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MATERNITY UNIT Site St-Elisabeth Site St-Michel Maternity Unit BREAST FEEDING

BREAST FEEDING - Cliniques de l'Europe€¦ · BREAST FEEDING BREAST FEEDING 2 3 1.34 FOREWORD Dear parents We would like to congratulate you on the birth of your child; it will be

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Page 1: BREAST FEEDING - Cliniques de l'Europe€¦ · BREAST FEEDING BREAST FEEDING 2 3 1.34 FOREWORD Dear parents We would like to congratulate you on the birth of your child; it will be

MATERNITY UNIT

Site St-Elisabeth Site St-Michel

Maternity UnitBREAST FEEDING

Page 2: BREAST FEEDING - Cliniques de l'Europe€¦ · BREAST FEEDING BREAST FEEDING 2 3 1.34 FOREWORD Dear parents We would like to congratulate you on the birth of your child; it will be

BREAST FEEDING

1

1 FOREWORD .......................................................................................................................................................... 3

2 THE CHOICE OF FEEDING METHOD ........................................................................................................... 4

3 MOTIVATION ....................................................................................................................................................... 5

4 THE ANATOMY OF THE BREAST ................................................................................................................. 7

5 THE ROLE AND FUNCTION OF HORMONES .......................................................................................... 9

5.1 Oxytocin .................................................................................................................................................. 9

5.2 Prolactin ................................................................................................................................................. 9

6 THE DIFFERENT STAGES OF MILK PRODUCTION ............................................................................ 11

6.1 Development of the breast ...................................................................................................... 11

6.2 Lactogenesis .................................................................................................................................... 11

6.3 Galactopoesis .................................................................................................................................. 12

6.4 Involution ............................................................................................................................................. 12

7 THE MECHANISM OF MILK PRODUCTION ........................................................................................ 13

8 PREPARATION FOR BREAST FEEDING ................................................................................................. 14

8.1 Physical preparation .................................................................................................................... 14

8.2 Nipple preparation ........................................................................................................................ 14

8.3 Information gathering ................................................................................................................. 14

9 PRACTICAL BREAST FEEDING .................................................................................................................. 15

9.1 When do i start? ........................................................................................................................... 15

9.2 Care required? ................................................................................................................................ 15

9.3 How do i breast feed? Presentation and latching on to the breast ................ 16

9.4 When, how long and how often? .......................................................................................... 20

9.5 How do we know if the newborn baby is suckling well?

Can we be certain that he is receiving enough? ......................................................... 23

9.6 How to wake a newborn ............................................................................................................ 26

9.7 Ways to wake the ejection reflex ........................................................................................ 27

10 THE INFLUENCE OF DIET ON THE MOTHER ....................................................................................... 30

10.1 General ................................................................................................................................................ 30

10.2 Calorie requirements during lactation .............................................................................. 32

10.3 Weight loss ....................................................................................................................................... 32

10.4 Sport and exercise ....................................................................................................................... 32

10.5 Breast feeding and osteoporosis ......................................................................................... 33

10.6 Breast feeding and pollutants ................................................................................................ 33

CONTENTS

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1. FOREWORD

Dear parents

We would like to congratulate you on the birth of your child; it will be the begin-ning of a new life. You have chosen the best start for your child; breast feeding.

This brochure is designed to bring together both our years of experience and the results of medical research to help you make the best decision concerning breast feeding by answering your many questions on the subject.

To help you we also organise ante-natal classes. One evening is dedicated to the feeding of a newborn. Further individual instruction and advice is given on the delivery ward and later on the maternity ward to help make the breast feeding as easy as possible. Once you return home further help and advice is available from an Independent Midwife, Lactation expert, or your doctor. With this booklet we hope to support you before, during and after the birth of your child.

Remember that we are always available to help you with advice concerning your breast feeding.

The medical and midwifery team of the Europe Hospitals.

11 THE STOOLS OF A BREAST FED CHILD ................................................................................................. 34

12 DIFFICULT PERIODS DURING BREAST FEEDING .............................................................................. 35

12.1 Mammary engorgement ............................................................................................................ 35

12.2 Blocked milk ducts and mastitis .......................................................................................... 37

12.3 Cracked nipples .............................................................................................................................. 39

13 PUMPING .......................................................................................................................................................... 42

13.1 Choosing a pumping method .................................................................................................. 42

13.2 Basic principals of breast pumping .................................................................................... 45

13.3 Different pumping methods for different circumstances ...................................... 49

14 SAFE HANDLING OF MOTHER’S MILK ................................................................................................. 54

14.1 How long can mother’s milk be stored? .......................................................................... 54

14.2 The choice of conservation method for mother’s milk ............................................ 55

14.3 Usage and defrosting of mother’s milk ............................................................................ 56

15 THE CRYING BABY ........................................................................................................................................ 58

16 PROGRESSIVE WEANING OFF FROM BREAST FEEDING ............................................................. 59

17 MOTHER’S GROUPS AND OTHER SUPPORT NETWORKS AND THEIR FUNCTIONS ........ 60

17.1 The Leche League ......................................................................................................................... 60

17.2 ASBL Breast feeding ................................................................................................................. 61

17.3 Infor-allaitement ............................................................................................................................. 62

17.4 BCT (Brussels Childbirth Trust) ........................................................................................... 62

18 USEFUL WEBSITES ........................................................................................................................................ 64

CONTENTS FOREWORD

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BREAST FEEDING

3. MOTIVATION

WHAT ARE THE ADVANTAGES OF BREAST FEEDING?

Advantages for your baby

• Mother’s milk adapts to the needs of your baby, the composition changing according to his evolution.

• Mother’s milk is well tolerated and easily digested by your baby.

• Mother’s milk contains maternal antibodies, which give a passive protection to the newborn child. It stimulates the immune system of the baby to start producing its own antibodies (scientific research has demonstrated that a breast feed baby produces even more anti-bodies after vaccination, therefore being better protected).

• Mother’s milk contains a none pathogenic bacteria “lactobacillus bifida” which inhibits the growth of pathogens in the intestine of the infant.

• The first milk or colostrum contains a product which stimulates the intestine and facilitates the production of the first stools. This first motion or meco-nium is the remains of life in the womb and is formed by the decomposition of blood within the intestine. If meconium remains in the circulation of the baby it may provoke an icterus or jaundice in the baby due to an increase in bilirubin. Colostrum is, therefore necessary to prevent elevated bilirubin levels, which would result in jaundice.

• Mother’s milk reduces the risk of allergy. It is advisable that the mother elimi-nates all milk products from her diet to reduce the risk of the infant becoming intolerant to milk products.

• Mother’s milk enhances the development of the senses of touch, smell and taste in the infant. Breast feeding also assists in the development of the maxillary muscles, the tongue and the teeth.

• Recent studies show that the brain and nerve cells develop quicker in breast fed children.

• Breast fed babies demonstrate a more balanced weight gain.

• Breast feeding strengthens the bonding between the mother and the infant.

THE CHOICE OF FEEDING METHOD MOTIVATION

2. THE CHOICE OF FEEDING METHOD

• Is very personal

• Follow your own feelings

• Do not be influenced by the surroundings

• Make your decision based on the correct and trust worthy information you have received

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4. THE ANATOMY OF THE BREAST

Figure 1: Anatomy of the breast

In order to better appreciate of the working of the breast it is necessary to have some knowledge of anatomy.

• The breast is bounded by the axilla, the mid line of the sternum and the diaphragm. The breast itself is attached to the large pectoral muscle which passes behind not through the breast. The breast is a secretery ganglion.

• The size and shape of the breast are defined by the presence of fatty tissue. The size of the breast has therefore nothing to do with milk production.

• The breast contains a fine network of blood capillaries and lymph ducts which ensure the oxygenation and removal of waste product from the tissue of the breast. They also transport the requisite materials for the production of milk.

• A second large network within the breast consists of the ganglions and the milk or collecting ducts. Every woman has around 15 to 20 ganglion per breast. Each lobe consists of 20 to 40 small milk or collecting ducts. These contain ganglionic islets are composed of 10 to 100 alveoli.

• The synthesis of milk occurs in the breast and alveoli under hormonal control. This milk is transported via a network which connects to the large milk or collecting ducts which arrive at the aureole. These ducts are surrounded by muscular fibres which are under the control of hormones which stimulate contractions to eject the milk (ejection reflex).

1. Ribs

2. Large pectoral muscle

3. Ganglionic tissue where milk production com-

mences

4. Nipple, where the milk or collecting ducts exit

5. Aureole, where we find the Montgomery and

sweat glands, and hair follicles

6. Milk or collecting ducts which are under the

control of the hormone oxytocin. This hor-

mone is responsible for the let-down reflex

7. Fatty tissue

8. Mammary lobe

1

2

3

4

5

6

78

MOTIVATION THE ANATOMY OF THE BREAST

Effect on the mother

• Mother’s milk is always convenient and ready at the correct temperature.

• Breast feeding saves time; there is no need for preparation, washing, or ste-rilisation of the bottles. It should be noted that the actual feeding may take a little longer, but there is an overall time saving.

• Once breast feeding goes well it becomes a pleasant relaxing experience.

• The intense contact between the mother and child plays an important role.

• Mother’s womb recovers much more quickly.

• Breast feeding requires more energy from the mother. A breast feeding mother needs more rest and a balanced diet. The calories required for breast feeding result in a quicker weight loss on the part of the mother.

• Breast feeding saves money, increases resistance to illness (fewer doctors and pharmacy bills) and is environmentally friendly (less packaging materials to be disposed of).

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5. THE ROLE AND FUNCTION OF HORMONES

A hormonal stimulus is necessary to start the production of mother’s milk. Two hormones play an essential role, oxytocin and prolactin.

Function of hormones. (source: Breastfeeding and Human Lactation, Third Edition, J. Riordan)

5.1 OXYTOCIN

Oxytocin is secreted by the pituitary gland when the nipple is stimulated and is responsible for uterine contractions before and after the delivery and during orgasm. During breast feeding oxytocin stimulates the muscular fibres around the aureole stimulating the milk or collecting ducts to expel milk. Oxytocin also augments the circulation especially around the breast. This hormone is strongly influenced by the emotions: positive emotions increase the ejection reflex: nega-tive emotions will decrease this reflex. Sometimes this reflex can be stimulated without the infant suckling, hearing it cry or even thinking about it may be suffi-cient.

5.2 PROLACTIN

• Prolactin is secreted by the anterior pituitary gland following stimulation of the nipple.

• Prolactin works at the level of the ganglion and lactic ducts provoking the secretion of milk.

• During the pregnancy prolactin secretion is inhibited by the hormones. Fol-lowing the release of the placenta this inhibition stops and prolactin stimu-lates lactation. Over the following three days, levels reaching a maximum five

• The milk canals end at the nipple. The nipple is surrounded by the aureole, both of which very sensitive, this is comparable to the sensitivity of the lips. (Should they become dry or sore simply smear cream on them). The nipple and aureole become enlarged during pregnancy. The Montgomery Glands take care of disinfection and moisturising the area, they also produce sebhorrea. Rinsing with warm water suffices to clean them.

• The firmness of the breast is determined by the conjunctive tissue which becomes less firm with age. Breast feeding has no influence on this.

• Nerves and nerve fibres transmit the feelings from the nipple and aureole to the brain.

• Most women have small hairs around the aureole. Sebaceous glands may also be found.

Hypothalamus

Pituitary gland

OxytocinProlactin

Lacteal

Myoepithelial cell

Uterus

THE ANATOMY OF THE BREAST THE ROLE AND FUNCTION OF HORMONES

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6. THE DIFFERENT STAGES OF MILK PRODUCTION

The production of milk changes with the development of the woman. There is no other organ in the human body which experiences so many changes of shape, size and function, during our lifetime. (From birth: through puberty: pregnancy to lactation).

6.1 DEVELOPMENT OF THE BREAST

• The development of the breast begins in the foetus during the fourth week of the pregnancy. The development is identical in young boys and girls until puberty, the phenomenon of “witch’s milk” (lactation) occurring in adolescent boys as well as girls.

• Oestrogens and maybe growth hormone cause young girl’s breasts to swell and the aureole will become more prominent. Boy’s breasts do not change during this period.

• Progesterone causes the milk or collecting ducts and ganglion to grow usually up to 18 or 19 years.

• Up to 30 years of age the milk or collecting ducts and ganglion will grow approaching menstruation slowly returning to normal.

• From 18 months after the first period girls are capable of breast feeding.

• During pregnancy there is an immediate effect on the breast, even before the end of menstruation. The ganglion continues growing to the end of the pregnancy.

6.2 LACTOGENESIS

The transition from pregnancy to lactation is called lactogenesis and can be divi-ded in to two stages.

Lactogenesis 1: from the second half of the pregnancy to the second day post partum.

• Milk production starts from the second half of the pregnancy.

• Colostrum production: This is a nutrient rich in carbohydrates, minerals, anti-bodies.... Only a small quantity of colostrum is produced, but this is sufficient for baby during his first days.

• This is under hormonal control.

Lactogenesis 2: from the third to the eighth day post partum.

• The start of large quantities of milk production.

• Transition to mature maternal milk.

THE ROLE AND FUNCTION OF HORMONES THE DIFFERENT STAGES OF MILK PRODUCTION

days after the birth. The level varies during the day in function of with the frequency of feeding. It is also governed by a circadian cycle: there is a higher level of prolactin during the night and sleep.

• The theory of prolactin receptors Scientific research has shown that during the first few days of lactation, when

baby is placed on the breast, receptors are created. The more receptors the more prolactin will be produced thus the more mother’s milk will be produced. This theory explains the need to put the child on the breast frequently during the first 72 hours (8 to 12 times in 12 hours is perfectly acceptable). After this initial period the number of receptors remains constant.

• This theory explains why mothers who have previously breast fed have more receptors (previous lactations + new receptors) than mothers’ breast feeding for the first time.

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1312 THE MECHANISM OF MILK PRODUCTIONTHE DIFFERENT STAGES OF MILK PRODUCTION

7. THE MECHANISM OF MILK PRODUCTION

It is important to know that putting the baby to the breast stimulates the produc-tion of prolactin and oxytocin. It is only now that milk production starts.

The production may occur instantaneously or after a few minutes. The speed of the response depends on the sucking technique of the child, the correct positio-ning of the child and the reaction of the mother.

The infant will then quickly drink the “the foremilk” which is present in the lactic ducts and alveoli. This precursor is composed mainly of water, mineral salts and antibodies. (About 1/3 of the meal) After the hormonal response the hindmilk is produced and excreted. Now you will be able to hear baby eating. The prolactin peak has been reached and lasts for about 45 minutes. Throughout the period of lactation, milk production goes through various stages, the formulation adapting at each stage according to the needs of the baby. The formulation of your milk is never twice the same. In the beginning the milk contains mainly sugars, changing to proteins and progressing to fatty acids. The more the baby drinks the greater the fatty content. (fatty acids = energy = growth and cerebral development). Once the baby has been motivated to breast feeding it is important to let him decide how much and how often, so that he receives sufficient fats. After he has released the first breast it is advisable to wait a few moments, giving the chance to burp, before proposing the second. According to his appetite the baby will eat a lot, a little, or even refuse this breast. The following breast feeding you should start with what was the second breast, or in other words alternate the breast with which you start each mealtime.

• Full warm breasts.

• Transition from hormone controlled production to autocratic working based on supply and demand.

6.3 GALACTOPOESIS

This occurs from the ninth day post partum to the start of involution • Mature mother’s milk.

• Supply-demand response: the more mother the mother breastfeeds, the more milk is produced, inversely if there is reduced demand there is reduced pro-duction.

The size of the breast reduces after about nine months, but this has no in-fluence on milk production.

6.4 INVOLUTION

• About 40 days after the last breast feeding. • Due to the increase of supplements proposed.

Ganglionic tissue reduction

Milk production

Prolactine respons

No drain of the breast

BB is hungry

Drain of the breast

Milk stagnation

BB to the breast

Blokkade Oxytocine

Oxytocine respons

Milk transport

Others influences Others influences

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1514 PRACTICAL BREAST FEEDINGTHE MECHANISM OF MILK PRODUCTION

9. PRACTICAL BREAST FEEDING

9.1 WHEN DO I START?

• As soon as possible: within the first hour after the birth, providing that your and the baby’s condition permits it.

• Reasons for early introduction to the breast

- Suckling stimulates contractions of the womb, reducing the risk of postnatal bleeding,

- Straight after the delivery baby will be wide awake and alert,

- The suckling reflex is at its highest at this moment,

- Suckling stimulates prolactin, which stimulates lactation,

- If the baby has had a successful first experience of breast feeding, he will quickly improve his technique.

9.2 CARE REQUIRED

• Personal hygiene is very important.

- Most important is hygiene of the hands, before every feed,

- Normal daily hygiene is enough, rinsing your nipples with warm water, do not use soap,

- The secretions of the Montgomery Glands keep the nipple and aureole soft and clean. The use of disinfecting creams, lotions, or ointments may have an adverse effect on the secretions from these glands. The skin may dry out leading to cracking.

• In the case of in growing or flat nipples massaging with the thumb and forefin-ger before presenting baby will help erection of the nipple.

• At the end of the feed, remove your baby from the breast after placing the little finger in his mouth. This avoids the feeling of an empty mouth thus redu-cing associated problems.

- Delicately dry your breast: warm moist skin is always more vulnerable to infections and tissue damage than dry skin,

- Maybe express a little milk and gently massage it into your nipple and aureole. (the milk works as a protection and healing agent),

- Leave your breast bare in the open air,

- Cover “leaking” breasts with a dry compress, replacing as necessary to avoid a humid environment,

- Sensitive or cracked breasts should be treated with an oily cream such as Lansinoh® or Purelan®. Both of these creams contain double purified lano-lin. Lanolin oil protects the wound from the air and allows healing from the

8. PREPARATION FOR BREAST FEEDING

8.1 MENTAL PREPARATION

The psychological preparation for breast feeding is very important: you must be motivated and want to breast feed, theoretically all woman are capable of breast feeding.

Before proposing the first feed certain manipulations are necessary. You should explore your breasts and understand their anatomy.

8.2 PHYSICAL PREPARATION

• During lactation it is important that you are well nourished eating a balanced diet. Small amounts of sugars, alcohol and fats may be consumed, but nico-tine should be avoided.

• Nipple preparation

- This is not necessary and should even be avoided,

- Colostrum is produced during the last trimester of the pregnancy. This may begin to leak from the nipples towards the end of the pregnancy or during sexual stimulation. It is not necessary to do anything about this (never try to suck the milk as this may result in premature contractions),

- The appearance of the breast when the baby is not feeding has little im-portance. It is the shape whilst the baby is suckling which counts. Nipple exercises for ingrown or flat nipples have very little influence on their shape.

• The best preparation is to do nothing.

8.3 INFORMATION GATHERING

• Support groups listed in section 17 may be of assistance.

• Prenatal courses cover the subject of breast feeding.

• Books, videos or DVD’s.

• Talk to women who have had one or more positive experiences of breast feeding.

Practical experience of your own child will quickly teach you the correct procedure.

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1716 PRACTICAL BREAST FEEDINGPRACTICAL BREAST FEEDING

- Find a feeding position where you can hold the baby close to your breast and you can relax, without strain on your muscles,

- Place as many cushions or rolled up blankets around you so you can support the weight of your baby at the height of your breast,

- Sitting up in bed is more tiring because your legs are stretched out straight in front of you. If you must feed in bed make sure your back is well supported and place a pillow of the like under your knees, or raise one knee,

- Women with large breasts may find it easier to support the breast using a rolled up small towel, so you will be able to see what the baby is doing, and avoids blocking the baby’s nose,

- Find the position which best suits you and your baby.

b) Laying

• If you lie on your side to feed, cushions and other material will make it more comfortable.

- Usually it is necessary to place a pillow under your head, - Pillows should be placed behind your back, so that you can lean backwards

with support, - A cushion under the upper thigh is usually more relaxing. • If you lie on your side, it follows that the baby should also lie on his side, sto-

mach to stomach.

• Breast feeding lying on the side is easier for women with large breasts as against women less well endowed. The breast will be supported by the mattress.

How to hold the baby

• Bring the baby to you - not your breast to the baby.

• Hold the baby close to you with his head in front of your breast so that he does not need to turn his head or stretch his neck to get to your breast.

• He needs to be well supported so that he feels safe.

• Just before the latch on the head of the baby needs to be level with or slightly lower than your nipple.

Useful breast feeding positions

a) The Madonna

• The most popular breast feeding position.

• You sit up straight. The baby’s head lies on your forearm. The baby lies on his side facing you (stomach to stomach) pulled in close. The baby can put his forearm under your breast or lay it against himself, whichever is easiest.

inside out. They contain little or no water thus avoiding problems of humidity and infection,

- Double purified lanolin provokes no adverse reaction from the baby so does not need to be cleaned off prior to the next feed. When necessary massage a small amount of the cream into the nipple and aureole after each feeding. Should you be allergic to lanolin oil of Demeter®, is available in a slightly perfumed presentation.

9.3 HOW DO I BREAST FEED? PRESENTATION AND LATCHING ON TO THE BREAST

During the first two weeks of the breast feeding be very conscious of the position of your baby during breast feeding and the way you introduce it to the breast. After this learning period it is no longer necessary to be so attentive. A good presenta-tion reduces the problems of sensitive breasts and allows a better delivery of milk.

Mother and child are a pair (like a couple in perfect harmony). Breast feeding is influenced by both mother and child, but we need to remain practical. Some babies get the hang of breast feeding from the beginning, latch on easily and start to suckle; others need more help and practice. With time patience and training they will also learn to drink from the breast.

The position of the Mother – makes it easy

a) Sitting In the beginning you will spend a lot of hours in the day breast feeding. A few tips to make it more comfortable: - The sitting position is easiest when you sit up straight in a chair with arm-

rests. The chair should give support to the back. A bench or a settee with cushions is less comfortable,

- Use a chair which is low enough for the feet to be flat on the ground, the thighs pointing slightly upwards. (the sort your grandparents used to have) If the chair is too high use a cushion or a tabouret to achieve a comfortable position,

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1918 PRACTICAL BREAST FEEDINGPRACTICAL BREAST FEEDING

Latching on How does the baby take the breast?

a) If necessary support the breast • During the first weeks most of the mothers say that it is easier to breast feed

if the breast is supported during the latching on and the feeding.

• You should support your breast with a “C” grip: the thumb to the top and the fingers under the breast the little finger towards the chest (the same as with the cup of a bra the breast lies in the palm).

• The cigarette grip of the nipple between the two fingers is not advised and has disadvantages: the baby cannot take the entire nipple in his mouth: the extra pressure of the fingers the can block the milk or collecting ducts.

• The nipple sandwich is another technique which can help the locking on:

- Step 1: first use the “C” grip to support your breast with your fingers under the breast and the thumb above. The fingers and thumb should be as far as possible from the aureole,

- Step 2: press gently with your thumb and fingers. This makes the aureole oval instead of round. Reducing the size which the baby needs to take, thus making it easier for the baby to latch on,

- Step 3: you then press inwards towards your chest, causing the nipple to become more erect. So making it easier for the baby to take it,

- Step 4: press harder with her thumb then with her fingers. This directs the nipple towards the pallet of the baby.

• If you have large breasts you may need to support them even after the appren-ticeship.

b) Encouraging the baby to open his mouth wide enough. • Good latching on requires the baby to open his mouth wide and suck as much

of the breast as deeply into the mouth as possible.

• When is wide enough wide enough?

• Compare your baby to a fledgling waiting to receive a worm. Good latching on is just as important for mother as for baby. You can test the depth of pene-tration on yourself simply by inserting a finger into your baby’s mouth. To the first knuckle in the nipple, the second is nipple and aureole. Suck on your finger to feel the difference in suction in the two positions. Note also the position of your tongue.

• When the baby is well positioned should feel little or no pain on your nipple. After a day of breast feeding it is normal for the nipple to be sensitive at the start of the feed, because as baby begins to suckle the nipple is pulled to the back of the mouth. If bad suckling is the cause of pain, the pain should go away within two days of correction of the position.

• Put cushions behind your back and shoul-ders, and under the elbow that you use to support the baby and on your lap to take the weight of the child.

• If the baby chokes due to a strong cough reflex or hypotonia, the baby can be posi-tioned so that his neck and throat are higher than your nipple.

b) The Rugby • You sit up straight. Baby lies on your

arm from under your shoulder. The head of the baby should be supported by your hand. Baby’s feet should be supported by a cushion.

• Place a cushion to support your back and one under your arm to support the baby at the height of your breast.

• The rugby position provides a good view with better control of the head of the baby, in certain special circumstances this may be the optimal position: if you have large breasts: or flat or ingrown nipples: after a Caesarean Birth (lees pressure on the wound): premature baby’s: baby’s with a low suckling reflex. You will be able to see what is happe-ning.

c) Lying on your side • You both lie on your sides facing each

other with the baby’s knees pulled close to your stomach.

• Place cushions under your head behind your back and under your knee and on top of your leg.

• You lean backwards against the cushion behind your back.

• Both breasts can be given from this posi-tion or you can hold baby against your breast and roll onto your other side.

• Lying on your side allows you to rest or even sleep whilst baby feeds. This is also a comfortable position after a Caesarean Delivery.

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• Gently tickle baby’s lips with the nipple to attract his attention and open his mouth wide.

• Other methods which may be used to encourage baby to open his mouth include saying loudly “open” at the same moment as gently pressing his chin downwards to open his mouth presenting the breast. You can also try pres-sing downwards on the chin with the breast to open the mouth.

c) Pulling baby close and holding him there.

• When baby is well positioned a large amount of the breast will be in his mouth. He will be very close to you with his chin touching your breast. The nose will rest against the breast, the nostrils widen out during feeding, so he will not have problems breathing. Timing is primordial.

• If baby does not adopt this position, you should gently withdraw the breast and try again.

• The baby’s body should be as close as possible to yours.

• Good positioning and support ensure that baby keeps suckling to the end of the feed.

• Some babies need extra help to stay latched on: baby’s with poor suckling reflex, short tongue, cleft pallet etc.

d) Removing baby from the breast

• Wait until baby indicates that he has finished with a breast before presenting the other. When baby has finished with a breast he will release it or fall asleep.

• It is important let baby choose the rhythm of the feeding, in this way he will derive the most benefit from the foremilk and full milk which is rich in calories.

• If you decide to remove baby from the breast before he has finished, the vacuum should first be released to avoid damage to the tissue of the breast. There are different methods:

- Squeeze the breast close to baby’s mouth,

- Gently press baby’s chin downwards,

- Insert a finger in the corner of his mouth.

9.4 WHEN, HOW LONG AND HOW OFTEN?

Firstly it is important to understand that a newborn child who came into the world following problem free delivery, has reserves of sugars in his liver and fats under his skin.

It is completely normal that during the first few days of life he will lose about 10% of his birth weight: making stools, urinating, crying, breathing...

Premature babies may not have built up these reserves. Babies who had difficult deliveries may have used up these reserves already. These babies should be closely monitored and regularly fed.

When to feed?

• Consult baby not the clock.

• Feed baby at the first signs of hunger. Crying is a «late» signal. Early signs of hunger are: arm or leg movements: putting his fingers in his mouth: making noises: being restless and whimpering are «middle signs» of hunger.

• Crying troubled babies are almost impossible to put on the breast. By quickly reacting to the early signs of hunger, mother has time to prepare both baby and herself, calmly getting in position and bringing to the breast. If baby is over troubled, first try to calm him, and then regain his interest.

How often?

• This varies from child to child. The first day’s baby will usually ask for the breast quite often: colostrum is limited in quantity and easily digested. A suckling child can determine for himself the regularity of feeding. This is important for the “supply and demand” reaction of the body. Make sure that baby is well positioned. Sometimes baby will be happy with one breast, but the majority will usually need two. Move from one breast to the other after baby spontaneously stops with the first.

• Sometimes during the first days baby can be bothered by phlegm and does not want to drink very much.

• A good drinker will drink every 3 to 5 hours. Observation at this time is very important. The length of the feed will be decided by the baby.

• After baby has released the breast leave him for 2 to 5 minutes, let him burp and reintroduce him to the breast.

• After the end of the feed you will also wish to relax and maybe even fall asleep, this is a side effect of the oxytocin.

• Whenever the baby is not suckling well it is important to remove him from the breast by putting the little finger in the corner of his mouth to release the vacuum.

• At night baby should drink when he asks. Premature babies, or jaundiced babies who have been under the lamp, should be regularly stimulated to feed.

• Normally baby only receives breast feeding, no other supplements. If other supplements should be prescribed medically they should pre-ferably be dissolved in mother’s milk which has been drawn off using a breast pump.

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Mother will notice that her breasts feel softer and less full. This indicates that the milk product has begun to adapt to the needs of baby. It is therefore normal that the sensation of a full feeling disappears.

Normal feeding schedule

Minimum 8 times per day = normal during the first days.

• Baby will want to feed every couple of hours and then sleep for a couple of hours. This routine will continue until you begin to produce more milk.

• Baby will feed often for short periods. When baby wakes he can be put straight away on the breast, even before he starts to cry, do not bother how long it was since the last feed, it is not important.

• Baby remains passive, perhaps a throwback to the birth: still try to feed him. Encourage baby to feed ten or twelve times per day even if it means waking him from a light sleep signs of this are rapid eye movements with the lids closed (REM sleep), movements of the arms and legs, movements of the lips and changes of facial expression.

• Minimum once a night is normal.

• If this rhythm is reversed, wake baby during the day, being careful only to wake him during light sleep not according to the time. If baby does not want to drink try again later.

• If meconium remains in the intestines for too long it may be reabsorbed by the intestines.

9.5 HOW DO WE KNOW IF THE NEWBORN BABY IS SUCKLING WELL? CAN WE BE CERTAIN THAT HE IS RECEIVING ENOUGH?

Many mothers are convinced during the first days that baby is not drinking during the breast feeding.

Nothing is less true: during the first days baby receives colostrum. This food is sufficient for baby’s needs. Colostrum is produced in small highly concentrated quantities and is quickly digested. It can be that baby wants to drink frequently. It is useless to weight baby before and after the feed as we are talking about 10 to 20ml. a gain of 20g which could discou-rage mother. It is only between the third and fifth day that under the influence of prolactin, mother’s milk is produced.

Evolution of the milk?

a) Colostrum

Colostrum is a component of the first milk production, a concentrated liquid which delivers its nutrients in a concentrated low volume. It contains a mild laxative encouraging the meconium (first stools), clearing the bilirubin (dead red blood cells) reducing the chance of jaundice. Antibodies (immunoglobins), providing passive immunity and growth hormones are also carried by colos-trum. The breasts produce small amounts of colostrum from the delivery to the third or fourth day. The prolactin response begins with the suckling, the production increases and stays in the blood for 45 minutes.

• Better often and short feeds than long and less often.

• But no clock! Baby can eat as long as he wishes.

• Baby stops and releases = OK.

• Baby stops and sleeps = OK.

• The baby stops feeding, but continues to chew: attention for cleft pallet.

• Remove baby from the breast, better good and short feeds, this stimulates prolactin.

IMPORTANT

REGULAR AND OFTEN A LITTLE BIT

DO IT WELL

BABY ONLY DRINKS A SMALL AMOUNT

(7 to 14ml. At a time)

Around 72 hours after the delivery of the placenta (following a Caesarean = 24 hours) the breasts will become fuller. It is now that the largest quantities of milk are produced. This is transitory milk, a combination of colostrum and full mo-ther’s milk. Nature plays safe to ensure that baby does not miss out on anything. After about two weeks the offer seems to adapt according to the needs of baby. The balance between supply and demand seems to be stabilising.

Stress and other external factors (low haemoglobin..) may retard the filling of the breasts to the twelfth or fourteenth day. Occasionally this may occur around the tenth or fourteenth day.

b) More mature mother’s milk

After about two weeks mature mother’s milk begins to be produced, taking about two weeks for the full transition. At the same time the volume of milk produced increases.

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first two to three days. A loss of 10% is still acceptable, but could be a sign that all is not well with the breast feeding and that you are in need of help.

• Routine supplementation of the breast feeding is not necessary during the first days and taking them may lead to health problems for both you and your child.

• Supplementary feeding satisfies baby in such a way as to reduce his interest in breast feeding.

• Giving extra water may provoke jaundice in the newborn child.

• Synthetic milk products given too soon after the birth may lead to allergy to cow’s milk.

• Supplementary feeding with a bottle and teat may cause breast feeding pro-blems; the sucking power of baby reduces causing him to reduce the breast feeding.

• Supplementary feeding has a negative effect on the evolution of mother’s milk. Milk production is directly proportional to how often, how long and how effec-tively baby feeds from the breast.

• Early supplementary feeding is directly related to a shorter breast feeding period.

Signs of sufficient milk transfer

• Baby is alert, giving signs of satisfaction after the feed. • Baby suckles a minimum of 160 – 180 minutes per day, during the first two

weeks of breast feeding. • Baby suckles audibly. • After the feed mother’s nipple is comfortable, wet and intact. • Mother and child are content with the feed. • Baby’s gums are moist and the skin is elastic and soft. • About three to four days after the birth, baby produces between three and five

pampers with sloppy yellow stools. Less frequent defecation is normal after six weeks.

• At the end of the first week baby has six or more wet nappies per day, the urine being pale in colour with a mild smell.

• The normal weight gain during the first three months is 115 to 225 grams per week.

Baby is not drinking enough

• Signs - No increase in weight during the first week,

- Crying or drowsy baby,

- Not enough wet nappies.

Signs of good suckling

• Baby’s body lies in front of his mother so that he does not need to turn his head.

• Baby has his mouth full of breast. If he is good latched on his chin should be as far behind the nipple as possible. Mother will not be able to see this for herself, but can ask someone else to look if more of the aureole is covered below, than above.

• Baby is so close to mother that his chin presses into the breast and his nose is touching the beast.

• Once he has latched on his lips will be relaxed and curled outwards.

• Baby’s tongue will be below the breast.

• You feel no pain during the feed.

Indications of good drinking

• After several quick sucks the rhythm will slow and get deeper and mother will hear the regular sucking. There may be a visible movement between the ears and the temples.

• If the breast feeding produces a feeling of well being we can assume that baby is well positioned and is feeding correctly.

• A baby who is well fed will release the breast when he has drunk enough.

• If you wish to be certain that baby is drinking well you should examine baby’s nappies (diapers) paying attention to the faeces.

• During the first two days the new-born has one or two wet nappies (diapers) if mother is only produ-cing colostrum. Once milk pro-duction begins this will increase to six to eight. Stools will be pro-duced two to five times.

• Colostrum is a natural laxative which helps baby to produce the first stools. As the mother’s milk evolves, so will the colour and consistency of the stools change.

• It is normal for baby to lose 5% to 7% of his birth weight during the

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Keep baby interested

• Support your breast enough to prevent it pressing on the chin of your child.

• When baby starts to lose interest, change the breast.

• Before changing breast, let baby burp or change him.

• Feeding in the rugby position instead of the Madonna may also help.

• During the feed massage his crown in a circular motion.

9.7 WAYS TO WAKE THE EJECTION REFLEX

Signs of a good ejection reflex

• The ejection reflex is under hormonal control, and is stimulated by baby suckling. Each time baby feeds the rhythmical movements of his cheeks, lips and tongue stimulate the nerve endings of the breast. These stimulations send directions to the pituitary mother’s gland which stimulates production of prolactin and oxytocin. Oxytocin stimulates contraction of the muscles around the alveoli forcing out the milk so that it is available for baby.

• Signs indicating that the milk is ejected.

- Contractions and blood loss during or just after the feed,

- A tickling, sometimes painful feeling for a few seconds just after the latching on,

- Milk leeks out of the other breast.

- You feel thirsty during the feed,

- A change in the sucking or swallowing rhythm of the baby, from short and quick to slow powerful sucking, with a breath after every two or three sucks,

- Noisy drinking,

- You feel relaxed.

• Reason

- Poor suckling technique therefore poor stimulation,

- Exhausted mother,

- Premature baby or a baby who is not yet strong enough to suckle.

• Approach - Do not make a big deal of it as this can also have a negative effect,

- Lay baby regularly and correctly on the breast,

- Get enough rest,

- Babies who are not yet strong enough to suckle can have their suck reflex stimulated before the feed. If necessary suck of excess milk after thee feed,

- Should baby need more food this milk may be given preferably using a cup or a syringe.

9.6 HOW TO WAKE A NEWBORN

Techniques

• Try to wake baby during a light sleep. Pay attention to rapid eye movements, arm or leg movements sucking or change in facial expresions.

• Dim the lights as the reaction of baby to bright light is to close his eyes.

• Loosen the bedding or remove it completely.

• Strip baby down to his pamper if the room is warm. Suckling reduces above 27°C.

• Talk to baby and try to make eye contact.

• Hold baby in a sitting or standing position.

• Hold baby’s head between the hands and gently bring him to a sitting position.

Increase the stimulation

• Run your fingers along baby’s spine, this reflex causes baby to tense his muscles and become more alert.

• Change his nappy.

• Tickle the soles of his feet, or the palms of his hands this provokes the grip reflex.

• Increase skin to skin contact through giving a massage or bath.

• Move the arms and legs in a clapping motion.

• Wipe his cheeks and forehead with a cool damp cloth.

• Pass a fingertip around his lips.

• Express a little milk and wet his lips with it.

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- Reduce distractions: take the phone off the hook – not forgetting your mobile, put relaxing music on your music system, get a glass of water, and maybe something to eat. If you already have older children feed them first and make sure they have everything they may need,

- Follow a ritual: Warm the breasts by having a warm shower, or using warm compresses, put a jumper or shawl over the shoulders. In winter maybe sit by a heater. Gently massage your breasts, stimulate the nipples. Relax for five minutes breathing deeply and thinking pleasant thoughts,

- Extract milk with a rhythmic movement imitating the movements of a feeding baby: this can stimulate the ejection reflex,

- Only think about baby. Have a photograph or some keepsake nearby,

- Pump milk with baby close by or whilst feeding, - Take a break to massage: let the milk flow for about ten minutes, then take a

break to massage the breast before continuing,

- Alternate the breast several times during the same session. • Your emotions can prevent the ejection reflex; this should be got under control

by relaxation, breathing exercises yoga etc.

• After lactation has stabilised the ejection reflex can occur several times during the feed giving fatty hindmilk. A baby who is feeding well will stimulate this reflex, thus receiving several times watery foremilk as well as hindmilk.

Slow or disturbed ejection reflex

• Baby can become unsettled by a slow or disturbed ejection reflex as the majo-rity of the milk does not come to the nipple. Only a small amount of milk col-lects in the milk or collecting ducts leading to the nipple. Without the ejection reflex the majority of the milk remains in the breast no matter how hard baby tries.

• Unusual stress, painful nipples or pain from forcing the milk can result in slow or disturbed ejection reflex.

• Emotional crisis or high adrenaline levels may reduce the hormonal production necessary to provoke to ejection reflex and reduce or completely block milk production. This reduction is only temporary and production will return to normal once the problem has passed and mother has relaxed.

• Painful nipples may slow or disturb the ejection reflex. Look for the probable cause and talk about it with your helpers, they will be able to give useful advice.

• Forcing the ejection may prevent the ejection reflex temporarily to stop wor-king. Warm compresses, gentle massage and pumping off a little milk will help to awaken the ejection reflex. Using ice will have an adverse effect and block the reflex, so avoid contact of ice on the nipples and aureoles.

• Smoking, alcohol, caffeine containing drinks, hormonal problems or the use of certain medicinal products may also slow or disturb the ejection reflex.

If you are taking medicines which may be affecting the ejection reflex, you should discuss it with your doctor.

• After the delivery and during the first weeks it may take a while for the ejec-tion reflex to be fully operational. It may be necessary to try other means of stimulation of the ejection reflex before such as breast massage looking at baby, or touching him, hearing a baby cry, or smelling him before placing him on the breast.

Stimulation of the ejection reflex

• Problems with lactation are usually put down to a badly Way of working ejec-tion reflex, not low milk production.

• Suggested ways to stimulate the ejection reflex.

- Find a pleasant environment: routinely feeding in a known pleasing environ-ment helps relaxation thus helping the ejection reflex,

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3130 THE INFLUENCE OF DIET ON THE MOTHERTHE INFLUENCE OF DIET ON THE MOTHER

- One cup (150ml) decaffeinated coffee = 3mg caffeine,

- 30g chocolate = 6mg theo-bromine.

• Colic

- This varies from culture to culture. As a general rule mother may eat what she would normally eat and has eaten during her pregnancy.

- You should not eat excessive amounts of cabbage or onions.

• Allergy

- 10% of allergies are hereditary,

- The largest culprit is cow’s milk, followed by soya milk, peanuts and beans, This may be related to absorption rates from the large intestine,

- If baby appears to be over sensitive to something which mother has eaten she should try to avoid that food for a few weeks.

• Milk production

- Sage inhibits milk production, in certain cases giving better results than Parlodel® and Dostinex®,

- Peppermint causes a slight reduction in milk production,

- Alcohol reduces the hormonal stimulus about half an hour after consump-tion, reducing milk production by about 20%,

- If you wish to drink alcohol do it preferably after the feed. Alcohol when drunk in reasonable amounts is excreted from the body within about two hours,

• The vegetarian mother

- There are different types of vegetarianism depending which foods are avoided; some vegetarians use certain animal proteins,

- Lactating mothers who eat no animal proteins must supplement their diet to avoid baby not receiving enough vitamin B12 during breast feeding,

- Vegetarian mothers usually use less calcium and vitamin D. This has no effect in this context on the mother’s milk,

- Milk from vegetarian mothers usually contains fewer pollutants compared to mothers who eat meat.

Advisable foods

• Rule: the demand from baby controls the production. • Fennel: is an ideal treatment for colic when consumed by the mother, not by

baby. Giving an infusion of fennel to baby may have an adverse effect on the flora of the intestine.

• Aniseed stimulates milk production.

• Breast feeding teas: are relaxing and stimulate the circulation, there is no evidence of any benefits, but some mothers enjoy drinking.

THE INFLUENCE OF DIET ON THE MOTHER

10.1 GENERAL

• Baby is a parasite: the young life always has priority. Only after long, serious malnutrition is the quality of the milk compromised.

• Good healthy eating is important, more for your health than that of baby.

• Malnourishment results in a lack of vitamins and fats.

Food supplements

• Regular use of vitamins and/or mineral supplements is not necessary during lactation.

• If you have an unbalanced diet you may well benefit from supplements.

Forbidden foods

• There are not foods which are strictly forbidden varied and within reason are the keywords.

• Changes in the diet changes the taste of the mother’s milk, preparing for the day that he begins eating solid foods.

• Research has shown that babies eat more and longer after you have eaten vanilla or garlic flavoured foods.

• Caffeine and chocolate

- A moderate amount of coffee (less than 5 cups a day) does not cause a problem for lactating mothers,

- More than 5 cups a day can make baby restless and even keep him awake. To check if the symptoms are caused by excess caffeine, you should avoid caffeine for two to three weeks,

- If you wish to reduce your caffeine intake you need to know which drinks to avoid: coffee, tea, cola, chocolate drinks, certain over the counter drugs such as painkillers,

- You should also be aware that theo-bromine has the same effect as caffeine and is present in choco-late and coco drinks,

- One cup of coffee (150ml) = 130mg caffeine,

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3332 THE INFLUENCE OF DIET ON THE MOTHERTHE INFLUENCE OF DIET ON THE MOTHER

10.5 BREAST FEEDING AND OSTEOPOROSIS

• Some mothers believe that breast feeding can lead to osteoporosis. The op-posite is true. There may be a loss of bone marrow during breast feeding, but this is quickly replaced after breast feeding has finished, and will be denser than in mothers who did not breast feed.

10.6 BREAST FEEDING AND POLLUTANTS

• Research has shown that mother’s milk contains pollutants such as dioxins, PCB’s and pesticides. The concentration of these in mother’s milk depends on various factors such as the local environment, the age of the mother, how many siblings, and feeding habits. There is little known of the long term effects of these pollutants. It is however know that if these pollutants are removed from the environment the production of mother’s milk reduces.

• Over the past years there has been a lot of research into the pres-ence of these pollutants. The levels found do not exceed the pros-cribed norms.

• Usually mother gives the largest amounts of these pollutants to baby during pregnancy. The amount given via mother’s milk is comparatively small.

• During the first two weeks of breast feeding mother loses body fats, thus releasing stored deposits of pollutants. The first child to be breast fed receives the largest amount of pol-lutants due to deposits having been built up over the lifetime. The second and subsequent siblings will receive correspondin-gly reduced quantities.

• The risks associated with these pollutants are far outweighed by the benefits bestowed by breast feeding.

• Water and other liquids: drink when thirsty one glass during or after breast feeding according the amount drunk by baby. Never drink against your wishes as this disturbs the liquid balance of the body. A rule of thumb is for mother to examine her stools and urine. Constipation along with concentrated darkly coloured urine is a sign of dehydration.

10.2 CALORIE REQUIREMENTS DURING LACTATION

• The calorie requirements of a nursing mother remain a point of discussion. The nursing mother will not necessarily have a much higher calorie require-ment than normal. Between four and five hundred calories per day may be necessary to avoid weight loss.

10.3 WEIGHT LOSS

• Nursing mothers lose more weight after the delivery than none nursing mo-thers.

• Weight loss by nursing mothers is greatest during the first year after the delivery, being most noticeable during the second half of the year. The longer the nursing period the more weight is lost.

• Nursing mothers begin to lose body fat after the 15 day post partum.

• Restricted diets during nursing have no negative effect on the breast feeding. An average weight loss of four to five hundred grams per week has no adverse effect on the quantity or quality of mother’s milk. Strict diets based on energy intake reduction and drinks are not advisable.

10.4 SPORT AND EXERCISE

• Regular exercise is healthy throughout the lifetime this includes the lactation period.

• Sport has no influence on mother’s milk production or feeding routine of the baby.

• Excessive sport to the point of exhaus-tion will increase lactic acid levels causing baby to refuse the milk. It is the-refore not advised.

• Daily or weekly exercise sessions, not to the point of exhaustion will have no effect on mother’s milk, and is healthy. It helps you to lose weight.

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DIFFICULT PERIODS DURING BREAST FEEDING

12.1 MAMMARY ENGORGEMENT

In General

• Mammary engorgement is decided by the hormonal balance. Oestrogen and progesterone have decreased; prolactin has increased and can do its work.

• There is a large amount of milk available.

• The apprenticeship is finished; baby has his suckling technique more or less in order.

• If you breast fed regularly in the beginning the engorgement will not be so serious.

What is engorgement?

2. Alveoli with milk

IN Breast OUT

3. Low in oxygen

4. Lymph

1. Oxygen rich

Painful engorgement is due to milk accumulation due to over production.

The alveoli are under constant pressure.

The milk producing cells are in danger of being damaged by the pressure.

ALARM SIGNALS:INFECTION DUE TO TISSUE REACTION INFLUENCED BY

DAMAGING INFLUENCES

• Blood vessels open up = more blood to reduce damage = reabsorb milk cau-sing milk destruction.

THE STOOLS OF A BREAST FED CHILD

• They can be very variable, after every feed or every two to three days.

• If baby is feeding well, gains weight, is quiet and has no fever, there is no need for concern.

• The first days the stools may be dark green due to meconium.

• After three days they will become yellow and lumpy. This is a period of adap-tation for baby; he will have more pain from his intestines.

• During the breast feeding period baby will drink larger quantities leading to increased stool production.

• If baby regularly has colic, liquid stools with mucus or blood he may be suffe-ring from an allergy. It is advisable to consult a paediatrician.

• If baby makes few stools or has difficulty passing them should be gently mas-saged on his lower abdomen or back. A warm bath may also help.

• Never give baby laxatives on your own initiative.

• If baby has a fever, runny evil smelling stools or the stools are green. Consult a doctor; if possible take a sample of the stools with you.

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• If baby only wants to eat from one breast relieve the tension in the other by pumping, if necessary under a warm shower. The tension will become more bearable.

• Even if baby has fed from both breasts it may be necessary to pump to relieve remaining engorgement.

• Ask for help during the latching on.

• Sometimes the breast can be so congested that it is and latching on is really difficult. Take a warm shower and manually express off some of the milk. This should improve the situation.

• If there are hard places which are red and feel warm, gently massage them during the feed.

• Between feeds it is possible to reduce the pain by regularly showering, locally apply warmth using a hot water bottle or cold according to your personal taste.

• Never place the hot or cold water bottle directly on the bare breast.

• If the pain remains unbearable ask for a painkiller.

• Remember that once the milk production has stabilised the engorgement will disappear.

12.2 BLOCKED MILK DUCTS AND MASTITIS

• You will have pain and localised swelling in your breast and feel ill caused by mastitis will feel depressed over breast feeding, and will be worried about yourself and your baby.

• Mastitis is a general term for any inflammation of the breast with or without the presence of an infection.

• Inflammation is a localised are of redness, heat, and/or swelling. Inflammation can be the result of physical, chemical, or microbiological damage.

• Infection is the result of pathogenic bacteria causing damage either localised or systemic involving the whole body.

Differentiation between blocked milk ducts and mastitis

• Symptoms: redness, heat, pain and swelling.

• Activities: inflammation is a locally occurring reaction of the cells to damage. It is a normal body defence mechanism. It arises from a complicated series of changes to the structure of the breast, caused by physical trauma perhaps provoked by lactation (engorgement of the breasts) or by an infection. The body tries to repair this damage by increasing the blood supply to the area. This results in the redness, swelling and heat. If the cause was an infection extra lymphocytes will be produced to combat the pathogens. This may lead to the formation of pus.

• REDNESS, SWELLING, WARMTH, PAIN AND OEDEMA = INFLAMMATION (-itis), NOT INFECTION.(=bacterial)

Conclusion: Engorgement is related to OVER PRODUCTION OF MILK.

Treatment of breast engorgement

• Encourage the flow of milk.

• Relax the milk or collecting ducts by applying warmth before the feed = MOST IMPORTANT.

• Use ice compresses after the feed (symptomatic treatment), this initially causes vasoconstriction, followed by vasodilatation. Use for short periods (10 – 15 min.) preferably using a cold compress.

• If baby has problems latching on, let a little milk escape, and massage your nipple to make it softer to use.

• If necessary express a little milk from the breast. This may be repeated the following day. This will enable a better way of working of the breast. If you pump it is best to do it thoroughly and empty the breast. The advantage of occasionally emptying the breast by pumping improves the flow of milk balan-cing out the disadvantage of the stimulation which this provokes.

• The levels of hormones in the blood become automatic after a week to ten days.

• Sometimes due to the continuous pressure of the milk on the cells around the alveoli which may cease to function and atrophy, thus stopping milk produc-tion.

• Ensure that the breasts are well supported and that this does not interfere with the circulation.

• Lay baby regularly on the breast. Make sure that he takes the aureole as well as the nipple completely into his mouth to enable correct suckling.

• Let baby drink longer from one breast. Due to the higher milk production the engorgement of the breast will decrease. This will make the tension in the breast more bearable.

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Treatment of mastitis Improve the milk flow

• Heat and massage. Heat is a treatment of the cause. The stagnation of the milk will be treated and the milk flow improved, as opposed to cold which is a treatment of the symptoms. Therefore, better warm than cold. At least twice a day, between feeds, place a bowl of warm water under the breast, take a warm shower, or bath. Gently massage the hard areas of the breast, then feed baby or suck off milk so permitting milk to flow whilst the breast is warm.

• Feed baby from the inflamed breast: start with the inflamed breast every two hours even during the night while ever the breast remains sensitive.

• Loosen tight clothing especially the brassiere: if possible try not to wear a brassiere for a few days, or wear one that is not too tight.

• Make sure that baby is well latched on with the nipple at the back of his mouth. • Vary the feeding position: Riordan and Auerbach recommend changing the

position of baby’s nose against the breast at least once. • Rest: mastitis may be a sign that you are doing too much. Take baby to bed

and stay there until you feel better. Rest is an important part of the treat-ment.

• If the fever has not reduced within 24 hours or of the temperature suddenly increases you should visit a doctor.

• If medication is necessary request something compatible with breast feeding. • It is important for both mother and baby to continue breast feeding during the

treatment of mastitis. • Mastitis can make mother’s milk saltier causing baby to refuse the breast.

After a week the saltiness should decrease and baby will once again accept both breasts.

• Some mothers with blocked milk or collecting ducts are sometimes able to suck the blockage out.

• If the lump has not reduced after a couple of day’s treatment, mother should consult a doctor to rule out other causes.

12.3 CRACKED NIPPLES

Cause

• Nipple problems are provoked by mechanical damage or skin irritation. • Mechanical damage may be caused by bad technique: bad latching on: bad

drinking technique: ingrown nipples or too short a frein. • Skin irritation may be caused by poor personal hygiene, allergy to certain

creams or materials which come into contact with the skin, an infection. • Women with sensitive skin are more susceptible to cracking. • Cracks may also become infected. Keep them clean.

Causes of mastitis

An inflammation is not an illness, but a reaction to an event. Before the inflam-mation can be treated it is first necessary to find the cause.

Conclusions may be drawn that mastitis is always the complication following a blockage of the milk or collecting ducts resulting in an infection.

• Missed or incomplete feeds with an irregular schedule. Anything which re-duces the time that baby spends feeding at the breast may result in the breast becoming overfull. Thus increasing the chances of mastitis.

Reasons for short, missed or irregular feeding schedules are

- Limited time for the feed or baby falls asleep before he has finished,

- Baby starts to sleep through the night,

- Baby receives supplementary feeding,

- Baby starts to use a dummy (soother),

- Busy day not leaving time for the feed,

- Sudden changes to the feeding schedule, the first teeth appear, baby re-fuses the breast, baby drinks less, mother starts work etc,

- Baby feeds less often with more than three hours between feeds.

• Permanent pressure on the breast. Any continuous pressure on any part of the breast can result in disturbance of the milk flow resulting in mastitis.

Examples:

- A tight brassiere,

- A brassiere not giving enough support,

- A baby transporter shoulder bag or such which causes pressure on the breasts,

- Thick nipple compresses or nipple protectors causing the brassiere to be too tight,

- Mother sleeps on her stomach,

- Baby lays on mothers breasts,

- Mother holds her breasts too tightly during the feed,

- Baby presses on the breasts with his hands,

- Poor latching on,

- Poor suckling by baby.

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• Drying the nipples in the air, sun or with a hairdryer does not help the treat-ment of cracked, painful or bloody nipples. Research has shown that deep skin humidity or moist wound healing encourages quicker healing without the formation of scabs.

• Deep skin humidity is not the same as applying moist compresses to the area. Deep skin humidity is provoked by smearing the affected area with a barrier cream to keep the moisture in the tissue and thus avoiding formation of cracks or scabs. Double purified lanolin may be used. (available as “Lansinoh®” or “Purilan®”)

• Many creams and other products sold for the treatment of painful nipples only increase the problem. A thick layer of cream can make the nipple slippery and block the pores. Removing the cream before feeding may further damage the area.

• Mother’s milk offers a natural alternative due to its antibacterial effects.

• Brassieres and compresses made of synthetic material may slow the heeling process.

• Nipple shields placed over the nipple during feeding may cause more problems than they solve.

• Interrupting breast feeding is seldom necessary.

• Sucking blood from the damaged nipple is not harmful for baby it will only be a very small amount as the vacuum closes the wounds and stops the bleeding.

• Assure mother that painful nipples will heal and that baby will be able to breast feed for a long time.

• Skin which remains warm and moist is more susceptible to cracking. Change your compresses regularly.

Signs

• Mechanical damage

- Pain during the feed,

- Usually not sensitive to the touch,

- Pain is localised,

- Begins in the period just after the delivery. • Following skin irritation

- Pain is during and after the feed,

- Sensitive to the touch,

- The entire aureole is affected,

- Can start any time unrelated to the birth.

• ATTENTION: the difference between mechanical damage and a skin irritation is not always obvious. They may even occur together.

Treatment

• The cause of the cracking, painful or bleeding nipples needs to be determined. Then we can decide on a proper treatment.

- Changes in the feeding position and locking on,

- Correct the drinking technique,

- Treat any thrush, eczema or other diagnosed problems,

- Employ relaxed breathing techniques, various feeding positions, older chil-dren can be asked not to bite so hard, suck off some milk before feeding baby if a newborn child.

• Once the cause has been determined we can take steps to combat the pain while the nipple heals. Once baby has latched on properly there should be no further damage to the nipple. The following will help:

- Before the feed manually stimulate the ejection reflex, start the feed with the least painful breast followed by the painful side paying attention to the positioning.

- After the feed allow excess milk to dry on the nipple. This does not apply in the case of thrush.

- Cover the nipple with purified lanolin after the feed to prevent drying out.

• If clothing causes pain use compresses to protect the nipples.

• Take analgesics which are compatible with breast feeding.

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The choice of equipment

The choice is dependent on various factors.

a) Depending on the work routine of the mother • How long will the separation be?

• Limited time available: double set usually takes 10 – 15 minutes, but expect leaks.

• Environment: relaxation and privacy.

• No electric sockets: double battery operated pump, or manual pumps which do not operate on both breasts.

• Space available.

• Battery operated electric pump which can be attached via a cigarette lighter point to the car battery.

• Full time workers:

- If baby can be close to you, plan the feeds to be no longer than four hours apart and coincide with work breaks,

- If you can go to baby, plan the feeds to be no longer than four hours apart,

- If you are working full time and exclusively breast feeding, the efficiency of the pump is very important.

• Part-time workers

- Double pumping is fast and efficient,

- Less than four hours absence, you are working from home or close by, breast feed just before leaving. In which case, pumping is perhaps not ne-cessary,

- If the absence is between four and six hours, pump at least once and on days off breast feed more often,

- More prolonged absence suck every two to three hours so that you feel comfortable, and maintain production levels.

b) Noise level Some pumps are silent but others are relatively noisy. Choose a noise level

which suits your circumstances.

c) The pumping must be effective • In order to:

- Stimulate prolactin,

- Release oxytocin,

- Produce milk.

• The effectiveness of the pump is in relation to:

- The pump sucks 45 – 60 times per minute; if the rhythm is less frequent the breast will be less well stimulated, resulting in less milk production,

PUMPING

13.1 CHOOSING A PUMPING METHOD

• The pumping method will vary according to the circumstances and your personal taste.

• Your personal feelings and circumstances are important in the choice of pumping method.

• Double sided pumping using a fully automatic machine is a quick easy and effective method; certainly if for any reason mother and child need to be separated for a long period.

• Pumping is an acquired art which needs practice, especially if a manual method is to be used as it requires co-ordination.

• Some mothers prefer to express the milk manually without the use of a pump.

Factors involved in the decision

• How often will you need to pump milk?

• Are you aware of the different methods available?

• The choice is very personal and needs to fit in with your needs. Is it to increase production? Powerful pumping is needed. Is it to make an evening out more comfortable? Less powerful pumping is needed.

• The choice is yours

- Effectiveness,

- Comfortable,

- Budget,

- Ease of use,

- Ease of access,

- Easy to clean,

- Cited reasons – quantity of milk produced – quickest – painless.

• Research involving 200 mothers showed that the most popular well when:

- It produced quick results,

- The amount of milk produced per breast was exceeded 60ml,

- It was painless,

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• To reduce pain use: a silicone teat: massage and apply positive pressure around the aureole; the smaller the teat the greater the pressure on the end of the nipple. The larger and deeper the teat the greater the stimulation.

13.2 BASIC PRINCIPALS OF BREAST PUMPING

Realistic aims

• Breast pumping is an acquired art. As with everything practice makes perfect.

• The more you do it the more proficient you will become.

• The first attempt should be considered as a trial.

• The quantity of milk which can be pumped of depends on many factors. - Are you mentally prepared to eject the milk?

- How long is it since your last pumping session?

- How much experience do you have in the use of the equipment?

- How comfortable one feels in the chosen environment,

- How much time is available?

- Milk production,

- If you are tense the ejection reflex with be reduced.

• Drinking larger quantities of liquid will increase neither the quantity of milk produced, nor the quantity pumped. Drink when you are thirsty is the best advice. Constipation and dark coloured concentrated urine are good indicators that you are not drinking enough.

• Breast pumping takes about as long as feeding baby, except if you are using a double pump.

• None of the pumping methods is as effective as baby at empting the breast. This is due to the emotional your feelings towards your baby and the better stimulation from baby, not only sucking, but using his tongue, cheeks etc.

Stimulation of the ejection reflex

• Problems associated with pumping are the result of poor ejection reflex as opposed to low milk production.

• Suggestions for stimulating the reflex.

- Find a comfortable location: routinely working in the same environment pro-duces a feeling of well being resulting in better Way of working of the ejec-tion reflex,

- Reduce distractions: take the phone off the hook and switch off your mobile, play relaxing music, see that you have everything you need close to hand; books; drinks; snacks. Make sure that older children also have everything they may need,

- How does the pump rhythm work? suck – short pause – deflate.

d) The size of the pump. Does it need to be portable, or can it be left where it will be used?

e) Safe efficient extraction of milk adapted to the breast f) Confort Automatic electric pumps are in general more comfortable than hand pumps

where you must make your own rhythm.

g) Energy source • Access to an electric socket influences the choice.

• Some large pumps need special sockets and adapters.

h) Price • If you are working full-time or baby never drinks directly from the breast a fully

automatic double pump is the most efficient and economic.

• If you wish to use a battery powered pump you needs to take into account the cost of the batteries.

Hormonal influences of a breast pump

a) Prolactin • Prolactin levels remain high even after the first weeks following the delivery.

The levels are comparable during breast feeding and pumping. After three to four months breast feeding the peaks are reduced.

• Pump at least eight times per 24 hours, at least once during the night, when the hormonal levels are at their highest.

• Avoid painful swelling of the breasts, if this lasts longer than 48 hours it may have a negative effect on milk production due to pressure on the alveoli stimu-lating the production of peptides.

• Begin breast feeding early: nipple stimulation and extracting the milk are necessary to enable the production of hindmilk later in the breast feeding, as explained earlier under the section “hormonal function during breast feeding”.

• It is a question of supply and demand, the more you take the more you get.

• In general double electronic pumps are more popular than hand pumps.

- Higher prolactin peaks,

- Small increase in the levels of fat in the milk, providing there is no time limit on the pumping.

b) Oxytocin • Increases the pressure in the ganglions and milk or collecting ducts.

• Stimulates the let-down reflex, promoting milk production.

• Baby taking the breast will cause this stimulation.

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the size of the aureole as this varies from person to person. The fingers are now resting on the milk or collecting ducts.

2. Press the thumb and fingers towards the ribs. Do not spread the fingers. Large breasts should be raised slightly before pressing.

3. Roll the thumb and fingers forwards as if making finger prints of the all at the same time.

4. Repeat this rhythmically to empty the reservoirs. The rhythm should be place the fingers, press, roll, and so forth.

5. Massage the whole of the breast so that all the milk or collecting ducts become involved. Use both hands on each breast in turn. Warn mother not to nip, or pull the breast to avoid damage to the breast. Alternate between caressing and shaking to stimulate the ejection reflex.

b) Massage the ganglion and milk or collecting ducts • Method

1. Use both hands for each breast and start at the base.

- Press the fingers towards the ribs and move in a circular motion,

- After a few seconds move the fingers further round and repeat,

- Massage the entire breast in this way moving towards the nipple, this is the same movement as inspecting your breast for growths,

2. Gently stroke the breast in the direction of the nipple. Do this around the entire breast to help stimulate your ejection reflex.

3. Lean forwards and shake the breasts from side to side. This acts as a relaxa-tion and stimulates the ejection reflex.

• If you wish to pump a complete feed you should proceed as follows: - Pump the milk until the flow reduces, - Stimulate the ejection reflex on both breasts by stroking, massaging and

shaking. You can perform this on both breasts at the same time, - Repeat this procedure several times, after the second or third time the milk

flow will reduce sooner than before, until the reserves are empty, • The complete process can take 20 – 30 min. - Pump each breast 5 – 7 min., - Massage, stroke and shake, - Pump each breast 3 – 5 min., - Massage, stroke and shake, - Pump each breast 2 – 3 min..

- Follow a ritual whilst pumping: warm the breasts using warm compresses or having a shower. Place a warm shawl over your shoulders and sit close to a heater, warmth helps relaxation. Gently massage the breasts and stimu-late the nipples. Relax for five minutes with breathing exercises. If you are separated from baby, calling to enquire about him will also help stimulate milk production,

- Pump the milk whilst moving rhythmically to imitate baby’s movements: this helps to stimulate the ejection reflex,

- Think about baby: look at a photograph or other reminder of baby,

- Pump with baby close by, or while feeding him at the other breast: if baby is in an incubator or lying skin to skin, but not feeding,

- Massage during pumping: take a break every ten minutes or so and massage the breasts before continuing,

- Pump each breast several times during the same session.

• Mother’s emotions can influence the ejection reflex, especially during the ap-prenticeship. Pump when you are feeling relaxed and can take time. Breathing exercises and yoga will help.

Pumping of milk using your hand

You should thoroughly wash your hands before starting. Hygiene is very impor-tant. Two techniques are explained here.

a) The marmet® technique

• Aspirating milk using the hand needs to be learned in the same way as pum-ping. Mother needs to imitate the movements of a suckling child and let the milk flow without a child on the breast.

• This technique consists of alternately aspirating the milk and massaging the breast, gentle rubbing and shaking. This technique may be used to relieve over full, or to pump a complete breast.

• Method

1. Both hands should be used on one breast. The thumb should be placed 2.5 – 4 cm above and behind the nipple, the index and middle fingers being placed below in the shape of a “C”. These measurements do not necessarily relate to

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- Adapt the pumping cup to the size of your breast using any necessary adap-ters,

- Avoid long periods of uninterrupted vacuum,

- Stop pumping when the flow is minimal, or ended.

13.3 DIFFERENT PUMPING METHODS FOR DIFFERENT CIRCUMSTANCES

Breast feeding needs to be delayed after the delivery

a) Baby cannot drink from your breast because he is premature, baby or you are sick

• Begin pumping as soon as possible, preferably within six hours of the delivery.

• After the delivery it can take several days before the milk production is fully functional. Until this time small quantities of colostrum will be produced. The first pumping sessions are important to stimulate milk production and acquire the necessary techniques.

• You should try to persevere with a daily pumping routine irrespective of the frequency of pumping. Short regular pumping sessions of minimum 10 – 15 min. stimulate the milk production better than longer less frequent ses-sions. A minimum of 5 – 6 times per day for 10 – 15 minutes per breast is advisable. Some women have remarked that if they only pump enough milk for the needs of baby whilst he is hospitalised, they have difficulty producing enough milk when he returns to the breast.

• Your feelings will decide when you pump during the night.

• The setting up of a daily pumping schedule five of six times a day should take account of the needs of other family members especially if there are older children involved. This is dependent upon the condition and needs of baby.

b) The first three days • Ideally you should start pumping within six

hours of the delivery. Early and regular pum-ping has been shown to result in greater milk production later in the lactation.

• The aim is to minimalise painful swollen breasts and encourage milk production.

• During the day pump regularly every three hours, during the night it is not necessary.

c) Baby is three to five days old when the milk production increases • If baby cannot breast feed for two weeks pumping is necessary to maintain

milk production.

• If you wish to produce more milk you should pump every three hours for ten to fifteen minutes per breast. At night only if necessary.

c) The traditional method

• Manual milk pumping is used in many traditional societies. This technique is described in a breast feeding management document published by UNICEF (Helping Mothers to breast feed by F. Savage King (1992)).

• Manual pumping takes 20 – 30 min. regularly change the breast as soon as the milk production diminishes (3 – 5 min per breast).

• Stimulate the breast by gently massaging the nipple and aureole.

• Place your index finger below and your thumb above the aureole.

• First press the finger and thumb towards the ribcage, then squeeze rhythmi-cally with the finger and thumb to stimulate the milk flow.

• By moving the fingers round the beast all parts of your breast can be emptied.

• Your hands start too hurt try changing your technique.

Recommendations for using a pump

• Read the instructions for use before you start.

• Wash your hands before every session and ensure that the pump and reci-pient to be used are clean.

• You will obtain the best results if you follow the instructions and place the nipple in the centre of the correctly sized shield and set the suction to a mini-mum.

• Pumping should be painless, if this is not the case change your technique.

• The frequency of the pumping sessions depends on your aims: occasional pumping, stimulates milk production, keep milk production working, go out to work...

• Duration of a pumping session.

- Awaken the ejection reflex,

- Use as much pumping as is needed to maintain the milk flow, whilst remai-ning comfortable,

- Massage your breast in quadrants before and during the session, to in-crease inter-mammary pressure.

- Make sure you have enough time for the pumping as rush – rush will only result in reduced milk production,

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you need to be comfortable. Do not expect the first time to be perfect, if he wishes let him amuse himself by licking the nipple or playing with it. This will only help in the future.

• Good positioning and latching on are essential for good breast feeding.

• Keep a watchful eye on baby and stimulate the ejection reflex so that he will be instantly rewarded for his efforts, maybe express a little milk as encoura-gement.

• Do not restrict the time let him feed for as long as he wishes.

• If the attempt is not successful reward him by feeding mother’s milk by a different means.

• You can check the success or failure of the feed by checking to see if the ten-sion in your breasts has reduced, and later by checking his nappies (diapers). You can also check to see what weight gain has occurred.

• Whilst baby is undergoing the transition to breast feeding if is not advisable to feed with a bottle at the same time as baby may become confused.

• If baby has become used to drinking from a bottle the transition make take longer.

• If baby becomes restless, sooth him and try again.

• Eventually breast feeding will become natural.

i) Breast feeding is interrupted • Mothers stop breast feeding for various reasons such as illness, medication,

journeys etc., but plan to start again.

• Temporarily stopping breast feeding is stressful for both mother and baby. You may experience physical problems in-cluding painful swol-len breasts, and emotional stress. Baby may also ex-perience feeding problems and become restless due to the lack of your inti-mate contact.

d) Baby is being fed intravenously or only takes a small amount of mother’s milk e) The needs of baby increase or baby comes home within two weeks • If baby is soon expected home a sufficient milk supply will ensure an easier

transition to breast feeding.

• Try to increase daily pumping sessions to 7 – 8 times and set the alarm at least once during the night. It is best to pump until your breasts become softer, which usually corresponds to 10 – 15 minutes pumping per breast.

• The target is to increase milk production to accommodate the needs of baby.

f) When baby begins to breast feed • Once baby begins to suckle you will need to adjust your pumping in accordance

with how much and how often baby wish to eat. This will reduce your need to pump.

• Try one way or another to pump eight times per day.

• Goal: pump sufficiently to soften your breasts.

• If baby mainly drinks from your breast it is important that he gets enough food.

• Some mothers notice after a time that milk production reduces. If this is the case you should pump more often to increase your milk production.

• If you are going through a difficult period emotionally it is normal for your milk production to reduce temporarily.

• You should ask advice from the hospital where your baby is being treated how you should store your milk for baby: sterile storage bags, feeding bottles. You should ensure that any packaging carries a label with baby’s name and the time and date of pumping.

• If baby stays in the hospital and you return home you will need to ensure that you milk is delivered to the hospital. It is important that cooled milk does not warm up and frozen milk does not thaw out during transportation. You can either pack it in ice or place it in a cool box1.

g) If you are not in a condition to breast feed • If you are not in a physical condition to breast feed after the delivery, it is

perhaps best not to begin pumping especially if baby can feed normally.

• Aim: stimulate sufficient milk production to make the transition easier when you recover.

• To avoid confusion concerning the feeding method: use alternative means, but not a bottle.

h) Transition to the breast • To get baby used to mother’s milk you can lay a compress which contains a few

drops of your milk close to his head, so that he gets used to the smell.

• The first feeds will take patience and time. Try feeding in a different isolated place to where you would normally feed him. Make sure you have everything

1. See chapter 14: Safe handling of mother’s milk

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• You need to plan when you are going to pump and when you are going to breast feed and what you are going to give while you are away, mother’s milk or synthetic products.

l) Casual separation • If you are only aspirating on a casual basis you can do this either using your

hand or a manual pump.

• If you are feeding on a demand basis you can organise you pumping sessions in several ways.

- Pump once a day for example in the morning,

- Pump small amounts several times a day,

- Pump one breast while baby drinks from the other.

• Always explain to your baby sitters how they should use mother’s milk and give baby the bottle.

• Instead of aspirating you can simply take baby with you.

• During the separation pump as often as you would feed baby to keep your milk production working.

• If you are only breast feeding, or even mainly breast feeding, you will have to find an pumping method which suits your circumstances.

• You will have to choose an alternative method for baby also.

• If you do not pump often enough during the interruption you may find that your milk production reduces, normally this will return to normal once you start again.

• Sometimes baby may need encouragement to restart breast feeding.

j) Breast feeding will be replaced by pumping

• There are many reasons why you would choose to pump rather than breast feed.

- Baby does not want to latch on,

- Baby cannot latch on because of a deformity,

- Baby refuses the breast after a long break in breast feeding,

- During the first week of hospitalisation baby preferred the bottle,

- Your nipples were sore and baby did not latch on properly,

- Pumping and bottle feeding fit in better with your lifestyle,

- You do not feel at ease breast feeding in public.

• Mothers who pump one breast at a time take twice as long to produce the same amount of than those who pump both at the same time.

• Mothers have said that during the first week they need to pump more than six times in the day to keep their milk production at al level high enough to feed baby solely with mother’s milk. Once the milk production started they could reduce this to between four and six times.

• The quantity of pumped milk was influenced by the time between pumping sessions.

• As long as you keep aspirating, you will produce milk.

• If you decide to stop pumping you need to slowly reduce the number of daily sessions to avoid painful swollen breasts and other such problems. There are several methods you can use:

- Reduce the number of daily feeds by one every three days,

- Progressively reduce the quantity of milk you pump per session by 30ml at a time,

- The aim is to stop aspirating with the minimum possible discomfort.

k) Regular separation of mother and baby

• Even if you need to be apart from baby due to work, studies or other reasons you can still breast feed.

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needs to be thawed out before use by the crèche, baby minder or whoever, you should also mention the full name of your baby to avoid confusion.

• If baby is only receiving pumped mother’s milk, you should also give vitamin C.

• If baby was premature or in sick other guidelines may be followed.

14.2 THE CHOICE OF CONSERVATION METHOD FOR MOTHER’S MILK

• Bottles, pots or other storage containers used for the storage of mother’s milk maybe made of glass, plastic or stainless steel. If you feed baby mainly directly from your breast and only occasionally pumped mother’s milk, the storage medium is of little importance as compared with those used if baby is receiving mainly pumped mother’s milk.

• Research into the type of storage media used to the materials used for sto-rage are contradictory. The storage time must also be taken into account.

• All media used for the storage of mother’s milk must be clean.

• For rigid storage media you should use boiling water containing baking soda, rinse thoroughly with clean boiling water and allow to drip dry in the air.

Plastic storage sacks for mother’s milk

• Advantages

- They take less storage space than bottles,

- They can be attached directly to the aspirator,

- They are quicker to use as the milk does not need to be transferred into them using accessories which also need to be cleaned,

• Disadvantages

- Risk of leakage,

- Less airtight,

- More chance of infection.

• Precautions

- Use bags which are thicker, and double walled, and available pre-sterilised,

- Squeeze the air out of the top,

- Roll the sack to about 2.5 cm (1 inch) above the level of the milk,

- Fold the sack and stick closed,

- Place to sealed bag upright in a box and close the lid before placing it in the deep freeze.

Glass

• Glass is the material of choice as storage media.

SAFE HANDLING OF MOTHER’S MILK

14.1 HOW LONG CAN MOTHER’S MILK BE STORED?

• Research has shown that mother’s milk has natural antibacterial properties which protect the milk against bacterial growth which means it can be stored longer than was previously thought possible.

• The storage time of mother’s milk varies according to where and how it is being stored.

• The following guidelines apply to mothers who:

- Have a healthy growing baby,

- Wish to store their mother’s milk at home as opposed to in the hospital,

- Wash your hands before every pumping,

- Wish to store their milk in bottles or containers which have been thoroughly washed.

Room Temperature

Refrigerator(2-4°C)

Freezer tray in Refrigerator

***Freezer(min. –15°C)

Chest freezer(-20°C)

Transport to or from the hospital

Colostrum 12-24 hours

Maximum 6 hours

Fresh mother’s milk

6-10 hoursMaximum 8 days

at the back of the refrigerator

Cannot be frozen in this location

Frozen within 24 hours,

may be stored for 24 hours

Frozen within 24 hours,

may be stored for 6 months

In a cool box with cooling elements

Maximum 6 hours

Maximum 48 hours

Cannot be frozen in this location

Frozen within 24 hours,

may be stored for 24 hours

Frozen within 24 hours,

may be stored for 6 months

In a cool box with cooling elements

Deep frozen mother’s milk

Defrost 2 weeks 3 months 6 monthsIn a cool box with cooling elements

Defrosted mother’s milk

Use within the hour

• Guidelines for the home situation.

• Guidelines for the hospital.

• If you are storing mother’s milk in the refrigerator do not place it inside the door as the temperature changes when opening and closing the door, it is best placed at the back of the refrigerator where the temperature remains constant.

• If you are planning to store the milk you need to make labels with the date and time of the pumping so that you can use them in date order. If the milk

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BREAST FEEDING BREAST FEEDING

5756 SAFE HANDLING OF MOTHER’S MILKSAFE HANDLING OF MOTHER’S MILK

• If you are storing mother’s milk to be used at your workplace or in a crèche there are no particular precautions necessary, just keep it cool in a refrigera-tor.

Warming mother’s milk

The warming of mother’s milk is a delicate procedure. Research has shown that bacteria proliferate once you start to warm your mother’s milk. This should pre-ferably be done as quickly as possible to keep this proliferation to a minimum. In this respect it would seem logical to use the micro wave. Unfortunately the micro waves have a detrimental effect on the quality of drastically reducing the protective properties of mother’s milk. It is therefore advisable to employ one of the following methods.

- In a bottle warmer,

- Under running warm water,

- In “bain-marie” using warm not boiling water,

- At room temperature.

Irrespective of which method you choose the time required should be limited to 15 to 20 minutes to reduce bacterial growth. If these guidelines are followed you can me sure that mother’s milk has a better nutritional value than artificial powdered milks.

• Advantage

- Rigid,

- Most protective as it is the least porous,

- Best protection for frozen milk.

• Precautions.

- Only tighten the top once the milk has frozen to allow the air top escape.

Opaque hard plastic (polypropylene)

• The second choice material.

• Usage and precautions are the same as for glass.

14.3 USAGE AND DEFROSTING OF MOTHER’S MILK

Using mother’s milk

• Fresh mother’s milk will curdle, because it is not homogenised and may have a blue, yellow or even brown tinge.

• Mother’s milk which has been pumped over a period of 24 hours may all be stored in the same storage media, which has been stored between 0°C and 15°C during this time. The shelf life of this media dates from the time and date of the first mother’s milk which it contains.

• Freshly pumped mother’s milk may be added to frozen mother’s milk, providing that the fresh mother’s milk has been cooled to avoid melting the top layer of the mother’s milk and that it has a smaller volume.

Defrosting mother’s milk

• Defrosting can be done as follows.

- In the refrigerator,

- Under cold running water which is gradually warmed but not boiling until room temperature is achieved,

- In “bain-marie” using warm not boiling water,

- In a bottle warmer if you are going to use the mother’s milk straight away.

- NEVER in the micro wave as valuable elements will be destroyed if the tem-perature exceeds 55°C.

• Once defrosted mother’s milk may be kept cool for up to 24 hours, but never refrozen.

• Store frozen mother’s milk in quantities of between 60 and 120ml to avoid wastage.

• Baby needs less mother’s milk than artificial powdered products.

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BREAST FEEDING BREAST FEEDING

5958 PROGRESSIVE WEANING OFF FROM BREAST FEEDINGTHE CRYING BABY

THE CRYING BABY

• Crying babies cause great consternation among their parents.

• It is easy to think that they are crying because they are hungry, but this is not always the case.

• Do not forget that crying is one of the few ways that baby can show his dis-pleasure with a situation.

• Eventually you will learn to understand the various different cries: hunger, colic, defecated or a need to defecate, tired, over exited, needing a cuddle, needs to burp, over full.

• Colic or stomach cramp is a common cause of crying. These may be caused by baby sucking too much air during feeding and has not been fully winded, eats too greedily or too much. Observation of baby is important. A baby suffering from colic has a harsh angry cry and will normally kick with his legs and ball his fists.

• In the event of colic hold baby upright to let him burp. Massaging his back and stomach maybe even giving him a warm bath can reduce the symptoms and calm him. Other calming methods are:

- Hold baby upright with his stomach on your shoulder with his arms down your back and massage the bottom of his back,

- Sit down and lay baby across your knees, massage his lower back,

- Lay baby on his back and massage his stomach with either your fingers or hand in a clockwise motion,

- Massage baby’s stomach whilst he lays in a warm bath.

• Colic can last between an hour and an hour and a half.

• If the crying continues or you can no longer cope with it, do not hesitate in asking for help.

PROGRESSIVE WEANING OFF FROM BREAST FEEDING

• Either you choose when to stop breast feeding to suit your lifestyle, or you can let baby decide.

• Guidelines from the World Health Organisation:

- During the first six months it is advisable to give 100% breast feeding,

- From six months solid foods such as mashed vegetables and fruit may be added to the diet. These should be given after baby has taken the breast,

- After a year this order should be changed. First give solids, then your milk, - Breast feeding is advised up to at least two years because of the active

immunology it provides, as the immunological system of the baby is not yet fully Way of working. The immunological system of the child functions fully from six or seven years of age.

• When you decide to stop breast feeding you should do so slowly to avoid pain-ful swelling of the breasts with all the associated problems.

• Begin by giving a bottle in place of the breast for either the noon or afternoon feed. Let you body get used to this new rhythm.

• After two or three days repeat the process for another of the feeds, and so forth.

• You should aim for a system of – breast feeding – artificial food – breast fee-ding etc. The aim is to reduce to three daily sessions of breast feeding.

• Reduce this to two, then one breast feeding session daily. Finally stopping completely.

• This process can take two weeks or more.

• If despite the fact that you have stopped breast feeding you are still producing large amounts of mother’s milk, consult your doctor who will prescribe medi-cation to inhibit the production of prolactin. Drinking two or three cups of sage tea over a few days may also help.

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BREAST FEEDING BREAST FEEDING

6160MOTHER’S GROUPS AND

OTHER SUPPORT NETWORKS AND THEIR FUNCTIONSMOTHER’S GROUPS AND OTHER SUPPORT NETWORKS AND THEIR FUNCTIONS

• Telephone helpline

- English 02/768 14 85 (Mandy), 02/660 77 67 (Carla)

- French 02/268.85.80

• Site Web

- http://users.pandora.be/la leche league/

- Website in English, French, German and Netherlands.

17.2 ASBL BREAST FEEDING

a) Activities

• A feminine association aiming to make breast feeding a success.

• The contact persons are mothers with a large experience of breast feeding

who have been trained by the association.

b) Way of working

• Telephone helpline.

• Groups of mothers

- Monthly information evenings,

- Pregnant women, breast feeding mothers and their spouses.

• Lectures and conferences.

- Aimed at other associations, schools...

- Aimed at doctors, midwives, nurses...

• Lists of material: books about breast feeding.

• Magazine

- “L’enfant allaité” – the breast feeding child,

- Published quarterly,

- Aimed at parents and other interested people.

• Protection, improvement and support for breast feeding aiming for a healthy

lactation. Member of l’IBFAN.

MOTHER’S GROUPS AND OTHER SUPPORT NETWORKS AND THEIR FUNCTIONS

Once you are home you can obtain help and information about breast feeding from one or more of the organisations listed.

17.1 THE LECHE LEAGUE

a) Activities

• An international organisation founded in 1956.

• Provides information for mothers wishing to breast feed.

• Gives information on breast feeding through a worldwide network of around 10,000 trained volunteer advisers.

• LLL International works in conjunction with the WHO, UNICEF, and a group of international advisers.

b) Way of working

• Mother to mother

- Mothers who have breast fed,

- Extra training,

- Continuous information.

• Meetings to discuss breast feeding

- Monthly meetings,

- For future mothers, breast feeding mothers, family and any other interested parties.

• Advice on health matters

- Courses and lectures for schools and health workers,

- Quarterly newsletter with medical and scientific information “breast feeding abstracts”.

• Publications

- Brochures,

- Handbook in many languages,

- Newsletter “breast feeding today”.

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BREAST FEEDING BREAST FEEDING

6362MOTHER’S GROUPS AND

OTHER SUPPORT NETWORKS AND THEIR FUNCTIONSMOTHER’S GROUPS AND OTHER SUPPORT NETWORKS AND THEIR FUNCTIONS

b) Way of working • Conduct prenatal courses for couples covering all aspects of the pregnancy

and delivery.

• Telephonic advice about breast feeding, from trained volunteers.

• Provide information concerning doctors and hospitals.

• Organise social events to get to know other people.

c) Where? • BCT IMAGINE, Mechelsesteenweg 77, 1970 Wezembeek-Oppem.

• Telephone: 02/215.33.77

• www.bctbelgium.com

17.3 INFOR-ALLAITEMENT

a) Activities • Promotion and support of breast feeding.

• Aimed at pregnant parents, breast feeding mothers and carers.

• Women volunteers with in depth experience of breast feeding. The volunteers have had specific training.

b) Way of working • Telephone helpline 02/242 99 33.

• Animation.

• Training of professionals, volunteers...

• Media.

• Distribute a free brochure developed in collaboration with the French commu-nity of Belgium.

• Make available brochures and reference manuals

- Have a large range of brochures and documentation for all needs,

- A large range of manuals for the health professionals.

• Support the international breast feeding week

- During the 40th week of the year: from 1st to 9th of October,

- Organised by WABA and supported by UNICEF.

• Supported by the Federal Committee for breast feeding.

• www.infor-allaitement.be

17.4 BCT (BRUSSELS CHILDBIRTH TRUST)

a) Activities • An independent non-profit making association.

• Aimed at parents with young children.

• Mainly target English speaking people, but welcome all nationalities.

• Provide help and support during the pregnancy, delivery and parenthood.

• Provide help in making friends and organise social activities.

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BREAST FEEDINGBREAST FEEDING

6564 USEFUL WEBSITES

USEFUL WEBSITES

- www.allaitemntmaternel.be

- www.infor-allaitment.be

- www.babyboom.be

- www.santeallaitementmaternel.com

- www.illfrance.org

- www.allaite.org

- www.breastfeeding.com

- www.breastfeedingoline.com

Sources used in the production of this brochure

• Protection, promotion and encouragement of breast feeding in the politics of healthcare. Declaration of the innocents UNICEF/WHO July 1990.

• International code of practice concerning substitutes for mother’s milk, WHO.

• “Breast Feeding and Human Lactation” third edition by John Riordan.

• Courses in lactation at Arteveldehoogeschool in Gent, school year 2004 – 2005

- Gonneke van Veldhuizen, lactologist IBCLC, Lecturere Arteveldehoogeschool Gent,

- Karin de Graaf, Lactologist IBCLC, Lecturere Arteveldehoogeschool Gent.

• Handbook of Lactologie, La Leche League, 2002.

• Medical Dictionary. Pinkhof-Hilfman, 9th edition.

• “Medications and mother’s milk “. Thomas Hale.

• Evidence for the ten steps to successful breast feeding, WHO.

• The websites mentioned in chapter 18.

MATERNITY UNIT

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entrance Avenue Ptolémée

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ACCESS

SITE ST-ELISABETH

Car: Paying parking under the hospital, avenue De Frélaan.Bus: Lines 41 (Hôpital Sainte-Elisabeth/Sint-Elisabeth Ziekenhuis),

38 (René Gobert), 136, 137 (Defrélaan), 365 & W (Avenue Defré).

SITE ST-MICHEL

Car: Paying parking under the hospital, in rue Charles Degrouxstraat Tram: Lines 7 & 25 (Georges-Henri), 81 & 83 (Mérode/Merode) Underground: Lines 1 or 5 (Mérode/Merode)Bus: Lines 28 (Vergote), 27 & 80 (Georges-Henri), 61 (Chevalerie) and

22 (Mérode/Merode) Train: Mérode/Merode train station

MATERNITY UNIT

Site St-Elisabeth Tel.: 02-614 29 20 Site St-Michel Tel.: 02-614 39 80

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www.europehospitals.be

Site St-Elisabeth

avenue De Frélaan 206 - 1180 Brussels Tel.: 02-614 20 00

Emergency 24 h/24Tel.: 02-614 29 00

Site St-Michel

rue de Linthoutstraat 150 - 1040 Brussels Tel.: 02-614 30 00

Emergency 24 h/24Tel.: 02-614 39 00

The Europe Hospitals (www.europehospitals.be) are the largest private hospital group in Brussels with 715 stay-in beds and 150 one-day beds. They employ about 300 medical doctors and 1,600 staff members spread over two sites (St-Elisabeth in Uccle and St-Michel in Etterbeek).

The Europe Hospitals have a sound and solid financial foundation to invest in advanced medical technology and modern infrastructure and offer patients and their relatives optimal healthcare and services.

Their competent and efficient teams share a common vision that healthcare requires a multidisciplinary approach that focuses on each patient’s well-being and comfort.

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