Breastfeeding

In 2020, following a complaint by the Breastfeeding Promotion Network of India (BPNI),  the government pulled up lobby groups among pediatricians (Indian Academy of Pediatricians) and gynaecologists (Federation of Obstetrics and Gynaecological Societies of India – FOGSI) over seminars sponsored by pharma companies and major food companies which were in contravention of the  Infant Milk Substitutes, Feeding bottles and Infant Foods Act (IMS Act), which clearly states that no producer, supplier or distributor of infant milk substitutes, feeding bottles and infant foods shall offer or give any contribution or pecuniary benefit to a health worker or association of health workers including funding of seminars, meetings, conferences educational course, context, fellowship, research work or sponsorship. These are cognizable offences. Similar complaints had been made against Nestle, which through its frontal organisation Nestle Nutrition Institute, was attempting to influence doctors to recommend baby products, including infant milk powder, to parents.

Doctors who get lured by these pharma or food companies are unlikely to genuinely promote breastfeeding and will tend towards promoting baby foods at every opportunity. It is not uncommon for a mother to be told that her breast milk is inadequate. Coming from a doctor, this can adversely affect a mothers decision-making about her child’s feeding, and can literally make her feel that she is not doing enough for the baby, thus opening the door for formula milk. It is also often easy in nuclear families with tight schedules and the need for the couple to get back to full time jobs, to rely on formula, more so if they depend on a child help or older family member taking care of the baby.  In what they think is adequate precaution, the parents may opt for sugar free formula. However, sugar is not the main problem with formula. It is also about the addition of soya oil, soya powder, maltodextrin, additives, flavouring agents etc.

According to established standards, babies should be breastfed exclusively for 6 months (no additional food or drink, including water), with complementary feeds being introduced after that,  so that at the end of the year, the baby is able to consume what the family usually eats. The baby can receive medicines, drops, syrups etc. as recommended by a doctor.

The lactose, protein (whey and casein), fat etc. in breast milk are easily digested and it contains most nutrients that the baby needs, except possibly vitamin D. Research shows that breastfed children are likely to have better immunity against ear infections, diarrhoea, respiratory infections etc. and also a lesser risk of allergies, asthma, diabetes, obesity etc.  Breastfeeding helps the uterus to contract, and also has a reduced risk of breast cancer, uterine and ovarian cancer in the mother.

While breastfeeding, the mother has to be in the position most comfortable for her, and whether is is sitting or lying down doesn’t really make a difference. The initial breast milk (foremilk) is more watery in consistency and helps quench thirst, so if the baby just needs fluids, it will be satisfied with the foremilk. There is no additional need for water or other fluids. The milk that is secreted later is hind milk and is rich with fats and other nutrients and this is the food which helps the baby grow. If the baby has adequate quantity of the hind milk, it is more likely to feel full. This is why mothers are encouraged to feed from one breast at each meal instead of constantly shifting.

Correct latching means the baby’s mouth is round the areola (dark part around the nipple), and this will stimulate milk production without causing pain to the mother. If the mother feels pain, then the flow of milk can be reduced. The baby should be breastfed within half hour after birth unless the mother has had a Caesarean section, in which case –at the earliest. The baby can be fed on demand and this is initially every 2-3 hours. Mothers should avoid alcohol or at least give a break of 2 hours after a single alcoholic drink. Caffeine intake also should not be very high.

The mother normally produces as much milk as the baby requires upto the age of six months after which, she can continue breastfeeding but would require to supplement the milk with additional nutrient dense foods. After a Caesarean section the mother can still feed the baby and should find  a position that is most comfortable for her. A mother who is stressed or in pain will find it difficult to feed the baby so ensuring her comfort is important. Even if a woman becomes pregnant again after delivery of the previous baby, she can still continue breastfeeding.

The baby should not just be sucking on the nipple, as this can, over time, actually interfere with breastfeeding and can cause pain and discomfort for the mother. When the angle of the baby’s mouth is stimulated with the nipple, the baby automatically turns towards the breast and opens its mouth. At this point, the baby should be held close to the mother, so that the chin is close to the breast, the baby’s mouth is open, the lower lip is turned outward and most of the areola (darker skin around the nipple) is in the baby’s mouth. Since most of the ducts are located around the areola, when the baby sucks, the areola is stimulated and the flow of milk is initiated through the milk ejection reflex. When the baby sucks a milk ejection reflex is stimulated and It doesn’t have anything to do with the size of the breast.After baby feeds, keep her/him upright and gently stroke back so that baby burps.Make sure the baby is immunised and has regular weight monitoring which should be mapped on a growth chart. If the baby shows steady gain in weight, then there is no need for any further intervention.

When this reflex starts, hormones oxytocin and prolactin are released which stimulate breast milk. The breasts can get full and  there can be some amount of leaking of milk. This is completely normal. However after the reflex starts and if the baby doesn’t feed properly, then painful breast engorgement can happen. If this continues, there are possibilities of infection that can even lead to formation of  a breast abscess. If this happens, the mother may require antibiotics, and in some instances, even surgical draining of the abscess. Explaining this to the mother is crucial to prevent undue distress and discomfort.  It is not required to wash the nipple each time the mother feeds the baby. The secretions are protective and maintain the texture around the nipple and areola. Washing too frequently can lead to drying of the skin, causing cracks to form which can become extremely painful for the mother, or even infected. The colostrum, or watery yellow liquid as soon as baby is born is filled with immunoglobulins and antibodies so this should not be discarded, as is often done in Indian culture.

Mothers, especially new mothers, become vulnerable to all kinds of ‘expert advice’. She is asked to eat food she doesn’t like or tolerate, or give up foods she enjoys. Some foods are hot, some cold, some spicy, some bland and based on what people think is best for the baby she is given different and often conflicting advice. What is important is that the mother has a balanced and diverse diet that has a good amount of proteins, vitamins and minerals – by the end of a year the baby should be consuming what the family usually eats. Nursing mothers should be given an additional 300 -500 calories and their requirements of other nutrients also goes up. Encouraging skin to skin contact of mother and baby helps the baby especially premature to adjust body temperature. The sooner this is done the better. If the mother is not able to for any reason, any other trusted person can support with skin to skin contact (Kangaroo method).When the mother feeds regularly and follows the correct method,breast engorgement can be prevented. Feeding techniques have to be discussed when women are pregnant rather than after delivery when she is stressed and handling a yelling, hungry baby. This is the wrong time to try and give advice on anything.

From six months onwards, semi solid foods can be introduced. This includes soft cereal with pulses, mashed potatoes. Slowly the texture can be diversified and foods added one by one so that it is easier to assess what a baby cannot tolerate. Preparing foods hot and then cooling it down can help the baby avoid gastrointestinal infections. Addition of butter or ghee is important as the baby needs energy. The baby rapidly gains weight and height and needs fats for energy but also for other vital functions. Only giving the child sugary drinks, high carbohydrate foods and junk/processed foods like biscuits not only affect the child's nutrition status, but can also create a lifelong culture of poor eating and its subsequent complications.

Sometimes the very first exposure of a baby to oral fluids is some sugary syrup. This is not advisable. Holding back on sugar till the child has been exposed to a variety of other tastes is important. Sugar can be addictive even for babies !! Even babies can develop a ‘sweet tooth’, which means that even when they grow older, there may be a preference for sweetened foods and this can directly link to caries and obesity with its associated non-communicable disease consequences.

There are simple ways to find out if the baby is feeding adequately. In the first two months the baby should be fed on demand and at least every 2-3 hours. After that the duration and frequency may reduce. If the baby is passing urine frequently and the urine is not very concentrated (dark yellow) it means the baby is well hydrated. Regular growth monitoring is important. If the baby falls within the expected weight for age on the growth chart, it means the baby is growing well and this is much more reliable and objective. Baby initially passes urine 5-6 times in 24 hours and gains around 500 gm every month.

If costs are calculated over time, formula costs a lot because of which some families may tend to make it more dilute and watery, which means the baby may not get enough. In case the baby refuses formula feed after it is mixed, it can be stored for use later, and then becomes a possible source of contamination. Formula doesn’t contain antibodies that are found in breast milk.  Formula has to be mixed in the right proportion and there is a need for availability of clean drinking water, preferably boiled and cooled. It is best to feed the child with a sipper or with a bowl and spoon rather than a bottle. The nipple of the bottle can store bacteria and become a potential source of infection. It has to be sterilised in hot water. Once the baby gets hungry, it takes time to prepare formula so anticipating and preparing for the meal in advance is good.

However, some women may not be able to breastfeed for a variety of reasons. They should not be made to feel that they are not good mothers but should be supported . Women who may not be able to breast feed are those with communicable diseases with preclude breastfeeding, breast abscess or infections, separation of mother and baby, baby or mother in the intensive care unit, psycho-social issues of mother etc. Although bonding between mother and child doesn’t only depend on whether breastfeeding is taking place or not, formula fed babies may spend less time with their mothers as anyone can feed them, so it is important for mothers to make time to spend with the baby, and also for families, society and workplace to facilitate this bonding time. It also gives the mother time to recover her health.

Infant and child foods are a multibillion industry. India with its burgeoning aspirational middle class are a ready target. Parents must plan better for their children. It is unlikely that when parents are themselves consuming sugary, high carbohydrate, processed/ultra processed foods that they will feed their children healthy foods. By the age of one, children should be consuming what the family regularly eats. Therefore committing to a balanced diet with diversity and without cultural/social prejudices against naturally available nutrient dense foods should be a good place to start.  Parents are also facing the burden of protecting the climate by making poor personal dietary choices such as veganism. Veganism itself offers very poor nutritional benefits to a baby. Vegan or undernourished mothers are unlikely to be able to sustain healthy breastfeeding practices. 

References

Chandna H., “Govt shoots off letters to doctors, seeks answer on seminars ‘sponsored’ by baby-food makers” 20th August, 2020, The Print

Himani C., “Nestlé in trouble for ‘influencing doctors to prescribe baby food’ in India.” The Print.  10th January 2019

“Question and Answer sheet on Exclusive breastfeeding and complementary feeding of Infant and young Children.” Breastfeeding Promotion Network of India. Information sheet 7 (2004)

“Guidelines for breastfeeding and complementary feeding” Breastfeeding Promotion Network of India. Information sheet 1. 2000-2002

Joseph E.P.B., “Breast feeding vs Formula Feeding” Kids Health website

“The Infant milk substitutes, feeding bottles and infant foods (Regulation of production, supply and distribution) Act, 1992” Act No. 41 of 1992