Recommendations for Effective Breastfeeding

Ignorance/Difficulties on the part of the mother: having the impression that the baby is hungry, believing that she does not produce enough milk, not knowing if the infant is breastfeeding enough, how long it takes for the milk to come in...

Health issues of the mother or baby: it must be kept in mind that due to lack of knowledge or fear, breastfeeding may also be unreasonably discontinued: due to maternal infection with HBV, HCV, or cytomegalovirus; fever; having to take medications which are compatible with breastfeeding; smoking; alcohol consumption; mastitis; neonatal jaundice; and phenylketonuria in infants, among others.

Personal causes: work, desire for privacy during feedings, disorganization, and alteration of her role as a woman.

Aesthetic reasons: drooping breasts.

yellowish in color, thick, and low in volume (2-20 ml/feeding), but sufficient to keep the baby well fed.

is produced during the first 4 days after childbirth.

stimulates the maturation of the digestive system of the baby.

favors the discharge of meconium.

It is important that, after delivery, the baby be placed on top of its mother, in skin-to-skin contact, and that the baby be allowed to latch on to the breast spontaneously. If it is not possible to do so immediately after birth, it is advisable to do so as soon as possible. Newborns are awake and very active during the first 2-3 hours after birth, and then go on to a phase of sleep and physiological lethargy that can last between 8-12 hours, during which it is difficult to breastfeed it.

With regard to the frequency of feedings, it is important to bear in mind the importance of “breastfeeding on demand,” i.e. breastfeeding according to the needs of the baby and the mother, avoiding schedules and time constraints.

Although not strictly, at the beginning of lactation, the baby should breastfeed at least 8-12 times a day, despite showing no signs of appetite. It should be noted that there are babies who may show excessive drowsiness, ask for little breastfeeding, and breastfeed less than they need. In these cases, they should be actively breastfed and helped to wake up by gently stimulating them, stripping them, or placing them in skin-to-skin contact, so that they respond to the mother’s scent and thus breastfeed spontaneously.

When the baby is hungry, it performs a series of identifiable early signals. It places its hands on its mouth, opens it, and sticks out its tongue. It also makes sucking sounds and movements. It starts to become restless and to move its limbs, while looking for visual contact with its mother. Crying is a late sign of hunger which also hinders proper breastfeeding. First, the baby must be calmed and then fed.

In order to perform a proper breastfeeding technique, it is important to hold the breast correctly. It should be held by placing the hand in a “C” or “U” shape, thus providing a better support. It is not advisable to hold the breast in the shape of a clamp, because the position of the nipple is shifted and it makes it difficult for the baby to suckle on the nipple and part of the areola.

When the baby is correctly positioned, the mother holds her breast with one hand and directs it towards the infant, gently touching its upper lip with her nipple to encourage it to open its mouth.

Nipple pain from sucking is relatively common in mothers during the first week after delivery. The pain appears along with increased sensitivity in the area in the first few seconds of starting breastfeeding. If it persists or increases, it is no longer considered normal and must be assessed for the cause. Breastfeeding should not cause pain. The most common cause of nipple pain is usually an improper positioning and latching on of the baby, infection in the nipples and ducts, or nipple vasospasm.

It is not necessary to wash the breast before or after each feeding. This is unnecessary and even counterproductive, as such continuous cleaning can remove the protective layer provided by the Montgomery glands (small bumps on the areolae.)

For the position to be correct, the mother and baby must be “belly to belly.” The infant should be turned, with its head and shoulders facing its mother’s breast. This promotes contact between the baby’s eyes and its mother.

In order for the breastfeeding position to be carried out correctly, the mother places her arm (the one on the opposite side to the breast she is offering) along the baby’s back, placing the palm of her hand on its shoulders, and her fingers around its neck, forming a wide “C.” This prevents the baby’s neck from turning, flexing, or extending during the feeding.

To achieve a good positioning, the baby should be placed in front of the breast, with its chin stuck to it, and with its lower lips turned outward, covering the nipple and much of the areola.

Successful breastfeeding depends to a large extent on the positioning and latching on the breast. There is a variety of different positions which can be chosen for breastfeeding, but the comfort of the mother is the priority when it comes to choosing the most appropriate position.

The feeding will end when the baby is relaxed, satisfied, and lets go of the breast on its own.

There are times when the baby has finished breastfeeding, but does not let go of the breast. In such cases, one of the easiest ways to make the baby stop sucking is to gently insert the little finger into one of the corners of the baby’s mouth and turn it around, so that the baby automatically opens its mouth and lets go of the nipple.

It is recommended that the baby finish breastfeeding on one breast before offering the other breast. The milk at the end of the feeding is richer in fat, satiates the baby more, and causes less colic. When the baby spontaneously releases the first breast, the same breast should be offered again until the baby rejects it (a sign that it has been emptied), and then the other breast is offered, which the baby will accept if hungry.

To avoid breast engorgement, it is advisable to start each feeding with the breast from which the baby had not previously sucked or from which the baby had sucked less in the previous feeding.

Regardless of the size and shape of the breast or nipple, what is really important for suckling to be effective is that there is a proper coupling between the baby’s mouth and the mother’s breast.

If the baby inserts only the mother’s nipple into its mouth, it will not be able to milk the lactiferous sinuses with its tongue, and thus sucking will lose effectiveness because the baby will only benefit from what is aspired. This is why very large nipples can be more problematic than flat ones.

To find out if the baby is sucking the milk correctly, one can observe the movements of its temples, ears, and jaw. The baby’s deglutition can also be heard, moving from vigorous sucking to slower, deeper sucking at regular rhythmic intervals.

Two types of sucking can be distinguished: nutritive and non-nutritive. Nutritive sucking is the one that babies do to feed themselves. It is deep and rhythmic, and lasts for minutes. Non-nutritive sucking is a superficial and fast sucking; it is the one performed in the final stretch of the feeding, and serves the baby to relax rather than to feed, although babies also feed while doing it. Both types of sucking are combined by babies throughout a feeding and serve to obtain all the milk necessary for their nourishment. Both help to stimulate the production of breast milk.

One of the signs that the baby is not swallowing the milk well is the presence of constant reflux of the milk through its nose. It may indicate that the baby is suffering from gastroesophageal reflux, which occurs when the stomach contents return to the esophagus.

Sometimes this may be physiological or normal, and can be reduced by breastfeeding the baby in an upright position while straddling the mother’s thigh, facilitating belching after the feeding, not moving the baby too much after the feeding and placing it on the left side, raising the head of the crib about 300, or in a hammock or baby seat about 30 or 450, depending on the age of the baby.

If the baby has reflux problems, it may suffer from a persistent cough during feeding and will arch its back (pull its head back) during or right after feeding, making it difficult for it to swallow milk properly and enjoy a good rest.

Breathing problems can make feeding difficult, because the baby cannot swallow the milk correctly, and can cause fatigue in the baby. If the baby has an excess of mucus in the nose, nasal irrigation is recommended before feeding.

When feeding on colostrum, it is normal to wet 1-2 diapers in 24 hours.

After the fourth day, at least 4-6 diapers a day.

From a month and a half, the frequency will be similar, but the amount will be higher.

0-6 weeks: 20 g/day

Less than 4 months: 100-200 g/week

4-6 months: 80-150 g/week

6-12 months: 40-80 g/week

At 17-20 days of age: At this point, the baby has regained birth weight, breastfeeding works, and the baby may be regular in terms of the number of feedings. Suddenly, however, the baby only wants to suckle, increases its demand in an exacerbated way, seems to refuse to sleep, and only calms down by suckling. This behavior of the baby baffles the mother, who thinks that she does not produce sufficient milk or that the baby still remains hungry, which is joined by the fact that the mother feels that her breasts are soft. But what the baby is actually doing is increasing the amount of breast milk by multiplying the number of feedings over 3-4 days. Once milk production has increased, the baby will return to feedings which are less frequent.

At 6-7 weeks of age: The second lactation crisis occurs. The baby needs more milk and thus increases the number of feedings. This increase can modify the behavior of the baby when breastfeeding (it becomes more restless, jerks while suckling, cries when breastfeeding, and arches the back), because the taste of the milk changes significantly and transiently (acquiring a saltier taste) and some babies do not like the change. After about a week, they return to the usual breastfeeding pattern prior to the crisis.

At 3 months of age: At this point, the baby no longer asks to be breastfed so often, feeds only for few minutes, the feedings are often chaotic and the baby is distracted by anything, cries soon after starting to be breastfed, puts on less weight, makes fewer bowel movements, begins to suck its fingers voraciously, and the mother feels her breasts are soft. The mother attaches all these signs to an insufficient milk production, because her breasts are noticeably very soft and she does no longer notice the milk coming in. However, what actually happens is that the milk production system has changed and the body takes about two minutes to trigger the milk ejection reflex to provide the baby with all the milk it needs, and thus the baby becomes irritated because it has to wait that long. This gives the mother a mistaken feeling of lack of milk or rejection on the part of the baby. To overcome this crisis, it is recommended not to force the baby to suckle, to breastfeed in semi-darkness and in silence while minimizing external stimuli, to breastfeed the baby before it starts to cry, and to be patient.

Using teats and pacifiers at the beginning of lactation can impair the entire breastfeeding process due to the differences between the two forms of sucking and their physical characteristics. Teats cause changes in the baby’s breathing, sucking, and oral cavity. In addition, the use of nursing bottles reduces the baby’s appetite and, as a result, the number of feedings, which, in turn, causes less stimulation in the production of breast milk.

It is crucial that the first thing to be inserted into the infant’s mouth is the mother’s breast, so that the baby learns to suck correctly from the very first moment. For this reason, using teats should be avoided in the first weeks of the baby’s life, as they can create confusion when it comes to breastfeeding.

To prevent the occurrence of cracked nipples, it is advisable to avoid using teats and pacifiers at the beginning of lactation. Their early use produces an inadequate and less effective breast latch, which results in potential wounds.

It is not necessary to use water and other supplements, such as artificial milk, in babies who are effectively breastfed. On the contrary, this can cause more problems than benefits. For example, it causes the baby’s interest in breastfeeding to decrease, as well as a decrease in appetite and, as a result, in the number of feedings as well.

Artificial milk supplements are related to a delay in milk coming in and a greater difficulty in milk production. Supplements make the baby lose interest in breastfeeding and even reject it.

The sucking performed by the baby is the greatest stimulus for breast milk production, so the more feedings per day, the greater the mother’s production.

During the first 6 months of life, the baby needs nothing more than its mother’s milk to stay healthy and well fed, as it contains all the nutrients it requires for its perfect development at this stage.

If foods or drinks with caffeine are consumed in high doses (more than 300 mg per day), the baby may experience episodes of restlessness, irritability, and insomnia. The elimination time in babies can range from 3-4 days.

The use of regular analgesics, anti-inflammatories, and antibiotics is compatible with breastfeeding. Their use is recommended when the mother needs treatment for infectious and/or painful conditions.

Alcohol consumption during lactation is contraindicated, since alcohol passes into the milk, can alter its characteristics, and reduce milk production. Total abstinence is usually recommended during the first 3 months of the baby’s life. After the first months, if alcohol is consumed, it should be done on a moderate and occasional basis, avoiding drinks with high alcohol content, drinking it always after a feeding, and waiting for 2-3 hours until the next feeding.

Nicotine passes into breast milk, but not at levels that may be toxic to the baby. However, the stimulating effect of nicotine can cause sleep disturbances in the baby. The most harmful thing is the smoke that the baby inhales, which makes it more likely to suffer Sudden Infant Death Syndrome (SIDS), as well as respiratory infections, asthma, and otitis. In spite of this, it is never recommended to discontinue breastfeeding, as breast milk protects the infant from infections and partly counteracts the harmful effects of secondhand smoke.

If the individual is unable to stop smoking, it is recommended to try to reduce the number of cigarettes smoked, to smoke away from the baby, not to smoke for at least 2 hours before breastfeeding, and to do so right after the feeding.

Pathological engorgement occurs if, in addition to the normal process of milk coming in, milk is produced and if, for some reason, this milk accumulates in the ducts and is not drained effectively.

Engorgement may occur in the first days after delivery, is gradual, and affects both breasts equally. It can last about 10-15 days and, if not treated properly, can lead to mastitis.

The breasts are sore, swollen, edematous, and tight, and their skin is bright and diffusely red. The nipple is flattened due to the edema and the tightness of the areola, making it difficult for the baby to latch on. The milk does not flow well due to the compression of the ducts, and the lactiferous breasts do not empty well because latching on is difficult. As a result, the baby is left unsatisfied after breastfeeding. Sometimes, engorgement causes a fever with chills and general malaise.

Most pathological engorgements can be prevented with the following: early onset of breastfeeding; frequent feedings without time restrictions; no supplements, teats, or pacifiers; correct positioning with effective latching on; and an assessment of the first feedings to advise the mother on the most appropriate position.

It is not recommended to apply heat before the feedings, as heat dilates blood vessels and increases vascular edema.

Applying dry cold between feedings while avoiding the nipple and areola is an effective way to relieve breast inflammation, but it can also cause the ducts to contract and the milk to flow less well, or it can cause painful ischemia in the nipple due to the vasoconstrictive effect of the cold, so it must be applied with caution.

Do not use compression bandages on the breasts, as it increases pain and does not decrease inflammation. The mother must be advised to wear a nursing bra with wide straps 24 hours a day.

Analgesics/NSAIDs may also be recommended for pain and inflammation.

In the event of peripheral engorgement, a manual massage can be performed to express breast milk using the Marmet technique (manual pumping) before the feeding, just enough to provide relief and feed it in a small cup, syringe, or finger-feeder after the extraction. As there is an inflammatory component, in some cases, mechanical breast pumps may increase the edema of the areola and may not be very effective in removing the accumulated milk.

The lymphatic drainage or reverse pressure softening technique must be explained and shown to the mother. This technique is done before each feeding and always in the case of the edema having caused such tightness of the areola that the baby cannot latch on well. The mother can check to see if this is the case, because such tightness will prevent her from being able to sink a finger into it . The aim is for the areola to be completely soft, so that the baby is able to latch on better, suckle properly, and empty the breast.

Acute mastitis can occur with various symptoms, one of the most common being a set of flu-like symptoms (fever, malaise, nausea, vomiting, and headaches).

There are also other types of mastitis (subacute and subclinical), which, although they do not present these features, should be assessed because they can affect milk production and cause discomfort in both the mother and the baby.

The obstruction of a duct occurs as a lump that produces mild redness and localized pain in the area. The main causes are inadequate emptying of the breast due to the use of very tight bras, breastfeeding always in the same position, holding the breast with fingers in the shape of a scissor, poor latching on of the baby, infrequent feedings, or trauma to the breast (cracks or milk blisters).

High fever, 38.5° or higher, occurs in acute mastitis. In obstruction, as well as in subacute and subclinical mastitis, there is no fever, which is why in many cases they are not diagnosed.

Subacute mastitis is the most frequent type, which presents as intense pain similar to a puncture or cramp in the nipple area. There is an indurated area in the breast, but no redness.

In subclinical mastitis there is a sensation of decreased milk production.

In these cases, it is recommended not to apply heat, as it boosts bacterial growth and may worsen the symptoms. The area must be massaged for a few minutes towards the nipple and the baby must be placed with its chin towards the affected quadrant of the breast.

The mother must be advised to wear a nursing bra with wide straps 24 hours a day.

Avoid using nursing pads or spreading a drop of milk on the nipple while the infection is not controlled.

Analgesics/NSAIDs may also be recommended for pain and inflammation.

Breastfeeding must not be discontinued, as it would aggravate the problem. Treatment consists of draining the retained milk after breastfeeding by pumping it mechanically or by expressing it manually (although it is not always easy to express milk from a breast with mastitis). The baby is not at risk for infection from breast milk. The milk turns a little saltier in the affected breast and some babies reject it due to its taste.

In cases of subacute and subclinical mastitis, treatment with specific probiotics for lactation contributes to the balance of the physiological flora of the mammary gland for several weeks. If treatment with probiotics is not effective, an antibiotic can be used after conducting an antimicrobial susceptibility profiling of the breast milk.

The occurrence of cracks in the nipples must be avoided, as this is an important cause for discontinuing breastfeeding due to the pain they generate. Cracks do not heal on their own and must always be assessed to prevent them from worsening and cause infection, engorgement, and mastitis.

The main causes for nipple cracks are the following: performing an incorrect technique, where the baby does not latch on to part of the areola; the baby has short lingual frenulum; using pacifiers and teats; and excessive cleaning.

At the end of the feeding, the nipple should be elongated, but not deformed or with symptoms of compression. These changes are usually related to a poor latching of the baby on to the nipple.

In the event of nipple cracks or trauma, physical examination may show erosions or bleeding lesions. To avoid this situation, it is advisable for the baby to be well latched on to the nipple and areola, and for the mother to take different positions at each feed or even during each feed.

It must be recommended to start each feeding with the breast that feels less sore. It is necessary to explain and show the mother the biological nurturing position to obtain pain relief or other positions until the mother finds the one that is less painful. Analgesics may be recommended for pain.

In cases of suspected infection, milk should not be applied to the nipple and areola after feeding, as this may worsen the problem.

If the lesion is bleeding, the use of pure lanolin creams or vitamin E oils is contraindicated, as is the use of nursing pads.

It is recommended to take specific probiotics for lactation, which contribute to the balance of the physiological flora of the mammary gland, and thus speed up healing for several weeks.

If necessary (due to unbearable pain during breastfeeding or due to weight loss), breast milk should be expressed and fed in a small cup, syringe, or finger-feeder.

In these cases, it is important to monitor the baby’s weight, as ineffective breastfeeding may occur.

At room temperature: about 8 hours maximum (with temperatures between 22-25º).

In the fridge: 3-5 days.

In the freezer of a fridge-freezer: 3 to 4 months.

In a standalone freezer: 6 months.