Session Objectives
On completion of this session, participants will be able to:
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| 1. Identify the parts of the breast and describe their functions. | 5 minutes |
| 2. Discuss how breast milk is produced and how production is regulated. | 15 minutes |
| 3. Describe the baby’s role in milk transfer; | 20 minutes |
| 4. Discuss breast care. | 5 minutes |
| Total session time | 45 minutes |
Materials
Slide 6/1: Parts of the Breast.
Slide 6/2: Back massage.
Slide 6/3: What can you see – inside view.
Slide 6/4: What can you see – outside view.
Cloth breast model.
Doll (optional).
Further reading for facilitators
Session 3, How breastfeeding works, in Breastfeeding Counselling: a training course. WHO/UNICEF.
Introduction
In order to assist Miriam and Fatima with breastfeeding you need to know how the breast produces milk and how the baby suckles.
In normal breastfeeding, there are two elements necessary for getting milk from the breast to the baby:
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a breast that produces and releases milk, and
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a baby who is able to remove the milk from the breast with effective suckling.
The manner in which the baby is attached at the breast will determine how successfully these two elements come together. If the milk is not removed from the breast, more milk is not made.
1. Parts of the breast involved in lactation
5 minutes
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Use slide 6/1 – to identify the parts of the breast
On the outside of the breast you can see the Areola, a darkened area around the nipple. The baby needs to get a large amount of the areola into his or her mouth to feed well. On the areola are the glands of Montgomery that provide an oily fluid to keep the skin healthy. The Montgomery glands are the source of the mother’s smell, which helps the baby to find the breast and to recognise her.
Inside the breast, are:
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Fat and supporting tissue that give the breast its size and shape.
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Nerves, which transmit messages from the breast to the brain to trigger the release of lactation hormones.
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Little sacs of milk-producing cells or Alveoli27 that produce milk.
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Milk ducts that carry milk to the nipple. The baby needs to be attached to compress the milk ducts that are under areola in order to remove milk effectively.
Surrounding each alveolus are little muscles that contract to squeeze the milk out into the ducts. There is also a network of blood vessels around the alveolus that brings the nutrients to the cells to make milk.
It is important to reassure mothers, that there are many variations in the size and shape of women’s breasts. The amount of milk produced does not depend on breast size
28. Be sure to tell every mother that her breasts are good for breastfeeding, and avoid frightening words like “problem.”
2. Breast milk production
15 minutes
Prolactin
Prolactin is a hormone that makes the alveoli produce milk. Prolactin works after a baby has taken a feed to make the milk for the next feed. Prolactin can also make the mother feel sleepy and relaxed.
Prolactin is high in the first 2 hours after birth. It is also high at night. Hence, breastfeeding at night allows for more prolactin secretion.
Oxytocin
Oxytocin causes the muscle cells around the alveoli to contract and makes milk flow down the ducts. This is essential to enable the baby to get the milk. This process is called the oxytocin reflex, milk ejection reflex, or letdown. It may happen several times during a feed. The reflex may feel different or be less noticeable as time goes by.
Soon after a baby is born, the mother may experience certain signs of the oxytocin reflex. These include:
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painful uterine contractions, sometimes with a rush of blood;
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a sudden thirst;
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milk spraying from her breast, or leaking from the breast which is not being suckled;
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feeling a squeezing sensation in her breast.
However, mothers do not always feel a physical sensation.
When the milk ejects, the rhythm of the baby’s suckling changes from rapid to slow deep, sucks (about one per second) and swallows.
Seeing, hearing, touching and thinking lovingly about the baby, helps the oxytocin reflex. The mother can assist the oxytocin to work by:
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Feeling pleased about her baby and confident that her milk is best.
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Relaxing and getting comfortable for feeds.
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Expressing a little milk and gently stimulating the nipple.
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Keeping her baby near so she can see, smell, touch and respond to her baby.
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If necessary, asking someone to massage her upper back, especially along the sides of the backbone.
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Show slide 6/2
Oxytocin release can be inhibited temporarily by:
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Extreme pain, such as a fissured nipple or stitches from a caesarean birth or episiotomy.
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Stress from any cause, including doubts, embarrassment, or anxiet.,
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Nicotine and alcohol.
Remember that how you talk to a mother is important to help her milk flow – you learnt about this in the earlier session on communication skills. If you cause her to worry about her milk supply, this worry may affect the release of oxytocin.
Feedback Inhibitor of Lactation (FIL)
You may have noticed that sometimes milk is produced in one breast but not the other – usually when a baby suckles only one side. This is because milk contains an inhibitor that can reduce milk production.
If milk is not removed and the breast is full, this inhibitor decreases production of milk. If milk is removed from the breast, then the inhibitor level falls and milk production increases. Thus, the amount of milk that is produced depends on how much is removed. Therefore, to ensure plentiful milk production, make sure that milk is removed from the breast efficiently.
To prevent the Feedback Inhibitor of Lactation from collecting and reducing milk production:
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make sure that the baby is well attached;
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encourage frequent breastfeeds;
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allow baby to feed for as long as she or he wants at each breast;
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let the baby finish the first breast before offering the second breast;
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if baby does not suckle, express the milk so that milk production continues.
3. The baby’s role in milk transfer
20 minutes
The baby’s suckling controls the prolactin production, the oxytocin reflex and the removal of the inhibitor within the breast. For a mother to produce the milk that her baby needs, her baby must suckle often and suckle in the right way. A baby cannot get the milk by sucking only on the nipple.
Good and poor attachment
The next two pictures show what happens inside a baby’s mouth, when she or he is breastfeeding.
In picture 1: Good attachment
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The nipple and areola are stretched out to form a long “teat” in the baby’s mouth.
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The large ducts that lie beneath the areola are inside the baby’s mouth.
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The baby’s tongue reaches forward over the lower gum, so that it can press the milk out of the breast. This is called suckling.
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When a baby takes the breast into his or her mouth in this way, the baby is well attached and can easily get the milk.
In picture 2: Poor attachment
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The nipple and areola are not stretched out to form a teat.
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The milk ducts are not inside the baby’s mouth.
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The baby’s tongue is back inside the mouth, and cannot press out the milk.
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This baby is poorly attached. He or she is sucking only on the nipple, which can be painful for the mother. The baby cannot suckle effectively or get the milk easily.
How to decide if a baby is well or poorly attached
You need to be able to decide about a baby’s attachment by looking at the outside. The next two pictures show what you can see on the outside.
In picture 1: Good attachment
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The baby’s mouth is wide open.
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The lower lip is turned out.
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The chin is touching the breast (or nearly so).
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More areola is visible above the baby’s mouth than below.
Seeing a lot or a little of the areola is not a reliable sign of attachment. Some women have a large areola and some have a small areola. It is more reliable to compare how much areola you see above and below a baby’s mouth (if any is visible).
These are the signs of good attachment. If you can see all these signs, then the baby is well attached. When the baby is well attached, it is comfortable and painless for the mother, and the baby can suckle effectively.
In picture 2: Poor attachment
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The mouth is not wide open.
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The lower lip is pointing forward (it may also be turned in).
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The chin is away from the breast.
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More areola is below the baby’s mouth (you might see equal amounts of areola above and below the mouth).
These are the signs of poor attachment. If you see any one of these signs, then the baby is poorly attached and cannot suckle effectively. If the mother feels discomfort, that is also a sign of poor attachment.
The action of suckling
When the breast touches the baby’s lips (or the baby smells the milk ), he or she puts their head back slightly, opens their mouth wide, and puts their tongue down and forward, to seek the breast. This is the rooting reflex.
When the baby is close enough to the breast, and takes a large enough mouthful, the baby can bring the nipple back until it touches the soft palate. This stimulates the sucking reflex.
The muscles then move the tongue in a wave from the front to the back of the mouth, expressing the milk from the ducts beneath the areola into the baby’s mouth. At the same time, the oxytocin reflex makes the milk flow along the ducts.
The baby swallows when the back of the mouth fills with milk, (the swallowing reflex). The rooting, sucking and swallowing reflexes happen automatically in a healthy, term baby. Taking the breast far enough into his or her mouth is not completely automatic, and many babies need help.
A baby who is sleepy from his or her mother’s labour medications, a premature or ill baby may need more help to attach effectively.
Signs that a baby is suckling effectively
If a baby is well attached, she or he is probably suckling well and getting breast milk during the feed. Signs that a baby is getting breast milk easily are:
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The baby takes slow, deep sucks, sometimes pausing for a short time.
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You can see or hear the baby swallowing.
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The baby’s cheeks are full and not drawn inward during a feed.
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The baby finishes the feed and releases the breast by himself or herself and looks contented.
These signs tell you that a baby is “drinking in” the milk, and this is effective suckling.
Signs that a baby is NOT suckling effectively
Artificial teats and suckling difficulties
Ask: Fatima asks you what she can do to have plenty of milk. What are the main ways to ensure a good milk supply?
Wait for a few replies.
4. Breast care
5 minutes
Ask: What do mothers need to know about caring for their breasts when breastfeeding?
Wait for a few responses.
Ask: Some mothers may not be breastfeeding. Is there anything they need to know about caring for their breast in the days after birth?
Wait for a few responses.
A mother who is not breastfeeding also needs to care for her breasts. Her milk dries up naturally if her baby does not remove it by suckling
30, but this takes a week or more. She can express just enough milk to keep her breasts comfortable and healthy while her milk dries up. This milk can be given to the baby. If a mother is HIV-positive, she may decide to express and heat-treat her milk to give to her baby.
Ask if there are any questions. Then summarise the session.
Session 6. Summary
Size and shape of the breasts are not related to ability to breastfeed.
Prolactin helps to produce milk and can make the mother feel relaxed.
Oxytocin ejects the milk so that the baby can remove it through suckling. Relaxing and getting comfortable, and seeing, touching, hearing, thinking about baby can help to stimulate the oxytocin reflex. Pain, doubt, embarrassment, nicotine, or alcohol can temporarily inhibit oxytocin.
If the breast gets overfull, feedback inhibitor of lactation will reduce milk production. Milk production only continues when milk is removed. The breasts make as much milk as is removed.
Early feeding and frequent feeds help to initiate milk production.
Signs of effective suckling
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Slow, deep sucks and swallowing sounds
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Cheeks full and not drawn in
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Baby feeds calmly
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Baby finishes feed by him/herself and seems satisfied
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Mother feels no pain.
Signs that a baby is not suckling effectively
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Rapid, shallow sucks and smacking or clicking sounds
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Cheeks drawn in
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Baby fusses at breast or comes on and off
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Baby feeds very frequently, for a very long time, but does not release breast and seems unsatisfied
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Mother feels pain.
Breast care is important
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Breasts do not need to be washed before feeds
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Mothers who are not breastfeeding need to care for their breasts until their milk dries up.
Session 6 Knowledge Check
Describe to a new mother how to tell if her baby is well attached and suckling effectively.
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One gland is an alveolus and multiple glands are alveoli.
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Small breasts may not be able to store as much milk between feeds as larger breasts. Babies of mothers with small breasts may need to feed more often, but the amount of milk produced in a day is as much as from larger breasts.
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Cluster feeding – when baby feeds very frequently for a few hours and then sleeps for a few hours, is normal.
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The milk production stops because the Feedback Inhibitor of Lactation (FIL) stops the breast from producing milk if the breast is overfull. See Session 10 for information on relieving engorgement.
