Supporting Breast-Feeding

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Supporting

Breast-Feeding

Sidney R. Kemberling, M.D.

Franz the Department of Pediatrics, University of Arizona. Tucson

Although most pediatric and infant nutrition

textbooks cite the time-honored clich#{233}“breast is

best,” little instruction is provided to assist

moth-ers in mastering the technique. A major

publica-tion on newborns makes the following

commen-tary:

Although the American pediatrician cannot take much

pride in his success in encouraging the use of human breast milk for infant feeding, pediatric research in this country has

played a major role in the development of “humanized”

proprietary formula.’

Although the American Academy of Pediatrics

speaks positively for breast-feeding, its

Commit-tee on Nutrition and Committee on Standards of

Child

Health Care pay scant attention to the

importance of breast-feeding to the health of

children.

If one feels that the skills of teaching

breast-feeding to mothers are not adequately

empha-sized in the pediatric literature, then one is

probably even more aware that even less

empha-sis is provided in pediatricians’ training programs.

I

do not believe my experience is atypical. In 27

years of pediatric practice, I can recall only two

health professionals who were able to

demon-strate with mothers the practical aspects of

breast-feeding. One was a ward nurse in

Philadel-phia and the other a nurse in a Tucson newborn

nursery. The rest of my knowledge has come

entirely from many mothers who tolerated my

ignorance while I attempted to develop my

teaching skills.

My initial motivation was as much personal as

professional. All ten of my children were

breast-fed. As I attempted to support my wife during this

period, I became all too aware of my lack of

knowledge about the techniques of

breast-feed-ing.

In 1965, I began to limit my newborn practice

to nursing mothers. Since then I have followed up

1,034 children and have medical and laboratory

records; 931 of these children began

breast-feeding in the nursery.

The La Leche League and the Childhood

Education Association have been the only

orga-nizations that have promoted breast-feeding to

any extent. Both groups have been at work in

Tucson since the 1950s, assisting parents who

wished to participate in more “natural”

child-rearing practices. Due, in part, to their efforts, the

average percentage of women in Tucson

begin-ning breast-feeding during the past 15 years has

increased from less than 15% to almost 60%.

These data are based on manual inspection of

regular nursery records by random sampling one

day a month for ten years in two local hospitals

that have handled most of the normal deliveries in

the city. Deliveries at the University Hospital are

not included.

Health professionals have been forced to adapt

to the demands of articulate parents who wish

more natural means of giving birth and feeding

their babies. In my experience healthier children

are the result. I have found the following

proce-dures useful in supporting successful

breast-feed-ing in private practice patients.

INSTILLING CONFIDENCE

Confidence is the single most important

deter-minant of successful breast-feeding. If the mother

thinks she will succeed, she most likely will. The

more successfully she breast-feeds, the more

confidence she develops in all aspects of child

rearing. After several months of breast-feeding,

most mothers will admit to both physical pleasure

and psychological satisfaction. Frequent

commu-nication between parents and the physician’s

office is essential to encourage the development

Received December 5, 1977; revision accepted for publica-tion May 5, 1978.

ADDRESS FOR REPRINTS: (S.R.K.) 1601 North Tucson

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TABLE

PEDIATRICS FOR THE CLINICIAN 61

BREAST-FEEDING TECHNIQUES

1. The nipple should be cleaned only with water; soap causes irritation.

2. The physicial position of the mother should be that which is most comfortable for her and the baby.

Sitting in a straight-back chair with knee and leg propped up with a stool on the breast-feeding side.

Sitting with baby held under the axilla (the “football” position). Laying on side in bed.

3. The nipple should be pulled outward with fingers to stimulate erection. 4. The nipple should be placed next to baby’s cheek to encourage “rooting.”

5. The index and third finger should be used to make a V with the index finger above the nipple and the third finger below the nipple. This increases nipple control and allows the baby’s nasal passage to be free.

6. Total feeding time, including catnaps, bathing, and diaper changes, may consume as much

as one hour with a newborn and less than ten minutes with a 6-month-old infant.

7. A relaxed environment helps but if other children need attention, this is the time to read

storybooks.

8. Methods to encourage the letdown reflex are reported in the books listed at the end of this article. Too much emphasis has been placed on this natural reflex. (In my series of breast-feeding mothers, only 20% could describe it.)

9. The most eloquent and concise description of breast-feeding techniques are in Nelson, Vaughan and McKay’s Textbook of Pediatrics.””7’

of the individual skills. Mothers must find an

obstetrician, as well as a pediatrician, who will

support her and answer her questions about

breast-feeding. More time must be spent with the

prelactating mother in group sessions. After birth,

the rooming-in method should be used in the

hospital, and the hospital stay should be as short

as possible. The babies and parents should be seen

48

hours after discharge and recurrent visits

should be made based on the need for support.

Telephone communication with the nurse and

receptionist should be encouraged for as long as

the mother feels she needs help.

It has been my impression that the mother’s

motivation and family background for

breast-feeding are influenced more by the degree of

higher education and higher socioeconomic status

than by a history of having been breast-fed

herself. The duration of breast-feeding, however,

is influenced by the maternal grandmother who

breast-fed her children.

The attitude of the father is crucial. If he has

cultural, psychological, or sexual hang-ups about

mother’s breasts, feeding becomes a bore, or,

because of his symbolic competition with the

infant, a cause of marital disunity. A husband who

has been breast-fed as an infant enhances the

chances of success. I attempt to explore all of

these matters in an antepartum visit with both

parents. Most fathers were questioned as to

whether they were breast-fed as an infant and

approximately 70% had been. Of the series, 558

patients were of Mexican descent and the ethnic

bias is toward breast-feeding. This may explain

the increase in successful breast-feeding.

Howev-er, this is not the preference of the younger

generation of families of Mexican descent.

Surprisingly, in my original series many fathers of

Mexican descent insisted that their babies be

breast-f#{231}d. There are several books on

breast-feeding that my patients have found helpful and

they are listed at the end of this article.

I also examine the mother’s breasts and discuss

nipple care. Preparation is essential for rapid

conversion to the tough nipples that are needed

for a vigorous infant suck. Many techniques

(Table) have been advocated but the simplest is

exposure to dry, warm air. A woman with smaller,

globular breasts need not wear a bra for the last

two months of pregnancy. If the breasts are large

and pendulous and need support for comfort, a

nursing bra with the flaps down will expose the

nipples to air. Many women toughen up their

nipples by rubbing them with a bath towel for 15

minutes each day. The closest simulation for a

vigorous infant suck occurs in second pregnancies

where the mother had breast-fed the first infant

for 6 to 12 months; these mothers have fewer

nipple problems. In the first pregnancy,

toughen-ing the nipples may be accomplished by the

husband simulating the sucking act. Most mature

people should have no problem understanding

this natural phenomenon, despite cultural and

religious taboos.

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THE FIRST WEEKS

During the first two to three weeks of

breast-feeding the mother is most vulnerable to

discour-agement. The role of the pediatrician during this

period must be one of frequent communication

with both parents.

My practice is to see the baby and parents 48 hours after hospital discharge for physical

evalua-tion of the child and complete examination of the

mother’s breasts; recurrent visits are made based

on need for support. The mother’s and father’s

attitudes should be reevaluated at this time. Many

women will ask questions about their breasts at

these visits that they never asked previously.

The physician should have an understanding of

the anatomy and physiology of breast tissue.2

Much has been written regarding the components

of breast milk but little about the lacatating

breast tissue. Women may have marked

varia-tions in size, function, and consistency of their

two breasts. So distinct is the difference that some

babies develop a definite preference for one.

Occasionally, a baby will even cease feeding from

one breast, causing, of course, great anxiety to the

mother. She should be reassured that,

cosmetical-ly,

this uneveness will disappear when she stops

breast-feeding. Within three to six months after

breast-feeding it is difficult to recognize which

breast was involved.

Engorgement during the first two weeks is the

second most common cause of maternal

dissatis-faction. The simplest remedial technique is to use

manual expression on the opposite breast which

causes milk to leak at the time of breast-feeding.

This bilateral letdown of milk often occurs

spon-taneously and may be of sufficient quantity to

collect in wide-mouth bottles for freezer storage.

It is not uncommon to leak as much as 120 to 240

ml (4 to 8 oz) in a 24-hour period. The frozen milk

may be stored for 6 to 12 months for use in

emergency situations. Hand or pump expression

may be used to relieve engorgement but just to

the point where relief is first felt. Continued

pumping will defeat the purpose by stimulating

milk production.

OVERCOMING FATIGUE

A fundamental deterrent to successful

breast-feeding is fatigue. The husband must be

encour-aged to step in and do some of the housework and

preparate some meals. As an added benefit some

men emerge from this experience as gourmet

cooks. More important, all achieve a heightened

awareness of the nature of routine household

chores.

Despite the fact that some babies have very

erratic feeding times, the mother must develop a

work attitude that is both realistic and organized.

In the first three months as many as 50% of babies

may eat as often as every 1#{189}to 2 hours before

developing a more “civilized” schedule.

A major error made by physicians, in-laws, and

friends is to meddle and advise mothers of

frequently feeding babies to add supplementary

foods. The pediatrician must assure the mother

that additional foods are not necessary, and that

breast milk alone is adequate. A completely

breast-fed infant will maintain adequate iron

stores up to 12 to 18 months of age.:! In my

practice of approximately 1,000 infants during a

ten-year period who nursed more than six months,

only one developed iron deficiency anemia and it

was very mild. The mother later admitted to

feeding the baby additional food as early as 6

weeks of age. Breast milk alone is adequate for

nutritional needs until the baby demonstrates an

interest in table foods.4

FAILURES

The breast-feeding failures in my practice

generally fall into three catagories:

Unsupportice Husband. Some men feel that

breast-feeding interferes with a satisfactory sex

life. Milk leaks during sexual activity, particularly

during orgasm, and some men are repulsed by

this.

Physical Factors. Breast engorgement coupled

with small nipples and mastitis are two

trouble-some conditions that may force discontinuation of

nursing. “Insufficient milk” is often used as an

excuse, but it is in fact an extreme rarity.

Absent Pediatrician. A number of failures

occurred because I was not available during the

crucial first three weeks.

The guidelines for a definition of breast-feeding

failure depend on the biases of the physician. Any

mother who begins to breast-feed in today’s

society has to overcome the modern social pres-sures against the practice. Early in my experience

with complete breast-feeding, I accepted six

weeks to three months as sufficient for total

breast-feeding with no solid foods; today I perfer

six to nine months.

CONCLUSION

For those interested in another approach to

breast-feeding, Jelliffe and Jelliffe ha.ye recently

published an elegant paper titled “Breast Is

Best.”4

Developing skills that enhance breast-feeding

can be learned by reading the books listed at the

end of this article. If pediatricians want to be

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PEDIATRICS FOR THE CLINICIAN 63

convinced of the advantages of breast milk. Many physicians say that they support breast-feeding

but will, for instance, send formula bottles to the

bedside of a breast-feeding mother.

The antagonistic physician or member of the

office team may make remarks such as “Are you going to breast-feed until your child goes to

school?” “Are you still breast-feeding?” or “The

baby needs solid foods for good nutrition.” These innuendos can defeat and demoralize the

breast-feeding mother. Unless the physician provides

strong support against these remarks, the mother

will lose her confidence. Many husbands who are

advocates of breast-feeding will defend her against these discouraging remarks. Group sessions of lactating mothers also bolster morale. Many mothers find duenna substitutes whom they

can communicate with by telephone. (A duenna is

an elderly woman who has charge of young

unmarried women in a Spanish family.) However,

when breast-feeding mothers confront a serious

problem for which they have no simple solution,

the pediatrician has to provide the ultimate

backup support.

REFERENCES

1. Raye JR: Feeding the normal newborn, in Schaffer JS, Avery ME (eds): Diseases of the Newborn, ed 4.

Philadelphia, WB Saunders Co, 1977, p 840.

2. Arey LB: Deuelopuu’ntal Anatomy, ed 7. Philadelphia,

\VB Saunders Go, 1974, p 452.

3. McMillan JA, Landaw SA, Oski FA: Iron sufficiency in breast-fed infants and the availability of iron from

human milk. Pediatrics 58:686, 1976.

4. Jelliffe DB, Jelliffe EFP: Breast is best: Modern

mean-iiigs. N Eng! I .‘ie(l 297:912, 1977.

5. Nelson \VE, Vaughan \‘C III, McKay RJ: Textbook of

Pediatrics, ed 10. Philadelphia, \‘B Saunders Go, 1975.

RECOMMENDED READINGS

Eiger NIS, Olds S\V: The Complete Book of Breastfeeding.

New York, Workman Publishing Co mc, 1972.

Jelliffe DB, Jelliffe EFP: liunian Milk in the Modern World.

London, Oxford University Press, 1977.

La Leche League International: The Womanly Art of

Breast-f

eeding. Franklin Park, Ill, Interstate Printers Publishers,

1978.

Pryor K: Nursing Your Baby. New \ork, harper & Row,

1963.

Raphael D: The Tender Gift. New York, Schocken Books Inc. 1976.

Zabriskie JR: Brcastfceding Iour Babi,. Philadelphia, JB Lippincott Go, 1968.

ACKNOWLEDGMENT

Thanks to .braham B. Bergman, NIl)., for editing this article: to Grant Morrow, Ml)., for suggestions, deletions,

and support: and to Kenneth Rogers, M.D., who has been of

valuable assistance both in editing this article and in

provid-ing support over the past ten years; and thank you,

Marian.

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1979;63;60

Pediatrics

Sidney R. Kemberling