Breast milk is the best nutrition for babies. Breast-feeding provides many health benefits for both baby and mother. A vitamin D supplement is recommended for all breast-feeding women.
Most women can breast-feed. It is very unusual for a mother to be unable physically to breast-feed. It doesn't matter whether you have small or large breasts, or even if you have inverted nipples. The breast tissue is designed to make enough breast milk for your baby. If you have twins, it is usually possible to make enough milk for both babies.
Breast-feeding can, however, take a lot of practice and perseverance. As with many things, it is something to be learnt. There are many benefits to breast-feeding and this leaflet is designed to inform you of the benefits, as well as providing some information on breast-feeding technique and commonly encountered problems. Don't be scared to ask for help if you are finding breast-feeding difficult. This is nothing to be ashamed about.
The baby is referred to as 'he' throughout this leaflet.
What are the benefits of breast-feeding for the baby?
Formula milk can never quite match this perfect recipe. Infant formula is made from cow's milk. The important factors for your baby's growth and protection cannot be manufactured in a factory and added to infant formula.
No other fluids (such as water) are needed for a breast-fed baby. Even in the hottest weather, the breast milk composition changes, to provide everything your baby needs. Even when your baby is unwell - for example, if he has diarrhoea - you should continue to breast-feed. (In some circumstances, you might be advised by a medical professional to give extra fluids or oral rehydration therapy. However, for mild illnesses, breast milk alone is fine.)
Even if your baby is premature, or unwell and in hospital (for example, in the neonatal unit or special care baby unit), breast milk is still best for your baby. You may be asked to try to express some milk and can be shown how to do this.
Breast-feeding reduces the risk of developing infection
On average, breast-fed babies have fewer infections in their early life. The main reason for this is that antibodies are passed in the breast milk from mother to baby. Antibodies are proteins that help to fight infection. Compared with babies who are not breast-fed, babies who are breast-fed have less diarrhoea and are sick (vomit) less; they have fewer chest infections and fewer ear infections.
Breast-feeding reduces the risk of cot death
There is good evidence that sudden infant death syndrome (SIDS) - also known as cot death - is less common in breast-fed babies. This is not fully explained, although the fact that breast-fed babies have fewer infections is possibly a contributing factor.
Developmental and emotional factors and bonding
Some studies have shown that performance in childhood intelligence tests is better in children who have been breast-fed compared with those who have been bottle-fed. It is difficult to assess emotional factors, and no firm conclusions can be drawn.
It is thought that breast-feeding enhances the bonding process between baby and mother. Early skin contact is promoted from the moment of birth. Your baby needs to feel safe, secure and warm. Being cuddled naked, against the mother's bare skin (covered with a blanket or towel) for as long as possible, is important. This should be done if you decide not to breast-feed. Putting your newborn baby straight to your breast for a feed is ideal.
Breast-fed babies are less likely to become constipated. They also tend to be less fussy when it comes to new foods at weaning. Breast milk appears to help loosen a newborn baby's mucus. It also acts as a laxative and helps with the passage of the first poo (stools). The first stools are called meconium and are sticky, black and like tar.
Advantages in long-term health
There is now good evidence from research studies that, on average, the following health problems in later life are less common in those who had been breast-fed compared with those who had not: obesity and overweight; high blood pressure; high cholesterol level; eczema; type 2 diabetes; asthma.
Exclusive breast-feeding for the first six months of life provides maximum benefit. However, there is still a reduction in the risk of developing the above diseases even in partially breast-fed babies, and in those who are breast-fed for a shorter time.
Cow's milk should not be introduced for feeds until after the baby is one year of age (although cheese, yoghurts and milk on cereals are fine for weaning).
What are the benefits of breast-feeding for the mother?
Advantages to health
Various studies have looked at the possible health benefits to women who have breast-fed. There is now good evidence that, on average, the following health problems are less common in women who have breast-fed one or more babies compared with those who have never breast-fed: breast cancer; ovarian cancer; type 2 diabetes; postnatal depression.
It is also suggested, by recent research, that six months of breast-feeding may lower the risk of developing high blood pressure (hypertension) in the mother in later life. Another health benefit for some mothers is that it is easier to lose weight after giving birth if you are breast-feeding.
Breast-feeding is the most convenient method of feeding. There is no preparation time, and it is always available. This can be a real benefit when you are tired and woken in the middle of the night to feed your baby.
Breast-feeding is free. Formula feeding costs, on average, at least £450 per year.
Getting going with breast-feeding
Ideally, when you first start to breast-feed, it is best to have a trained person to watch and provide skilled help and support. A midwife or breast-feeding counsellor can do this. Getting the first few feeds right can make a huge difference to getting established successfully, and can prevent problems such as sore nipples, breast pain and poor milk supply.
The very first milk produced is called colostrum. It is a yellow, sticky substance sometimes referred to as liquid gold. It is rich in antibodies and high in proteins, vitamins and minerals, in a very concentrated form. A newborn baby has a tiny stomach that can hold about a teaspoonful of milk. So, even though there is only a small amount of colostrum, it is enough for the baby in the early days, until the milk supply comes in. Even one feed of colostrum is valuable for both baby and mother's health.
Some women try breast-feeding and give up after a few feeds because of problems. Problems may well have been prevented by advice on things such as the correct positioning of the baby. Try to stay relaxed, as you will find things easier if you are calm.
Breast-feeding can be time-consuming and does require quite a lot of commitment. A newborn baby will need feeding probably every 2-3 hours, day and night. As the baby gets older, he will feed more quickly. Remember, your breasts produce more milk the more your baby feeds - they will never be empty.
Babies do, generally, get into a routine of feeding. However, it is better not to stick rigidly to a feeding timetable. It is advised to feed on demand. Demand feeding means the baby dictates feeding and you feed him when he seems hungry. This will take into account periods of growth when he may need to feed more often, and other factors, such as when it is hot and he is thirsty.
Your baby receives a more watery foremilk when he starts a breast-feed. This quenches his thirst. As a breast-feed continues, the later milk (or hindmilk) is richer in fats. The hindmilk fills your baby up. The hindmilk contains more energy and nutrition needed for your baby to grow and thrive. It is therefore important that the baby finishes on one breast before being offered the second (otherwise he would only drink two lots of foremilk).
How to breast-feed
This information is intended as a guide only. Ask a midwife, breast-feeding counsellor or friend/relative whom you trust (and who has successfully breast-fed) to show you. Books, magazines and internet resources have good photographs, video and pictures/diagrams to demonstrate positioning and technique.
There are lots of different positions for breast-feeding. Key points are:
- Are your baby's head and body in a straight line? This is important so your baby can swallow easily.
- Are you holding your baby close to you? Support the baby's neck, shoulders and back. The baby should be able to tilt his head back and shouldn't have to stretch to feed.
- Make sure you are comfortable. Breast-feeding can take some time. Sometimes it helps to use a pillow or special breast-feeding cushion for support. Your arms or back may end up aching if you are hunched up for a long period of time.
Latching on is the term for getting your baby attached to your breast for feeding. Again, pictures and diagrams make this easier to understand. Some general points are:
- Hold your baby with his nose opposite your nipple. Your baby needs to get a big mouthful of breast from underneath the nipple. Placing him 'nipple to nose' will allow him to reach up and attach well to the breast.
- Let your baby tip his head back, so his top lip brushes against your nipple.
- Wait for your baby to open his mouth wide. As he does so, his chin will touch your breast first. His tongue will be down.
- Quickly bring your baby in to the breast so he can take a large mouthful.
- There should be more of the darker areola visible above the baby's top lip, than below his bottom lip.
- The let down reflex is when milk is produced from the breast and ejected. This is caused by the chemical (hormone) oxytocin released in the brain. Just the thought of breast-feeding, or of your baby, or hearing him cry, can stimulate milk to be produced. You may see the milk as you are preparing yourself to breast-feed - and this is why breast pads inside your bra are needed, to catch this milk.
Things you can look for, as signs that your baby is feeding well and latched on properly:
- The baby has a large mouthful of breast.
- The baby's chin is firmly touching the breast.
- It doesn't hurt - although the initial sucks are strong.
- The baby's cheeks are rounded throughout sucking.
- There is rhythmic sucking and swallowing, with occasional pauses. There will be cycles of short sucks and also long, deep drawing sucks.
- The baby finishes feeding and comes off the breast on his own.
If it feels uncomfortable when your baby is latched on, the position may not be quite correct. Use your little finger to break the seal between the baby's mouth and your breast by gently inserting it at the corner of your baby's mouth. Then try again with latching on. This is important to prevent sore, cracked nipples.
Some common problems with breast-feeding
Breast-feeding should not be painful. If you develop breast problems whilst breast-feeding, seek to identify and rectify the problem. You may need or wish to speak to your doctor, midwife, health visitor or breast-feeding counsellor. What you do not want is to end up becoming stressed and dreading feeds, as this emotional factor will adversely affect your milk supply and make breast-feeding even more difficult.
Breast discomfort and pain
A normal full breast can be tender. In particular, breast engorgement can occur on days 2-7 after birth when milk comes in. If milk is not removed by a feeding baby then milk production will soon stop.
The best way to minimise pain and engorgement is to give your baby frequent feeds. Some women need some painkillers such as paracetamol or ibuprofen for a few days. Some women benefit from expressing some milk by hand to ease any engorgement.
The most common cause of this is excess suction by your baby. It is often caused if your baby does not latched on well. If your baby is held so that just your nipple is in their mouth, then sore nipples are more likely to develop.
If you squeeze a little breast milk out of your nipple (this is called expressing milk) and allow it to dry in the air, this can help with sore nipples. Nipple creams, especially those containing lanolin, are also available to soothe and promote healing.
Sometimes a thrush infection of the breast or nipple is the cause. In this situation the nipple may become sore, red and cracked. Your doctor may then prescribe treatment, both for you and your baby, for thrush.
A blocked milk duct
A blocked milk duct sometimes occurs in breast-feeding women. A blocked milk duct can cause a painful swollen area in a breast. When you feed your baby, the pain may increase due to the pressure of milk building up behind the blocked duct.
A blocked milk duct will usually clear within 1-2 days and symptoms will then go. It may clear more quickly by feeding the baby more often from the affected breast and gently massaging the breast whilst feeding. However, in some cases a blocked milk duct becomes infected and develops into a mastitis.
Mastitis is an infection of your breast. Germs (bacteria) sometimes get into the milk ducts of the breast to cause the infection. This is often through a crack or sore in the nipple. See separate leaflet called Mastitis (Breast Infection) for more information.
Occasionally, an abscess may form inside an infected section of breast. An abscess is a collection of pus. This causes a firm, red, tender lump. With an abscess, you may feel more generally unwell. As well as the breast symptoms, you may feel flu-like or that you have a high temperature (feverish).
If you suspect an abscess, you should seek medical attention. The pus in a breast abscess needs draining with a needle and syringe, or even with a small operation (called incision and drainage). You will probably need antibiotic medication as well. With a breast abscess you should not feed from the affected side, but you can express and discard the milk to stop your breast from becoming swollen with fluid (engorged).
There is still a debate regarding the optimal time to introduce solid food to your baby. The World Health Organization's (WHO) recommends exclusive breast-feeding for six months (ie only breast milk or water should be given). However, the Department of Health guidelines recommend the introduction of solid food 'at around six months'.
Many experts belive that the timing of weaning should vary between babies, as their demands and need for solid food vary depending on their weight and development. Some babies may need to be weaned between 4 and 6 months of age.
Babies born prematurely usually require special consideration and you should therefore seek advice about this from your doctor.
Some worries about breast-feeding
If you have any worries or concerns about breast-feeding, then do talk to your health visitor or midwife. Most worries are unfounded, and difficulties can usually be overcome. Medical professionals are keen to advise and to offer help. This is because breast-feeding is such an important issue and women need support so that they don't abandon breast-feeding too quickly.
There are a number of organisations (listed at the end of the leaflet) who can also offer help and advice. Often, there is a local breast-feeding workshop or clinic, where you can attend with your baby for professional and practical help.
Common concerns include the following:
"How do I know my baby is getting enough milk?"
This is a common concern amongst mothers new to breast-feeding. With bottles of formula you can see exactly how much milk has been drunk. Although you can't see the amount of breast milk consumed, there are several other ways to determine if your baby is feeding well.
Firstly, watch your baby feeding (see above). You should be able to see sucking, swallowing and full cheeks. When your baby has finished his feed, your breast will feel softer and lighter.
By the end of the first week, a breast-fed newborn baby will often produce about six wet nappies and 3-4 dirty nappies per day. Breast-fed baby poo (stools) does not tend to smell, and, typically, the stools are very soft and mustard-yellow in colour. (As a breast-fed baby gets older, it can also be normal for him to go up to a week without passing stools.)
If your baby is alert, usually happy when awake and making wet and dirty nappies, he is usually getting enough breast milk. It is common for breast-fed babies to lose a bit of weight initially but, by two weeks of age, he should be starting to gain weight.
Occasionally, a baby that is not putting on weight (known medically as failure to thrive) may need topping up with expressed breast milk (EBM) or formula. If your baby seems unwell, then he will need to be seen by a doctor.
"My baby has jaundice."
Jaundice is a medical sign with yellowing of the whites of the eyes and the skin. It is not a disease in itself, and has a number of causes. It is common in breast-fed babies and is often called breast milk jaundice. Medically, jaundice in a newborn baby is called neonatal jaundice.
About 6 in 10 full-term babies and 8 in 10 premature babies are jaundiced. This is called physiological jaundice and is due to changes in the baby's blood circulation and liver. It starts at 2-3 days of age and the baby remains well. Physiological jaundice is usually settling by the end of the first week and gone by about day 10.
Breast milk jaundice can be more prolonged, up to six weeks (occasionally a few months) but, again, is not present immediately at birth. Babies with breast milk jaundice often do not need any treatment. Jaundice can be worse if a baby is dehydrated, so it is important that he is feeding well.
Jaundice that is present at birth or within the first 24 hours of life is usually more serious and has an underlying cause. Your baby will probably need further tests if he develops jaundice so early on. Blood tests may also be needed if your baby is very strongly jaundiced. Some babies need treatment - for example, with ultraviolet (UV) light treatment (phototherapy) - if the jaundice is severe. Specific causes may need specific treatments.
"I have to go back to work soon - so is it worthwhile just for a short period of time?"
YES - even if you only breast-feed for a short period of time, there are benefits. In particular, the advantage of preventing infection has a knock-on effect, and you will have given the baby valuable antibodies. But, if possible, try to continue breast-feeding for six months.
"Doesn't it tie me too much to the baby?"
Breast-feeding does require commitment and time. However, most mothers are happy to give this time for the benefits to the baby.
Once breast-feeding is properly established (usually 4-6 weeks of age), breast milk can be regularly expressed and fed to your baby by cup or bottle. However, expressing milk can be time-consuming.
Breast milk can be expressed by hand, with a manual breast pump or with an electric breast pump. You can keep breast milk, in suitable sterile containers or bags, in a fridge for up to 5 days at 4°C or lower - it can even be frozen (up to six months at minus 18°C). EBM can be used if you have planned an evening out and you are happy for your baby to be fed breast milk from a bottle during the time you are away.
"The baby's father won't be able to feed."
There are many ways for fathers to be involved with their baby - holding, bathing, playing, and helping with caring for the baby in many other ways.
The baby's father also has an important role in terms of breast-feeding support. A mother is far more likely to persevere with breast-feeding if she has a supportive partner, and she is more likely to have a positive experience.
If the father is keen to feed the baby, he could give EBM by bottle. It is best to wait for a few weeks before introducing a bottle, so that the baby does not develop a preference for the teat. In general, teats, dummies (soothers) and breast shields should all be avoided in the early days, so that the baby's mouth gets used to (and prefers) the shape and feel of a nipple.
"It's too embarrassing and inconvenient whilst out."
More shops and public places now provide mother and baby rooms to cater for breast-feeding mothers. Breast-feeding has become a much more accepted part of society. Most mothers are able to breast-feed discreetly, using a blanket or muslin cloth to preserve their modesty.
Diet, vitamin D and breast-feeding
A normal healthy balanced diet is advised for breast-feeding mothers. Breast-feeding can make you thirsty, so make sure you drink plenty of fluids, including water. You don't need to drink milk in order to make milk (although it is a good source of calcium). Breast-feeding uses up approximately 500 calories per day, so it can help you lose weight. You may find that it makes you hungry, so try to eat healthy snacks that release energy slowly (like nuts, cereal bars, bananas, etc).
In addition, a vitamin D supplement is recommended for all breast-feeding and pregnant women. There are a number of multivitamin supplements for pregnancy and breast-feeding, that contain vitamin D, or you can take a calcium/vitamin D tablet. 400 units (10 micrograms) per day is advised. If you cannot find a suitable product, your GP, midwife or health visitor should be able to advise you.
Your baby may need to receive drops containing vitamin D from 1 month of age if you have not taken vitamin D supplements throughout your pregnancy. If you did take supplements when you were pregnant then your baby should start taking vitamin D drops when he is 6 months old.
(Bottle-fed babies do not need vitamin D supplements, as formula milk is fortified with vitamin D. All weaned babies who take cow's milk need vitamin D supplements, as it contains little natural vitamin D. Outside the UK, some countries do add vitamin D to cow's milk, to fortify it.)
Breast-feeding and maternal illness
For most mild illnesses, such as diarrhoea, being sick (vomiting), coughs and colds, it is important that you continue to breast-feed, if you are able. Your milk will help to protect your baby from the same illness, or at least make it milder because of the antibodies that you make that are passed to your baby through breast milk. Remember your baby will have been exposed to any illness you have, before you know you are unwell.
You may need to drink extra fluids, especially if you have diarrhoea or vomiting, but this is standard medical advice to prevent lack of fluid in the body (dehydration). Avoid coughing and sneezing over your baby (whether breast-feeding or not).
It is perfectly safe to breast-feed, and poses no risk to your baby, if you have a long-term (chronic) health problem. This includes illnesses such as diabetes, asthma, arthritis, heart disease, etc. It is very rare that you would be advised by a medical professional to discontinue breast-feeding due to your medical condition.
If you have a chronic illness or infection, and are worried about whether you should breast-feed your baby, discuss this with your doctor.
Most medications can be safely taken whilst breast-feeding (see below).
Breast-feeding and human immunodeficiency viral infection
Without preventative interventions, about one third of babies born to mothers infected with human immunodeficiency virus (HIV) - the virus that causes acquired immune deficiency syndrome (AIDS) - also contract the disease. Babies can be infected during the pregnancy, through childbirth or through breast-feeding. About 15 in 100 of those infected babies contract the virus through breast-feeding.
In high-income (Western) countries, such as the UK, HIV-infected women should avoid breast-feeding.
Particularly in developing countries, the risk of HIV transmission with breast-feeding has to be balanced against the risks to the baby (particularly risks of other infections and poor nutrition) of NOT breast-feeding (and, indeed, the risks of bottle-feeding). In these countries, women cannot safely formula feed due to issues with supply and cost of formula, availability of clean water and facilities for sterilisation of equipment and storage of feeds. Breast-feeding is the only realistic option for these mothers. So, in developing countries, the WHO recommends that when HIV-infected mothers breast-feed, they should receive treatment for HIV and also breast-feed.
Breast-feeding and hepatitis B infection
If you have hepatitis B infection, you should still breast-feed your baby.
In the case of hepatitis B, it is vitally important that your newborn baby should be immunised against hepatitis B at birth. The hepatitis B vaccine and hepatitis B immunoglobulin (an immune system protein that fights infection), given within twelve hours of life, give the baby a 95% chance of being protected against hepatitis B infection.
Breast-feeding and prescribed medication
Most medicines pass into breast milk. Usually this is in very small quantities - amounts too small generally to be considered harmful.
It is safe to breast-feed with most prescribed medications. However:
- The age of your baby is important. If you have a low birth-weight or premature baby, the amount of medication in the breast milk could pose more risk.
- Many medications are unlicensed in breast-feeding mothers. This means that the manufacturers have not undertaken research into the safety, on ethical grounds. Put simply, breast-feeding women couldn’t be given medicines to find out if these would harm their babies. This would mean that infants would deliberately be put at risk. However, if a medication is also available in a formulation for children, it is likely to be safe in the tinier quantities present in mother's breast milk.
- The value of continued breast-feeding generally outweighs the risk of a small amount of medication being passed in mother's milk to the baby. Stopping breast-feeding for a few days can be enough to impair breast milk production severely.
- If it is felt that it would be safer for the baby not to take in (ingest) breast milk that might contain medication taken by the mother, breast milk should ideally be expressed and discarded, so that supply is maintained.
The combined oral contraceptive pill (COCP) - also known as 'the Pill' - may adversely affect your milk supply, so is not advised during breast-feeding. Progestogen-only contraceptives (including the progestogen-only pill - 'mini-pill') do not affect milk volume, and barrier (eg condoms) methods are also suitable.
Always make your doctor aware that you are breast-feeding, if you are being prescribed medication.
Breast-feeding and drugs, alcohol and smoking
So-called recreational drugs should NEVER be used by breast-feeding mothers. Not only do they impair your ability to feed and care for your baby safely, these drugs can cause serious harm directly to the baby.
If you must abuse these drugs, do not breast-feed your baby, and get urgent medical help for your addiction. Heroin, cocaine, 'angel dust' (PCP), and hallucinogens (such as LSD) are amongst the most dangerous substances; however, cannabis, amfetamines and other synthetic drugs of abuse also pose considerable risks.
Nicotine (in tobacco) and alcohol are also drugs, although more widely accepted. Still, there are potential dangers with their use in relation to breast-feeding.
Passive smoking is associated with an increased risk of sudden infant death syndrome (SIDS) and with increased rates of respiratory illnesses, including long-term problems such as asthma.
If you smoke, you should try to give up - there are so many benefits, not only for your baby's health, but for your own as well. Nicotine replacement therapy (NRT), such as patches, gum, lozenges and inhalers, is not licensed for use in breast-feeding mothers. However, the amount of nicotine your baby is exposed to is considerably less than with smoking and, importantly, your baby is not exposed to all of the other poisonous (toxic) chemicals in cigarette smoke.
Alcohol passes into breast milk freely, and levels are similar in the milk as they are in the mother's bloodstream. Long-term exposure of a breast-fed baby to more than two units of alcohol per day can have an adverse effect on development.
In general, occasional social drinking will not cause harm to your baby, so long as you are sensible and take steps to minimise the amount of alcohol indirectly consumed by your baby, through breast milk.
A few other points
It is possible to breast-feed whilst pregnant, although for many women the time of planning a subsequent child coincides with stopping breast-feeding. It is also possible to tandem feed, which means breast-feeding a baby and his older sibling. It can be difficult to decide when to stop breast-feeding, and it is usually a personal choice. Returning to work, your baby becoming more of a toddler (with teeth) and further pregnancies may play a role in this decision - but there is no right or wrong. In general, you would reduce the number of breast-feeds, replacing them with formula feeds and/or solids. Often, the last feed of the day before bed is the final feed to be dropped.
Although this leaflet is intended to promote breast-feeding and its numerous benefits to mother and child, formula feeding does require a mention. Some women will choose to formula feed their baby for personal, physical or health reasons. If you choose to formula feed, you should not feel guilty about this decision; neither should you feel like you have failed because you have not breast-fed or could not breast-feed. Formula feeds provide excellent nutrition for your baby and some people find formula feeding more convenient. It is easy to feel pressurised, but you should be supported in the decisions you make.
Further help & information
Dr Tim Kenny
Dr Louise Newson
Dr Helen Huins