Breastfeeding in public: is nine months really the end of the road?

bibAlthough the NHS recommend breastfeeding for at least a year, and the World Health Organization for two years and beyond, I’m well aware that Western culture doesn’t really allow for this. Thanks possibly to hard-line health awareness campaigns, it now seems generally acceptable to be seen feeding very little babies in public, but it’s also still acceptable for people to vociferously object to anyone breastfeeding an older child. Gauging the point at which breastfeeding goes from ‘good’ to ‘bad’ is a tricky business, however. When does your gorgeous little infant suddenly lose their innocent penchant for breast milk, and turn into an ‘older child’, apparently in danger of being psychologically damaged by continued nursing?

Many people I know have given me their opinion on breastfeeding beyond this (as yet undefined) ‘baby’ stage.

After a television programme on extended breastfeeding, a fairly inebriated friend of my husband held forth about how how unpleasant it was to see people breastfeeding children (which doesn’t entirely explain why he spent an hour watching it on television). It wasn’t clear why he held this view, but the fact he is an avid reader of such publications as The Sun, Nuts, FHM and Maxim perhaps gives some indication of his attitude towards, and personal interest in, breasts. ‘Surely it’s got to do some long term psychological damage – f*** up your attitude towards breasts,’ is an argument that is wheeled out quite frequently (as demonstrated in this discussion of Nell McAndrew’s decision to breastfeed her toddler), although interestingly, I’ve yet to hear it from a woman. It is of course possible to turn this argument on its head – in many other countries, breasts are viewed as primarily practical, rather than sexual, so if you must view these things in black and white, you could argue that this is the ‘right’ way round – but such men seem strangely unreceptive to this possibility.

The idea that a child may be negatively affected by a memory of breastfeeding is another charge that comes up quite frequently. I’ve never got to the bottom of quite why this would be the case, but it seems, again, to be to based on the premise that breasts are for grown-ups, and getting them out for children is slightly suspect.

I had a recent discussion about feeding older children with a couple of very good friends, and although a concrete age was never mentioned, the topic came up when I started to breastfeed C, who is now nine months old. Although obviously still a baby (she can’t yet walk), she is able to sit up, wave, clap and generally communicate. It’s presently quite unusual for babies in Britain to still be breastfed at this point – according to the latest Infant Feeding Survey, only 20% of mothers make it to nine months. The timing of the conversation may have been entirely coincidental, of course, and nothing to do with me giving C an afternoon snack, but I found it hard to dismiss the thought that there was a coded message in there.

I’ve since talked to my friend about this, and while she was adamant this wasn’t the case, she also admitted she has a bit of a problem with breastfeeding toddlers. When she asked me how long I was planning to feed C, I said I wasn’t sure, but I couldn’t dismiss the possibility of continuing for another few months. She understood my reasons for this, and agreed that this was, in theory, a positive thing, but it clearly wasn’t something she felt entirely comfortable with. I’m ashamed to say that it isn’t something I feel entirely comfortable with either. The idea of feeding C (behind closed doors) is lovely, but the thought of admitting to anyone that I’m ‘still’ doing it is less appealing. I am, however, convinced that this is something I have to address: it isn’t much good complaining about our society’s attitude to breastfeeding, unless I’m prepared to challenge it myself.

The antibacterial properties of breast milk

lab_technicianMany years ago, breast milk was thought to be sterile. While this is far from being the case (it actually contains all manner of germs1), the role it plays in helping keep babies free from harmful disease means it does display some pretty impressive bug-busting capacities.

The immunological components of breast milk help to protect both a mother’s breast and her baby from infection during feeding, as well as aiding the development of the baby’s immune system2. They also have another useful consequence, however: protecting breast milk from disease for some time after it has been expressed, enabling it to be stored. Several studies have examined whether it is safe to keep expressed milk for short periods, and there is general agreement that it can be stored for 8 hours at room temperature (25 degrees C), for three days in the fridge (4 degrees C) and for up to a year in the freezer (-20 degrees C) without any increase in the levels of pathogens (harmful bacteria) it contains3.

Not only does breast milk inhibit the growth of pathogens, however – it actively reduces them. This was convincingly demonstrated in a piece of research examining what happened to milk during short term storage4. Milk was collected from 9 mothers and divided into three samples: the first was analyzed the same day; the second was refrigerated (at 4 to 6 degrees C) for 48 hours; and the third was refrigerated for 72 hours. Each sample was then contaminated with an E.coli solution (the kind of nasty bacteria that dwells in toilets) and left for two hours. When the samples were tested, levels of E.coli had reduced by 80% in both the milk that was fresh and the milk that was 48 hours old. Levels had also diminished in the 3 day-old milk, but only by around 10%, indicating that the antibacterial properties, whilst still present, had started to degrade by this point.

If your baby needs to feed from a bottle or cup, a considerable body of research indicates that it’s safe to give him breast milk that has been stored in the fridge for up to three days, or in the freezer for several months. There is also evidence that if the milk you express does come into contact with germs (keeping pumping equipment sterile in your bag at work isn’t always easy), then the bactericidal components of breast milk should be able to take care of them, providing the milk is under two days old. There may still be potential issues associated with feeding stored, rather than fresh breast milk to your baby: various chemical changes occur in milk once it has left the body, and it’s possible some of these may affect its nutritional value3,5,6. Nevertheless, expressed breast milk remains a healthy alternative to formula, and as a result of its antibacterial qualities, you can rest assured that if your baby can’t feed from you directly, he still has a safe source of food and drink.

  1. Mastitis: causes and management. World Health Organization; 2000.
  2. Adv Food Nutr Res. 2008;54:45-80.
  3. Acta Paediatr Suppl. 1999 Aug;88(430):14-8.
  4. J Pediatr Gastroenterol Nutr. 2007 Aug;45(2):275-7.
  5. Acta Paediatr. 2001 Jul;90(7):813-5.
  6. Biofactors. 2004;20(3):129-37.

Could persistent nipple pain be caused by the strength of your baby’s suck?

barracudaUp to 90% of women experience nipple pain or soreness in the initial stage of breastfeeding, with the pain peaking in the first week, then gradually subsiding1. But what if, after 6 weeks, breastfeeding still hurts? You have been observed by what seems like hundreds of lactation professionals, and everything looks fine: your baby is latching on properly and you don’t have an infection. It simply feels to you like she is just a very ‘enthusiastic’ feeder, demonstrated by her toe-curlingly strong suck. Surely that couldn’t be the problem… could it?

Very little research has investigated the causes of chronic pain during breastfeeding, but one interesting study in this area has found a link between nipple pain and a baby’s ‘intra-oral vacuum’, or suck2. The study looked at two groups of women: 30 mothers who were experiencing persistent, unexplained nipple pain (without injury), despite help from lactation specialists; and a control group of 30 mothers with no problems breastfeeding. The vacuum produced by each baby whilst on the breast was measured using a small tube taped to the nipple and attached to a pressure sensor. The amount of milk the babies consumed was also measured, by weighing the babies before and after the feed.

The results were startling. The babies of the mothers who experienced pain when feeding exerted a vacuum when they were ‘actively’ sucking (taking in milk) that was more than 50% higher than the babies in the control group. In between these periods, when they were resting, the vacuum produced by the babies in the pain group was more than twice as high. Unfortunately, a stronger suck did not translate into more milk: babies in the pain group consumed on average 42% less milk, despite feeding for a similar length of time.

The cause of the lower milk intake wasn’t clear. There is a possibility that it was due to chance, or the experimental set-up, although the amount consumed in the control group babies matched that recorded in previous research, making this less likely. As pain can interfere with the let-down reflex, it’s possible that the simple fact that it hurt was enough to stop the milk from flowing properly3. This may in turn have affected milk production, as the amount of milk a baby consumes determines the rate at which it is produced4. It is important to point out, however, that all the babies in the study were gaining weight sufficiently, so the lower milk consumption documented in this single feed did not appear to translate into a more general nutrition problem.

The reason for the higher vacuum is also elusive. It may in some way be the effect rather than the cause of the restriction in milk flow, although this is purely speculative, and how and why this would happen isn’t clear. It’s also possible that the babies in the study may have been experiencing some other feeding difficulty that they compensated for with a stronger suck, although this had not been identified by any of the health professionals who had come into contact with them.

The study data indicate quite clearly that the women suffering from persistent, unexplained nipple pain had babies who exerted a significantly higher intra-oral vacuum on the breast when feeding. Although the data can’t prove the stronger suck caused the pain, it’s likely the two are related. Could this be the reason why for some women, breastfeeding never really seems to become comfortable? If you’re on the receiving end of high suction, then it’s easy to see how you could feel ambivalent about these results. On the one hand, it may be a relief to know that breastfeeding can be painful as a result of the way that your baby suckles, and not because of something that you are doing wrong. On the other hand, the prognosis may be a little disheartening, as it isn’t immediately clear how you solve a problem like this.

At present, such a diagnosis is unlikely, as intra-oral vacuum is rarely tested. The results of this study, however, suggest that in situations where chronic nipple pain has no obvious cause, that it probably should be (the authors certainly think so). Discomfort when breastfeeding is a difficult and stressful situation to deal with, and only with more research in this area can a cause (and hopefully a treatment) be identified. In the meantime, it seems that affected mothers need to carry on gritting their teeth, and perhaps reach for the pain killers…

  1. Acta Paediatr. 2008 Sep;97(9):1205-9.
  2. J Obstet Gynecol Neonatal Nurs. 2005 Jul-Aug;34(4):428-37.
  3. J Pediatr. 1948 Dec;33(6):698-704.
  4. J Exp Physiol. 1996 Sep;81(5):861-75.

Peppermint might help prevent early breastfeeding nipple problems

peppermintThere are many substances said to prevent or relieve nipple pain and damage during the early days of breastfeeding, including lanolin, expressed breast milk and water compresses. Unfortunately, none as yet have been found to offer any real improvement over leaving nipples untreated1. Given the prevalence of the problem, however, the search for a preparation that can make early breastfeeding more comfortable continues.

Recent research reported in the International Breastfeeding Journal and Medical Science Monitor finally seems to offer a ray of hope. It suggests that peppermint, in the form of a gel or ointment, could play a role in preventing nipple soreness and injury from appearing in the first place. A team at the Alzahra Teaching Hospital in Iran conducted two studies examining whether peppermint could prevent nipple problems caused by breastfeeding, after noticing its use by women in the Azarbaijan Province, North West of Iran. As peppermint has antibacterial properties and can increase tissue flexibility2 it does have the potential to prevent this kind of injury occurring, but it has not before been properly evaluated in a clinical setting.

In the first study, 196 women were randomly allocated to either the experimental group, where they were asked to apply peppermint water after each feed, or the control group, where they applied expressed breast milk3. Mothers who applied the peppermint water reported significantly less pain on breastfeeding, and had significantly fewer nipple cracks (9% in the peppermint group and 28% in the milk group) than the other mothers. Cracks that occurred in the peppermint group were also less severe than those in the milk group.

The second study evaluated the effectiveness of a peppermint gel in a double blind study4. 216 women were randomly allocated to one of three groups: the first used peppermint gel after each feed; the second used lanolin; and the third used a placebo gel. The peppermint gel was shown to be more effective than both lanolin and the placebo gel at preventing nipple cracks. Women in this group were also more likely to be exclusively breastfeeding at 6 weeks, possibly because they had suffered less discomfort.

Both these studies were large and well designed, and as such offer reasonable evidence that peppermint may indeed help to prevent the nipple pain and trauma that can occur when women start to breastfeed. These results alone, however, do not constitute conclusive proof that peppermint is a panacea for nipple problems. The main issue is that both experiments were carried out by the same research group, in a part of the world where peppermint is regularly used as a nipple treatment. In the first study women knew they were applying peppermint water, and this may have affected their perceived levels of pain. These mothers were also found to nurse their babies more frequently and for longer periods than those using milk. The authors suggest this may be due to the lower pain levels in this group, but the possibility that the more frequent feeding somehow reduced pain and trauma cannot be ruled out.

In the second study, both the mothers themselves and the researchers classifying the severity of nipple cracks were unaware which type of gel they were applying, reducing the chance that the results were due to a placebo effect. In this experiment, however, there was no true baseline (where nipples were left untreated) against which to compare the peppermint gel. It was better at preventing cracks than the placebo gel (which was the same preparation, just without the peppermint), but we can’t be sure that the gel didn’t make it worse, and the peppermint simply helped to ease the problems caused by the gel.

Despite these shortcomings, this research does provide a strong indication that peppermint may have the potential to protect mothers against nipple soreness and injury. Peppermint has medicinal qualities that suggest it might be helpful in this context, and it is likely to be a reasonably safe and practical treatment, as it is not harmful to babies when consumed in small quantities. Whether future research can replicate these results is yet unknown, but if it can, then an effective preventative measure for nipple problems may finally be on the horizon.

  1. J Obstet Gynecol Neonatal Nurs. 2005 Jul-Aug;34(4):428-37.
  2. Fitoterapia. 2006 Jun;77(4):279-85.
  3. Int Breastfeed J. 2007 Apr 19;2:7
  4. Med Sci Monit. 2007 Sep;13(9):CR406-411
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