Breastfeeding, lactation failure and complementary feeding

Overview

Breast milk is the ideal and complete food for a baby for the first 6 months. Improving breastfeeding alone could prevent a large share of child deaths from diarrhoea and pneumonia. Poor feeding in the weaning period is a major cause of malnutrition in Pakistan, so counselling mothers well is a core house-officer skill.

Physiology of lactation

Mother's reflexes:

• Prolactin (milk secretion) reflex: suckling sends impulses to the hypothalamus → anterior pituitary releases prolactin → alveoli make milk. More suckling = more milk.
• Oxytocin (let-down or milk ejection) reflex: suckling → posterior pituitary releases oxytocin → myoepithelial cells contract and push milk out. Inhibited by pain, anxiety and embarrassment, helped by privacy and confidence. Oxytocin also contracts the uterus.

Baby's reflexes: rooting (turns to the touch on the cheek), sucking, and swallowing.

Colostrum and breast milk composition

• Colostrum: thick, yellow, the first milk of the first 2-3 days; small volume (about 30-40 mL on day 1). Rich in protein, secretory IgA and other anti-infective factors. It is the right food at this time; no other feeds are needed. Mature milk comes in by about day 3-6.
• Foremilk (start of the feed) is watery and quenches thirst; hindmilk (end of the feed) is rich in fat and energy, so let the baby finish one breast before switching.

Protective factors in breast milk: secretory IgA (blocks attachment of microbes to the gut), lactoferrin (binds iron that bacteria need, especially E. coli), lysozyme (bactericidal), bifidus factor (favours lactobacilli and keeps the gut acidic), live white cells, oligosaccharides and growth factors.

Benefits of breastfeeding

Technique

Getting started

• Put the baby skin to skin and to the breast within the first hour of birth (Akbar and BFHI: within half an hour).
• No prelacteal feeds (ghutti, honey, sugar water, green tea): they carry infection, reduce suckling and delay milk.
• Rooming-in day and night; feed on demand, at least 8 times in 24 hours, including at night; wake a small baby every 2-3 hours.
• Offer both breasts; start the next feed on the other side; burp after feeds.
• No bottles, teats or pacifiers.

Positioning (4 points)

1. Baby's head and body in a straight line.
2. Body held close to the mother.
3. Whole body supported (not just neck and shoulders).
4. Baby facing the breast, nose opposite the nipple.

Attachment (4 signs: all should be present)

1. Chin touching (or very close to) the breast.
2. Mouth wide open.
3. Lower lip turned outwards.
4. More areola visible above the mouth than below.

Effective suckling: slow, deep sucks with pauses to swallow. Fast shallow sucks, cheeks drawn in, or a sore nipple suggest poor attachment.

Is the baby getting enough?

• 6 or more wet nappies a day after the first few days, yellow stools.
• Satisfactory weight gain on the growth chart (birth weight regained by about 10 days).
• Baby settles and sleeps between feeds; at least 8 feeds a day.
• Test weighing before and after feeds is possible but impractical.

Indications and contraindications

Indication: every baby. Exclusive breastfeeding for 6 months (no water, juice or other milk), then continued with complementary food to 2 years or beyond.

Breastfeeding and jaundice

Expressed breast milk

For preterm or sick babies, or when the mother is away: hand expression (thumb and finger in a C shape behind the areola, press back then together) and cup or spoon feeding, never a bottle.

Lactation failure

Lactation failure means milk is not enough for the baby's needs. True inability to make milk is rare; perceived insufficiency is common.

Causes

Management

• Observe a feed; correct positioning and attachment.
• Frequent feeds including at night; skin-to-skin; let the baby finish the first breast.
• Stop bottles, teats and prelacteal feeds; use a cup if supplements are temporarily needed.
• Reassure and support the mother; involve the family; treat pain.
• Treat breast problems: express when engorged, correct attachment for sore nipples, continue feeding plus antibiotics for mastitis, drain an abscess.
• If breastfeeding has stopped: refer for relactation (frequent suckling, often with a supplementer).
• Follow up weight in a few days.

Artificial (replacement) feeding

Only when breast milk is truly unavailable.

• Needs: about 100-110 kcal/kg/day and 150 mL/kg/day of milk in infancy.
• Infant formula made exactly as instructed with boiled, cooled water; clean utensils; cup feeding is safer than bottles.
• Unmodified cow's milk should not be the main drink before 12 months: low and poorly absorbed iron, occult gut blood loss, high protein and salt (renal solute load), few essential fatty acids.
• Over-diluted feeds (to save money) cause marasmus; over-concentrated feeds cause hypernatraemia and obesity.

Complementary feeding (weaning)

Weaning is the gradual introduction of other foods while breastfeeding continues, not a sudden stop.

Timing

• Start at 6 months (WHO, IMNCI and Park). Akbar's textbook gives 4-6 months, an older range; current national and WHO advice is 6 months.
• Why 6 months: breast milk alone no longer meets the needs for energy, iron and zinc; the gut and the swallowing and chewing skills are ready.
• Too early: diarrhoea and infection, less breast milk, allergy.
• Too late: growth faltering, malnutrition, iron deficiency, feeding difficulties.

Age-appropriate feeding (IMNCI)

Methods and types

• One new food at a time, a few days to a week apart, to spot intolerance (Akbar).
• Progress in texture: purée → mashed → finely chopped (8-10 months) → family food (1 year), with less chilli and spice.
• Make foods energy-dense: thick, not watery; add oil, ghee or butter.
• Include animal-source foods (egg, meat, chicken, fish, yoghurt) for iron, zinc and protein, plus pulses, and vitamin A-rich fruit and vegetables.
• Local home-made foods: khichri, dalia, suji, kheer, firni, mashed potato, banana, egg yolk.
• Responsive feeding: feed slowly and patiently, encourage but never force, talk and keep eye contact; use a cup and spoon, not a bottle.
• During illness: feed more often, give more fluids and breastfeed more; offer extra food during recovery to catch up.

Avoid: honey under 1 year (infant botulism, Nelson), any other drink or food under 6 months, whole nuts and hard sweets (choking), tea with meals (lowers iron absorption), sugary drinks and junk food.

Nutritional requirements (Akbar)

Every newborn needs vitamin K 1 mg IM at birth (Akbar), and breastfed babies need vitamin D 400 IU daily from soon after birth (Nelson); vitamin A is given every 6 months from 6 months.

Growth monitoring

Weigh monthly in the first year and plot on the growth chart. A flat or falling curve after 6 months often signals late or poor complementary feeding.

Caregiver counselling and hygiene

• Wash hands with soap before preparing food and feeding, and after toilet or changing nappies.
• Use clean utensils and safe (boiled) water; prepare food fresh and do not keep cooked food for long without refrigeration.
• Store food covered; keep raw and cooked foods apart.
• Explain the age-appropriate amounts and textures; praise good practices.
• Encourage continued breastfeeding through illness; counsel the family, not just the mother.

Complications of improper breastfeeding and weaning

Quick revision

• Exclusive breastfeeding 6 months; continue to 2 years; start within the first hour.
• Prolactin makes milk, oxytocin ejects it; anxiety blocks let-down.
• Colostrum: high protein and secretory IgA.
• Breast milk: whey-dominant, high lactose, low solute, well-absorbed iron.
• Attachment: chin, wide mouth, lower lip out, more areola above.
• Absolute contraindication: galactosaemia; continue in hepatitis B, TB on treatment and mastitis.
• Lactation failure: mostly poor attachment, infrequent feeds and bottles.
• Weaning at 6 months; thick, energy-dense food; 2-3 meals at 6-9 months, 3-4 later.

Written by The House Job from standard references (Basis of Paediatrics by Pervez Akbar; Nelson Essentials of Paediatrics; Park's Preventive and Social Medicine).

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