damage the skin of the nipple and areola, causing sore nipples and fissures (or “cracks”). Poor attachment is the commonest and most important cause of sore nipples (see Session 7.6), and may result in inefficient removal of milk and apparent low supply. 2. The physiological basis of breastfeeding Figure 6 Good attachment – inside the infant’s mouth Good attachment Figure 6 shows how a baby takes the breast into his or her mouth to suckle effectively. This baby is well attached to the breast. The points to notice are: K much of the areola and the tissues underneath it, including the larger ducts, are in the baby’s mouth; K the breast is stretched out to form a long ‘teat’, but the nipple only forms about one third of the ‘teat’; K the baby’s tongue is forward over the lower gums, beneath the milk ducts (the baby’s tongue is in fact cupped around the sides of the ‘teat’, but a drawing cannot show this); Figure 7 Poor attachment – inside the infant’s mouth
14 INFANT AND YOUNG CHILD FEEDING-MODEL CHAPTER FOR TEXTBOOKS FIGURE8 Sometimes much of the areola is outside the baby's Good and poor attachment-external signs mouth,but by itself this is not a reliable sign of poor attachment.Some women have very big areolas, which cannot all be taken into the baby's mouth. If the amount of areola above and below the baby's mouth is equal,or if there is more below the lower lip, these are more reliable signs of poor attachment than 4 the total amount outside 2.9 Effective suckling If a baby is well attached at the breast,then he or she can suckle effectively.Signs of effective suckling indi- Signs of good and poor attachment cate that milk is flowing into the baby's mouth.The Figure 8 shows the four most important signs of good baby takes slow,deep suckles followed by a visible or and poor attachment from the outside.These signs audible swallow about once per second.Sometimes can be used to decide if a mother and baby need help. the baby pauses for a few seconds,allowing the ducts The four signs of good attachment are: to fill up with milk again.When the baby starts suck- ling again,he or she may suckle quickly a few times, more of the areola is visible above the baby's top lip stimulating milk flow,and then the slow deep suckles than below the lower lip; begin.The baby's cheeks remain rounded during the the baby's mouth is wide open; feed. the baby's lower lip is curled outwards; Towards the end ofa feed,suckling usually slows down, with fewer deep suckles and longer pauses between the baby's chin is touching or almost touching the them.This is the time when the volume of milk is breast. less,but as it is fat-rich hindmilk,it is important for These signs show that the baby is close to the breast, the feed to continue.When the baby is satisfied,he and opening his or her mouth to take in plenty of or she usually releases the breast spontaneously.The breast.The areola sign shows that the baby is taking nipple may look stretched out for a second or two,but the breast and nipple from below,enabling the nipple it quickly returns to its resting form. to touch the baby's palate,and his or her tongue to reach well underneath the breast tissue,and to press Signs of ineffective suckling on the ducts.All four signs need to be present to show A baby who is poorly attached is likely to suckle inef- that a baby is well attached.In addition,suckling fectively.He or she may suckle quickly all the time, should be comfortable for the mother. without swallowing,and the cheeks may be drawn in The signs of poor attachment are: as he or she suckles showing that milk is not flow- ing well into the baby's mouth.When the baby stops more of the areola is visible below the baby's bot- feeding,the nipple may stay stretched out,and look tom lip than above the top lip -or the amounts squashed from side to side,with a pressure line across above and below are equal; the tip,showing that the nipple is being damaged by the baby's mouth is not wide open; incorrect suction. the baby's lower lip points forward or is turned Consequences of ineffective suckling inwards; When a baby suckles ineffectively,transfer of milk the baby's chin is away from the breast. from mother to baby is inefficient.As a result: If any one of these signs is present,or if suckling is the breast may become engorged,or may develop a painful or uncomfortable,attachment needs to be blocked duct or mastitis because not enough milk improved.However,when a baby is very close to the is removed; breast,it can be difficult to see what is happening to the lower lip. the baby's intake of breast milk may be insufficient, resulting in poor weight gain;
14 Infant and Young Child Feeding – Model Chapter for textbooks Signs of good and poor attachment Figure 8 shows the four most important signs of good and poor attachment from the outside. These signs can be used to decide if a mother and baby need help. The four signs of good attachment are: K more of the areola is visible above the baby’s top lip than below the lower lip; K the baby’s mouth is wide open; K the baby’s lower lip is curled outwards; K the baby’s chin is touching or almost touching the breast. These signs show that the baby is close to the breast, and opening his or her mouth to take in plenty of breast. The areola sign shows that the baby is taking the breast and nipple from below, enabling the nipple to touch the baby’s palate, and his or her tongue to reach well underneath the breast tissue, and to press on the ducts. All four signs need to be present to show that a baby is well attached. In addition, suckling should be comfortable for the mother. The signs of poor attachment are: K more of the areola is visible below the baby’s bottom lip than above the top lip – or the amounts above and below are equal; K the baby’s mouth is not wide open; K the baby’s lower lip points forward or is turned inwards; K the baby’s chin is away from the breast. If any one of these signs is present, or if suckling is painful or uncomfortable, attachment needs to be improved. However, when a baby is very close to the breast, it can be difficult to see what is happening to the lower lip. Sometimes much of the areola is outside the baby’s mouth, but by itself this is not a reliable sign of poor attachment. Some women have very big areolas, which cannot all be taken into the baby’s mouth. If the amount of areola above and below the baby’s mouth is equal, or if there is more below the lower lip, these are more reliable signs of poor attachment than the total amount outside. 2.9 Effective suckling If a baby is well attached at the breast, then he or she can suckle effectively. Signs of effective suckling indicate that milk is flowing into the baby’s mouth. The baby takes slow, deep suckles followed by a visible or audible swallow about once per second. Sometimes the baby pauses for a few seconds, allowing the ducts to fill up with milk again. When the baby starts suckling again, he or she may suckle quickly a few times, stimulating milk flow, and then the slow deep suckles begin. The baby’s cheeks remain rounded during the feed. Towards the end of a feed, suckling usually slows down, with fewer deep suckles and longer pauses between them. This is the time when the volume of milk is less, but as it is fat-rich hindmilk, it is important for the feed to continue. When the baby is satisfied, he or she usually releases the breast spontaneously. The nipple may look stretched out for a second or two, but it quickly returns to its resting form. Signs of ineffective suckling A baby who is poorly attached is likely to suckle ineffectively. He or she may suckle quickly all the time, without swallowing, and the cheeks may be drawn in as he or she suckles showing that milk is not flowing well into the baby’s mouth. When the baby stops feeding, the nipple may stay stretched out, and look squashed from side to side, with a pressure line across the tip, showing that the nipple is being damaged by incorrect suction. Consequences of ineffective suckling When a baby suckles ineffectively, transfer of milk from mother to baby is inefficient. As a result: K the breast may become engorged, or may develop a blocked duct or mastitis because not enough milk is removed; K the baby’s intake of breast milk may be insufficient, resulting in poor weight gain; Figure 8 Good and poor attachment – external signs
2.THE PHYSIOLOGICAL BASIS OF BREASTFEEDING 15 the baby may pull away from the breast out of frus- FIGURE9 tration and refuse to feed; Baby well positioned at the breast the baby may be very hungry and continue suck- ling for a long time,or feed very often; the breasts may be over-stimulated by too much suckling,resulting in oversupply of milk. These difficulties are discussed further in Session 7. 2.10 Causes of poor attachment Use ofa feeding bottle before breastfeeding is well estab- lished can cause poor attachment,because the mecha- nism of suckling with a bottle is different.Functional difficulties such as flat and inverted nipples,or a very small or weak infant,are also causes of poor attach- ment.However,the most important causes are inex- perience of the mother and lack of skilled help from a)Sitting the health workers who attend her.Many mothers need skilled help in the early days to ensure that the baby attaches well and can suckle effectively.Health workers need to have the necessary skills to give this help. 2.11 Positioning the mother and baby for good attachment To be well attached at the breast,a baby and his or her mother need to be appropriately positioned.There are several different positions for them both,but some b)Lying down key points need to be followed in any position. Position of the mother He or she should be facing the breast.The nip- The mother can be sitting or lying down(see Figure9), ples usually point slightly downwards,so the baby or standing,if she wishes.However,she needs to be should not be flat against the mother's chest or relaxed and comfortable,and without strain,particu- abdomen,but turned slightly on his or her back larly of her back.If she is sitting,her back needs to be able to see the mother's face. supported,and she should be able to hold the baby at The baby's body should be close to the mother her breast without leaning forward. which enables the baby to be close to the breast, and to take a large mouthful. Position of the baby The baby can breastfeed in several different positions His or her whole body should be supported.The in relation to the mother:across her chest and abdo- baby may be supported on the bed or a pillow,or men,under her arm,or alongside her body. the mother's lap or arm.She should not support only the baby's head and neck.She should not Whatever the position of the mother,and the baby's grasp the baby's bottom,as this can pull him or general position in relation to her,there are four key her too far out to the side,and make it difficult for points about the position of the baby's body that are the baby to get his or her chin and tongue under important to observe. the areola. The baby's body should be straight,not bent or These points about positioning are especially impor- twisted.The baby's head can be slightly extended tant for young infants during the first two months of at the neck,which helps his or her chin to be close life.(See also Feeding History Job Aid,0-6 months, in to the breast. in Session 5.)
15 K the baby may pull away from the breast out of frustration and refuse to feed; K the baby may be very hungry and continue suckling for a long time, or feed very often; K the breasts may be over-stimulated by too much suckling, resulting in oversupply of milk. These difficulties are discussed further in Session 7. 2.10 Causes of poor attachment Use of a feeding bottle before breastfeeding is well established can cause poor attachment, because the mechanism of suckling with a bottle is different. Functional difficulties such as flat and inverted nipples, or a very small or weak infant, are also causes of poor attachment. However, the most important causes are inexperience of the mother and lack of skilled help from the health workers who attend her. Many mothers need skilled help in the early days to ensure that the baby attaches well and can suckle effectively. Health workers need to have the necessary skills to give this help. 2.11 Positioning the mother and baby for good attachment To be well attached at the breast, a baby and his or her mother need to be appropriately positioned. There are several different positions for them both, but some key points need to be followed in any position. Position of the mother The mother can be sitting or lying down (see Figure 9), or standing, if she wishes. However, she needs to be relaxed and comfortable, and without strain, particularly of her back. If she is sitting, her back needs to be supported, and she should be able to hold the baby at her breast without leaning forward. Position of the baby The baby can breastfeed in several different positions in relation to the mother: across her chest and abdomen, under her arm, or alongside her body. Whatever the position of the mother, and the baby’s general position in relation to her, there are four key points about the position of the baby’s body that are important to observe. K The baby’s body should be straight, not bent or twisted. The baby’s head can be slightly extended at the neck, which helps his or her chin to be close in to the breast. 2. The physiological basis of breastfeeding b) Lying down Figure 9 Baby well positioned at the breast a) Sitting K He or she should be facing the breast. The nipples usually point slightly downwards, so the baby should not be flat against the mother’s chest or abdomen, but turned slightly on his or her back able to see the mother’s face. K The baby’s body should be close to the mother which enables the baby to be close to the breast, and to take a large mouthful. K His or her whole body should be supported. The baby may be supported on the bed or a pillow, or the mother’s lap or arm. She should not support only the baby’s head and neck. She should not grasp the baby’s bottom, as this can pull him or her too far out to the side, and make it difficult for the baby to get his or her chin and tongue under the areola. These points about positioning are especially important for young infants during the first two months of life. (See also Feeding History Job Aid, 0–6 months, in Session 5.)