Breastfeeding and being sick

thermometerAt 3.00 am, C started coughing. The cough turned into a whine, and as my heart sank, a full-blown wail. As I got out of bed to comfort her, I felt a bit odd, but put it down to the early hour and my chronic tiredness.

I sat down to feed C, who was still grumbling, hoping that I’d feel better shortly. I didn’t. After what seemed like an age, C finally had enough milk to send her back into a doze and I put her back into her cot. I then bolted to the bathroom. I only just got there in time.

After I had vomited every last bit of the lovely meal my husband had cooked the night before, I collapsed on to the floor filled with worry. It was one thing for me to be sick, but what if C was too? What if we all were? My thoughts then turned to breastfeeding. To avoid C catching a virus (if that’s what it was) surely the best thing to do would be to steer clear of her? But this would also mean not passing on valuable antibodies, not to mention ruining my milk supply and risking engorgement or mastitis. It was also highly likely that C had already been exposed to any infectious illness before I started exhibiting symptoms, so continuing to nurse as I usually did was really the only sensible option.

I carried on breastfeeding C as normal, washing my hands first and trying to minimize the germs she encountered. Or at least I tried to feed her as normal. After half a day of this, I realised that germs were only a small part of the problem. My energy levels were at rock bottom, I couldn’t keep anything down and I was massively dehydrated. Engorgement was the least of my worries! My let-down reflex took an age to kick in and C ended up bawling in frustration. I’m still trying to work out why exactly my ability to breastfeed was so depleted, but I can only assume it was related to my poor ability to keep food or drink down, and the resulting plunge in fluid levels and blood sugar. Assuming I had norovirus – the winter vomiting bug – this acute phase of sickness shouldn’t last more than 24 hours. I sincerely hoped this would be the case.

Thankfully, 6 hours later, I was sick for the last time. Although it took me several days to recover completely, my milk supply soon picked up and C remained impressively illness-free.  Whether she had developed sufficient immunity through exposure to antibodies in my milk, or simply didn’t come into contact with the virus I don’t know, but she didn’t show a hint of being sick. Unfortunately, the same couldn’t be said for my husband, who started racing to the bathroom the minute I stopped…

Let down by my let-down

pramIn theory, I am a strong supporter of nursing in public: it is the perfect way to demystify and promote breastfeeding, and the only realistic way to feed your baby when you’re on the move. In practice, I have always struggled with it. In the first few weeks, when it was excruciatingly painful, and the latching on ‘dance’ (as it is optimistically termed) C and I performed actually resembled a boxing match, my reticence was understandable. Three months later, with a finely-honed technique, I had run out of excuses.

One weekend, I decided to get some much needed public nursing practice in on a trip to a family-friendly department store. Previously, I had fed C in the car, or in the specially provided breastfeeding area. One trip to this part of the store was enough, however (it was an open-plan extension to the nappy changing facility) and I decided to feed C in the cafe, where I’d previously seen lots of other women breastfeeding.

To set the scene: this particular store is packed with the kind of educated, middle class parents who understand the importance of breastfeeding, and wouldn’t dream of raising any objection. My husband J went off to get some drinks, and I settled down to feed C. She was peckish, but not overly so, and was happy enough to spend some time performing the short suckling movements that help initiate let-down. Ten minutes later, she was starting to get frustrated. What was going on? Nothing was coming out! I hadn’t nursed for several hours, so had plenty of milk on board, but for some reason my let-down reflex was failing to function.

After another five minutes of suckling, and a bit of time reassuring a very confused C, my milk finally kicked in. I’m not quite sure why my let-down deserted me on this particular day, but I can only put it down to the noise and stress of feeding in a public place. In situations which other mothers find problematic, such as expressing milk when their baby is absent, I have no problem at all. When I think someone might be watching, however, I often end up in a vicious cycle of stress->no let-down->more stress.

As time has gone on, I find it easier to relax, and haven’t yet had a repeat of this particularly serious let-down failure. Although I can still suffer from performance anxiety from time to time, I try not to let it put me off completely, and as ever, things are improving with time.

Can stress affect the let-down reflex?

cartoon of person with numbers flying round their headOne piece of advice you might have heard from midwives (and well-meaning friends and family), is to make sure you breastfeed in quiet and relaxing surroundings. Given the choice, this is probably what you’d opt for (who wants to feed in noisy and distracting surroundings?), but could it actually cause a problem if you’re not able to do this?

Well, there’s a possibility it could. For some time, medical evidence has existed that indicates temporary stress or distraction can interfere with the let-down, or milk ejection reflex, meaning your baby has to wait longer for milk to start flowing freely.

Normally, cues that indicate your milk will soon be required (such as your baby crying before a feed, or suckling at the start of one1) trigger the release of the hormone oxytocin, which enters the bloodstream in ‘pulses’ a few minutes apart, forcing milk to flow from the ducts and out of the nipple (see ‘Breastfeeding and Human Lactation’ by Jan Riordan for a full description of this somewhat complicated process.)

In 1948, an experiment conducted with a single breastfeeding woman indicated that distractions can inhibit the release of oxytocin, delaying the start of milk ejection2. This effect was confirmed in a more recent study, which monitored the oxytocin levels in the blood of three groups of breastfeeding mothers who had given birth five days previously3. The first group was asked to perform difficult verbal arithmetic problems whilst nursing their babies (the stress condition), the second was subjected to the noise of a building site through earphones (the noise condition) and the third breastfed without these distractions (the control group).

Oxytocin release occurred significantly later and less frequently in the noise and arithmetic groups than it did in the control group, indicating that these temporary stressors impaired the mothers’ let-down reflexes. The amount of milk the babies consumed (measured by weighing them before and after the feed) did not differ between the groups, however, so although stress affected the frequency of let-down, it did not appear to prevent babies from consuming an adequate amount of milk.

These results demonstrate that mild temporary stress, such as trying to perform difficult arithmetic problems (five days after giving birth!) or being exposed to the noise of construction work can delay the let-down reflex, both at the start of a feed, and throughout its duration. This may explain why in situations where you feel under pressure or distracted (for me, this certainly applies to feeding in public), it feels like your milk takes forever to appear – not great when you’re trying to deal with an angry baby. Fortunately, this problem doesn’t appear to affect the amount of milk your baby consumes overall, so it isn’t necessarily anything to worry about (this would probably only make it worse, after all…) Nevertheless, it is an irritation that both you and your baby would probably prefer to avoid, and therefore the perfect excuse to insist that your surroundings whilst breastfeeding are as chilled out as possible.

  1. Br Med J (Clin Res Ed). 1983 Jan 22;286(6361):257-9.
  2. J Pediatr. 1948 Dec;33(6):698-704.
  3. Obstet Gynecol. 1994 Aug;84(2):259-62

Could a laid-back approach to breastfeeding help your baby latch on?

baby_cryingAlthough it’s perfectly feasible to feed your baby any way that feels comfortable, four positions are commonly recommended. These are the cradle hold, the football hold, lying on your side, and the cross-cradle hold. This last position requires you to sit up with a straight back, hold your baby sideways on, and carefully position him with his nose opposite your nipple so he has a large mouthful of breast when he latches on. It can seem like quite a complicated process for a beginner, particularly when a crying baby is added to the equation. Nevertheless, it is particularly recommended to new mothers, as it is apparently the best position in which to ensure your baby is latching on correctly – something that many women (and babies) can find quite difficult.

Despite the strong recommendation of these feeding positions, there appears to be virtually no scientific evidence to justify their use. In practical terms, it is easy to see why being able to discreetly breastfeed whilst sitting up is a useful skill to master, but for a new mother, simply being able to comfortably nourish her baby may be a more immediate priority.

A recent study conducted at hospitals in the UK and France calls into question the idea that the traditionally recommended feeding positions are automatically the best ones1. During the study, 40 women whose babies were less than a month old were videotaped breastfeeding in a series of recording sessions. As long as feeding was going well, mothers were not advised or guided in any way: they were simply left to get on with it in whichever was most comfortable for them. In the ‘best’ recorded feeding session 21 of the mothers sat upright to feed their babies, one lay flat on her back, and one lay on her side; the remaining 17 were semi-reclined with their babies lying on their tummies (a behaviour termed ‘Biological Nurturing’).

There were some striking differences in the feeding process when mothers adopted a reclining position, as opposed to sitting upright. When babies lay on their mothers’ tummies, their mothers’ hands were free to gently guide them. Stroking their babies’ feet seemed to be particularly helpful, as it released mouth and tongue reflexes that helped them to latch on. By contrast, when babies were held in their mothers’ arms, their legs and feet were left in thin air, and the foot-to-mouth connection was lost.

The reclinining group did not need to line up the nose and nipple, and make sure the baby’s mouth was open wide enough before initiating the latch: as the baby was on top, gravity pulled his tongue and chin forward, allowing him to attach himself, even when he was sleepy. Gravity also automatically ensured a close fit between the baby’s chin and the mother’s breast, facilitating deep suckling and producing the ear and jaw movements that indicate successful feeding.

Perhaps the most interesting result, however, was that babies exhibited reflexes that helped feeding when their mothers were reclined, but hindered it when their mothers were upright. When they were lying on their mothers’ tummies, head-righting and -lifting reflexes allowed the baby to orientate himself for successful latching on. When mothers were upright however, these irregular, jerky head movements had the opposite effect: the head bobbing that resembled ‘nodding’ when a mother was reclined was perceived as ‘head butting’ when a baby was held sideways against an upright mother. The gravitational forces that had helped attachment in reclining postures dragged babies away from their mothers when they sat up. It was harder to keep the baby latched on, and mothers reacted by tightening their grip, resulting in back arching and arm and leg cycling that appeared like thrashing or flailing.

It is important to view these results in context: this was an observational, rather than a controlled study, so the data cannot ‘prove’ that one feeding method is better than another. Many of the mothers who participated fed quite happily whilst sitting upright – as do many women every day – so it’s clear that a reclining posture is not required for successful feeding.

Nevertheless, this research does call into question the idea that a position like the cross-cradle hold is the best one to recommend to new mothers. Innate early breastfeeding behaviours were observed to help attachment when a mother lay back with her baby lying on her tummy, but not when she sat up;  reflexes and gravitational forces which aided latching on when a mother reclined, hindered it when she was upright. If, as this study suggests, women can just lie back and let nature take its course, the often fraught early days of breastfeeding could potentially be a much more relaxed affair.

  1. Early Hum Dev. 2008 Jul;84(7):441-9.

Milk stasis – not infection – is the main cause of mastitis

holding_babyPrior to my brush with it, I thought that mastitis was caused by a bacterial infection. This is not completely unreasonable, given that this is precisely how numerous ‘health’ websites define it (FreeMD, eMedicineHealth, HealthSquare to name just a few). When you consider that the symptoms of mastitis can include a fever as well as redness, lumps and pain in the breasts, and treatment can involve antibiotics, the definition seems to make sense.

Unfortunately, it turns out to be somewhat misleading. Whilst bacterial infection may play a part in mastitis, it is in fact inflammation of the breast tissue that is at the root of the condition, and causes the majority of the symptoms. The World Health Organization describes mastitis as ‘an inflammatory condition of the breast, which may or may not be associated with infection’1. They summarize the uncertain relationship between bacterial infection and mastitis as follows:

Many lactating women who have potentially pathogenic bacteria on their skin or in their milk do not develop mastitis.
But:
Many women who do develop mastitis do not have pathogenic organisms in their milk.

This basically means that you can be carrying the bacteria associated with mastitis – and even have it in your milk – without developing the condition, and conversely, you can succumb to mastitis when there is no evidence you’re carrying the bacteria.

So, if mastitis isn’t due to an infection, what does cause it? It appears that the inflammation that characterizes mastitis is a consequence of ‘milk stasis’: milk is produced, but then remains in the breast, rather than coming out during feeding. Milk stasis can occur for many reasons, including blockages in the ducts, a decrease in feeding frequency and poor attachment1,4. It’s also possible that stress might play a role, by both increasing milk production and delaying the letdown reflex2. Why milk stasis goes on to cause inflammation isn’t so clear, though it could result from inflammatory substances found in milk irritating the breast tissue, or an immune reaction to certain milk proteins3.

Although bacterial infection is not often the primary cause of mastitis, it is sometimes thought to exacerbate the symptoms3. Determining the precise role it plays, however, is a tricky business. Firstly, it is very hard to ensure that milk cultures are sterile, so it isn’t always possible to know that the bacteria found in a woman’s milk haven’t in fact come from her skin when the sample was taken1. Secondly, as stated above, harmful bacteria can be found in the milk of women who don’t have mastitis, indicating that there is not a simple cause and effect relationship between the two. One possibility is that mild changes initiated by milk stasis may be exacerbated by bacterial activity: symptoms could be considered to be on a scale, from a reduction in milk output but no pain (known as subclinical mastitis), to breast abscess and severe pain, with increasing amounts of bacterial involvement as you move from one end to the other3.

What does all this mean if you find yourself suffering from mastitis? Perhaps the most important thing to remember is that the symptoms are probably due to a milk flow problem, so your top priority should be to address any causes of this. This might include making sure your baby is properly latched on, feeding more frequently and emptying the breast properly at each feed. Many doctors also choose to treat mastitis with antibiotics, although there is a lack of consensus as to which ones to use, and even whether it’s appropriate to use them at all (see when should mastitis be treated with antibiotics?). Whether or not you take medication, the most important thing is to keep the milk moving. Whilst feeding with mastitis doesn’t appear to pose a risk to you or your baby, stopping could well do: not only will it make the symptoms worse, but it will almost certainly jeopardize your milk supply5. Mastitis is a common reason for giving up breastfeeding, but it needn’t be – focus on sorting out your feeding technique and you should hopefully make a rapid recovery.

  1. Mastitis: causes and management. World Health Organization; 2000.
  2. Mediators Inflamm. 2008;2008:298760.
  3. Arch Dis Child. 2003 Sep;88(9):818-21
  4. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD005458.
  5. Am Fam Physician. 2008 Sep 15;78(6):727-31.
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