Infant Feeding

• Mothers with managerial and professional occupations
• Those with the highest educational levels
• Those aged 30 or over
• First time mothers

These patterns are seen in all countries, and are consistent with previous surveys.

Breast milk is free and available without preparation. There is no need to buy a steriliser, bottles or formula milk.

Breastfeeding in public still can be socially taboo. There is an initiative from the UNICEF/ WHO to (amongst other targets) increase public awareness and encourage certain environments to be more welcoming to breast-feeding mothers e.g. surgery waiting rooms, restaurants.³

Child

• Immunity/ infection protection: Infants who are breast-fed have been reported to have lower rates of otitis media and lower respiratory tract infections.⁴ Also fewer episodes of gastroenteritis.
• Protects against constipation: Bottle fed babies have more problems with constipation, than their breast-fed counterparts.⁵
• Atopy: Exclusive breast-feeding for 4 months has been shown to reduce the risk of asthma and eczema at the age of 4 years.^6,7 3 months or more of partial breast-feeding seems to offer some protection. The effects tend to be stronger in children without a family history of allergy.
• Sudden Infant Death Syndrome (SIDS): Outcomes from studies of variable quality, have shown breastfeeding to be protective against SIDS.⁸ Analysis showed that bottle-fed infants are twice as likely to die from SIDS.
• IQ: Studies have shown that breast-feeding for longer than 4 months has a positive effect on the child's mental development at 24 months of age.⁹ Parental intelligence also appears to influence cognitive development.
• Obesity: In a population of low-income children, breast-feeding was associated with a reduced risk of obesity at age 4 years.¹⁰ This effect was seen only among white children, whose mothers did not smoke in pregnancy and only when breast-feeding continued for at least 16 weeks without formula, or at least 26 weeks with formula.

Mother

• Breast cancer: The longer women breastfeed, the more they are protected against breast cancer.¹¹ The lack of (or short lifetime duration of) breastfeeding typical with women in developed countries makes a significant contribution to the high incidence of breast cancer in these countries.
• Contraception: The Lactation Amenorrhoea method has been shown to be 98% effective¹² if:
  • Child is up to 6 months old
  • Mother is amenorrhoeic
  • Child is exclusively breast-fed

Transmission of Human Immunodeficiency virus (HIV)

• The rate of mother-to-child transmission of HIV (in the absence of preventive interventions) is about 15-25% among HIV-infected women who do not breastfeed¹³ and 25-45% among HIV-infected women who do.¹⁴
• The risk of transmission can be greatly reduced by:
  • Anti-retroviral treatment (for the mother and the infant)
  • Delivery by caesarean section
  • Avoiding breastfeeding
  When used in combination, these interventions can reduce the risk of mother-to-child HIV transmission to below 2%.¹⁵
• The risk of transmission of HIV from an infected mother to her infant (through breastfeeding) is greater if she becomes infected during the breastfeeding period, compared with mothers who were already infected. Therefore, it is important that uninfected women (who are considered at risk of exposure to HIV) are offered appropriate advice and support to help reduce their risk of becoming HIV infected while breastfeeding.¹⁶

If a woman will be moving to somewhere where safe infant formula milk feeding is unavailable, breastfeeding may be the safer option.

Hepatitis B and C

If there is appropriate immunoprophylaxis, including hepatitis B immune globulin and hepatitis B vaccine, breast-feeding babies from chronic HBV carrier mothers poses no additional risk for the transmission of the hepatitis B virus.¹⁷ Breastfeeding does not seem to influence the rate of vertical transmission of Hepatitis C (approx 5%).¹⁸

Other Infections

Certain bacterial infections in the mother may be transmitted through breast milk and temporarily stopping breastfeeding may be appropriate for a limited time; 24 hours for N. gonorrhoeae, H. influenzae, Group B streptococci and staphylococci. Longer for others e.g. B. burgdorferi, T. pallidum, and M. tuberculosis. Most antituberculosis drugs appear to be safe for use with breastfeeding.¹⁹
In certain situations, prophylactic therapy may be advisable for the infant e.g. T. pallidum, M. tuberculosis and H. influenzae.²⁰ Decisions about stopping breast milk because of infection should balance the potential risk with the huge benefits of breast milk.

Mastitis/ abscess

Breast infections are usually caused by Staphylococcus aureus, which has entered through a cracked nipple. The infection takes place in the parenchymal (fatty) tissue of the breast and causes swelling which pushes on the milk ducts. This results in pain and swelling.
Treatment may include applying moist heat to the infected breast tissue for 15 to 20 minutes four times a day. Antibiotics can be given e.g.flucloxacillin 250 mg qds. Breast-feeding (or pumping to relieve breast engorgement) should continue while receiving treatment.

Cracked/ sore nipples

Nipple soreness is very common during the first weeks of breastfeeding. Some breastfeeding mothers describe nipple soreness as a pinching, itching, or burning sensation. It may be caused by:

• Improper position of baby; using different feeding positions may help reduce soreness.²¹
• Improper feeding techniques; nipple soreness may be caused by incomplete suction release at the end of baby's feeding. Gently inserting a finger into the side of the mouth to break the suction. It can also be caused by baby chewing or biting on the nipples.
• Improper nipple care; excessively dry (or excessively moist) skin can cause nipple soreness. Moisture can be caused by bras made of synthetic fabrics. Ointments containing lanolin may be helpful. Olive oil and expressed milk are also effective for soothing uncomfortable nipples.

Thrush and breastfeeding/ductal candidiasis

There is an increasing vogue to treat fungal infections of the breast. This is recognised by deep breast pain after breast feeding, often in both breasts and associated with cracked nipples that won't heal.
Culture of the fungus is difficult - it is essentially a clinical diagnosis.
The nipple can be treated with miconazole cream after feeds (not licenced under 4 months). Oral fluconazole for the mother is not licenced, however it does have a paediatric licence for higher doses than the baby would get by transmission through breast feeding. Commonly used dosing schedules and further information can be obtained from www.breastfeedingnetwork.co.uk

Breast engorgement

This is caused by congestion of the blood vessels in the breast. The breasts feel swollen, hard and painful. The nipples cannot protrude to allow the baby to latch on and feeding becomes difficult.
Advise to nurse 8 times or more in 24 hours, for at least 15 minutes for each feed, to prevent engorgement. To relieve it express milk manually or with a pump. Alternate warm showers followed by cold compresses help to relieve the discomfort.

Insufficient milk/ hungry baby

Frequent feedings, adequate rest, good nutrition and adequate fluid intake can help maintain a good milk supply.
Checking weight and growth will determine whether baby is taking enough milk.

NB: colostrum is nutrient-rich and babies do not need to eat much in the first hours and days of life.
Professional support for mothers has been shown to prolong the time they breast-feed their children.²²

• Keep baby skin-to-skin
• Watch for early feeding cues e.g. turning the head and 'rooting'
• Offer feed within the first hour after birth
• Mums should sleep in the same room as the baby and be together as much as possible
• Don't limit baby's time at the breast
• Let baby finish the first breast before offering the other
• Learn how to position the baby to 'latch-on' well

• Well infants >34 weeks are usually able to co-ordinate sucking, swallowing and breathing. They can usually establish breast or bottle feeding.
• Extremely pre-term babies, or those expected to have a prolonged stay in neonatal intensive care, may require total parenteral nutrition.
• Preterm human breast milk, compared with artificial formula milk, may not provide sufficient nutrition for preterm or low birth weight infants.²³
• However, human milk may have advantages in terms of decreased incidence of adverse gastrointestinal (necrotising enterocolitis) and neurodevelopmental outcomes:
  • There is little good quality research on this.²⁴
  • Multinutrient fortifiers can be added to human milk.
  • Fortification with calcium and phosphate may improve bone mineral content. Protein and energy supplementation of human milk increases the rate of weight gain and head growth, at least in the short term.^25,26
• Despite the benefits, the incidence and duration of breastfeeding preterm infants is less than that of full-term infants. The lower incidence is probably related to challenges that preterm infants and parents face, including establishing and maintaining a milk supply and changing from gavage (tube) feeding to breastfeeding.²⁷

The most common reasons reported for ceasing milk expression are:

• Low milk supply
• Returning to work
• Inability to pump as often as needed

Mothers report that pumping is worth the effort.²⁸

There have been case reports suggesting that children born to women with silicone breast implants may have an increased risk of rheumatic disease and/or oesophageal disorders. Subsequent analyses of outcomes among children born after a mother's implant surgery were not significantly higher than among children born before a mother's implant surgery.^29,30
Mothers who have had surgery may have problems providing adequate milk, especially if they are preterm.^31,32 Preoperative counselling and informed consent is necessary if the mother wishes to provide breast milk for her baby.

Infant formula is the only alternative to breast milk. It is available ready-made in cartons (expensive, but handy for days out or holidays) or as powder to be made-up as directed.
Cows' milk is not suitable until a baby is a year old, because it contains too much salt and protein, but insufficient iron.
Cows' milk infant formulas are the alternative to breast milk, and should be given until baby is at least a year old. Follow-on milks can be given from six months old, but this isn't necessary.

• Hydrolysed protein infant formulas can be prescribed if the baby has an allergy to cows' milk.
• Soya-based infant formulas can also be used, but babies who are allergic to cows' milk may also be allergic to soya.
• Goats' milk infant formulas are not suitable for babies, and are not approved for use in Europe.

When starting solid foods, mix a teaspoon of one of the following with your baby's usual milk (breast or formula):

• Smooth vegetable purées e.g. carrot, parsnip, potato
• Fruit purée e.g. banana, cooked apple, pear or mango
• Cereal (not wheat-based) e.g. baby rice, sago, maize, cornmeal or millet

This should be offered before or after one of the usual milk feeds, or in the middle of a feed, if that works better.
If the food is hot, it should be stirred, cooled and tested before being offered. Most babies take time to learn how to take food from a spoon.
Avoid giving:

• Salt; babies up to 6 months old should have less than 1g salt a day. From 7 months to a year old they should have a maximum of 1g salt a day. Don't add salt to any food. Limit foods that are high in salt e.g. cheese, bacon and sausages. Processed foods that aren't made specifically for babies (e.g. pasta sauces and breakfast cereals) can be high in salt.
• Sugar; avoid adding sugar. Sugar could encourage a sweet tooth and lead to tooth decay when your baby's first teeth start to come through. Stewed sour fruit e.g. rhubarb can be sweetened with mashed banana, breast or formula milk.
• Honey; should not be given until one year old. Honey can (rarely) cause infant botulism.³³

Until 2006 growth charts were based on children with mixed feeding patterns, predominantly bottle fed, but evidence from various studies suggested that exclusively breastfed infants gained weight differently:²¹

• The worry has been that misinterpretation of growth charts could lead to breastfed babies being given unnecessary supplements of formula.
• This has led WHO to develop new charts, which the Department of Health has recently recommended be adopted for all children from 2 weeks to 2 years, with a planned launch by early 2009.
• After these charts are adopted fewer infants will be defined as underweight, whereas the proportion who are overweight will increase.³⁴