Breastfeeding the newborn

Delivery and hospital practices are well known to influence the early breastfeeding experience. Stressful experiences during delivery and in the first hours and days post-partum can influence the timing of lactogenesis II (secretory activation) and long-term lactation success. Secretory activation, defined as the initiation of copious milk production, is triggered by the withdrawal of progesterone, with milk coming in at approximately two to three days post-partum. At this point the breast is fully differentiated and functional, and is marked by a feeling of ‘breast fullness’. Mums who experience delayed secretory activation (> 72 hours) are at greater risk of shorter breastfeeding duration than mums who initiate lactation earlier.

Risk factors for delayed secretory activation

Certain biological factors including BMI, maternal and baby illness, birth weight, gestational age, breast and nipple type, anxiety and stress can influence the early breastfeeding experience and potentially delay secretory activation. In addition, specific risk factors related to delivery and hospital practices can negatively influence long-term lactation if they are not managed appropriately in the early post-partum period.

Risk factors related to delivery include:

• caesarean section
• duration of labour
• elevated cortisol levels in the mum and foetus
• labour medications

Risk factors during the hospital stay include:

• timing of first breastfeed
• feeding frequency
• use of dummies
• social support
• motivation to breastfeed
• baby’s sucking ability and temperament

To overcome these challenges during labour, delivery and the hospital stay, mums may require support from a healthcare professional early on so that they can breastfeed their newborn.

Early initiation of breastfeeding

Consistent evidence suggests that newborns that are placed skin to skin with their mum immediately after birth and breastfeed within the first hour after birth have better breastfeeding outcomes. This includes a reduced risk of delayed secretory activation, improved milk production, and increased breastfeeding duration. It is therefore important that the mum be given the opportunity to breastfeed and have the baby skin to skin immediately after birth in the delivery room. Avoiding any maternal-baby separation in the first hours is recommended. The initial feed should not be interrupted as long as it is medically safe.

After a caesarean section birth, the newborn may still be placed skin on the upper abdomen and chest. Mums who deliver by caesarean section likely require additional support from nursing staff and family members to position the baby.

If breastfeeding is not possible in the first hour due to maternal-baby separation, pumping in the first hour after birth is recommended. Mums who start pumping in the first hour have been shown to initiate lactation earlier, breastfeed for longer and have greater milk production compared to mums who initiate pumping later.

Frequent breastfeeding

Frequent breastfeeding is important for helping the mum achieve adequate milk production and for minimising postnatal weight loss and decreasing bilirubin levels in the baby. Mums who breastfeed more frequently in the first two weeks post-partum have shown increased milk production compared with mums who breastfeed less frequently. A similar effect has been shown for pump-dependent mums who pump frequently.

New mums should therefore be encouraged to feed or offer each breast at every time they breastfeed. Typically, newborn babies will breastfeed eight to twelve times per 24 hours, with the interval varying from two to three hours on average, however, this varies widely between babies.

Hospital practices

Staff training and evidenced-based lactation policies should be implemented. This includes policies that acknowledge the importance of breastfeeding, and encourage cue-based/on-demand feeding, rooming in, time at the breast without interruption and standardised breastfeeding management protocols if the mum or baby is experiencing problems. In addition, dummies and supplementation (unless medically indicated) should be avoided. At discharge, support in terms of ongoing assistance with contact and referrals to lactation professionals is important.

Study abstracts

Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding

Delayed onset of lactogenesis (OL) is most common in primiparas and increases the risk of excess neonatal weight loss, formula supplementation, and early weaning. ...

Nommsen-Rivers LA, Chantry CJ, Peerson JM, Cohen RJ, Dewey KG (2010)

Am J Clin Nutr. 92(3):574-84

Association of timing of initiation of breastmilk expression on milk volume and timing of lactogenesis stage II among mothers of very low-birth-weight infants

Feeding breastmilk to premature infants decreases morbidity but is often limited owing to an insufficient milk supply and delayed attainment of lactogenesis stage II. Early ...

Parker LA, Sullivan S, Krueger C, Mueller M (2015)

Breastfeed Med. 10(2):84-91