Dr. Siripatana Siritanaratkul M.D.
Breastfeeding has been important for human survival since the ancient times. Human beings have been breastfeeding for thousands of years .Breastfeeding culture is also an international culture. Evidence of breastfeeding couples could be seen on art objects, paintings and sculptures in every civilization. It must have been an everyday life experience that can inspire artists to perform arts. The relationship between mother and child , the closeness and tender love and care could be felt every time we observe these masterpieces of arts..
In early civilization every mother breastfed their baby . As shown in this graph , mother in elite group as well as urban poor and rural all breastfed fully. The trend shifted when industrialization began in 1940s .Elite women and working mothers used BM substitutes and breastfeeding rate began to fall. Urban poor and rural mother followed the rich .Breastfeeding rate fell to the lowest during the time generation X babies were born.
Definition of “the generation X “is the generation of people born between 1965-1979 . So they are around 33 to 47 years old. They were born after the Baby Boomers which is the babies born during their parent ‘s difficult time after World War II . So the generation X babies were born when the economy is better and their parents are more affluent, have more money. GenerationX children are well educated ,resourceful ,individualistic. They tend to be self reliant because they have more freedom than the previous generation.
When these generation X babies were born , their family have more money so the chance is high that they were bottle –fed with infant formula . In those days the poor breastfed their newborns but the richer would use infant formula because it is the trend of infant feeding then. They probably grew up not having seen any mom breastfeeding ! Because they are highly-educated ,highly independent and highly self-confidence, they would like to achieve the best in their career and when it’s time for them to have their own children, they surely would like the best for their little ones from the beginning.
Before their babies were born , gen X mother will search for knowledge about infant feeding and they know that breastfeeding is best . Who will they turn to for advice? Their mothers ? No , mothers of gen X moms didn’t have experiences in breastfeeding . Their doctors and hospital? Yes, they will rely on information from obstetricians pediatriacians and nurse practitioners.The medical professions have to update their skills and knowledge about breastfeeding so that they can give advice and help these mothers begin breastfeeding from the first day.
If the doctors are not getting updated , they may fall behind the mothers and give outdated advice. I will show one example of an event in a clinic, several mothers told this same story. The mother had been breastfeeding her child for one year and came to see the doctor because the child was sick or just came for vaccination. As soon as the doctor learnt that the mother was still breastfeeding ,he exclaimed with horrible expression that “ What! You are still breastfeeding your child? Breast milk beyond one year is useless…. no value anymore , it’s as clear as water . You can stop breastfeeding and give this formula milk instead..” The mother always listens to advice of doctors and if she is not firm on her choice she is likely to stop breastfeeding unnecessarily.
The recommendations of WHO
“Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond.”
WHO recommends
WHO strongly recommends exclusive breastfeeding for the first six months of life. At six months, other foods should complement breastfeeding for up to two years or more. In addition:
· breastfeeding should begin within an hour of birth;
· breastfeeding should be 'on demand', as often as the child wants day and night; and
· bottles or pacifiers should be avoided.
- Why not infant formula?
- Infant formula does not contain the antibodies found in breast milk. When infant formula is not properly prepared, there are some risks arising from the use of unsafe water and unsterilized equipment or the potential presence of bacteria in powdered formula. Malnutrition can result from over-diluting formula to 'stretch' supplies. Further, frequent feedings maintain the breast milk supply. If formula is used but becomes unavailable, a return to breastfeeding may not be an option due to diminished breast milk production.
HIV and breastfeeding
An HIV-infected mother can pass the infection to her infant during pregnancy, delivery and through breastfeeding. Antiretroviral (ARV) drug interventions to either the mother or HIV-exposed infant reduces the risk of transmission of HIV through breastfeeding. Together, breastfeeding and ARV interventions have the potential to significantly improve infants' chances of surviving while remaining HIV uninfected. WHO recommends that when HIV-infected mothers breastfeed, they should receive ARVs and follow WHO guidance for breastfeeding and complementary feeding
Regulating breast-milk substitutes
An international code to regulate the marketing of breast-milk substitutes was adopted in 1981. It calls for:
- all formula labels and information to state the benefits of breastfeeding and the health risks of substitutes;
- no promotion of breast-milk substitutes;
- no free samples of substitutes to be given to pregnant women, mothers or their families; and
- no distribution of free or subsidized substitutes to health workers or facilities.
· Support for mothers is essential
- Breastfeeding has to be learned and many women encounter difficulties at the beginning. Nipple pain, and fear that there is not enough milk to sustain the baby are common. Health facilities that support breastfeeding - by making trained breastfeeding counsellors available to new mothers - encourage higher rates of the practice. To provide this support and improve care for mothers and newborns, there are now more than 20 000 'baby-friendly' facilities in 152 countries thanks to a WHO-UNICEF initiative.
· Work and breastfeeding
- Many mothers who return to work abandon breastfeeding partially or completely because they do not have sufficient time, or a place to breastfeed, express and store their milk. Mothers need a safe, clean and private place in or near their work to continue breastfeeding. Enabling conditions at work can help, such as paid maternity leave, part-time work arrangements, on-site crèches, facilities for expressing and storing breast milk, and breastfeeding breaks.
The next step: phasing in new foods
To meet the growing needs of babies at six months of age, complementary foods should be introduced as they continue to breastfeed. Foods for the baby can be specially prepared or modified from family meals. WHO notes that:
- breastfeeding should not be decreased when starting complementary feeding;
- complementary foods should be given with a spoon or cup, not in a bottle;
- foods should be clean, safe and locally available; and
- ample time is needed for young children to learn to eat solid foods.
Why a lot of mothers are not successful when they have knowledge and strong intention to breastfeed? What ‘s the art and science behind breastfeeding successfully?
A mother need not be a lactation consultant to success in breastfeeding her own child. She has to follow her instinct , let her feeling lead the way , hold her baby to her breast and let the baby use its own reflexes to begin feeding from the breast.
Breastfeeding is a success when mother and child become one single biological system ie: waking and sleeping at the same time, understanding what another one is feeling .
Both have to learn how to breastfeed by having a relaxed time together in the first hour after birth.
The baby lead the way for the mother -baby –led learning.
Mammalian behavior is both genetically scripted and environmentally adaptive. Newborn behavior is also coming from within himself and from what he learn from the environment that is learn from what his mother respond to his need. –interactive environment of his mother’s care.
Dr.Donald Winnicot(1960) a British pediatrician once commented that “ There is no such thing as a baby, there is a baby and someone” which means that the infant cannot learn by itself alone , he learns by having interaction with its mother or someone caring for him.
So if the interaction is a positive one from the beginning the learning process will go on smoothly.
If we would like to have a positive interaction, we have to
-understand that the infant is a capable creature equipped with reflexes which will help it to adapt
to the environment.
-The mother is prepared to understand and communicate with her baby by following her feeling and instinct that is to say “ let the right brain lead her way , not the left brain.”
Newborn’s competency
Reflexes of the newborn help him to breastfeed : Rooting reflex
Grasping reflex , stepping reflex
Babies’ feeding behavior
When a hungry human baby is placed on his mother’s abdomen , or chest or arms he will begin to make movements of:
-bobbing his head up and down
-“pecking” with his open mouth
-moving his head and neck , flexing his arms and legs
-squirming , trying to push himself in one direction or another to the breast.
We will see this behavior in alert and hungry babies not seen in deeply sleeping or frantically crying babies. Such behavior is the response of “feeding cue” or “rooting response”. Unexperienced mothers might wonder what is he doing but experience mothers will notice that he is hungry and will put him to the breast. Mothers have confidence in their babies ‘ability and know that it is not merely a “reflex response” but a full fledged and purposeful “ Feeding behavior”.
Feeding behaviors initiate a cascade of behaviors that take the baby to the breast and allow him to find the nikpple and begin suckling.
If mother understands his behavior and support him rather than restraint his movement , the infant will bob its way bouncing gently and throw his body down toward the breast. On the other hand , if the mother doesn’t understand or does not expect the newborn’s ability or could not see what he is trying to do , she will restraint her baby, protect the head and neck,thus interfere with his movement.
Innate mammalian newborn feeding behaviors
In non human mammalian such as cats, monkeys the newborn babies can find its way to its mother’s teat on its own without any help from the mother. In human the same newborn behavior sequences has been described.
Lancet 1990 Nov3, 336(8723):1105-7
Effect of delivery room routines on success of first breast-feed. Righard L,
Alade MO.
Source Department of Paediatrics, University of Lund, Malmö General Hospital, Sweden.
Abstract
72 infants delivered normally were observed for 2 h after birth. In the separation group (n = 34), the infant was placed on the mother's abdomen immediately after birth but removed after about 20 min for measuring and dressing. In the contact group (n = 38) contact between mother and infant was uninterrupted for at least 1 h. After about 20 min the infants began to make crawling movements towards the breast; the rooting reflex soon came into play, and at an average of 50 min after birth most of the infants were sucking at the breast. More infants in the contact group than in the separation group showed the correct sucking technique (24/38 vs 7/34). 40 (56%) of the 72 mothers had received pethidine during labour; the infants were also sedated and most of them (25/40) did not suck at all. It is suggested that contact between mother and infant should be uninterrupted during the first hour after birth or until the first breast-feed has been accomplished, and that use of drugs such as pethidine should be restricted.
At the beginning of a breastfeeding relationship :“ let the right brain lead her way , not the left brain.”
What’s all about these right and left brain? I will summarize the function of each side of the brain briefly before going on .
Right brain function
Left brain function
Co-ordination between the two sides of the brain in human activites.
When two persons just meet each other for the first time, how will they communicate ? They have to be in the same wave length . If the sender send off with AM wavelength but the receiver end just have FM , they cannot communicate . They have to tune in to the same wavelength. In our case , the mother has to tune in to the infant which has right brain dominate.
The mother has to let her feeling , her sense lead her way . Forget all the left brain things such as : how may cc must my baby get ,what ‘s the duration between the feed. It is as simple as let the baby suckles when he is hungry stop when he is satisfy, no need for questions or doubts.
When two stranger just meet they would begin with topic which is important and make sense to both and with the feeling of relaxation. If one of the two is a newborn infant just coming out of its mother’s womb , what language would the mother use to communicate? Surely it is not a word but a signal sending from one heart to another, from one brain to another. The topic is “breastfeeding with calmness and relaxation.”
Schore A.N. (2001) The effects of a secure attachment relationship on right brain development, affect regulation ,and infant mental health.
Infant Mental Health Journal, 22,7-66
Allan Schore , an American neuropsychoanalyst , integrated research from the neuroscience, psychology, behavioral pediatrica and psychiatry and offer a theoretical model that described the right brain communication between mother and infant as important to the infant’s state regulation and psychoneuro development.
Episodes of “
Affective synchrony” with his mother : interactive resonance between amygdalae, limbic system and right brain of both mother and infant.
Through these encounter does the infant achieve state regulation necessary for breastfeeding.
Direct sensory communiations: eye to eye contact, skin to skin contact, vocal --all these open the right brain to right brain communications.
For the mother to communicate with her baby, she has to be in a calm state also so that she can pick up subtle clues from the infant. She must let her right brain leads her so that she can connect and respond accordingly to her infant’s state.
In a calm environment just leave the left brain agenda behind , do not have to know what ‘s the infant is suppose to do , just follow the instinct to touch your baby let the love flow through your hand through the baby. Just when you can keep calm and relax , the baby will feel the same way her feeling is his feeling and that would make the two right brain to resonate as one.
The mother and infant will gradually evolve into a single neurobiological system.
All of these happen with the help of the hormonal influence too.
Breastfeeding: physiological, endocrine and behavioural adaptations caused by oxytocin and local neurogenic activity in the nipple and mammary gland K Uvnäs-Moberg
*, M Eriksson
DOI: 10.1111/j.1651-2227.1996.tb14078.xActa Paediatrica Volume 85, Issue 5, pages 525–530, May 1996
It is now well established that oxytocin, as well as stimulating uterine contractions and milk cjection, promotes the development of maternal behaviour and also bonding between mother and offspring. In addition, oxytocin exerts by way of peripheral, circulating as well as by central, neurogenic mechanisms multiple physiological, endocrine and behavioural effects in connection with milk ejection and lactation. Some effects of oxytocin in the nipple and mammary gland appear to be exerted in close collaboration with peptides released from axon collaterals of somatosensory nerves originating in this region. The distribution of peptides localized to the somatosensory afferents in the nipple and mammary gland as well as possible effects by oxytocin and/or local neurogenic peptides in connection with milk ejection and lactation are reviewed in this paper.
Cognitive deficits in women after childbirth.
Eidelman AI,
Hoffmann NW,
Kaitz M.
Obstet Gynecol. 1993 May;81(5 ( Pt 1)):764-7.
Source Department of Neonatology, Shaare Zedek Medical Center, Hebrew University-Hadassah Medical School, Jerusalem, Israel.
Abstract OBJECTIVE: To test the cognitive function of parturients in the days immediately after delivery.
METHODS: One hundred postpartum mothers who delivered normal full-term infants were tested on standardized neuropsychological tests--the Wechsler Logical Memory Test and the Wechsler Visual Reproduction Test. Their test results were compared with those of nonpregnant childless women, third-trimester high-risk pregnant women, and fathers of newborns.
RESULTS: Postpartum women scored significantly lower than nonpregnant women on both tests on the first postpartum day. The use of intrapartum analgesia mitigated the cognitive deficit. High-risk pregnant women and fathers scored lower than nonpregnant women only on the Logical Memory Test.
CONCLUSION:
Objective documentation that postpartum women have transient deficits in cognitive function, particularly in memory function, can guide caretakers in the design of care plans for the postpartum lying-in period.
How to help Gen X mothers to achieve their goals of giving breast milk to their babies?
First and the most important thing is that doctors and healthcare professionals must have faith in and value breastfeeding. And they have to express their opinion and advocate loudly to the public. Nowadays expectant mothers are bombarded with advertisement which try to persuade them to get the idea that formula milk is as close to breast milk as ever –which is a false assumption.
We have to inform all pregnant women about the benefits of breastfeeding and the adverse effects of formula milk feeding . So that mothers can make
informed decision about breastfeeding.
Breast milk has a distinct and irreplaceable value to human infants.
1 .
Species specificity : Human breast milk for human infants.
2.Nutritional benefits: Unique composition of breast milk is the ideal nutrients for human brains. All the nutritional ingredients in breast milk has functions which facilitate each other in a combination of events. That means by mixing in just one or two nutrients into formula milk does not bring out the same benefits resulting from breastfeeding.
3.Infection protection : Leukocytes, specific S IgA, lactoferrin ,oligosaccharide, cytokines .
It is confirm by Evidence-based systematic review.
(Ip, Chung M, Raman G et al: Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries Evidence Report Technology Assessment 153. Rockville, Md, April 2007, Health Care Research and Quality.)
In 2007 two careful comprehensive assessments of the value of human milk and breastfeeding were published.
- From the AHRQ (Agency for Health Research Quality)
- From Department of Child and Adolescent Health and Development of the WHO
AHRQ : review the evidence on the effect of short and long term breastfeeding on infants and maternal health outcomes in developed countries. 9000 abstracts were screened and 400 studies reviewed.
TABLE 7-1A -- Advantages of Breastfeeding as Determined by AHRQ
| Full-Term Infant Outcomes |
Reduction in Relative Risk |
| Acute otitis media |
50% reduction |
| Atopic dermatitis |
Equivocal |
| Gastrointestinal infections |
64% reduction |
| Lower respiratory tract disease |
72% reduction |
| Asthma |
27% reduction |
| Cognitive development |
Equivocal because of confounding factors |
| Obesity |
24%, 7%, 4% for each month of breastfeeding |
| Risk for cardiovascular disease |
Blood pressure: up to 1.5 monthly reduction
LDL cholesterol: 7.0-7.7 mg/dL reduction
All cause CV mortality: needs further investigation |
| Type 2 diabetes |
39% reduction (confounders not well controlled) |
| Childhood leukemias |
19% reduction (all); 15% (AML) |
| SIDS |
36% reduction |
Summarized from AHRQ report No. 153 (references 57 and 58).
| AHRQ, Agency for Health Research Quality; AML, acute myelogenous leukemia CV, cardiovascular; LDL, low-density lipoprotein; SIDS, sudden infant death syndrome. |
Martin RM ,Gunnell D,Smith GD :Breastfeeding in Infancy and blood pressure in later life: Systematic review and meta- analysis,
Am J Epidemiol 161:15-26,2005 From this analysis ,they confirm that long-term subjects who were breastfeeding experienced - lower mean blood pressure
- lower cholesterol
- higher performance on intelligence tests
- lower prevalence of overweight , obesity and type 2 diabetes
4.Allergic prophylaxis :
Oddy WH ,Holt PG,Sly PD, et al
: Association between breastfeeding and asthma in 6 year old children: Findings of a prospective birth cohort study ,BMJ 319:815,1999
A significant reduction in risk for childhood asthma at 6 years was reported by Oddy if exclusively breastfeeding is continued for at least 4 months.
Gdalevich M, Mimoumi D , David M , et al :
Breastfeeding and the onset of aopic dermatitis in childhood: A Systematic review and meta-analysis of prospective studies,
J Am Acad Dermatol 45(4):520-527,2001
Exclusive breastfeeding for at least 3 months is associated with a reduced risk
for atopic dermatitis in children with a family history of atopy.
5.
Psychological and cognitive benefits:
Breastfeeding and adult intelligence,
JAMA 287:2365, 2002
A prospective longitudinal cohort study of more than 3000 individual in Denmark born between 1959-1961. They found that there is a significant positive association between duration of breastfeeding and intelligence test results, using two separate intelligence tests.
Kramer MS , Aboud F , Mirovouova E et al:
Breastfeeding and child cognitive development: New evidence from a large randomized trial,
Arch Gen Psychiatry 65(5):578-584,2008
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Brief Summary of Breastfeeding Sick Babies 
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