Concept of breast feeding
Human breast milk is the healthiest form of milk for human babies.[1] There are few exceptions, such as when the mother is taking certain drugs or is infected with tuberculosis or HIV. Breastfeeding promotes health, helps to prevent disease, and reduces health care and feeding costs.[2][3][4] Artificial feeding is associated with more deaths from diarrhea in infants in both developing and developed countries.[5] Experts agree that breastfeeding is beneficial, but may disagree about the length of breastfeeding that is most beneficial, and about the risks of using artificial formulas.[6][7][8]Emphasizing the value of breastfeeding for both mothers and children, the World Health Organization (WHO) and the American Academy of Pediatrics (AAP) both recommend exclusive breastfeeding for the first six months of life and then supplemented breastfeeding for at least one year and up to two years or more.[9][10] While recognizing the superiority of breastfeeding, regulating authorities also work to minimize the risks of artificial feeding.[7]The acceptability of breastfeeding in public varies by culture and country. In Western culture, though most approve of breastfeeding, some mothers may be reluctant to do so out of fear of public opinion[says who?].Not all the properties of breast milk are understood, but its nutrient content is relatively stable. Breast milk is made from nutrients in the mother’s bloodstream and bodily stores. Breast milk has just the right amount of fat, sugar, water, and protein that is needed for a baby’s growth and development.[11] Because breastfeeding uses an average of 500 calories a day it helps the mother lose weight after giving birth.[12] The composition of breast milk changes depending on how long the baby nurses at each session, as well as on the age of the child. The quality of a mother’s breast milk may be compromised by smoking, alcoholic beverages, caffeinated drinks, marijuana, methamphetamine, heroin, and methadone.[13]Benefits for the infantScientific research, such as the studies summarized in a 2007 review for the U.S. Agency for Healthcare Research and Quality (AHRQ)[14] and a 2007 review for the WHO[15], has found many benefits to breastfeeding for the infant. These include:Less necrotizing enterocolitis in premature infantsNecrotizing enterocolitis (NEC) is an acute inflammatory disease in the intestines of infants. Necrosis or death of intestinal tissue may follow. It is mainly found in premature births. In one study of 926 preterm infants, NEC developed in 51 infants (5.5%). The death rate from necrotizing enterocolitis was 26%. NEC was found to be six to ten times more common in infants fed formula exclusively, and three times more common in infants fed a mixture of breast milk and formula, compared with exclusive breastfeeding. In infants born at more than 30 weeks, NEC was twenty times more common in infants fed exclusively on formula.[16] A 2007 meta-analysis of four randomized controlled trials found “a marginally statistically significant association” between breastfeeding and a reduction in the risk of NEC.[14]Greater immune healthDuring breastfeeding antibodies pass to the baby[17]. Breast milk contains several anti-infective factors such as bile salt stimulated lipase (protecting against amoebic infections), lactoferrin (which binds to iron and inhibits the growth of intestinal bacteria)[18][19] and immunoglobulin A protecting against microorganisms.[20]Fewer infectionsAmong the studies showing that breastfed infants have a lower risk of infection than non-breastfed infants are:In a 1993 University of Texas Medical Branch study, a longer period of breastfeeding was associated with a shorter duration of some middle ear infections (otitis media with effusion) in the first two years of life.[21]A 1995 study of 87 infants found that breastfed babies had half the incidence of diarrheal illness, 19% fewer cases of any otitis media infection, and 80% fewer prolonged cases of otitis media than formula fed babies in the first twelve months of life.[22]Breastfeeding appeared to reduce symptoms of upper respiratory tract infections in premature infants up to seven months after release from hospital in a 2002 study of 39 infants.[23]A 2004 case-control study found that breastfeeding reduced the risk of acquiring urinary tract infections in infants up to seven months of age, with the protection strongest immediately after birth.[24]The 2007 review for AHRQ found that breastfeeding reduced the risk of acute otitis media, non-specific gastroenteritis, and severe lower respiratory tract infections.[14]Less tendency to develop allergic diseases (atopy)In children who are at risk for developing allergic diseases (defined as at least one parent or sibling having atopy), atopic syndrome can be prevented or delayed through exclusive breastfeeding for four months, though these benefits may not be present after four months of age.[25] However, the key factor may be the age at which non-breastmilk is introduced rather than duration of breastfeeding.[26] Atopic dermatitis, the most common form of eczema, can be reduced through exclusive breastfeeding beyond 12 weeks in individuals with a family history of atopy, but when breastfeeding beyond 12 weeks is combined with other foods incidents of eczema rise irrespective of family history.[27]Protection from SIDSBreastfed babies have better arousal from sleep at 2–3 months. This coincides with the peak incidence of sudden infant death syndrome.[28] A study conducted at the University of Münster has shown that breastfeeding reduces the risk of sudden infant death syndrome by approximately 50% at all ages throughout infancy. [29]Higher intelligenceStudies examining whether breastfeeding in infants is associated with higher intelligence later in life include:Horwood, Darlow and Mogridge (2001) tested the intelligence quotient (IQ) scores of 280 low birthweight children at seven or eight years of age.[30] Those who were breastfed for more than eight months had verbal IQ scores 6 points higher (which was significantly higher) than comparable children breastfed for less time.[30] They concluded “These findings add to a growing body of evidence to suggest that breast milk feeding may have small long term benefits for child cognitive development.”[30]A 2005 study using data on 2,734 sibling pairs from the National Longitudinal Study of Adolescent Health “provide[d] persuasive evidence of a causal connection between breastfeeding and intelligence.”[31]In 2006, Der and colleagues, having performed a prospective cohort study, sibling pairs analysis, and meta-analysis, concluded that “Breast feeding has little or no effect on intelligence in children.”[32] The researchers found that “Most of the observed association between breast feeding and cognitive development is the result of confounding by maternal intelligence.”[32]The 2007 review for the AHRQ found “no relationship between breastfeeding in term infants and cognitive performance.”[14]The 2007 review for the WHO concluded “Subjects who were breastfed experienced… higher performance in intelligence tests.”[15]Two initial cohort studies published in 2007 suggest babies with a specific version of the FADS2 gene demonstrated an IQ averaging 7 points higher if breastfed, compared with babies with a less common version of the gene who showed no improvement when breastfed.[33] FADS2 affects the metabolism of polyunsaturated fatty acids found in human breast milk, such as docosahexaenoic acid and arachidonic acid, which are known to be linked to early brain development.[33] The researchers were quoted as saying “Our findings support the idea that the nutritional content of breast milk accounts for the differences seen in human IQ. But it’s not a simple all-or-none connection: it depends to some extent on the genetic makeup of each infant.”[34] The researchers wrote “further investigation to replicate and explain this specific gene–environment interaction is warranted.”[33]In “the largest randomized trial ever conducted in the area of human lactation,” between 1996 and 1997 maternity hospitals and polyclinics in Belarus were randomized to receive or not receive breastfeeding promotion modeled on the Baby Friendly Hospital Initiative.[35] Of 13,889 infants born at these hospitals and polyclinics and followed up in 2002-2005, those who had been born in hospitals and polyclinics receiving breastfeeding promotion had IQs that were 2.9-7.5 points higher (which was significantly higher).[35] Since (among other reasons) a randomized trial should control for maternal IQ, the authors concluded in a 2008 paper that the data “provide strong evidence that prolonged and exclusive breastfeeding improves children’s cognitive development.”[35]DiabetesInfants exclusively breastfed have less chance of developing diabetes mellitus type 1 than peers with a shorter duration of breastfeeding and an earlier exposure to cow milk and solid foods.[14][36] Breastfeeding also appears to protect against diabetes mellitus type 2,[14][15][37][38] at least in part due to its effects on the child’s weight.[38]ObesityBreastfeeding appears to reduce the risk of extreme obesity in children aged 39 to 42 months.[39] The protective effect of breastfeeding against obesity is consistent, though small, across many studies, and appears to increase with the duration of breastfeeding.[14][15][40]Other long term health effectsIn one study, breastfeeding did not appear to offer protection against allergies.[41] However, another study showed breastfeeding to have lowered the risk of asthma, protect against allergies, and provide improved protection for babies against respiratory and intestinal infections.[42]A review of the association between breastfeeding and celiac disease (CD) concluded that breast feeding while introducing gluten to the diet reduced the risk of CD. The study was unable to determine if breastfeeding merely delayed symptoms or offered life-long protection.[43]An initial study at the University of Wisconsin found that women who were breast fed in infancy may have a lower risk of developing breast cancer than those who were not breast fed.[44]Breastfeeding may decrease the risk of cardiovascular disease in later life, as indicated by lower cholesterol and C-reactive protein levels in adult women who had been breastfed as infants.[15][45] Although a 2001 study suggested that adults who had been breastfed as infants had lower arterial distensibility than adults who had not been breastfed as infants[46], the 2007 review for the WHO concluded that breastfed infants “experienced lower mean blood pressure” later in life[15]. Nevertheless, the 2007 review for the AHRQ found that “the relationship between breastfeeding and cardiovascular diseases was unclear”[14].Benefits for mothersZanzibari woman breastfeedingBreastfeeding is a cost effective way of feeding an infant, and provides the best nourishment for a child at a small nutrient cost to the mother. Frequent and exclusive breastfeeding can delay the return of fertility through lactational amenorrhea, though breastfeeding is an imperfect means of birth control. During breastfeeding beneficial hormones are released into the mother’s body[17] and the maternal bond can be strengthened.[11] Breastfeeding is possible throughout pregnancy, but generally milk production will be reduced at some point.[47]BondingHormones released during breastfeeding help to strengthen the maternal bond.[11] Teaching partners how to manage common difficulties is associated with higher breastfeeding rates.[48] Support for a mother while breastfeeding can assist in familial bonds and help build a paternal bond between father and child.[49]If the mother is away, an alternative caregiver may be able to feed the baby with expressed breast milk. The various breast pumps available for sale and rent help working mothers to feed their babies breast milk for as long as they want. To be successful, the mother must produce and store enough milk to feed the child for the time she is away, and the feeding caregiver must be comfortable in handling breast milk.Hormone releaseBreastfeeding releases oxytocin and prolactin, hormones that relax the mother and make her feel more nurturing toward her baby.[50] Breastfeeding soon after giving birth increases the mother’s oxytocin levels, making her uterus contract more quickly and reducing bleeding. Pitocin, a synthetic hormone used to make the uterus contract during and after labour, is structurally modelled on oxytocin.[51][edit]Weight lossAs the fat accumulated during pregnancy is used to produce milk, extended breastfeeding—at least 6 months—can help mothers lose weight.[52] However, weight loss is highly variable among lactating women; monitoring the diet and increasing the amount/intensity of exercise are more reliable ways of losing weight.[53] The 2007 review for the AHRQ found “The effect of breastfeeding in mothers on return-to-pre-pregnancy weight was negligible, and the effect of breastfeeding on postpartum weight loss was unclear.”[14][edit]Natural postpartum infertilityBreastfeeding may delay the return to fertility for some women by suppressing ovulation. A breastfeeding woman may not ovulate, or have regular periods, during the entire lactation period. The period in which ovulation is absent differs for each woman. This Lactational amenorrhea has been used as an imperfect form of natural contraception, with a greater than 98% effectiveness during the first six months after birth if specific nursing behaviors are followed.[54] It is possible for some women to ovulate within two months after birth while fully breastfeeding.[edit]Long-term health effectsFor breastfeeding women, long-term health benefits include:Less risk of breast cancer, ovarian cancer, and endometrial cancer.[10][14][55][56]A 2009 study indicated that lactation for at least 24 months is associated with a 23% lower risk of coronary heart disease.[57]Although the 2007 review for the AHRQ found “no relationship between a history of lactation and the risk of osteoporosis”[14], mothers who breastfeed longer than eight months benefit from bone re-mineralisation.[58]Breastfeeding diabetic mothers require less insulin.[59]Reduced risk of post-partum bleeding.[51]According to a Malmö University study published in 2009, women who breast fed for a longer duration have a lower risk for contracting rheumatoid arthritis than women who breast fed for a shorter duration or who had never breast fed.[60][edit]Organisational endorsements[edit]World Health Organization” The vast majority of mothers can and should breastfeed, just as the vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother’s milk be considered unsuitable for her infant. For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat – depends on individual circumstances.[9] “The WHO recommends exclusive breastfeeding for the first six months of life, after which “infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond.”[9][edit]American Academy of Pediatrics” Extensive research using improved epidemiologic methods and modern laboratory techniques documents diverse and compelling advantages for infants, mothers, families, and society from breastfeeding and use of human milk for infant feeding. These advantages include health, nutritional, immunologic, developmental, psychologic, social, economic, and environmental benefits.[10] “The AAP recommends exclusive breastfeeding for the first six months of life.[10] Furthermore, “breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child.”[10][edit]Breastfeeding difficultiesMain article: Breastfeeding difficultiesWhile breastfeeding is a natural human activity, difficulties are not uncommon. Putting the baby to the breast as soon as possible after the birth helps to avoid many problems. The AAP breastfeeding policy says: “Delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed.”[10] Many breastfeeding difficulties can be resolved with proper hospital procedures, properly trained midwives, doctors and hospital staff, and lactation consultants.[61] There are some situations in which breastfeeding may be harmful to the infant, including infection with HIV and acute poisoning by environmental contaminants such as lead.[42] The Institute of Medicine has reported that breast surgery, including breast implants or breast reduction surgery, reduces the chances that a woman will have sufficient milk to breast feed.[62] Rarely, a mother may not be able to produce breastmilk because of a prolactin deficiency. This may be caused by Sheehan’s syndrome, an uncommon result of a sudden drop in blood pressure during childbirth typically due to hemorrhaging. In developed countries, many working mothers do not breast feed their children due to work pressures. For example, a mother may need to schedule for frequent pumping breaks, and find a clean, private and quiet place at work for pumping. These inconveniences may cause mothers to give up on breast feeding and use infant formula instead.[edit]HIV infectionAs breastfeeding can transmit HIV from mother to child, UNAIDS recommends avoidance of all breastfeeding where formula feeding is acceptable, feasible, affordable and safe.[63] The qualifications are important. Some constituents of breast milk may protect from infection. High levels of certain polyunsaturated fatty acids in breast milk (including eicosadienoic, arachidonic and gamma-linolenic acids) are associated with a reduced risk of child infection when nursed by HIV-positive mothers. Arachidonic acid and gamma-linolenic acid may also reduce viral shedding of the HIV virus in breast milk.[64] Due to this, in underdeveloped nations infant mortality rates are lower when HIV-positive mothers breastfeed their newborns than when they use infant formula. However, differences in infant mortality rates have not been reported in better resourced areas.[65] Treating infants prophylactically with lamivudine (3TC) can help to decrease the transmission of HIV from mother to child by breastfeeding.[66] If free or subsidized formula is given to HIV-infected mothers, recommendations have been made to minimize the drawbacks such as possible disclosure of the mother’s HIV status.[67][edit]Infant weight gainBreastfed infants generally gain weight according to the following guidelines:0–4 months: 6 oz. per week†4–6 months: 4-5 oz. per week6–12 months: 2-4 oz. per week† It is acceptable for some babies to gain 4–5 ounces per week. This average is taken from the lowest weight, not the birth weight.The average breastfed baby doubles its birth weight in 5–6 months. By one year, a typical breastfed baby will weigh about 2½ times its birth weight. At one year, breastfed babies tend to be leaner than bottle fed babies.[68] By two years, differences in weight gain and growth between breastfed and formula-fed babies are no longer evident.[69][edit]Methods and considerationsThere are many books and videos to advise mothers about breastfeeding. Lactation consultants in hospitals or private practice, and volunteer organisations of breastfeeding mothers such as La Leche League International also provide advice and support.[edit]Early breastfeedingIn the half hour after birth, the baby’s suckling reflex is strongest, and the baby is more alert, so it is the ideal time to start breastfeeding.[70] Early breast-feeding is associated with fewer nighttime feeding problems.[71][edit]Time and place for breastfeedingBreastfeeding at least every two to three hours helps to maintain milk production. For most women, eight breastfeeding or pumping sessions every 24 hours keeps their milk production high.[10][not in citation given] Newborn babies may feed more often than this: 10 to 12 breastfeeding sessions every 24 hours is common, and some may even feed 18 times a day.[72] Feeding a baby “on demand” (sometimes referred to as “on cue”), means feeding when the baby shows signs of hunger; feeding this way rather than by the clock helps to maintain milk production and ensure the baby’s needs for milk and comfort are being met.[citation needed] However, it may be important to recognize whether a baby is truly hungry, as breastfeeding too frequently may mean the child receives a disproportionately high amount of foremilk, and not enough hindmilk.[73]”Experienced breastfeeding mothers learn that the sucking patterns and needs of babies vary. While some infants’ sucking needs are met primarily during feedings, other babies may need additional sucking at the breast soon after a feeding even though they are not really hungry. Babies may also nurse when they are lonely, frightened or in pain.”[74]”Comforting and meeting sucking needs at the breast is nature’s original design. Pacifiers (dummies, soothers) are a substitute for the mother when she can’t be available. Other reasons to pacify a baby primarily at the breast include superior oral-facial development, prolonged lactational amenorrhea, avoidance of nipple confusion and stimulation of an adequate milk supply to ensure higher rates of breastfeeding success.”[74]Rooming-in bassinetMost US states now have laws that allow a mother to breastfeed her baby anywhere she is allowed to be. In hospitals, rooming-in care permits the baby to stay with the mother and improves the ease of breastfeeding. Some commercial establishments provide breastfeeding rooms, although laws generally specify that mothers may breastfeed anywhere, without requiring them to go to a special area. Dedicated breastfeeding rooms are generally preferred by women who are expressing milk while away from their baby.
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