A lot of women in Pakistan are not well prepared for birth as the time for delivery approaches. They do not have access to proper prenatal care that is essential at the time of pregnancy and are bereft of knowledge required in ensuring a safe and healthy pregnancy. Nursing and breastfeeding the infant, a matter of great importance, also remains a neglected topic. Prenatal time is the best time for mothers to discover the merits of breastfeeding. Mothers can utilize this time to prepare themselves mentally and physically for the forthcoming experience by taking diet that encourages lactation.

Mother’s milk is the ideal and the most natural source of infant nutrition; it is uniquely superior to all other substitute-feeding options. Mother’s milk is easy to digest because its balance of proteins, fats, carbohydrates, vitamins and minerals is very well suited to the digestive ability and nutritional needs of an infant. Exclusive breastfeeding is encouraged in order to fulfill an infant’s dietary needs for the first six months. At the age of six months complementary foods should be added along with breast feeds, and may be continued until two years of age.

Nutrients in breast milk

On demand, exclusive feeding results in sufficient milk production to meet an infant’s nutritional needs. Furthermore, the composition of breast milk continues to change according to the child’s specific nutritional requirements. Also, the temperature of the mother’s milk is at the most suited level for the child. Milk produced by the mother for her nursing toddler contains much higher levels of fats and energy compared to a mother nursing a younger child. Beyond the first year, breast milk maintains the major nutrients in appropriate amounts and also continues to supply the nursing child with huge amount of immunological factors, anti-inflammatory agents, and growth factors needed by the young body. Milk produced by the mother of a premature or low birth weight infant is especially constituted to meet the unique nutritional needs of the child.

Importance of starting feeds early

Ideally, breast-feeding has to be initiated within an hour of birth. Delayed feeding will diminish milk supply. Majority of newborns can be at the breasts within minutes of birth. Even in cases of caesarean births, early initiation is possible and beneficial. In case of premature babies, this may even be more important than for a normal newborn. In the first few days of nursing, a mother produces thick, yellow fluid called colostrums. Although the amount of colostrums produced by the body is small, its importance is immense. It is a natural laxative that helps clean the newborns stomach. It has a high content of protein and antibodies that protects the newborn from harmful bacteria and viruses. The concentration of immune factors in colostrums is much higher than in the mature, creamy, bluish milk that the mother later produces. Pre-lacteal feeds like ghutti, honey, glucose, or any other should be abstained. The baby does not need these and may harm the child as the digestive system is not prepared to take food supplies other than breast milk.

Guidelines for successful breast feeding

Initiation of breastfeeding may seem daunting but with proper guidance and practice, every mother can comfortably breastfeed her child successfully. Unfortunately, sometimes it happens that new mothers have poor information and advice regarding breastfeeding, which leads them to avoid breast-feeding or adopt improper feeding practices. 

Frequent breastfeeding causes increased milk production. It is advisable to initially feed the baby on demand as often and for as long as s/he wants, both during the day and night. Newborns should be nursed approximately 8 to 12 times every 24 hours. Later when a routine develops, the baby should be fed 2 to 3 hours apart. In the early weeks after birth, non-demanding babies should be aroused to feed if 4 hours have elapsed since the last nursing. Each feed should last between 15- 20 minutes. Child should be fed from both breasts at each feeding. Feeding should be started on alternate breast at each session. Milk flow is enhanced if the mother is rested and relaxed and takes proper, healthy diet. A comfortable position and stress-free mind are helpful in successful feeding. Drinking a glass of fluid at the start of a feeding session improves milk flow. The process of feeding increases the body’s requirement of water so the mother should raise her intake of fluids. The mother must make sure that the baby burps after every feed as the undigested milk can choke the breathing tract of the baby which could be dangerous..

An Judging adequacy of feeds

An infant who is being adequately breastfed will pass urine six to seven times in 24 hours.  Adequacy of feeds can be assessed by monitoring the weight gain of the infant. An exclusively breast-fed infant will gain about ½ to 1 kg weight per month. The child will be content and will sleep well. Crying of a baby is not always an indication of inadequate milk supply; babies cry for various reasons, e.g. sleep, wet nappies, uncomfortable position or colic. A mother should try to find the reason and address it.

The case of working mothers

Working mothers too can breastfed successfully. If the mother is going to be away from her baby for several hours, she can express her milk and store it in a clean, covered container. A responsible adult may feed the infant with a spoon and a cup when needed. Milk can also be expressed manually or with the help of a breast pump. At room temperature, breast milk remains safe for six hours. If refrigerated (temperature 39°F or 4°C), breast milk can be used for 5 days. Refrigerated milk should be warmed to room temperature by putting the milk container in warm water. Stove or microwave must not be used for warming the milk.

Benefits of breast feeding

To the baby:
Breastfeeding provides several advantages with regard to general health, growth, and development, while significantly decreasing risk for a large number of acute and chronic diseases to the baby. These benefits range from improving the survival rates of premature babies, to protection against a multitude of diseases, to enhanced mental development. There is no doubt that nature knows the best. There is strong evidence that human milk feeding decreases the incidence and/or severity of childhood infections like diarrhoea, respiratory infections, ear infections and allergies. Breastfeeding has also been related to possible enhancement of sensory and cognitive development. Breastfed infants are found to have a protective effect against diabetes, high blood pressure, high cholesterol, as well as overweight, and obesity.

To the mother:
Breast feeding contributes immensely to the health and well-being of mothers. Breastfeeding results in less postpartum bleeding thus reducing the risk of anemia. In the early months of breast feeding, there are decreased chances of next pregnancy. However, the couple should use a suitable ‘child spacing’ method as advised by the health care provider. Child spacing is important for the health of the mother as well as the child. Spacing ensures that a mother can continue to breastfeed for the first two years of the baby’s life. Spacing is also important because it gives the mother’s body some time to recover from the last delivery and renew nutritional stores before the next pregnancy. Stimulation from nursing causes the uterus to contract and return to its original shape quickly. Feeding mothers return to their pre-pregnancy weight faster and more easily than those who choose bottle-feeding. Moreover, the risk of ovarian cancer and breast cancer are reduced in women who breastfeed.

Social and Economical:
In addition to health benefits for the infant and mother, breastfeeding provides significant social and economic benefits to the nation, including reduced health care costs and reduced employee absenteeism for care attributable to child illness. The significantly lower incidence of illness in the breastfed infant allows the parents more time for attention to other kids and family duties. The direct economic benefits to the family are also significant. During the first 6-week lactation period, maternal caloric intake is no greater for the breastfeeding mother than for the non-lactating mother. After that period, food and fluid intakes are greater, but the cost of this increased caloric intake is much lower than the cost of purchasing formula milk.

Above all these sound reasons for breast-feeding lies the bond fostered between the breastfeeding pair. There is so much more to breastfeeding than nutrition - the resulting special relationship between the mother and child is priceless and non-measurable in material terms.

Comparison of mother’s milk with complementary feeds

Water:
Breast milk contains 87 per cent water. A breastfed infant does not need extra water. Water should be avoided for the first six months as it fills the infant’s stomach leaving little place for milk. At the start of suckling foremilk is produced which is mainly water, a thirsty infant will stop after satisfying his thirst with foremilk. A hungry infant will continue to suckle and hind milk will start to flow. Hind milk is high in energy and nutrients. Using a bottle for water feeds or formula along with breast feeds will cause nipple confusion. An infant has to make more effort for suckling at the breast compared to a bottle. An easier flow and different suckling technique from the bottle may discourage breastfeeding. Nipples and bottles are difficult to keep clean and using unclean water or bottle may cause diarrhoea or other infections.

Supplemental Milk Feeds:
Sometimes a healthy mother may develop a misconception that her milk will be insufficient in quantity or quality for her baby. This fear may be self induced or be instilled in her by those around her. As a result, she may discontinue breastfeeds, and switch to animal milk, formula feeds or use these in addition to supplement breastfeeds. These practices should be discouraged, as it is not in the best interest of the child. The mother should be assured that her milk is best for her baby and that exclusive breast-feeding provides total nutrition to the infant.

Formula Feeds:
In recent years, the market has been flooded with different types of infant formula milks.  However, mothers and other caregivers need to realize that breast milk is far more superior to any of these and no infant formula can duplicate human milk. Mother’s milk is an incredibly complex substance, filled with living compounds that will be difficult, if not impossible to simulate in formula milk. Human milk contains living cells, hormones, active enzymes, immunoglobulin and compounds with unique structures that cannot be replicated in infant formula. Formulas increase the chances of waterborne diseases that arise from mixing powdered formula with unsafe water. Malnutrition may result from over-diluting a formula to ‘stretch’ supplies.

Alternate Feeds:
Even if the mother is not able to nurse her infant, she should be encouraged to express her milk while a responsible adult may feed the infant with a spoon and cup. If due to unavoidable reasons a mother cannot give her feeds, the first alternative of preference should be “wet nursing” that is: breast-feeding by another nursing mother. Only in case when no other alternative is available, should animal milk or any formula milk be used.

Mother’s milk is the ideal and the most natural source of infant nutrition; it is uniquely superior to all other substitute-feeding options. Mother’s milk is easy to digest because its balance of proteins, fats, carbohydrates, vitamins and minerals is very well suited to the digestive ability and nutritional needs of an infant.

A human baby under six months of age ought not to give animal milk unless it has been properly modified. Boiling any animal milk before use for a baby is essential because the protein of animal milk is difficult to digest.

A baby better digests cow or goat milk than sheep or buffalo milk. Every 100 ml of cow or goat milk should be diluted with 50 ml boiled water and 10 grams (2 teaspoons) sugar should be added before use.

Sheep and buffalo milk has more fat energy than cow’s milk so needs to be diluted more. Every 100 ml of sheep and buffalo milk should be diluted with 100 ml boiled water and 5 grams (1 teaspoon) sugar should be added before use.

Dietary needs of lactating mothers

A lactating mother produces about 23 to 27 ounces of milk every day. The mother should increase her food intake to provide extra energy/calories for this process. Normally, about 500 calories above her usual intake are enough to provide for lactation needs. Increased caloric intake should be maintained throughout the period of lactation. The volume or quality of breast milk is not affected by under nutrition of the mother. Nonetheless, maternal under nutrition has an effect on the health and nutritional stores of the mother. Deficiencies may not manifest themselves immediately but the affect on her teeth, bones and general health may be seen later in life.

A lactating mother may increase her calorie intake indifferent ways by increasing the quantity of her present meals, like adding an extra chapatti, a piece of meat, daal portion or an extra fruit to her usual meals. It may work out better for another mother if she adds extra small snacks to her regular meal pattern. One or two snacks over the day, comprising of protein foods along with bread or chapatti, fruit or milk are healthy additions. Another way of providing extra calories is by making foods calorie dense. This may be done by adding calories to the usual food by adding milk, a bit of oil and/or changing the cooking method from boiling to frying. Though excessive use of fatty and oily foods is not good unless the mother is undernourished and is losing a lot of body weight at a fast pace. A lactating mother should take some rest during the day. Avoiding activities which over tire her is a good idea in the lactation period.

Protein:
A mother should specially increase her intake of Protein-rich foods during the lactation period. Protein-rich foods are: meat, chicken, fish, lentils and beans. Increased use of these food items even in small quantities above the present consumption will meet the nutritional requirement of lactation. It is important to have milk or its products at least twice a day during lactation to increase protein and calcium intake for this stage of life.

Vitamin D:
Daily exposure to sunlight is necessary for the mother and her baby. UV rays of the sun produces vitamin D in the body and increases vitamin D content of breast milk. A good provision of Vitamin D and calcium are important for healthy bones and teeth of the mother and child.  A mother and her baby should spend a little time in sunlight every day.

 
Dietary Deficiency:
If a mother’s diet is deficient in calories and nutrients it will not harm the quality or quantity of her milk supply. Under nutrition of a mother will deplete nutritional stores of her own body, which will make her weak and unhealthy. She will not be able to take care for the baby and her family adequately. Therefore, the mother’s nutrition is of utmost importance for the health of the entire family.

Dietary Misconceptions:

Different cultures consider different foods good or bad for feeding mothers. Some people have cultural beliefs that certain foods irritate the baby, cause colic or influence milk supply if taken by the mother during the lactation period. There is no scientific evidence to back these claims. If a baby is especially disturbed on a certain day, the mother may be encouraged to remember the foods eaten in the past 24 hours. The suspect food may be eliminated from the diet for a while and then tried again later to see if similar symptoms reoccur in the baby.

When to avoid breast feeding?

Despite the benefits of breastfeeding, there are certain medical situations in which a mother should not breastfeed her infant. Example a mother who has untreated active tuberculosis should not feed her baby. A mother infected with hepatitis virus B or C should not breastfeed if she has cracked or bleeding nipples. Instead, milk should be expressed and discarded till it heals. After healing, breast feeds can be resumed. Nicotine from tobacco and narcotic drugs are passed in breast milk and can harm the baby. A mother who has been infected with the human immunodeficiency virus (HIV) should not breastfeed if alternate feeding option is affordable, acceptable, safe and sustainable. Although most medications are safe for the breastfed infant, yet there are a few medications that may make it necessary to discontinue breastfeeding temporarily. A mother should always check with her health care provider before using any allopathic or other medication.

About the Writer:
Ms. Ayesha Zahid Khan is a Nutritionist and is working as a Senior Research Officer at the Human Development Programme of Aga Khan University. She has been associated with Hospital Dietetics since 1987 and with Community Based Nutrition Education and Research since 2002.