Overview

Breastfeeding involves a physical process. The process of lactation starts during the pregnancy and culminates when the baby is either first put to the breast or the first milk, colostrum, is expressed. A mother needs to learn the technique of positioning and attaching a tiny, helpless infant, which may cause injury if not done correctly. There is also a strong emotional component. The effect of the skin-to-skin contact and the hormones released while breastfeeding are an important factor in the bonding process between the mother and baby.¹

The process of breastfeeding is a very different experience for different women. For some it is an empowering experience that fills them with a sense of fulfilment.²

Breastfeeding my baby also means that I have to stop and take time out, which relaxes me and allows me to connect with my baby - I believe that this helps to develop strong attachment between us. This helps to stop me being overwhelmed by my new role as a mum…³

For others there is no such experience; it is simply providing nutrition to their child.⁴
Some women simply feel like they are tied to their baby with a ball and chain, particularly if their baby won't even take a bottle of expressed milk.⁵

Women have identified the following concerns about breastfeeding during their initial hospital stay:

• over-worked staff;
• lack of skills in assisting with attachment difficulties;
• inconsistent advice; and
• noise and embarrassment.

Most mothers do not anticipate problems with breastfeeding and health professionals may inadvertently contribute to this perception by focusing on the benefits of breastfeeding rather than the practicalities and problems that can be encountered in the early weeks.⁶ The management of breastfeeding and breastfeeding issues needs to take into account the individual involved.⁷ There are things that will help one woman greatly and have little or no effect on another woman. Breastfeeding should be learned and continued in a supportive environment and there needs to be an understanding that ‘one size does not fit all’.

The science of supply

During pregnancy a woman’s breasts undergo changes and development to be ready to provide milk for the baby; this stage is called lactogenesis stage one. That milk is available even when a baby is born prematurely. The first milk in the breasts following delivery and often before delivery is called colostrum. It is thicker, yellowish milk which is more concentrated than mature milk. It is also rich in protein and in antibodies that help to protect the baby from disease. During the first three to four days post-birth, copious milk secretion occurs, called lactogenesis stage two.⁸

During pregnancy a woman’s breasts undergo changes and development to be ready to provide milk for the baby; this stage is called lactogenesis stage one. That milk is available even when a baby is born prematurely. The first milk in the breasts following delivery and often before delivery is called colostrum. It is thicker, yellowish milk which is more concentrated than mature milk. It is also rich in protein and in antibodies that help to protect the baby from disease. During the first three to four days post-birth, copious milk secretion occurs, called lactogenesis stage two.⁹

Breastfeeding works on a supply, demand basis. The rate of milk production is regulated to match the amount of milk removed from each breast at each breastfeed. If milk withdrawal has not started within three days post-partum, the changes in milk composition with both stages of lactogenesis are reversed and the likelihood of the establishment of successful breastfeeding declines.¹⁰ In the critical first six weeks of establishing lactation it is very important that babies are fed according to their needs not according to any kind of routine or schedule.¹¹ Most mothers find that they need to feed at least six times in 24 hours just to maintain their supply. Many new babies need eight to twelve or more feeds in 24 hours. However the frequency of feeds generally declines as the baby gets older.¹²

Initiation – the early days

As shown in chapter 2, initiation rates in Australia are close to the recommended levels. However, in the early days of breastfeeding, many women can find it to be very difficult, painful and confusing.¹³ For many women the level of pain experienced is unexpected and they may find breastfeeding quite complex.¹⁴ Even with the declared intent to breastfeed, damaged nipples, an upset, screaming baby and continuous, conflicting advice can jeopardise the breastfeeding relationship.
For the first 3 months I felt like quitting every single day. It was painful. It was hard. It was time consuming. I was extremely drained and in poor physical condition. Extremely sleep deprived, in the first few weeks, having to breastfeed 24/7 every single 3 hours...¹⁵

Correct positioning at the breast and correct latching-on and milking action are vital for the efficient removal of milk from the breast without nipple pain and trauma.

Mothers clearly need a high level of support at this time and they need consistent advice.¹⁶ The health system plays an important role in these early days, through provision of antenatal education and ongoing support and advice on how to initiate and continue breastfeeding (see chapter 6). One impact of the ‘baby boom’ on maternity wards means that midwives and lactation consultants have more patients and less time to sit, watch and help a new mother feed. Many inquiry participants reported that it was difficult to get help from busy staff.¹⁷ Some mothers felt very upset by the technique of midwives physically bringing the baby to the breast; mothers did not appreciate strangers grabbing at their breast without asking for permission.¹⁸ This technique also does little to promote proper attachment.¹⁹

Specific hospital practices such as skin-to-skin contact²⁰ can be very important for the mother and baby bonding process and is one of the 10 Steps of the Baby Friendly Hospital Initiative (see chapter 6). For example, early skin-to-skin contact has been shown to increase the length of time that mothers breastfeed by 42 days.²¹ Mothers with special needs such as those with type 1 diabetes are often routinely separated from their babies just after birth without this skin-to-skin contact and may need additional support to express after the birth.²²

The variability of behaviour in the newborn infant needs to be carefully explained to the new mother. Infants may be sleepy or unsettled which can both impact on the initiation of breastfeeding.²³ They may want to feed frequently before the milk has come in and mothers need to know that these frequent feeds will help to stimulate the milk supply. It is important that health professionals and parents are aware that the use of bottles and dummies are usually inappropriate at this early stage of breastfeeding.²⁴ Infants will also cry and once the causes of hunger, heat, cold, noise or a clearly defined medical problem are ruled out, a crying infant can be a cause of deep distress and frustration for parents.²⁵

The process of babies rooming in with their mothers, in contrast to the previous ‘baby nursery’, has assisted the initiation of breastfeeding. This is one of the ten steps of the Baby Friendly Hospital Initiative.²⁶ Some hospitals have a policy where a mother needs to sign a consent form²⁷ before infant formula can be given to their baby and the committee considers this should be mandatory in all hospitals. These forms will often clearly outline the reasons not to give infant formula and the acceptable medical reasons for supplementation.

As well as the complexity of expressing another issue relating to early discharge is that women have barely learnt about attaching their baby to the breast and they may be sent home with less than optimal attachment, which gets worse with breast engorgement. Their nipples then get sore and insufficient milk is transferred to the baby as poor attachment means the baby cannot drain the breast well. The baby then is not getting as much milk as it would with optimal attachment. The weight gain of the infant then may be less than desirable and mothers are told ‘your milk's dried up!’ It is normal phenomenon for most babies to lose weight in the first week, surviving on low volume colostrum and interstitial body fluid, often voiding only once or twice in 24 hours over the first three days.³¹ There is a lack of understanding of how this whole situation may have come about and also how to fix it. Relatives often put pressure on them to ‘just switch to the bottle, it is easier that way’.³²

Duration of breastfeeding

There are many factors that can influence the duration of breastfeeding as seen in chapter 2. Rates of initiation are high but women do not breastfeed for as long as is recommended or even as long as they would often like. Many women feel that the reality of breastfeeding is quite different to their expectations. Research has shown that these expectations can affect breastfeeding duration. The clash between highly idealised expectations and early breastfeeding problems can lead to disillusionment and ultimately to early weaning.³³
Women do not make one decision to breastfeed; they make a decision almost every day to continue, particularly when they are having trouble. Most women in Australia are initiating breastfeeding. It is how long they keep going.³⁴

Many women experience some difficulties with breastfeeding particularly in the early days. These can include sore nipples, lack of milk, engorgement, fast milk flow and lack of weight gain of the infant. These can usually be readily overcome with advice, assistance and support.³⁵

In the study ‘Psychology, the mother and breastfeeding duration’, two factors were identified which had an impact upon a mothers intention to wean. The first was how breastfeeding impacts the mother’s comfort and wellbeing both practically and in respect to her confidence to succeed at breastfeeding. The second factor encompasses the mother’s concern for the comfort and wellbeing of her baby, including concern over having enough milk for the baby and for the baby’s night sleeping behaviour. Both these factors may reflect the mother’s lack of confidence in breastfeeding meeting the needs of her baby. Interestingly milk supply and the baby’s sleeping behaviour are common breastfeeding problems which could almost certainly be improved by the provision of skilled postnatal support.³⁶

Duration of breastfeeding could be increased by identifying the factors which contribute to early weaning and finding a way to modify those factors or remove any negative effect. Unfortunately, most of these are difficult or impossible to modify. They are things like a woman’s age, years of education or early return to paid employment. There needs to be more research which focuses on identifying and exploring the modifiable factors.³⁷

Low supply and perceived low supply

Research has found that a perception of insufficient milk supply may not be a real insufficiency but a result of misinterpreting infant behaviour such as the effect of restricting the frequency of breastfeeding or a mother's lack of confidence in the ability to breastfeed. Mothers may also report that they weaned due to low milk supply because this is considered a socially acceptable reason for weaning.⁴²

As these issues may have nothing to do with actual milk supply, mothers require support and well informed advice from health professionals such as Maternal and Child Health Nurses, lactation consultants and GPs to help them through this period. Without appropriate assistance women may commence using infant formula. Many women are subsequently reassured by the volume they can mix, see, and deliver to their infant when using infant formula.
In a world where having tangible outcomes and evidence is promoted in earnest, it is little wonder that new mothers also want to see exactly how much milk their infant is receiving.⁴³

Demand feeding and routines

Demand feeding or baby-led breastfeeding can leave some women feeling tied to the couch for hours on end and this can be enough to prompt some mothers to give up breastfeeding.⁴⁴ It is normal for young babies to feed eight to twelve times in 24 hours and for these feeds to be unevenly spaced; for example, evening ‘cluster feeding’ is very common.⁴⁵

Demand feeding can be very difficult for a new mother to manage and she may seek advice or suggestions from health professionals and relatives. Evidence suggests that this is often to get the baby into a routine. This can lead to mothers trying to limit their baby to three to four hourly feeds rather than stimulating supply by putting baby to the breast as the baby demands.⁴⁶ For some women the change to three to four hourly breast feeds can interfere with the supply-demand relationship and cause their breast milk supply to drop, encouraging the belief that breast milk supply is inadequate. The resulting practice of then introducing formula to supplement their breast milk has the effect of further reducing supply.⁴⁷
Many mums I speak to don't understand the very basics of how breastfeeding works and think if they wait longer between feeds then their breasts will be fuller and there will be more for baby when the opposite is true.⁴⁸

Mothers may find that their supply is affected by something as simple as trying to establish a routine with their baby’s feeding. 'Sleep, Feed, Play' routines are a common suggestion for parents with unsettled babies⁴⁹ but due to fewer feeding opportunities, the reduced demand can have an effect upon a mothers milk supply.

Myths and misconceptions

There are many myths and misconceptions surrounding breastfeeding⁵⁰ and these can contribute to breastfeeding prematurely ceasing. These myths may come from health professionals, family members or even through advertising (see chapter 6).

Myths seem to be continually perpetuated in both the health system and the community. Myths and misconceptions, held by people years ago, appear to remain as prevalent today.  The effects of these myths can be compounded by poor advice from health professionals and lack of knowledge about breastfeeding which may cause mothers to doubt their ability to breastfeed. The committee received evidence of mothers of newborns who had given up breastfeeding within a week of leaving hospital for the following reasons:

• one mother with inverted nipples was told by a nurse that she would not be able to breastfeed;
  
• one mother was concerned that she couldn't get her one week old baby to settle;
  
• one mother was told by her paediatrician that she probably didn't have enough milk, so she should just switch to formula; and
  
• one mother was told by a baby health clinic nurse that she was overfeeding by breastfeeding on demand and needed to ‘get the baby into a routine’.⁵¹

Some of the more common myths relate to the composition of breast milk and its quality as well as how long breast milk has a nutritional benefit.⁵² Many mothers presume that genetic factors are responsible for their poor milk supply. When they have difficulties they may conclude that this ‘runs in the family’.⁵³ Other myths relate to normal infant behaviour such as sleeping, crying and bowel movements. One of the most prevalent myths is that if you give a baby infant formula it will sleep through the night. This myth was extremely prevalent.⁵⁴

When a breastfeeding mother becomes pregnant, she may be advised by health professionals to wean, without being told that she could continue breastfeeding. Often the mother may become pregnant and continue feeding during her pregnancy and then keep feeding her older child and the new baby, which is called tandem breastfeeding. This can be done safely if the mother eats well, gets enough rest and makes sure the new baby’s needs are met first and mothers can find it enhances their breastfeeding relationship.⁵⁵

These myths, in conjunction with the lack of breastfeeding support and inconsistent advice, may lead women to feel they are left with no choice other than to use infant formula.

One thing for sure is that as parents we are told what it is expected of us in relation to feeding our older children a healthy diet (ie healthy natural food not just processed foods) but it is not made clear that breastfeeding is the natural milk option and that choosing formula feeding is equivalent to offering a completely processed food diet. By educating women in this fact many may very well may look for different ways to solve the above issues without threatening their own ability to keep feeding.⁵⁶

Sleep

The physical demand that breastfeeding may place on a mother is often underestimated. Mothers may feel that if their baby is not sleeping through the night by three to four months of age, they have failed as a parent. If a mother is unable to express then they are the only one who can breastfeed and always have to be the one who gets up at night.⁵⁷

It is very, very difficult to stay focused on the benefits of exclusively breastfeeding your child for the first six months when you are absolutely at your physical and emotional limits, its four o'clock in the morning and you've just been up for the seventh time that night.⁵⁸

Co-sleeping, where the baby and mother sleep together and night feeding can take place in bed without much disruption, can be a strategy⁵⁹ and can assist with maintaining supply. However, it needs to be done safely and is not an option that suits all mothers or parents.

Infant weight

Mothers may be concerned that their baby is not gaining the appropriate amount of weight or be advised by health professionals that they need to complementary feed with infant formula. Information on weight and growth charts is covered in more depth in chapter 6. However, the committee noted the significant evidence of the impact that an infant’s weight has on a mother and her feeding decisions particularly in the early days.⁶⁰

Extended breastfeeding

The WHO recommends breastfeeding exclusively for six months and then to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond.⁶¹ The Dietary Guidelines note that after six months, continued breastfeeding along with complementary foods for at least 12 months will bring continuing benefits.⁶²

Breastfeeding a child over the age of one is considered to be ‘extended’ breastfeeding in the community. Mothers report that breastfeeding beyond 12 months elicits ‘significant stigma and taboo’ from the public.⁶³ Some mothers deliberately avoid feeding an older infant in public, and can feel quite sad at having to do this.

The community views breastfeeding an older baby, let alone a toddler, as sick and 'child abuse'. I know of many women who are scared to breastfeed in public. I know of women who have been abused for doing so.⁶⁴

There seems to be a curious dichotomy in the community where an infant of 18 months is still considered to be totally dependent on their parents for everything including food but is perceived to be too old to breastfeed. The committee would like to reaffirm its support for women being able to breastfeed for as long as they and the child wish to continue.