Twelve months on the breast - normal, natural, healthy

New statistics from the 2008 Infant Nutrition Survey show that while 95% of new mothers initiate breastfeeding, many do not go on to exclusively breastfeed for six months as recommended by the National Health and Research Council and World Health Organisation.(photo on canvas Acrylic canvas printing)

The recommendation that breastfeeding be continued for a further six months and as long as possible thereafter is the basis for Queensland Health’s 12+ months on the breast – normal, natural, healthy breastfeeding campaign which is aiming to help Mums overcome the barriers that lead many women to cease breastfeeding within six months.

    Returning to work is seen as a significant impediment to continuing breastfeeding, but by law your employer is obligated to reasonably accommodate your breastfeeding.

As encouraging as it sounds, it could also be considered very ambitious given that there are so many obstacles to long term breastfeeding such as an un-supportive work environment, temporary loss of fertility and medical concerns for both mothers and babies, besides other minor problems that range from having to limit alcohol intake and consumption of certain foods to the inability to share night feeding sessions with a partner.

It is these obstacles that (understandably) cause many mothers to cease breastfeeding and move on to formula feeding or weaning, despite being educated on the health benefits of breastfeeding. In fact the knowledge that the high levels of antibodies in breast milk protect children against SIDS and infections in babyhood, and lower the risk of developing chronic diseases later in life, only results in mothers feeling incredibly guilty when they do stop breastfeeding.

The Australian Breastfeeding Association stance is that with time, advice and support, breastfeeding can be learned by almost all mothers. Robyn Hamilton, the QLD president of the ABA says, “Some breastfeeding circumstances can prove challenging and take time to overcome. A long term view is important.”

Adopting a long term mindset can be extremely difficult for mothers whose experience of breastfeeding is tinged with the exhaustion, discomfort and pain that accompany a multitude of conditions such as thrush, leaking and overproduction, sore nipples, engorgement, and blocked milk ducts which can become mastitis, which can all occur repeatedly and simultaneously.

Swollen, cracked and bleeding nipples are very common and usually occur when your baby is not latched on properly, like in Tennille’s case. “My daughter was not attaching right,” says Tennille, 25. “After an emergency caesarean and being diagnosed with a severe post-op infection, trying to breastfeed to encourage my milk production and having the skin on my nipples become bruised, I was persuaded to put her on formula, for her health and my sanity.”

This type of situation is where expressing using a breast pump can be a godsend for mothers in helping to establish breastfeeding. However using a breast pump incorrectly can also damage breast tissue, especially if nipple trauma has already been sustained. “For mums with sore nipples whose babies are having attachment challenges, pumps can provide an even distribution of pressure around the breast, and allow damage to heal but should be used with care to ensure no further damage occurs,” Robyn says.

While breast pumps are an ideal solution for almost all breastfeeding issues that involve pain and inconvenience, they cannot help with supply problems. Amy, 26, initially attempted to breastfeed for six months but she stopped trying out of concern for her son’s health. “My son was almost ten pounds when he was born and always hungry and I didn’t have enough colostrum, plus I knew I would have to go back to work early so I made a decision to just go onto formula.”

“Perceived or real insufficient milk supply is a common concern, and is a major cause of infant weaning,” Robyn says. “Changes to breastfeeding management will be sufficient to increase milk supply in most women.”

Of course certain medical conditions can affect a woman’s milk supply until she recovers. True supply problems are uncommon but they do occur. Casey, 26, wasn’t unable to breastfeed because of low iron due to haemorrhaging. “After losing so much blood my breast milk didn’t come through properly and it took me about 8 months to get my iron back to normal,” says Casey.

Apart from haemorrhaging, other medical conditions such as abnormal thyroid function, polycystic ovary syndrome, some breast surgeries with nipple transposition and inadequate glandular tissue may stop a woman producing sufficient milk, but these are rare. For most women the actual problem is delivery not production, such as when a baby takes in plenty of  foremilk and not enough calorie rich hindmilk at the end of a feed because they are not latched on properly which may result in the baby not gaining enough weight. However there are other things to consider.

“Weight gain is only one indicator that a baby is getting enough milk,” Robyn says. “If there is growth in length or head circumference and your baby has thoroughly wet nappies, bright eyes, good skin tone, and is generally contented amongst periods of fussy behaviour then breast milk is supplying all your baby’s needs.”

With regards to continuing breastfeeding upon returning to work, breast milk can be fed in bottles to babies by child care providers because breast milk can be refrigerated for up to eight days and frozen from four to six months, retaining a higher level of antioxidants than infant formula. But the embarrassment of having to express milk in the office toilets before storing it in the communal fridge and stockpiling breast pads in a desk drawer in case of leaking breasts are just some of the deterrents working mothers have to deal with because most Australian workplaces do not have specific breastfeeding policies in place.

Robyn says, “So many mums in Australia go back to work before their babies are 12 months old and it is true that returning to work is seen as a significant impediment to continuing breastfeeding, but by law your employer is obligated to reasonably accommodate your breastfeeding.” This can comprise scheduled lactation breaks throughout the day and providing a suitable room (not the toilets) for expressing.

But expressing milk and bottle feeding has its own set of problems when combined with breastfeeding. When Hayley, 25, contracted mastitis she fed her daughter Mia from a bottle while her breasts recovered. She persisted with breastfeeding even after contracting mastitis three times only to find her daughter was losing interest. “Mia was getting lazy on the breast as she liked the bottle better so I only breastfed for 8 weeks,” Hayley says. This is known as nursing strike which occurs because there is less effort required for babies to suck from a bottle. For this reason it is generally advised to delay using a bottle until the baby is accustomed to sucking directly from the breast.

But if physically feeding from the breast is too painful during a bout of mastitis what else is there to do but express? One option is to use the other unaffected breast to feed whilst draining the affected breast regularly so that a baby’s feeding routine isn’t affected. But don’t persevere to the point where breastfeeding is prioritised ahead of safety because if mastitis is left untreated it can develop into a breast abscess which requires surgery.

Hayley says breastfeeding her new baby has been a much more gratifying experience. “I am having great success this time and no mastitis so far. Having a better understanding of how it all works has helped and I definitely won’t introduce the bottle yet.” Robyn suggests in Hayley’s case, mothers who were unlucky in breastfeeding the first time may even like to resume breastfeeding their eldest child once their second child is born. This may particularly appeal to older Mums who stopped breastfeeding early in order to regain their fertility and conceive more children.

But Robyn says this is often not the case due to a widely held perception that breastfeeding a child beyond infancy is indulgent. “By and large breasts are seen as sexual objects and as a nation we are fairly uncomfortable about feeding older children,” says Robyn. The 12+ months emphasised in the campaign highlights the significance of trying to normalise extended breastfeeding so that more women feel comfortable doing it.

The most important thing to remember is that because a long term strategy for nourishing a baby for twelve months is usually balanced with sleep deprivation, eight hour working days, breast pain and care of older children, that any women who manages to breast feed for any period of time is to be commended. Assistance in the form of Medicare subsidisations for pumps, sterilisation equipment and lactation consultations could greatly increase the number of women in continuing feeding breast milk beyond the six month mark, because it ensures women are supported financially and emotionally.

“A chat with a breastfeeding counsellor can be invaluable,” Robyn says. “More often than not mums know what they want to do but don’t feel confident. We will support them in whatever decision they make because it will be the right one for them.”