Breastfeeding

Under supervision

- Prof. Dr. Mohamed Latif, CEO of the Egyptian Health Council

 Dr. Kawthar Mahmoud, Head of the Egyptian Nursing Syndicate - Member of the Senate

Prepared by 

·        The breast consists of a mass of fat surrounding the glands and lactiferous ducts, and this mass is what determines the size of the breast.

·        Breast size has no relation to the ability to breastfeed.

·        The glands consist of milk alveoli lined on the inside with cells that secrete milk under the influence of the hormone prolactin (secreted from the anterior lobe of the pituitary gland).

·        The lactiferous ducts gather at the areola and are covered on the outside by muscle cells.

·        The muscle cells surrounding the mammary glands contract under the influence of the hormone oxytocin (secreted from the posterior lobe of the pituitary gland).

Reflexes and Hormones

·        Upon skin-to-skin contact between the baby and the mother before the first feeding, involuntary neural reflexes automatically appear, indicating the baby's desire to breastfeed.

·        These reflexes play an important role in the activation and maturation of the brain centers that lead to the newborn's proper attachment to the breast (widening of the mouth and good grasp of the areola to empty all lactiferous ducts in it).

·        Among the reflexes:

1.     Rooting reflex.

2.     Suckling reflex.

3.     Swallowing reflex.

·        The newborn discovers their way to the nipple using the "rooting reflex." When suckling begins, the sensitive nerve endings in the nipple area are stimulated, sending nerve signals to the pituitary gland to secrete prolactin and oxytocin (which is also secreted when thinking about the baby, hearing them cry, etc.).

·        The "suckling reflex" begins when the nipple touches the back of the roof of the baby's mouth. When the baby presses with their mouth (tongue) on the lactiferous ducts gathered under the areola, the milk is pushed into their mouth under the influence of the negative pressure formed at the back of the tongue.

·        This is followed by the "swallowing reflex," which allows breathing without interfering with the swallowing movement, so there is no obstruction to breathing, and thus the cycle of suckling, swallowing, and breathing is repeated.

·        The "relactation" process depends on the physiological reflexes of breastfeeding, which cause the activation of hormones responsible for milk secretion.

·        In the event that the alveoli and ducts are not emptied well of milk, the Feedback Inhibitor of Lactation is secreted, which reduces milk production. Therefore, the mother must be instructed to completely empty one breast in each feeding, alternating between the breasts during feeding. Therefore, the complete emptying of the ducts and alveoli of the breast is one of the most important factors for the continuation of milk supply.

"Skin-to-Skin" Contact Between Mother and Newborn

·        Ensures the success of the emotional bond between them.

·        In the mother, it stimulates the secretion of the hormone oxytocin, which leads to uterine contraction, reduces the sensation of pain, and generates maternal feelings and behaviors.

·        Activates a series of automatic neural reflexes that enable the newborn to crawl on its mother's chest until it finds the breast and latches onto the nipple and areola.

Diagram Highlights & Mechanisms

·        Oxytocin reflex: Causes contraction.

·        Prolactin reflex: Secretes milk under the influence of prolactin.

·        Key Anatomical Parts: Muscle cells, Milk-secreting cells, Ducts, Wide ducts, Nipple, Areola, Montgomery glands, Milk alveoli/glands, Fat cells and supporting tissues.

·        Hypothalamus and Pituitary Gland connection: Infant suckling at the nipple increases the secretion of the milk-producing hormone. Factors like confidence, thinking about the infant, love for the infant, and the sound of the infant help stimulate this reflex.

Clinical Importance of Breast Anatomy

·        The round shape of the breast allows for skin contact during breastfeeding.

·        The areola is characterized by high elasticity and therefore stretches during breastfeeding to reach the back of the mouth.

·        The tongue presses on the areola towards the roof of the mouth, pushing the milk.

·        The areola is distinguished by the presence of Montgomery glands, which are responsible for moisturizing the skin and secreting a scent similar to the amniotic fluid that surrounds the fetus inside the womb.

·        The nipple is highly sensitive as it is rich in peripheral sensory nerves that stimulate the hypothalamus and pituitary gland in the mother, thereby stimulating the brain reflexes for milk flow.

·        Completely meets the needs of the newborn in the first days despite its small quantity, as it meets their needs for calories, proteins, and vitamin A.

·        Colostrum is very useful for protecting the infant from many infectious diseases that may afflict the child early in life, as it contains a large amount of antibodies against many bacteria and viruses.

·        Colostrum acts as a mild laxative.

General Benefits for the Infant

·        Mother's milk is ideal for premature infants (rich in protein, immune bodies, and lactoferrin, which are factors that protect premature infants from serious disease infections).

·        Contains easily digested and metabolized proteins.

·        Contains antibodies (IGs), immune cells (macrophages), and immunomodulators (cytokines).

·        Encourages the growth of friendly bacteria in the infant's intestines (Lactobacillus bifidus) - Prebiotic.

·        Protects the child from obesity because it contains leptin, which gives the child a feeling of fullness and protects them from obesity.

·        Contains a unique set of nutrients and growth factors that help in the physical and neurological completion of the brain in the first six months as a result of stimulating the growth and maturation of many nerve cells and the myelination of nerves.

·        Contains the sugar "lactose," which provides the child with the energy needed during growth and also enters into the formation of the child's nervous system.

·        The percentage of iron in breast milk is sufficient for the child's needs in the first six months because it contains lactoferrin and a sufficient proportion of vitamin C, which helps in the absorption of iron, thus protecting the child from anemia.

·        Protects the child from rickets as it leads to the effective absorption of vitamin D despite its small amount, and contains a sufficient and proportionate percentage of calcium and phosphorus.

·        Breastfeeding affects the stability of the child's psychological state and is reflected in their behavior.

·        Creates close contact and supports the loving relationship between the child and their mother.

·        Affects the cognitive and emotional intelligence of the child, which increases proportionally with continued breastfeeding for two years.

·        All these benefits are more effective the earlier and more exclusively breastfeeding occurs in the first six months and continues for at least two years.

Important Tips:

·        The mother should start breastfeeding her newborn immediately after birth because this positively affects milk production and she should continue exclusive breastfeeding for 6 months.

·        Colostrum continues after birth for about three days, then milk production begins in larger quantities. If the breast is not continuously emptied, the mother may feel pain and tingling in the breasts with swelling, which may be accompanied by a high temperature.

·        Milk supply increases with continued breastfeeding and is stimulated by the baby's suckling of the mother's breast.

·        Helps in reducing the bleeding that occurs after birth.

·        Helps the mother quickly regain her normal weight.

·        Reduces breast engorgement and swelling and prevents the complications resulting from it.

·        Helps in spacing pregnancies because the hormone prolactin limits the activity of the ovaries and thus prevents ovulation. Three conditions must all be met to ensure ovulation does not occur:

1.     No more than six months have passed since the child's birth.

2.     No menstruation has occurred.

3.     Breastfeeding the child regularly day and night (exclusive breastfeeding of the child).

·        Reduces the likelihood of developing breast and ovarian cancer.

·        Breastfeeding is convenient, accessible, economical, and does not require a heating or sterilization process.

·        Works to strengthen the emotional relationship between the mother and the child.

Benefits of Breastfeeding for the Family and Society

·        For the Family: Saves time for the mother to care for the whole family, saves money as its cost is much less than artificial feeding, and reduces the cost of healthcare for the infant.

·        For Society: Reduces the cost of healthcare, improves the health of the child and society, serves as a natural method of family planning, and reduces government subsidies for artificial milk.

·        Diarrheal diseases are more prevalent (14 to 25 times) among children fed on artificial milk, and 3 to 5 times among children receiving partial (mixed) feeding.

·        The mortality rate resulting from diarrhea among children fed on artificial milk is 14 times higher than among naturally breastfed infants.

·        Merely being exposed to artificial milks reduces the benefit from the many advantages of breastfeeding, as artificial milks lead to a change in the microbial climate (Lactobacillus bifidus) in the infant's intestines, which helps in absorbing the unique components in breast milk, especially immune substances and micronutrients, replacing it with an unsuitable microbial climate (E. coli), which leads to an increased feeling of colic and destroys the inner immune lining of the intestines under the influence of casein present in artificial milks.

·        Respiratory diseases are more common among children fed on artificial milk, and the mortality rate increases 4 times among these children. Otitis media occurs 6 times more, leading to hearing loss and learning delays.

·        Bacterial and viral infections spread significantly among artificially fed children, who are exposed to severe infections from bacteremia, hepatitis, and meningitis compared to breastfed children.

·        Artificial feeding increases the incidence of urinary tract and skin infections.

·        Artificially fed children are more susceptible to disturbances in body salt levels, especially when dehydration occurs. An increase in the blood sodium salt level (hypernatremia) may lead to brain hemorrhage and convulsions.

·        Feeding on artificial or animal milk (partial or total) increases the risk of future incidence of diabetes, chronic bowel inflammation, leukemia, hypertension, atherosclerosis, angina, and obesity.

·        Allergies and asthma resulting from the use of cow's milk (used in preparing artificial milks) are more widespread among children fed on artificial milk, unlike breastfeeding, which protects against digestive, respiratory, and skin allergies.

·        Bottle feeding deprives the mother of the benefits of practicing breastfeeding, increasing the risk of breast and ovarian cancer, and deprives the mother and child of emotional bonding.

·        Artificial feeding leads to a decrease in the child's prescribed intelligence according to their genetic specifications and hinders the emotional and psychological stability granted by exclusive breastfeeding to the child, which may range from 5 to 12 intelligence points depending on their fetal age in the womb, especially emotional and cognitive intelligence.

The child faces the breast while on one side so that the ear, shoulder, and hip joint are in a straight line, close and facing the mother, and supported from behind.

·        Common Positions: Cradle hold, Cross-cradle hold, Side-lying position, Underarm (football) hold.

Good Attachment to the Breast:

The mother is directed to embrace her child so that their nose faces her nipple. This triggers the rooting reflex, and the lips part to take in the areola from below with a wide-open mouth. Here, the baby's head should be pushed toward the areola so that it enters the mouth toward the back of the palate, with the child's chin touching and pressing against the breast, and the lips turned outward.

Breastfeeding on Demand:

·        Means breastfeeding whenever the child desires or shows readiness to breastfeed, whether day or night, or if the mother also desires (if she feels her breasts are full).

·        The mother should start breastfeeding her child when the child shows a desire to feed by making sucking movements, moving the hand to the mouth, or looking restless and fidgety, without waiting until they cry.

·        Advantages of on-demand breastfeeding:

o   Fewer problems like breast engorgement.

o   Faster and increased milk production.

o   Faster and increased infant weight gain.

o   Easier habituation to breastfeeding.

o   Increased affection between mother and child.

·        To achieve this, Rooming-in must be practiced (keeping the mother and child together day and night).

-   Not giving the child any liquids or foods other than breast milk.

-  Not giving them any type of artificial nipples (feeding bottle with an artificial nipple) or a pacifier (dummy/soother).

-   Breastfeeding 8 to 12 times within 24 hours, including at night.

-   Not limiting the number of times or duration of breastfeeding.

·        Note: Giving the child liquids or foods before initiating breastfeeding negatively affects the success of exclusive breastfeeding. The use of artificial milks may expose the child to allergies. The use of feeding bottles or pacifiers leads the child to abandon the mother's breast due to nipple confusion (makes the child unable to open their mouth wide enough to take the largest part of the areola into their mouth).

Signs of Sufficient Breast Milk

The mother is advised to observe and record the number of times the infant urinates (more than 6 times daily) and defecates (4 or more times daily) to reassure her of the adequacy of the feed. However, to truly confirm its adequacy, the child's weight gain must be monitored regularly on the growth curve.

o   To feed a child who cannot breastfeed (premature or low birth weight).

o   To relieve breast engorgement.

o   To preserve milk to give to the child during the working mother's absence.

o   To maintain the rate of milk production during the mother's illness.

o   To increase the mother's milk supply.

o   To alleviate milk leaking from the breast.

·        Method of expressing the breast:

1.     The breast can be expressed using the hand or a pump. It is preferable to take a warm bath or apply warm compresses to the breast for 3-5 minutes to help the milk flow.

2.     Prepare a tightly covered container that has been washed well with hot water and detergent.

3.     Wash hands well with soap and water.

4.     Place the thumb on the breast above the areola and the index finger below the areola so they are opposite each other.

5.     Push the breast backward toward the ribs while pressing so the milk flows out. Continue this attempt for 3-5 minutes or until the milk flow rate decreases. Then express the breast perpendicularly to the previous expression site (to ensure emptying the tail of the breast located under the armpit). Then begin expressing the other breast in the same manner, alternating between the breasts.

6.     Store the milk in small quantities either in special plastic bags or small plastic jars prepared for milk storage, writing the date and number on each bottle. Use bottle number 1 before number 2.

7.     Place the milk for long-term storage on the refrigerator shelf or in the freezer.

8.     The milk is given either by spoon, dropper, or cup. A feeding bottle is never used for feeding because this will cause the child to refuse to breastfeed from the breast.

·        Avoiding giving the newborn child any drink or food other than breast milk (exclusive breastfeeding) for 6 months.

·        Breastfeeding on demand, day and night, without limiting its duration.

·        Keeping the mother and child together in her bed (Rooming-in).

·        It is sufficient to bathe or wash the breast once daily while avoiding wiping the nipple and areola with soap or alcohol, as this removes the natural oils secreted by the areola by which the child recognizes their mother.

·        After feeding the child, gently pat the breast dry or leave it bare for minutes to dry automatically. There is no need to use oils. A few drops of milk can be expressed onto the areola and nipple and left to dry.

Incorrect Practices in Breastfeeding

·        Giving glucose or sugar-sweetened water to the child after birth.

·        Giving water to the child, especially in the summer.

·        Giving anise and caraway to the child to relieve colic, which affects exclusive breastfeeding.

·        The mother stopping breastfeeding when she is sick or has a high fever.

·        Pacifiers lead to mouth and dental deformities and help cause oral thrush.

·        Scheduling breastfeeding, which contradicts the practices of exclusive breastfeeding.

·        Introducing complementary foods to the child before the sixth month.

·        Giving the child complementary foods that are not suitable for their age.

·        Not breastfeeding the child at night based on a misconception about resting the stomach.

Breastfeeding Assessment

·        What do you observe about the mother? (Her age - general health - nutrition - social and financial status).

·        What is the condition of the mother's breasts? (Size - signs of oxytocin reflex activity).

·        Look also for the following signs:

o   Fullness of the breast before the feed and its softness afterward.

o   Extreme fullness of the breast all the time, indicating the infant is not drawing milk from the breast.

o   Healthy appearance of the skin of the breast and nipples.

o   Redness of the skin or presence of cracks in the nipple.

o   Inflammation of the nipple or the appearance of a line on its tip or side when the infant releases the breast from their mouth is a sign of poor attachment.

·        What do you observe about the infant? (Nasal congestion - difficulty breathing - dehydration - tongue-tie - oral thrush fungal infections - cleft lip or palate).

·        How does the mother place the infant on her breast?

·        Does the infant appear to be well attached to the breast?

·        Is the infant suckling effectively?

·        How does the feed end and does the infant appear satiated? (The infant releasing the breast on their own, appearing full and sleepy - or the mother removing the infant from her breast before they finish feeding).

Feeding Guidelines by Age Group

Recommended Foods from 6 Months to 5 Years

·        Breastfeeding up to two years.

·        Staple foods give your child energy and include grains and tubers.

·        Staple foods do not contain sufficient nutrients on their own and must be accompanied by animal sources and other nutritious foods such as:

o   Foods of animal origin (liver, meat, eggs).

o   Dairy products (cheese, yogurt).

o   Legumes.

o   Colored leafy vegetables (yellow and green).

o   Fruits.

o   Oils and fats.

o   Ground nuts.

·        Give your child different types of the above foods alongside staple foods.

Preparing Safe and Clean Food

·        Wash your hands with soap before preparing food, before feeding your child, and after using the toilet.

·        Obtain clean drinking water and handle it properly (boil water for seconds, then let it cool on its own without adding ice. This water is considered safe and secure for the child to drink). Store it in clean, covered containers and use it in a clean cup.

·        Wash the cup and bowl the child drinks from well with soap and water, or boil them.

·        A feeding bottle must not be used as it leads to the detachment of the child from the mother, in addition to being difficult to clean.

·        Food is prepared using clean containers and the child is fed with a clean spoon.

·        Food preparation surfaces are washed with soap and water and detergents after each use.

·        Food is cooked well, especially meat, poultry, eggs, and fish.

·        Well-cooked food is prepared up to the boiling point.

·        Leftover food is covered or ideally placed in the refrigerator. It must be discarded if left at room temperature for more than two hours.

·        Avoid placing cooked food with raw food in the same container; it is best placed in separate containers.

Instructions for Dispensing Subsidized Artificial Milk for Eligible Children

Through Maternal and Child Healthcare Centers and Urban Health Centers in all governorates.

The primary role of maternal and child centers and clinics is to encourage, protect, and support breastfeeding and to help the mother breastfeed the newborn. Artificial milk is dispensed if any of the following reasons exist (Eligible Categories):

·        Twins (3 or more).

·        A sick mother taking medications that can be excreted in the milk and harm the child.

·        Complete cessation of breastfeeding for at least a month.

·        Death of the mother.

If the Guardian Requests Subsidized Formula, the Following Must be Done:

1.     When the guardian attends to request artificial milk, ensure the presence of the child's original birth certificate and the child's health card, along with valid national ID cards for the father and mother, while directing the necessity of the mother and child attending the assessment session.

2.     The guardian is directed to the designated center for dispensing milk close to their residence.

3.     The child's condition is assessed by the health team at the center designated for the maternal and child health clinic.

4.     The child is registered in the artificial milk dispensing registry, regardless of whether the child is eligible or ineligible for the milk.

5.     If the child is eligible for dispensing (within the eligible categories), this is recorded on both the original birth certificate and the third page of the health card, approved by the responsible center physician, and stamped with the center's seal.

6.     The number of milk cans to be dispensed is determined according to the instructions in each visit to dispense the specified monthly amount until the infant reaches 12 months of age (first stage up to 6 months, then second stage from the beginning of the seventh month until 12 months).

7.     The guardian is given a special card for milk dispensing recording the date of dispensing and the quantity dispensed, matching the registry.

8.     Proceed to the designated person responsible for collection, where the value of the milk scheduled for dispensing is paid with receipt voucher 33 A.H.

9.     A copy of the voucher with the ticket is handed to the guardian to proceed to the responsible pharmacist for dispensing.

10.  The financial document (receipt voucher 33 A.H.) and the package fee ticket Health/19 are collected with the financial officer at the center, as well as the cash amounts corresponding to the number of subsidized infant milk packages distributed, and regularly deposited to the health administration.

11.  The center prepares a daily/weekly/monthly report detailing the number of children attending for artificial milk, the number identified as eligible categories, and the amount of milk dispensed. The report is sent to the administration, then the directorate, where reports from all administrations are collected and a consolidated report is sent to the General Administration for Maternal and Child Healthcare.

·        Ensuring the availability of the papers and documents required to dispense artificial milk for the child and creating the child's file.

·        Completing the data of the child's eligibility assessment form for artificial milk, which includes family data (child, father, and mother) and the section related to the child's health status after assessing their growth using growth curves.

·        Recording the data regarding the dispensing of milk on both the child's health card and the milk dispensing registry.

·        Providing counseling and practical training to the mother on the proper method for preparing the artificial feed.

·        Giving the guardian the specific milk dispensing card showing the date of dispensing and the amount dispensed matching the registry, and informing the guardian of the next dispensing date.

·        Completing the aggregation pages in the milk dispensing registry and preparing the required reports (daily/weekly/monthly).