by Dr Louise Santhanam, General Practitioner
- Exclusive breastfeeding for the first six months, with continuation alongside the introduction of solid foods is recommended
- Breastfeeding can continue for as long as desired by mother and baby
- Positioning and attachment at the breast and frequent effective milk transfer are critical to establishing and maintaining breastmilk supply
- Swallowing during feeds, nappy output and adequate weight gain are indicators of effective milk transfer
- Skilled support can help to overcome breastfeeding challenges
- Breastfeeding can continue alongside the use of many medications
Breastfeeding is the biologically normal way to feed an infant. The NHS1, UK Department of Health2 and the World Health Organisation (WHO)3 recommend exclusive breastfeeding for the first six months of a baby’s life, followed by breastfeeding alongside the introduction of complementary solid foods. The NHS advises that breastfeeding can continue for as long as desired by mother and baby1 and the WHO recommends breastfeeding to 2 years and beyond as desired3. On a population level not breastfeeding and a short duration of breastfeeding are associated with comparatively poorer health outcomes for mother and baby in both developed world and developing world settings4, 5. This is the rationale behind Public Health policy to promote and support breastfeeding in the UK6, 7.
Initiating and Maintaining Breastfeeding- Key Points for the GP
Breastfeeding is a learned behaviour for the mother-baby dyad and skilled support and education can assist initiation and continued breastfeeding. The understanding of the physiology of breastfeeding and the importance of effective milk transfer to the infant in building and maintaining milk supply is critical to the understanding of breastfeeding problems, feeding difficulties and weight faltering.
When the mother is healthy and the infant is a healthy term baby:
- The hormone prolactin stimulates milk production and effective feeding triggers positive feedback and increased milk production.
- If the breast is incompletely drained for long periods the protein Feedback Inhibitor of Lactation accumulates and reduces milk production.
- Neonatal feeding reflexes (rooting, sucking and swallowing) are stimulated by skin-to-skin contact with the mother and enable active breastfeeding on the part of the infant.
- Positioning of the baby at the breast and effective attachment at the breast (the ‘latch’) are critical to enable effective milk transfer (see here).
- Frequent effective feeding and emptying of the breasts (facilitated by close proximity of mother and baby) establishes optimal breastmilk supply.
- When milk transfer is effective, feeding according to the infants’ cues (responsive feeding) maintains optimal milk supply.
- Breastmilk supply can be increased within a few days by increased suckling or expressing breastmilk.
- Skilled breastfeeding support can help facilitate optimal breastfeeding.
- It is not normal for breastfeeding to be associated with ongoing maternal pain beyond the initial familiarisation with positioning and attachment in the first few days and a breastfeeding assessment should be recommended if this occurs.
- Milk production and the effectiveness of milk transfer may be impacted by maternal or infant factors and each individual dyad may have a different issues requiring attention over time.
Facilitating effective breastfeeding therefore includes:
- Enabling early skin-to-skin contact and initiation of breastfeeding.
- Breastfeeding support to ensure optimal positioning and attachment.
- Awareness that optimal feeding requires attention to the whole feed (not just the ‘latch’).
- Frequent unrestricted responsive feeding.
- Avoidance of postponing breastfeeds (eg. with use of a dummy or breastmilk supplement).
- Observation of output (wet nappies, stools consistency/colour and frequency) and weight gain to confirm effective milk transfer.
- Recognition of when breastfeeding is suboptimal, initiating specialist management and the use of supplementation if necessary.
- Social support and encouragement for the family, especially in the early weeks as milk supply is established.
The following issues are covered in greater detail in our following webpages on breastfeeding and many of our other webpages within this site also make reference to the above principles.
In the case of premature babies, feeding reflexes may not have developed by birth. As well as supporting the infant nutritionally, care in the Neonatal Intensive Care Unit aids development of these reflexes and mothers of preterm babies can be offered support to stimulate and sustain their milk supply. See our page on ‘Preterm & Unwell Infants‘ for more resources on feeding preterm babies.
The UK population as a whole is at risk of low vitamin D status due to insufficient sunlight synthesis of vitamin D in the skin during the winter months. Neonatal vitamin D status is dependant on maternal status, and in the UK pregnant women and breastfeeding mothers are advised to take daily supplementary vitamin D. As a precaution, daily supplements of vitamin D are now also recommended from birth for exclusively breastfed infants and combination fed babies who receive less than 500ml of infant formula per day. See our page on ‘Vitamin D Supplementation‘ for further information.
Sucking Pattern in Effective Breastfeeding
It is useful to be aware of the distinctive breastfeeding suck-swallow pattern of effective breastfeeding9.
- Feeding is initiated by the infant rapidly sucking to stimulate the milk ejection reflex and the ‘let down’ of milk.
- Once milk flow has commenced, the baby actively feeds with long, rhythmic sucking and swallowing, with periodic pauses (see also ‘Positioning & Attachment‘)
- In the later stages of the feed breastmilk volume is lower and the fat content is higher. Swallowing is typically less frequent. Timed feeding, or removing the baby from the breast during this stage while the baby is still actively sucking and swallowing may lead to growth faltering.
Frequency and Duration of Breastfeeds
The proportion of fat in breastmilk varies from feed to feed throughout the day and increases throughout the feed. The concept of ‘foremilk’ and ‘hindmilk’ is simplistic and does not accurately represent this gradual increase. Responsive feeding enables the healthy baby to obtain the hydration and the calorific content from breastmilk that he/she requires at any time, regulating his/her own appetite.
Responsive feeding involves feeding according to infant feeding cues (see also our page on ‘The Infant’) and crying is a late sign. Understanding earlier feeding cues and responding in a timely manner can help to:
- Improve ease of attachment at the breast (attaching before the crying stage)
- Stimulate and maintain breastmilk supply
- Promote secure infant attachment
As well as responding to the infant’s feeding needs, a breastfeeding mother may need to feed for her own comfort if her breasts have become engorged (especially in the early weeks while the balance of milk supply and demand is established).
Where babies have been born sedated by the effects of intrapartum drugs or where they are unwell, drowsy, dehydrated or jaundiced, encouragement to feed many be necessary as feeding cues may be absent.
Important Points about Breastfeeding Frequency
- Breastmilk is easily digested, more rapidly than artificial baby milk, and the infant stomach is small.
- Frequent breastfeeding is normal and is critical to establishment and maintenance of milk supply.
- Healthy babies over 48 hours old will likely feed at least 8 times in 24 hours, but there is no absolute ‘maximum’ number of feeds9.
- Once breastmilk supply is established, after the early weeks, feeding frequency may decrease, depending on the mothers’ breastmilk storage capacity (which is unrelated to the size of the breasts)10.
- Night feeding in infants is normal, and many babies will continue to wake at night for feeds11.
Duration of Breastfeeds
In general the duration and frequency of responsive breastfeeding should not be restricted.
Some babies (especially in the early weeks) may only require one breast per feed, but after a short rest should still be offered the second breast, and the next feed should commence on the breast that was not drained. There is no absolute duration for an effective feed, as this will vary according to the infant’s needs at the time, however very long, very frequent or painful feeds should prompt urgent assessment of positioning and attachment10. Nipple damage is caused by poor attachment at the breast, not by prolonged feeds, and good attachment at the breast is critical to ensuring optimal milk transfer. Where attachment is suboptimal, improvements can enable nipple healing and facilitate more efficient milk transfer, potentially resulting in shorter and/or less frequent feeds.
Breastfeeding and Improving Health Equality
Improving breastfeeding rates is not the responsibility of individual women struggling alone in a culture that can be hostile towards breastfeeding– rather this is a public health challenge for which we all share responsibility. We must find a way to meet this challenge; failure to invest in breastfeeding leads to poorer health outcomes for children and women today and for generations to come.
Professor Dame Sally C Davies, Chief Medical Officer, from Public Health England: Infant Feeding- Commissioning Services (June 2016)
A number of recent studies and reports illustrate the significant impact increasing breastfeeding rates could have on health both in the UK and on the global scale. Breastfeeding in low income countries has been reported to prevent “…half of deaths caused by infections in children aged 6-23 months.”5. Breastfeeding contributes to reducing health inequalities between rich and poor children in low/middle income countries and is considered a major priority for global health and reducing inequalities3.
In high income countries there is clear evidence that breastmilk/breastfeeding reduces mortality from NEC and SIDS5, evidence of reduction in hospitalisation from respiratory tract infections and gastroenteritis12, and maternal breast cancer risk reduction13. Mothers who plan to and then are able to go on to breastfeed, have a decreased risk of postpartum depression, compared with those who do not plan to and then do not proceed to breastfeed14.
Our webpage ‘Risks of Not Breastfeeding‘ summarises current knowledge in this area.
Our webpage on ‘Infant Feeding‘ includes breastfeeding rates in the UK, maternal feeding intentions and the information on barriers to breastfeeding in the UK that can be gleaned from UK data on feeding methods.
Notably, in June 2016 The UN Committee on the Rights of the Child called on the UK to tackle the UK’s extremely low breastfeeding rates in order to improve and protect children’s health.
Significant research and reports which contribute to the understanding of this issue include:
- The Lancet Breastfeeding Series, January 2016
- Acta Paediatrica Special Issue: Impact of Breastfeeding on Maternal and Child Health, December 2015
- Unicef UK Preventing Disease and Saving Resources: The Potential Contribution of Increasing Breastfeeding Rates in the UK, October 2012
- RCPCH: tackling England’s Childhood Obesity Crisis, October 2015
- Public Health England:Commissioning infant feeding services- a toolkit for local authorities, June 2016 Details the rationale for working to increase UK breastfeeding rates.
- World Breastfeeding Trends Initiative (WBTi): UK Report 2016 A collaborative national assessment of the implementation of key policies and programmes from the WHO’s Global Strategy for Infant and Young Child Feeding.
Breastfeeding as a ‘Personalised Medicine’- Emerging Understanding
Findings from studies done with modern biological techniques suggest novel mechanisms that characterise breastmilk as a personalised medicine for infants.
Victora C.G. et al Lancet Breastfeeding Series (2016)
There is increasing awareness that maternal breastmilk influences the infant gut microbiome and immune responses. Specific prebiotics in human milk (for example the large range of human milk oligosaccharides) support growth of beneficial bacteria in the infant gut. Breastfed infants maintain persistent differences in their gut microbiome, independent of their mode of delivery5.
The Lancet Breastfeeding Series suggests that changes to the infant microbiome may be critical to future health- “Abnormal colonisation patterns have a deleterious long-term effect on immune and metabolic homeostasis”5. Our scientific understanding of this area is currently expanding with increased awareness of the role of the gut microbiome in human health, the impact of breastfeeding on infant gene expression (epigenetics), the role of multi-potent stem cells in breastmilk and the effects of breastfeeding duration on maternal health (see our webpage on ‘Breast Cancer Risk Reduction‘).
I love breastfeeding my 15 month old: it was hard at the beginning but from about six months in became easy and enjoyable and I could see no reason to stop. It’s so lovely to come home from work and settle down for a cuddle and a feed, it makes all the stresses of the day disappear!
Dr Ellen Dean, General Practitioner
Beyond the recommended six month period of exclusive breastfeeding, breastmilk is considered to be able to contribute over half of an infant’s energy needs between 6-12 months3 and between 1/3 to 40% of a child’s energy requirements at age 12-24 months, alongside complementary solids3,8. Breastmilk is also a critical source of energy and nutrients for breastfed infants during illness3.
While duration of breastfeeding is a personal parental decision, dependent on individual circumstances, employment support for breastfeeding mothers who return to work is an important contributor to enabling continued breastfeeding8.
If breastfeeding is going well with no parental concerns and the infant is healthy there is unlikely to be any reason for a GP to encourage cessation.
WABA recommends that the value of each extra day of breastfeeding for the health of mother and child be highlighted to mothers, families, communities and the wider society and that healthcare providers should seek to ensure this8.
NHS Choices: Benefits of Breastfeeding Includes the NHS recommendation regarding breastfeeding.
WHO: Infant and Young Child Feeding (Updated September 2016) The WHO statement on infant and young child feeding, which highlights the role of breastmilk as an important source of energy and nutrients for children aged 6–23 months and its impact on reducing overweight and obesity, reduction of health costs and contribution to national economic gains.
World Alliance for Breastfeeding Action (WABA): Protecting, Promoting and Supporting Continued Breastfeeding from 6-24+ Months- Issues, Politics, Policies & Action (October 2008) Details the importance of continued breastfeeding beyond 6 months including ongoing nutritional value, immune-protective factors, maternal breast cancer risk reduction and secure infant attachment.
KellyMom: Breastfeeding Past Infancy- Factsheet Summarises the evidence on continued breastfeeding.
Wherever possible, breastfeeding should not be stopped abruptly, as this puts the mother at risk of mastitis. Taking milk from a bottle or a cup is a completely different skill for the breastfed infant, and the infant will have to learn how to feed effectively via an alternative method.
Any recommendation to cease or temporarily postpone breastfeeding (‘pump and dump’) should be considered very carefully, and checked with the relevant sources or specialists (eg. specialist prescribing information, Infant Feeding Lead) if in any doubt. There are very few medications which are absolutely contraindicated in breastfeeding. Our webpages on ‘Drugs in Breastmilk‘ and ‘Prescribing Information‘ signpost to more detail on medication issues.
If it is genuinely medically indicated for a mother to stop breastfeeding, or if a mother consults the GP asking for advice on doing this after making an informed decision, the ideal is to:
- Signpost to the relevant breastfeeding specialist to advise on the safest way to cease breastfeeding.
- Advise gradually decreasing feeds while introducing alternative appropriate breastmilk substitutes (over 1 year of age this can be whole cows’ milk in ordinary circumstances).
- Where gradual reduction is not practical or possible, expression of quantities of breastmilk small enough to relieve engorgement is recommended until breastmilk production diminishes.
- Advise how to observe for symptoms and signs of mastitis and seek prompt attention to these if they occur (See our page on ‘Mastitis‘).
Stopping breastfeeding can be an emotional experience for mother and infant. Mothers who have to stop breastfeeding sooner than they originally planned to have a higher risk for postnatal depression14. See also our webpage on ‘Maternal Mental Health‘ and infant feeding.
La Leche League GB: When Breastfeeding Ends Suddenly Includes guidance on how to wean from the breast and discussion of when weaning is really necessary.
It is possible for a woman who has stopped breastfeeding to re-stimulate breastmilk production (relactate). Offering the baby the breast frequently, social support and if necessary, skilled lactation support can help to facilitate relactation.
Further Information and Resources
GPIFN: UK Infant Feeding Support Lists the national organisations providing practical breastfeeding support for families and training for health workers.
GPIFN: Online Learning for GPs links to modules covering breastfeeding issues, useful for GP education and appraisal CPD.
Academy of Breastfeeding Medicine A worldwide organisation of Physicians dedicated to the promotion, protection and support of breastfeeding and human lactation. The Academy of Breastfeeding Medicine produces evidence-based protocols on the medical management of breastfeeding issues.
Unicef UK Baby Friendly Initiative Website of the UK branch of the accreditation programme of Unicef/World Health Organisation, designed to support breastfeeding and parent infant relationships by working with public services to improve standards of care. Resources include clinical tools, patient information leaflets and demonstration videos.
Start4Life: Breastfeeding- Off to the Best Start The official NHS information service on healthy nutrition for pregnant women, new mothers and babies. Start4Life is informed by the latest research by the WHO and is aligned with NICE guidelines and UNICEF’s Baby Friendly Initiative.
KellyMom Website US Website run by an IBCLC providing evidence-based articles and links to resources on breastfeeding and parenting topics.
Best Beginnings: From Bump to Breastfeeding DVD NHS resource produced by the charity Best Beginnings. The DVD uses Mothers’ stories to show parents how to start breastfeeding and provides practical answers to common challenges.
Global Health Media:Breastfeeding Videos A series of videos detailing breastfeeding issues designed to improve global health outcomes.
- NHS Choices: Benefits of Breastfeeding Reviewed February 2017
- UK Department of Health: Infant Feeding Recommendation 2003
- WHO: Infant and Young Child Feeding Fact Sheet No 342 Updated September 2016
- Unicef UK: Preventing Disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK October 2012
- Victora C, Bahl R, Barros A, França G, Horton S, Krasevec J et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475-490.
- Public Health England: Infant Feeding- Commissioning Services July 2016
- Public Health England: Health Matters- Giving Every Child the Best Start in Life May 2016
- World Alliance for Breastfeeding Action (WABA): Protecting, Promoting and Supporting Continued Breastfeeding from 6-24+ Months- Issues, Politics, Policies & Action October 2008
- Unicef UK Baby Friendly Initiative: Three-day Course in Breastfeeding Management Participant’s handbook, November 2008
- Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals World Health Organisation (2009) ISBN-13: 978-92-4-1597494.
- Brown A, Harries V. Infant Sleep and Night Feeding Patterns During Later Infancy: Association with Breastfeeding Frequency, Daytime Complementary Food Intake, and Infant Weight. Breastfeeding Medicine. 2015;10(5):246-252.
- Quigley M, Kelly Y, Sacker A. Breastfeeding and Hospitalization for Diarrheal and Respiratory Infection in the United Kingdom Millennium Cohort Study. Pediatrics. 2007;119(4):837-842.
- Islami F, Liu Y, Jemal A, Zhou J, Weiderpass E, Colditz G et al. Breastfeeding and breast cancer risk by receptor status—a systematic review and meta-analysis. Annals of Oncology. 2015;379.
- Borra C, Iacovou M, Sevilla A. New Evidence on Breastfeeding and Postpartum Depression: The Importance of Understanding Women’s Intentions. Maternal and Child Health Journal. 2014;19(4):897-907.
Unicef UK Baby Friendly Initiative: Three-day Course in Breastfeeding Management Participant’s handbook, November 2008
Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals World Health Organisation (2009) ISBN-13: 978-92-4-1597494.