All your questions on breastfeeding answered

Q: Many mothers have difficulties to breastfeed their babies in the first few days and are concerned that they can't produce enough milk. How can we help them?

A: A mother's very first milk - colostrum - is extremely beneficial for new-born babies. Early contact, early suckling and early initiation of the flow of breast-milk can be aided by the support of midwives and health staff. Infants should be put to the mother's breast shortly after birth to keep skin-to-skin contact when they have the strongest instinct to suckle the mother's nipples. Babies should not be forced to suckle if they are not willing to. Early introduction of a milk bottle or powered milk can ruin the child's natural sucking reflex, and is one of the main reasons that infants can fail to breast-feed properly.

People usually worry that the baby will be hungry or dehydrated before sufficient colostrum is produced by their mothers. In fact, new-born babies have stored up adequate body fluids that completely meet their limited needs at this very early stage of life. No water, juice or formula milk is needed. Therefore, anything other than colostrum – mother's first milk – can have a negative impact on the baby's health. Lack of colostrum may cause diarrhea in the baby and mother's lactation can be interrupted because the baby loses it's instinct to breast feed.   

Q: Will Caesarean-section affect breastfeeding?

A: Research shows that Caesarean-section is another factor that affects breastfeeding, early initiation in particular. C-sections make delivery and neonatal care processes far more complicated, but have no impact on lactation. According to WHO guidelines, antibiotics commonly used after this surgery, such as amoxicillin and cephalosporin V will not cause any problems with breastfeeding. After regaining consciousness, mother can start skin contact with the baby and initiate breastfeeding right away. However, mothers who experienced C-sections will need more care when holding the babies and breastfeeding them with each nipple alternatively. They will feel constant pain during the first several days so breastfeeding in a lying position will be more suitable for new mothers who have just gone through a Caesarean section delivery.

Q: If in the first six months of its life, a baby is exclusively fed with breast milk without any intake of water, will it feel hungry, thirsty or suffer from excessive internal heat?

A: 88% of breast milk is water, and this is totally sufficient for babies less than 6 months old. There is no need to feed the baby water or other fluid. 

On the contrary, water can be hazardous for baby less than 6 months old. Water fills up the baby's stomach and prevents it from taking-in breast milk. It is also difficult to guarantee the safety of drinking water and the hygienic condition of utensils.

Even in a hot, dry environment, the baby can acquire adequate water through frequent breastfeeding. You can tell if the baby is provided with sufficient water by observing their urine. If the baby is passing yellowish urine six times a day it means they have adequate water supply.

Q: Is it true that after six months, the breast milk will contain no nutrients just like water?

A: Breast milk is perfectly designed to nourish human babies, and almost all women are able to produce breast milk with the expected nutrient composition. The quality of breast milk is affected in under-nourished women with very low Body Mass Index – below 18.

The composition of breast milk can vary at different stages, from colostrum at birth, to mature milk later on. And composition also changes within a feed from light fore-milk at the beginning of a feed to quench the baby's thirst, to richer hind milk to satisfy energy and nutrient needs. This is one of the miraculous qualities of human milk. The body adjusts the composition of milk to suit the babies changing needs.

The composition in terms of energy, protein, and iron is quite similar before and after 6 months. The percentage contribution varies from nutrient to nutrient. Immunity factors in breast milk also vary from time to time depending on exposure of the mother to various antigens. But it is untrue that breast milk has no nutrients after 6 months.

The fact is that after 6 months the energy and nutrient needs of the baby can no longer be met by breast milk alone. This is why UNICEF and WHO recommend continued breast feeding with complementary foods after 6 months.

Q: How can breastfeeding affect the development of preterm, low birth weight and twin babies?

A: The mother's body is able to adjust the formulation and amount of breast milk produced, according to the needs of the baby. Almost all preterm, low birth-weight and twin babies can be fed with breast milk. There is more protein in the breast milk of a mother who gave birth to a premature baby, and this helps produce faster growth. Nutritional supplements can be provided to lactating women when necessary to improve their nutritional conditions. 

It is extremely critical for the baby to suck the mother's nipples as early as possible. For babies who have problems in sucking nipples, breast milk can be pumped out and fed via stomach tubes, suction tubes or cups. Babies with more than 1,800 g of body weight can learn to suckle for breast milk normally.

Q: How can working mothers keep breastfeeding?

A: Mothers do not have to feed their babies with substitutes. 

If mothers can't stay with their children during working hours, it is suggested that when they are together, women should try their best to breastfeed as frequently as possible. Allowing children to breastfeed “on demand” is best and will help mothers to keep producing milk. 

If mothers can't breastfeed in their work-place, they can express their milk two or three times per weekday and store the milk in clean containers. Breastmilk can be stored at room temperature safely for up to eight hours. Children should be fed the milk from clean cups, not from a bottle.

Families and the whole community should urge employers to provide female staff with maternity leave with pay and day care centres at the work place, as well as to give them appropriate time and space to breast feed or express their milk.

Q: How does breastfeeding affect women's health?

A: Breastfeeding benefits mothers too. Exclusive breastfeeding for at least six months will help women lose the weight they gained during pregnancy, as the fat will then be used to generate breast milk. 

International studies have found a connection between exclusive breastfeeding and decreased incidents of breast cancer.

Breastfeeding soon after giving birth can also help mothers stop bleeding after birth and also helps the uterus to recover.

Q:There is a common concern that insufficient breast milk may impair an infant's growth. The fatter the babies, the better it is.  How can we evaluate the indicators of an infant's weight and length?

A:First you need a standard to measure child growth. The standard developed by the National Institute of Health (NIH) was adopted before WHO announced its Child Growth Standard in 2006. WHO's standard is based on primary growth data and related information from approximately 8,500 children from widely different ethnic backgrounds and cultural settings while NIH's standard is based on developmental status of children raised on American soil.

In regard to possible morbidity among infants, WHO's indicators on sufficient milk supply for babies within 6 months old are defined as: 1) an average of 500 grams increase in body weight per month, and 2) more than 6 times passing yellowish urine per day. Neonatal body weight 3 kilograms, on average, and by the time the infant is 6 months old, body weight should be doubled to around 6 kilo grams.  

The fact that a formula-fed infant grows faster does not necessarily mean they are healthier. We must abandon this old-time conception of “heavier equals to healthier”. Formula-fed infants gain their body weight rapidly yet are also faced with higher risks of developing obesity, diabetes and cardiovascular diseases.  

Q: Once infants fail to breast feed, formula has to be given. Some mothers feel that infants fed with formula often develop faster than breastfed, in terms of height and weight. The mothers therefore assume that formula is as good as breast milk. Does this saying have any scientific evidences? How to change the mothers' entrenched assumptions?

A:There are two issues here.

•First, the reasons why babies refuse breastmilk is when the newborn's natural sucking reflex is interfered with by the introduction of bottle feeding or the giving of baby formula very early on. All babies are born to breastfeed. The mother and the newborn are mutually responsive in the most sensitive period of half to one hour following delivery. This period is crucial for laying the foundation for successful breastfeeding.

•Second, maximum growth does not necessarily mean optimal growth. Fat babies are also NOT necessarily healthier simply because they are fatter. 

Breastfed babies grow faster during the first 2-3 months and growth slows down thereafter. This is quite normal as long as the baby's growth follows its natural percentile without crossing paths above or below.

The latest WHO growth percentiles were developed based on the first growth reference study of over 8,000 breastfed babies whose care was supervised by WHO experts in different parts of the world. The earlier growth standards were based on formula fed babies, who gain weight fast but in later life have increased risk of overweight, obesity, diabetes and cardiovascular disorders.

Q: At present, many producers of the breast milk substitutes, especially formula milk, claim to contain DHA, immune factors and other functional nutrients. Some have even advertised themselves “as good as breast milk”. Can formula milk substitute breast milk?

A:The manufacturers of infant formula spend millions of dollars to try and falsely convince mothers that their artificial products contain the same nutrients as breastmilk. This is not true. It can never be the same. 

Only breastmilk has a perfect combination of energy and nutrients needed for optimal growth of a human baby up to the age of 6 months. Thereafter, breastmilk continues to be a major source of nutrients if breastfeeding is continued substantially after introduction of complementary foods and drinks.

Yes, many infant formula products claim to contain a wide variety of added nutrients. It is because powdered cow's milk does not contain the essential nutrients perfectly suited to human infant growth and development. All of these additives such as DHA and AA, and many others, are derived from animal sources or artificially synthesized. The safety and efficacy of the sources of these fatty acids and of the formulas supplemented with them have not been established, the routine addition of these nutrients to formulas designed for full-term infants is not recommended in the USA and Canada.

DHA, an omega-3 fatty acid, is essential for the proper functioning of our brains as adults, and for the development of our nervous system and visual abilities during the first 6 months of life.

AA means arachidonic acid, a long-chain omega-6 fatty acid. Formulas with long-chain polyunsaturated fats (such as arachidonic acid [AA] and docosahexaenoic acid [DHA] claim to improve eye and brain development. However, these claims for infant formula are not well proven.

Q: If we compare the substitutes and breastmilk, how different will they affect the children's survival, growth, development and their entire life?

A:Carefully controlled studies reviewed by WHO experts demonstrate that breast-feeding or not breast-feeding can be a matter of life or death for the at-risk infant in developing countries.

Compared with breast-fed infants, non-breast-fed infants below two months of age are six times more likely to die from acute respiratory infection (ARI) and diarrhea;

In children up to two years of age, non-breastfed children are 1.5 times more likely to die than breast-fed infants.

There is evidence that breastfeeding protects against Sudden Infant Death Syndrome (SIDS), allergies, ARI, ear infections.

Formula also makes children more prone to infection, asthma, meningitis, obesity and diabetes.

This is because of the protective effect of human milk, as well as the fact that breast-feeding is simply the most hygienic and nutritious form of food for infants.

Even in industrialized countries, which have considerably lower incidences of infectious disease, many studies show that breast-feeding protects against acute infections.

As for the measurement of growth, previously, growth standards were developed based on growth of bottle fed children in the USA. More recently, WHO recommended the development of new growth standards based on growth of breastfed children in different parts of the world.

These results support the contention that mothers in developing countries should be encouraged to breast-feed their children for the first 2 years of life with the addition of good quality solid foods starting from about 6 months.

We need to get rid of the idea that the fatter the baby is, the healthier it is. This is not necessarily true.

In 2006, a WHO-led global study of children, young people and adults which suggested that breastfeeding may have long-term effects. Subjects who were breastfed:

• had lower mean blood pressure and total cholesterol
• had higher performance in intelligence tests.
• had lower prevalence of overweight/obesity and type-2 diabetes.

Q: Why should we advocate for, promote and support breastfeeding? What are the benefits?

A:Breastfeeding is the perfect method of feeding infants.  Global health authorities agree that breastmilk is unquestionably better for infant nutrition than any powdered milk formula.

1. No infant formula contains the perfect combination of nutrients to enhance infant growth and brain development as breastmilk does.
2. No infant formula contains antibodies to protect infants against infection as breastmilk does.
3. No infant formula is as safe to administer as breastmilk is, because infant formula administration is prone to contamination, through the water used, the bottles and teats, and the powder itself – as we know the powder could be fake and/or contaminated by melamine.
4. No infant formula is as affordable to families as breastmilk is providing the perfect nutrition for infants while protecting them from infections.

Every mother should therefore be counselled during antenatal, delivery and postnatal care on the benefits of breastfeeding for her baby, and for herself, and should receive skilled support to initiate and sustain breastfeeding.

Q: What are the risks of artificial feeding?

A:Using breastmilk substitutes mean first and foremost that children do not get all the benefits of breastfeeding – the four points outlined above.

Artificial baby milk can actually be harmful because it can be contaminated during its manufacture, preparation and use, as shown by alarming examples not only in China but all over the world. 

It certainly reduces the potential for optimal survival and development of children worldwide. Even if the formula is prepared under the best hygienic conditions and therefore free from contamination, it can never be as good as breastmilk and makes children more prone to infection, asthma, meningitis, obesity and diabetes, according to a number of studies in western countries.   

Breastmilk is always perfect!

Q: What are the risks of feeding babies with bottles, teats and cups?

A: Bottles and teats can cause various health problems thus not recommended to be used for feeding babies.

Unlike active sucking for breast milk, babies accept food passively when they are fed via milk bottles. With bottles and teats, the whole process is easier and requires less effort of sucking. Bottles and teats can create illusions that babies may refuse to suck nipples. Lacking of active sucking practice, babies may suffer from overweight due to excessive food intake, underdeveloped facial muscle or incoordination of bodily movement. Bottles and teats may also influence formation of irregular scissors bite (poor teeth alignment).

Bottle and teats have plenty of germ-prone seams and grooves which are difficult to clean and easily cause diarrhea. Synthetic bottles and teats may also pose potential risks to babies' health as well.  

Cups are recommended to use for feeding babies who have trouble in sucking nipples. Cup feeding requires extra patience and additional techniques.

Q: Considering the survival and health status of Chinese population, what suggestions will UNICEF give to Chinese parents to enhance children's health?

A:

1. Breastmilk alone is the best food and drink for an infant for the first six months of life. No other food or drink, not even water, is usually needed during this period.
2. Newborn babies should be given to the mother to hold immediately after delivery. They should have skin-to-skin contact with the mother and begin breastfeeding within one hour of birth.
3. Almost every mother can breastfeed successfully. Breastfeeding the baby frequently causes production of more milk. The baby should breastfeed at least eight times daily, day and night, and on demand.
4. Breastfeeding helps protect babies and young children against dangerous illnesses and conditions. It also creates a special bond between mother and child which promotes the child's mental development
5. Breastmilk substitutes such as infant formula or animal milk affects the baby's healthy growth and development in a negative way.
6. If a woman cannot breastfeed her infant, the baby can be fed expressed breastmilk from a clean cup.
7. In rare situations a medical condition might make it impossible for the mother to breastfeed – in this case, a quality breastmilk substitute from an ordinary clean cup is better than bottle feeding because of the bacteria issue.
8. A woman employed away from her home can continue to breastfeed her child. She should breastfeed as often as possible when she is with the infant and express her breastmilk when they are apart so that another caregiver can feed it to the baby in a clean and safe way.
9. After 6 months of age, when babies begin to eat foods, breastfeeding should continue for up to two years and beyond because it is an important source of nutrition, energy and protection from illness.