Adequacy of breastfeeding, attachment and Position

Assessment of Breast Milk Adequacy and Attachment

Assessment of Adequacy of Breast Milk

Mothers and grandmothers often worry about whether breast milk is sufficient, which frequently leads to the unnecessary introduction of infant milk substitutes. It is crucial to distinguish between a mother's perception of insufficiency and actual low supply.

The adequacy of breast milk in a 2-month-old baby is assessed using the following objective criteria:

• Urine Output: A baby getting enough milk passes plenty of pale-colored, dilute urine frequently, typically 6 to 8 times or more in 24 hours.
• Weight Gain: The most reliable indicator of adequate intake is satisfactory weight gain. A healthy infant should gain weight adequately after the initial physiological weight loss period (regaining birth weight by 10-14 days).
  • In the first 3 months, the expected weight gain is approximately 200 g/week.
  • The birth weight generally doubles by 4–5 months of age.
• Stool Pattern: The baby passes 1–6 liquid stools per day. While stool frequency can vary (breastfed babies may pass stools frequently or sometimes skip days), the passage of soft, yellowish stools is a sign of good intake.
• Sleep and Behavior: The baby sleeps for 2–3 hours after feeds and appears satisfied. However, crying is not always a sign of hunger; it could be due to other reasons like colic or a need for comfort.
• Audible Swallowing: During feeding, the mother or observer may hear the baby swallowing milk, indicating active transfer.

Management of Perceived Insufficiency: If the baby is gaining weight and passing adequate urine, the mother should be reassured. If there is genuine insufficiency (poor weight gain), the following steps are taken:

• Check for the use of other feeds or bottles, as these decrease sucking vigor and cause nipple confusion.
• Observe the feed to correct positioning and attachment.
• Ensure the mother is emptying the breasts fully to allow for milk production (driven by the prolactin reflex).

Features of Good Attachment

Proper attachment (latching) is critical for effective milk transfer and preventing nipple trauma. The four key signs of good attachment are:

1. Chin Touching Breast: The baby's chin should firmly touch the mother's breast.
2. Mouth Wide Open: The baby's mouth should be opened wide to take in a large mouthful of breast tissue, not just the nipple.
3. Lower Lip Turned Outward: The lower lip should be everted (turned outwards), not sucked in.
4. More Areola Visible Above: More of the dark area (areola) should be visible above the baby's mouth than below it. This indicates the baby has taken a large portion of the breast tissue into the mouth from the lower aspect.

Other signs of effective suckling:

• The baby takes slow, deep sucks, sometimes pausing.
• The cheeks are full, not hollow or dimpling during sucking.
• The mother feels no pain during breastfeeding.

Problems Associated with Poor Attachment

Poor attachment occurs when the baby sucks only on the nipple rather than the breast tissue (areola). This leads to ineffective removal of milk and various complications for both the mother and the infant.

1. Maternal Problems:

• Sore and Cracked Nipples: This is the most common cause of sore nipples in the first few days. The friction on the nipple skin causes physical trauma, leading to fissures and pain.
• Breast Engorgement: If the baby is not attached well, they cannot empty the breast effectively. The accumulation of milk, along with blood and edema fluid, causes the breasts to become hard, painful, and swollen (engorged). This back-pressure can suppress milk production.
• Breast Abscess and Mastitis: Untreated engorgement or cracked nipples (which serve as a portal of entry for bacteria) can progress to mastitis (infection of the breast) and potentially form a breast abscess.
• Pain: The mother experiences pain during feeds, which inhibits the oxytocin (let-down) reflex, further hindering milk flow and causing anxiety.

2. Infant Problems:

• Ineffective Milk Transfer: The baby cannot extract milk efficiently if only sucking on the nipple. This leads to the baby getting "foremilk" (thirst-quenching) but missing the fat-rich "hindmilk".
• Poor Weight Gain / Failure to Thrive: Due to inadequate caloric intake from ineffective suckling, the baby may fail to gain weight or even lose weight.
• Dissatisfaction and Crying: The baby remains hungry and unsatisfied after feeds, leading to frequent crying, fussiness, and a desire to feed very often or for very long periods.
• Frustration and Refusal: The baby may become frustrated due to low milk flow and may eventually refuse to suckle.
• "Not Enough Milk" Syndrome: The combination of the baby's hunger cues and the mother's pain/lack of emptying often leads to the false belief that the mother cannot produce enough milk, prompting the unnecessary introduction of artificial feeds.