August 1, 2011

Human breast milk is now widely acknowledged to be the most complete form of nutrition for infants, with a range of physiological and psychological benefits for both the infant and mother. Through the ages, humans have been dependent on it for its sustenance and even contraceptive attributes. Research supports the observation of benefits for infants’ growth, immunity, and development, as well as reduced financial cost to the family. Prevention of diarrheal diseases and even dental cavities are just some of its protective powers. Likewise, breast-feeding has been shown to improve maternal health, including reduction in postpartum bleeding, earlier return to prepregnancy weight, reduced risk of premenopausal breast cancer, and reduced risk of osteoporosis. Yet, in spite of these advantages, ambivalence surrounds the practice because of the myriad of factors that influence a woman’s ability and decision to commit to breast-feeding.

Pregnancy and preparation

This is an ideal time to assess attitudes and readiness for breast-feeding. A breast health assessment, including a review of breast self-examination and nipple evaluation, is prudent. Also, an understanding of the anatomy and physiology of lactation (milk production) is an essential complement to successful breast-feeding. Human breast tissue begins to develop in the sixth week of fetal life; thus, when you are born, you already have breast tissue (as does your newborn). These mammary glands or secretory glands undergo most of their maturation postnatally, during adolescence and adulthood. They are considered mature once capable of producing milk, and fully functional once lactation actually begins. Each portion of the breast has a function. The external dome is comprised of the nipple that is the exit point for all the milk ducts (aka lactiferous ducts) and the pigmented areola that houses the nipple, nerve endings, Montgomery’s glands (small, pimple-like openings that secrete a substance that lubricates and protects the nipple and areola during pregnancy and lactation), lymph drainage ports, and hair follicles. Internally, there are four main types of tissues: glandular (alveolar) tissue that produces milk; ducts that transport the milk; connective tissue that supports the breasts’ upright position; and adipose (fat) tissue that protects the breast from injury (note that adipose tissue determines the size of the breast, but size has absolutely no effect on milk production or quality). Arterial blood supplies nourishment to the actual breast tissue as well as essential nutrients and hormones to make milk. The lymphatic system removes cellular waste, and the nervous system is essential for, among other things, transferring the stimulus of suckling to trigger a hormonal pathway responsible for milk production and letdown.

In the early days of pregnancy, when the hormone estrogen (E) begins to increase, it directly stimulates the ductules to grow, while the surge in the hormone progesterone (P) stimulates the alveoli and lobular tissue (grapelike collection of alveoli) to grow; hence the feeling of breast fullness in the early phases of pregnancy. This glandular growth is also influenced by insulin and cortisol. In spite of the structural changes that occur in the breast because of E and P, these hormones inhibit actual milk production. The two main hormones responsible for milk production are prolactin and oxytocin. Prolactin, which has peak production at night, stimulates the production of specific milk proteins as well as attracts immunoglobulin A from gut-associated lymphoid tissue. Oxytocin, a trigger for uterine contractions, also contracts the myoepithelial cells surrounding the alveoli, causing them to squeeze the newly formed milk into the duct system. This process is also referred to as “milk ejection reflex” or “milk letdown.” Both of these hormones are released from the pituitary gland, into the blood, in response to the ovarian hormones (E and P), as well as the stimuli from the senses (visual, tactile, auditory, and olfactory). A number of factors, typical to the nursing mother, can also affect prolactin levels, including psychogenic stress, anesthesia, surgery, exercise, nipple stimulation, and sexual intercourse, to name a few. The most specific and effective stimulus for prolactin secretion, however, is suckling or nursing.

The early stage of pregnancy is an opportune time to acknowledge and assess your personal feelings and biases toward breast-feeding. Whether a health professional, a first-time mother, father, or friend, understanding our health beliefs is an integral component of making healthy behavior choices. Many times these beliefs are rooted in cultural practices, past personal experiences of others or ourselves, and even the teachings of those we respect as authorities on the subject. For example, many people believe breast-feeding is “intuitive” because it is a “natural” phenomenon. The art of breast-feeding is a learned skill, irrespective of a woman’s education level. Also, in some cultures, mothers who wish to breast-feed may be reluctant to give colostrum (premilk) to their newborn because they consider it unclean or harmful. Use this time to expand and alter your knowledge, skills, and attitude based on fact, not fiction or anecdotes (see resource list at the end of the chapter). Speak with a lactation consultant or attend a breast-feeding support class or group.

As delivery and childbirth become more of a reality, the opportunity to nurse or breast-feed should again be entertained, with focused choices to ensure a successful and positive experience. Anticipating what will be needed, what to expect, and arming yourself with information and practical skills are shared sentiments from lactation consultants and mothers who have had positive and negative experiences. Feeding all newborns (whether breast or bottle) will have challenging moments. Likewise, it seems that the support system you align yourself with during breast-feeding is one of the most important decisions a woman can make in this endeavor. Support can be defined as anything or anyone who provides healthy guidance or solutions to perceived stressors. This may be someone to burp a baby after a feeding or someone with words of encouragement. Choosing a health provider who supports the practice and is knowledgeable about breast-feeding, as well as surrounding oneself with experienced women, have been shown to dramatically increase the duration and success of nursing. Even the hospital or birthing center selected will impact on the decision to start or continue breast-feeding. The “Ten Steps to Successful Breastfeeding” as defined by the World Health Organization, the United Nations Children’s Fund, and adopted by the Department of Health and Human Services, outlines key practices for health care institutions. It recommends:

  • a written breast-feeding policy that is communicated to all health care staff;
  • staff training in the skills needed to implement the policy;
  • education of pregnant women about the benefits and management of breast-feeding;
  • early initiation of breast-feeding;
  • education of mothers on how to breast-feed and maintain lactation;
  • limited use of any food or drink other than human breast milk;
  • rooming-in;
  • breast-feeding on demand;
  • limited use of pacifiers and artificial nipples;
  • fostering of breast-feeding support groups and services.

Selecting a “breast-feeding friendly hospital” or institution with the above policies and philosophy provides a good environment for a healthy start.


The evidence for the shortand long-term benefits of breast-feeding on the health of the infant, women, and their families continues to grow. This has led a renewed commitment from the health care community to encourage and support this practice. The forces that improve success, however, lie not only in the guidance of health professionals, but seem grounded in the stories and support of mothers who have had positive or negative experiences. Understanding that breast-feeding is natural but is a learned skill is at the foundation of successful nursing. Consequently, the approach to breast-feeding requires a humble respect for the emotional, physical, and time commitment involved, as well as skill grounded in the experience of our ancestors. There are numerous books, videos, websites, support groups, and health professionals available to guide a woman and her family through this lifestyle practice. A referral listing with some of these resources is available at the end of this chapter.

SEE ALSO: Lactation, Pregnancy


Category: B, Breast-Feeding