Breastfeeding: understanding its phases and physiology until weaning
Happymami LactanciaPhases in the establishment of breastfeeding
Phases of lactogenesis
It may sound surprising, but from the 5th-6th month of pregnancy you can already produce a small amount of breast milk. This stage is called lactogenesis I. And after birth comes lactogenesis II, with an abundant production of breast milk which is popularly known as “the milk coming in”. And finally comes galactopoiesis, or lactogenesis III, the process that keeps up the production of milk once breastfeeding is established.
Unlike other mammals, lactogenesis II, or the milk coming in, starts a few days after birth. These days are a critical period for breastfeeding, as this is when most breastfeeding difficulties arise.
Regulation of milk synthesis, secretion and ejection
The maternal hormonal changes that occur after birth trigger the milk coming in, but it is frequent sucking and emptying of the breast that sustains it. In the processes of production and ejection, several regulatory systems are at work, all of them strongly influenced by your baby's sucking and other stimulation of the nipple.
Prolactin
During pregnancy, in response to rising levels of oestrogen and progesterone, the pituitary gland produces prolactin. This stimulates milk production. However, during pregnancy it remains inactive because progesterone and placental lactogen prevent prolactin from binding to its receptors (competitive binding). After birth, the levels of these two hormones fall rapidly and prolactin is no longer blocked, so breast milk secretion begins.
After birth, prolactin is released in pulses in response to various stimuli, the most effective being sucking at the nipple. The peak plasma concentration of prolactin occurs approximately 20-30 minutes after sucking, so its most important effect is to produce breast milk for the next feed. Hence the saying, “the more sucking, the more production”. This effect is particularly important while breastfeeding is being established, as after a few weeks there is no relationship between the amount of prolactin and the amount of breast milk produced.
Oxytocin
Oxytocin is released in response to nipple stimulation, through sucking or handling, and in response to pleasant physical, visual, auditory or emotional stimuli, generally related to your baby.
This hormone is responsible for the contraction of the cells surrounding the alveoli, causing the ejection of milk. This helps move the breast milk through the ducts towards the nipple.
This process happens continuously during sucking and refills the ducts as they become empty. It is important to bear in mind that stress, anxiety and other sudden unpleasant physical stimuli can block the oxytocin ejection reflex.
Other regulatory factors
Retention of breast milk inside the alveoli raises intra-alveolar pressure, affecting the function of the alveolar cells; it can also compromise the blood supply and hinder the arrival of hormones, slowing down milk production when the breast is full or the gland is not drained effectively.
Your baby cancels out these inhibitory effects by emptying your breast properly. In this way, the production of breast milk adapts to your baby's needs, from one feed to the next and independently for each breast.
Lactogenesis II. The milk coming in
As we have mentioned, the start of lactogenesis II, or “the milk coming in”, occurs after the sharp post-birth drop in progesterone and placental lactogen. During this phase the synthesis of the components of breast milk increases, which makes the breasts swell and feel hot and sore. There is no relationship between the intensity of the symptoms and the subsequent production of breast milk.
Clinically, the “milk coming in” occurs around the third day after birth, but up to 25% of mothers notice it after 72 hours. At that point, your baby takes around 20 ml of breast milk at each feed.
Factors that support lactogenesis and breastfeeding:
- Early skin-to-skin contact between mother and baby.
- Starting breastfeeding within the first hour after birth.
- Frequent breastfeeding.
- A good latch between mouth and breast.
- Proper emptying of the breast.
- Early and frequent sucking in the first few days.
- Obesity and diabetes that is insulin-dependent and poorly controlled contribute to the delay in the “milk coming in” seen in diabetic and obese mothers.
- Retained placental fragments, due to the presence of progesterone and placental lactogen, can even inhibit lactogenesis II.
- Difficult births and stress are another cause, and the one most associated with giving up breastfeeding early. In the mother, stress blocks the oxytocin reflex; in the baby it can affect latching on or lead to weak sucking.
Galactopoiesis, or stabilisation of milk production
Once the abundant production of breast milk has started, the amount depends on how effectively and how often the breast is emptied. As well as the volume, sucking can partly regulate the composition of the milk. Breast milk is produced continuously and is stored until the next feed inside the alveoli and in the duct system. Breastfeeding guide.
Weaning: how do you do it?
As with everything in life, there will eventually come a time when you bring your breastfeeding to an end, and it is important to understand how to do it. It is well known that the WHO and clinical guidelines recommend 6 months of exclusive breastfeeding and then breastfeeding alongside food until the age of two, and it is even described up to the age of 7. There is no reason to stop at any particular age, but obviously that decision is entirely yours, and at Happymami we will support you and offer you the best solution for whatever you decide.
Circumstances that can influence the end of breastfeeding, or “weaning”
And what reasons might lead to weaning? Every case is unique and all are worthy of respect; the most important ones are by maternal decision, by the baby's own choice, because of illness in the mother or the baby, or because of work needs. Remember that you have maternity leave and paternity leave posts available to you.
Types of weaning
In theory, there are 4 types of weaning, depending on the reason for it.
- Inevitable weaning due to medical or other causes. The reality is that there are few illnesses and medicines that rule out breastfeeding. You can always check the e-lactancia.org website to clear up any doubts about any medication. Guide to breastfeeding problems
- Voluntary weaning by the child: you will see how your baby decides to stop breastfeeding gradually. Sometimes it can be influenced by a new pregnancy, which can occasionally change the taste and amount of breast milk.
- Weaning by maternal decision: The decision to continue breastfeeding or not is legitimate, and you should not accept being judged for making the decision you consider best. Always find out about the pros and cons and you will make the best decision for your own case. As a personal note, you cannot change what people think, but you can change how it affects you, and you are doing great.
- Forced weaning due to external causes, whether social or family-related, and beyond the mother's and the child's control. Remember that the decision whether or not to keep breastfeeding is yours alone.
- Unnoticed weaning. Feeds gradually become further apart until your baby weans themselves.
Feelings that can arise during weaning:
During this weaning phase many feelings can arise, such as guilt and sadness, and that is completely normal. Lean on your midwife, who will support you in your decision and help you with your particular case, so that you cope better and understand the process. You should know that, on the one hand, your baby, if the weaning has been your decision, may throw tantrums or cry inconsolably. This is because, as a breastfed baby, when hungry they think about the breast they love and that comforts them, and obviously they do not understand why they cannot have it. And on the other hand, if breastfeeding was causing you stress and getting in the way of the bond between mum and baby, it will feel like a relief for both of you.
Guidelines for weaning
To wean there are several options, and if you talk to other mums, each one used a different method and it worked for some and not for others; every case is different and you should always adapt these recommendations to your own situation. First of all, you should know that if in your case you wean from one day to the next, your doctor may recommend specific medication to stop your milk. If, on the other hand, you wean gradually, the feeds will become further apart and the production of breast milk will gradually decrease.
How to wean gradually:
There are several strategies you can choose when weaning, as recommended by the AEPED:
- Don't offer, don't refuse. If your baby does not ask to breastfeed, do not offer the breast. If they ask for it, do not refuse.
- Space out feeds. Distract them in other ways (at the park, playing with them, reading a story, rocking them to sleep in your arms…).
- Offer another type of food at the times when they usually ask for the breast. Anticipate their need.
- Manage feeds together with your child. Tell them “only at home”, “only 3 minutes”, “only one breast”, “only to go to sleep”, etc.
- We should talk to them and agree the weaning with them, explaining that “mummy does not want to carry on breastfeeding”.
- If there is pain, you need to express milk regularly to avoid complications such as mastitis. If the weaning is well tolerated, this will not be necessary.
False weaning:
Remember that there are breastfeeding crises, and they do not mean that weaning is happening. These nursing strikes are completely normal: you will see that your baby seems to lose a little interest in feeding, for example if they are poorly, because of a fright during the previous feed or because they were forced to feed. Why is my baby crying?
As we have seen, several factors influence the production and ejection of milk, all of them essential for the correct establishment of breastfeeding. Prolactin and oxytocin are the key hormones in this process, but they need the whole system to work together. At Happymami, we want to remind you that it can be a difficult process at first, but after that it becomes very easy. Trust yourself, your baby and the healthcare team around you, such as your midwife, who will help you to achieve your breastfeeding.
Benefits of breastfeeding
Breast milk is unique. It is a living liquid specially designed for the human baby, and it changes from feed to feed, day by day and month by month, to meet your baby's needs. It also provides active defences against infection. If you are interested, you can find out more about the importance of breast milk.
Benefits for your baby
- Protects against respiratory infections, ear infections, gastrointestinal and even urinary infections.
- Protects against Sudden Infant Death Syndrome.
- Breastfeeding provides physical contact for babies, which helps them feel safer, warmer and comforted.
- Breastfed children have better dental development, with fewer orthodontic problems and less tooth decay.
- It boosts intellectual development, because breast milk contains specific components that are essential for brain development.
- Breast milk is easier to digest and has positive long-term effects on your child's health, reducing the risk of allergies, diabetes, coeliac disease, inflammatory bowel disease, obesity, high blood pressure or high cholesterol.
- It appears to offer some protection against lymphomas and some other types of cancer.
- Human milk is the food of choice for all children, including premature babies, twins and sick children.
Benefits for mum
- It prevents postpartum haemorrhage, as your baby's sucking helps the uterus return to its original size and reduces the likelihood of anaemia.
- It helps you return to your pre-pregnancy weight.
- It brings emotional wellbeing and provides a unique opportunity for the mother and baby bond.
- It reduces the risk of breast and ovarian cancer.
- It improves the calcium content of the bones by the time you reach the menopause.
Benefits for society and the environment
- It is free. It means savings on artificial formulas
- By reducing infections and their severity, it lowers medical costs and the work and family problems that these illnesses cause for parents and society. It reduces the use of human and material healthcare resources, and if children do fall ill, they recover sooner.
- Breast milk is a natural resource that does not pollute and protects the environment, as it produces no waste and needs no packaging or special treatments requiring energy in its production or CO2 emissions.
Are there any contraindications to breastfeeding?
There are very few situations in which breastfeeding is contraindicated, but they are minimal. This means that almost all women will be able to feed their babies with their own breast milk, if they decide to do so. The contraindications are:
- Mother with HIV infection: in our setting this is considered a true contraindication.
- Galactosaemia: a condition that very few babies are born with, which prevents them from digesting the lactose in milk, so feeding with breast milk is contraindicated.
How do I prepare my breasts for breastfeeding during pregnancy?
You do not need to do anything to prepare your breasts for breastfeeding during pregnancy. What is advisable, though, is to find out about it properly. You can go to antenatal preparation classes run by midwives. Seek help, support, advice and information from professionals who are experts in breastfeeding (nurses, midwives, gynaecologists, paediatricians, family doctors…). Ask about anything you need to know or that worries you. Talk to your partner, share the information so that you can decide together. Talk to other family members to organise a small support network at home, so that you can calmly enjoy breastfeeding and get to know each other, you and your baby.
Starting breastfeeding after a vaginal birth or a caesarean section
It is very important to start breastfeeding after birth as soon as possible, regardless of how your baby was born. Provided the condition of both baby and mother allows it, it is recommended that mother and newborn stay in skin-to-skin contact after birth for at least the first two hours, or until your baby has their first breastfeed.
Your baby has innate abilities which, if we let them, come into play after birth. Placed face down on your abdomen, thanks to their senses (especially touch and smell) and their reflexes, they are able to reach your breast on their own. Crawling towards it, they will smell it, touch it with their hands and then with their mouth, and finally they will be able to latch on to the breast spontaneously, with their mouth wide open, taking in the nipple and much of the areola. Find out more about the phases of breastfeeding.
Colostrum, a superfood
In this first feed, they will discover colostrum. It is the first milk produced by the mammary gland during the last months of pregnancy and the first days after birth, and it provides your baby with all the food they need in those first days. It is very thick and yellow, and the mother does not feel that her breasts are full. This liquid is rich in calories, proteins, antibodies and beta-carotenes, while its fat and lactose content is lower.
Little by little your milk will become whiter and lighter and the amount will increase (mature milk), according to your baby's needs. Clinically, the “milk coming in” occurs around the third day after birth, but up to 25% of mothers notice it after 72 hours. At that point, your baby takes around 20 ml of breast milk at each feed. Bear in mind that if your baby sucks on their hands, it is not because they are hungry; these are the reflexes of a normal, healthy child.
Factors that support the start of breastfeeding and the milk coming in.
- Early skin-to-skin contact between mother and baby.
- Starting breastfeeding within the first hour after birth.
- Frequent breastfeeding.
- A good latch between mouth and breast.
- Proper emptying of the breast.
- Early and frequent sucking in the first few days.
How does your baby react in the first days of breastfeeding?
Generally, newborns have a phase of around two hours, just after birth, in which they are very awake and active. During this period, most of them manage their first breastfeed spontaneously during early skin-to-skin contact. They then move into a sleepy phase (physiological lethargy, “recovering” from birth) that can last between 8 and 12 hours. During this phase, if they are kept in skin-to-skin contact, your baby will breastfeed again when they need to.
From the first day of life, your baby will usually feed frequently, around 8-12 times a day or more, and feeds will be irregular and more frequent at night. However, some babies remain very sleepy, ask for little and feed less than they need. In these cases it is a good idea to place them in skin-to-skin contact, which helps them respond to their mother's smell and feed spontaneously. Sometimes it may be necessary to help them wake up by undressing and dressing them again, giving them a circular massage on the sole of the foot or a gentle stroke on the back from bottom to top. Here is a link in case you need more information about whether or not to wake your baby.
Should I offer both breasts?
At this early stage, you should offer your baby both breasts at each feed, and they need to empty one breast completely before you offer the second, so that they get the milk from the end of the feed, which is higher in fat and helps your baby grow and gain weight. It is much more important to let your baby finish the first side before offering the second, even if that means they refuse the second side during that feed. You should not limit the length of feeds. It is better to let your baby feed until they show signs of satisfaction, such as letting go by themselves or having relaxed arms and hands. If they take a long time, you should insert your little finger pressing on the palate to avoid damaging the nipple. There is no need to wash the breast before or after each feed, and you should not use soap on the nipples as it dries them out.
Number of feeds
It is important to offer the breast on demand, whenever your baby needs it and for as long as they want. That way we can be sure they get everything they need: sometimes food, sometimes warmth, affection or comfort. Every child is different and needs their own time to feed, just as we do (we do not all eat at the same speed).
In the first few days they need to feed between 8 and 14 times a day, for two key reasons: the early establishment of breastfeeding and a lower risk of the baby developing hypoglycaemia. It is best not to use strict feeding schedules, as they inhibit natural mother-baby interactions, interfere with natural hunger cycles and cause anxiety in the mother.
The earliest signs of hunger are sucking, head bobbing, sticking out the tongue, bringing their hands to their mouth… This is the ideal moment to put them to the breast. It is not good to wait until they cry before putting them to the breast, as crying is a late sign of hunger and they will not latch on easily until they have calmed down. Here is a post about crying and what it means depending on the type.
Breastfeeding techniques
Most breastfeeding problems are due to issues with breastfeeding technique, whether from an unsuitable position, an incorrect latch or a combination of both.
For a good latch it is important that your baby's whole body faces the mother, and that when they open their mouth they take in a large part of the areola, especially the lower part (where their chin is), so that when they move their tongue actively they do not damage your nipple.
The signs of a good latch are:
- Your baby's chin touches your breast
- Your baby's mouth is wide open
- The lower lip is turned outwards (everted)
- The cheeks are round or flat (not hollow) when sucking.
- More areola is visible above the mouth than below.
Positions that will help you breastfeed
Whatever position you adopt with your baby for feeds, there are some basic tips you should bear in mind that will make it easier for your baby to latch on. There is no single correct position for breastfeeding: what matters is that the mother is comfortable, the latch is correct, and the baby is facing and close to the mother's body.
- As a mum, you should feel comfortable in the position. Using pillows or cushions can help.
- Your baby's body should be in close contact with yours. When you are lying back, your baby's weight will rest on your body. This makes it easier to maintain the close contact that helps your baby's reflexes kick in.
- Your baby's head should be in front of the breast, well aligned with the body (their neck should not be flexed, nor their head turned). It is better to move the baby than to move the mother's breast.
- Your baby's chin should rest on the breast, with the nipple above the upper lip, at the height of the nose. This way, when your baby triggers the rooting reflex and latches on to your breast, their neck will be slightly hyperextended, making it easier to coordinate sucking, swallowing and breathing.
- Remember that it is preferable to encourage your baby to latch on spontaneously. When your baby's mouth is wide open, bring them close to the breast and let your baby be the one to latch on. If your baby cannot manage it, a guided latch can help
Positions that support the start of breastfeeding
Below we mention some positions that can help you start a happy, long-lasting breastfeeding journey. Find out more about breastfeeding positions
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Cradle hold:
- As a mum, support your baby's neck and head with the arm and hand on the same side as the breast you are offering
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Side-lying hold:
- Lie on your side so that your breast rests on the mattress
- This position is especially useful to help the mother rest when there is perineal pain (assisted birth, haemorrhoids…)
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Rugby hold:
- Hold your baby's body and head with the forearm and hand on the same side as the breast you are going to offer. This leaves one hand free to guide the latch if you need to.
- This position is especially useful after caesarean sections, for mothers with very large breasts or morbid obesity, or when breastfeeding twins at the same time.
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Biological nurturing position:
- Sit back in a semi-reclined position (between 15-65°) and get comfortable
- This position is especially useful when there are difficulties with latching on, as it helps the newborn put their instinctive reflexes to work. You will see how your baby bobs their head and moves around looking for their mother's breast.
How do I interrupt my baby's sucking?
Break the suction before taking your baby off the breast. Do this by placing a clean finger at the side of your baby's mouth, between their jaws. Do not take them off until you feel they have finished. Or insert your little finger pressing on the palate to avoid damaging the nipple.
Do I need to take any special care of my breasts while breastfeeding?
Your breasts do not need any special care during pregnancy or breastfeeding. Daily washing is enough. Also, wear practical underwear with enough support, which will make you feel more comfortable.
How do I know if my baby is getting enough milk?
To know whether your baby is feeding well, you can look at:
- Feed frequency: your baby should have between 8 and 12 feeds a day.
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Stools: count the nappies whose contents are the size of the circle formed when you touch the tips of your thumb and index finger together.
- 1-2 days old: 1-2 wet nappies, variable meconium
- 2-6 days old: 5-8 wet nappies, at least 3 greenish stools
- 6 days to 6 weeks: 5-6 wet nappies, at least 3 mustard-yellow stools
- Over 6 weeks: 5-6 wet nappies; some babies have fewer stools, but they are larger and softer.
- Appearance and general condition: a normal colour, firm skin, and being active and alert.
- Weight gain and growth: this will be assessed by your paediatrician or paediatric nurse
Find out more about whether your baby is getting enough milk by clicking here
What should I eat while breastfeeding?
A breastfeeding woman does not need a special diet. The best nutrition comes from a healthy, varied diet, avoiding additives and contaminants. Only in some cases, due to illness or nutritional problems, may your doctor advise certain supplements. Although it is proven that the aroma of foods passes into milk and can change its smell and taste, there is no food that is forbidden while breastfeeding. Those changes in taste that breast milk undergoes help your baby become familiar with different flavours, which will make it easier for them to accept complementary feeding. Only if you repeatedly notice that after eating a particular food your baby shows some kind of discomfort (vomiting, diarrhoea, rashes, general discomfort or refusing the milk) might it be necessary to avoid that specific food.Can I take medication while breastfeeding?
If you need to take medication during pregnancy or after giving birth, you can consult a doctor. Remember that most medicines can be used while breastfeeding. Not all drugs pass into breast milk, and in general, alternatives can be offered in practically all circumstances if the drug chosen carries any kind of risk. You can check the compatibility of medication and breastfeeding on the page www.e-lactancia-org.Conclusion: breastfeeding guide for the first days.
Every case is unique, and you should adapt these recommendations to your own. Without a doubt, the key point is that if your free and informed decision is to offer your baby breast milk, you can do so. The beginning can be a little difficult because of the doubts this new stage brings, but little by little, with this breastfeeding guide you will learn and build a solid breastfeeding routine. Also, do not hesitate to lean on your midwife and breastfeeding groups, who will be delighted to help you with your own situation.
