Article Author:
Saieda Kalarikkal
Article Editor:
Jennifer Pfleghaar
12/1/2018 11:27:36 PM
PubMed Link:


Breastfeeding is an important part of a newborn's life. Breastfeeding or lactation provides total nutritional and emotional dependency of the baby on the mother. The strong emotional bonding between the mother-child dyad is needed for successfully prolong breastfeeding.[1] Breast milk is recommended as the optimal and exclusive source of early nutrition for all infants from birth to at least 6 months of age maternal milk is crucial for development.[2]

Milk production is regulated by the maternal hypothalamus and pituitary gland-derived hormones. Oxytocin and prolactin are the main hormones that play the role of milk production and the resulting letting down reflex.[3]

There are distinct stages seen in milk production which start before the birth of the baby. The first milk is colostrum which is available after labor. Occasionally, there is pre-colostrum before the postpartum stage. 

Colostrum is high in protein, sodium, and immunoglobulins while being low in lactose, and this is the first milk produced for the baby.[4] After  30 to 40 hours postpartum, the milk composition changes by an increase of lactose and dilution of other constituents as the volume increases.

Subsequently, the maintenance of lactation follows an autonomous pattern wherein the sucking of the baby and emptying of the breast are the main factors regulating the milk flow.[5]

Issues of Concern

Establishment of smooth bonding between the mother and baby is essential for successful breastfeeding.[6]

Baby and maternal factors can influence this bonding. Skin-to-skin contact in the first 2 hours after birth is essential for successful initiation of lactation. The breast crawl, soon after birth, while the baby is alert will initiate the bonding, and it will be an assurance, giving comfort and calm. The breast crawl is when the baby is placed on the mother's abdomen after birth, and the baby finds its way to the breast to suckle.[6][7]

Successful breastfeeding factors related to the baby include proper latching, alertness of the baby, rooting reflex, and active sucking reflex. Although lactation is a natural process, the mother needs support and education for proper positioning and latching.[8] The ability of the baby to empty the breast will determine the subsequent milk volume.[9][5]

Maternal factors like pain, anxiety, emotional instability, among others should be addressed before and after delivery. Lactation consultants or knowledgeable nurses can also be helpful with initiating of breastfeeding.[10]

Father and other supportive individuals, including physicians, also have an important role for the reassurance of the mother and the baby.[11][12]

Getting a correct latch on the nipple is important. If the latch is not correct due to issues such as lip tie, tongue tie, or too firm a breast, the mother can develop cracked nipples or pain while breastfeeding.[13] An evaluation by a lactation consultant or other health professional comfortable with diagnosing lip and tongue ties may be helpful.

The use of medications needs to be addressed while the mother is breastfeeding. Women should not be told to stop breastfeeding, but careful attention needs to be placed to find alternatives that are safe to use while breastfeeding. Some studies show women take more medication while breastfeeding compared to pregnancy.[14]

Clinical Significance

Colostrum is highly significant due to its immune-boosting effects because of the high amount of immunoglobulins.[15] It often referred to as the baby's first immunization. It produces mucosal immunity to the gastrointestinal (GI) tract via the secretory IgA (sIgA), IgM, and IgG. These vital immunoglobulins give barrier protection to the gut and also play a vital role in fighting the germs.

Milk contains microbiota like Bifidobacterium and Lactobacillus and this along with the oligosaccharides confer anti-bacterial activity to the gut.[16][17]  Furthermore, this results in the synthesis of essential nutrients such as vitamin B12, B6, folate, and vitamin K. Early introduction of breastfeeding will help in establishing the naturally sterile gut of the baby to colonize with these safe micro-organisms and also maternal organisms, rather than colonizing with the organisms of the hospital baby room and of the other caretakers. So early rooming in, where the baby is kept with the mother, is advisable.

Another component, lactoferrin, will act by increasing iron absorption and preventing its degradation by bacteria. Bacteria utilize this for its proliferation. It confers an immune protective action against bacterial, viral, fungal and parasitic infections.[18]

Milk produced can be classified as foremilk and hindmilk. Foremilk contains higher levels of lactose while hindmilk contains a higher proportion of proteins and fats. The baby's nutritional need controls the milk quantity and components. The knowledge of high lactose foremilk and high fat of hindmilk will help the mother to regulate the feed from both breasts.[19]

There is ample evidence showing that breastfeeding lowers the risk of upper respiratory tract infections and diarrhea in the newborn. Other postulated benefits include a lower risk of developing asthma, type 1 diabetes, food allergies, and obesity. Breastfeeding may also delay the return of menstruation. Also of importance is that breastfeeding is a lot cheaper than formula-which is of practical importance to women who are poor. In the United States,  about 75% of women start breastfeeding, but the majority stop the practice within a few months. The use of alcohol, smoking, or coffee is not valid reasons to stop breastfeeding. In general, breastfeeding can be stopped between 6 to 12 months, although some women breastfeeding until the child is 2 to 4 years.

A lactation consultant should provide emotional comfort to the mother. Empowering the mother is very important. The mother should have full confidence and full control of her baby‘s needs and feeds. She should have a positive attitude. Any negative comment, or even usage of negative words, like problem, difficulty, inadequate, improper, among others should be avoided entirely during the counseling of the mother. Presence of the postpartum disorders like depression and postpartum psychosis may be subtle in presentation and can rapidly deter breastfeeding. These emotional conditions should be kept in mind while managing the postpartum difficulties and breastfeeding failure. A lactation consultant should be provided during the hospital stay and after she leaves the hospital.[10]