13  Breastfeeding – Theory and Practice

Author

Prof Mrs Gyikua Plange-Rhule

Published

May 17, 2025

13.1 Introduction

Breastfeeding is more than just a method of feeding infants; it is a sophisticated biological process that nurtures, protects, and connects both mother and child. Over recent decades, scientific discoveries have deepened our understanding of breastmilk’s dynamic nature and its systemic benefits. This chapter examines the theoretical foundations and practical applications of breastfeeding, focusing on its physiological, immunological, nutritional, and psychosocial aspects. It also outlines strategies to overcome common challenges, ensuring healthcare workers can support mothers effectively.

13.2 Learning Objectives

By the end of this chapter, students should be able to:

  • State Ghana’s National Breastfeeding Policy.
  • Describe the protective systems in breastmilk and their mechanisms.
  • Explain the physiology of breastfeeding and how it supports maternal and infant health.
  • Identify common breastfeeding challenges and outline appropriate management strategies.

13.3 The National Breastfeeding Policy

Ghana’s policy promotes optimal breastfeeding practices, which include:

  • Early Initiation of Breastfeeding (EIB) with early skin-to-skin contact and initiation of breastfeeding within the first hour of life.
  • Exclusive Breastfeeding for the first six months, with no other foods or liquids, not even water.
  • Appropriate Complementary Feeding by introducing nutrient-dense foods at six months, while continuing to breastfeed.
  • Continue breastfeeding for up to two years or even beyond, if this is desirable for both mother and baby

This policy is grounded in evidence that links breastfeeding to improved neonatal, childhood, and even long-term health outcomes.

13.4 The Dynamic Nature of Breastmilk

Breast milk is an amazing, living, and dynamic fluid. Its composition adapts:

  • From one feed to the next (foremilk vs. hindmilk),
  • From day to night,
  • Depending on the baby’s gestational age (preterm vs. term),
  • In response to the mother’s health and environmental exposures.
  • With the age of the baby

These adaptations ensure optimal nutrition, immune protection, and developmental support for the infant.

13.5 Some biological systems in Breastmilk that promote the health of the newborn.

13.5.1 Infection Prevention

Breastmilk contains secretory IgA (SIgA), critical for mucosal immunity. Unlike formula, breastmilk actively defends the infant against bacterial, viral, and other infections such as:

  • HIV: Transmission risk is reduced significantly with exclusive breastfeeding under antiretroviral therapy.
  • Hepatitis B: Not transmitted via breastmilk; vaccination prevents perinatal transmission

During the COVID-19 pandemic, breastmilk was shown to contain antibodies against SARS-CoV-2, with no evidence of viral transmission, further reinforcing its immunological role.

13.5.2 Gut Microbiota and Disease Prevention

Human milk oligosaccharides (HMOs) act as prebiotics, fostering healthy gut flora that:

  • Shapes immunity,
  • Reduces the risk of allergies, asthma, and dermatitis,
  • Contributes to neurodevelopment and emotional regulation via the gut-brain axis.

13.5.3 Brain Development

Breastmilk supports brain growth through components such as:

  • Sphingomyelin: Vital for myelination,
  • Sialic acid: Enhances cognitive function,
  • Myo-inositol: Boosts neuronal connectivity

Studies using MRI have shown that breastfed infants demonstrate superior white matter development and cognitive outcomes compared to formula-fed peers.

13.5.4 4. Support for Preterm Infants

Breastmilk of mothers of preterm babies contains:

  • Higher energy content,
  • Increased lactoferrin for iron absorption,
  • HMOs and glycosaminoglycans that prevent necrotizing enterocolitis (NEC),
  • More bioactive molecules for immune support.

13.6 The Physiology of Breastfeeding

Breastfeeding involves the coordinated action of:

  • Prolactin: Stimulates milk production in the mammary gland
  • Oxytocin: Facilitates milk ejection by causing contraction of the smooth muscle surrounding the milk ducts. (the “let-down” reflex).

Early Initiation of Breastfeeding (EIB) serves as a crucial step in initiating and establishing effective lactation. Efficient breast emptying is the key to sustaining milk production.

13.7 Some benefits of Breastfeeding

13.7.1 For Infants:

  • Reduced incidence of infections (e.g., Pneumonia, otitis media),
  • Lower risk of chronic conditions  in adulthood (e.g., Diabetes, Leukemia, obesity),
  • Enhanced cognitive development.

13.7.2 For Mothers:

  • Reduced postpartum bleeding,
  • Delayed return of fertility,
  • Lower risks of breast and ovarian cancer,
  • Decreased risk of type 2 Diabetes and cardiovascular disease.

13.8 Practical Challenges and Solutions

13.8.1 EARLY INITIATION OF BREASTFEEDING (EIB)

Early Initiation of Breastfeeding is essential, as it significantly decreases the risk of neonatal mortality. Unless there is a complication with the mother or the baby that prevents early initiation of breastfeeding (EIB), the baby should be delivered directly onto the mother’s abdomen and allowed to “crawl” to the breast and start suckling. This process is like a light switch that kicks start the process of establishing successful breastfeeding.

13.8.2 Bottle Feeding

Health workers must be cautious about recommending feeding bottles, as mothers may not always be able to clean them due to inadequate water supplies and facilities for boiling and sterilizing. Feeding bottles and teats may also lead to nipple confusion, causing difficulties with latching.

13.8.3 Prematurity

Feeding methods vary (tube, cup, cup and spoon) based on gestational age and coordination of the suck-swallow reflex. Expressed breast milk is the food of choice for every preterm baby, unless there is a genuine contraindication, such as an inborn error of metabolism, in which case breastmilk is contraindicated.

13.8.4 Mouth Abnormalities

Mouth conditions, such as cleft lip and/or palate, or severe oral thrush, may necessitate expressed milk and alternative feeding methods.

13.8.5 Multiple Births

Frequent feeding stimulates supply. Twins and triplets can be exclusively breastfed with proper support for the mother. Higher multiples should also start with exclusive breastfeeding, but are likely to outgrow a mother’s milk supply rapidly and require supplementation. Support for the mother, making sure she is relieved of as many other chores as possible, is key to successful breastfeeding in multiple pregnancies.

13.8.6 Perceived or Real Milk Insufficiency

It is common for mothers, especially first-time mothers, to lack confidence in their ability to breastfeed and to feel they do not have enough breast milk. Once the baby is gaining weight and is generally well, support and counseling are essential and are often all that is needed. True breastmilk insufficiency is rare but distressing when it occurs. Good expression techniques can help maintain a sufficient milk supply.

13.8.7 Maternal Illness

Most conditions, including maternal tuberculosis and HIV (with precautions), are not necessarily contraindications to breastfeeding. Support and education are critical. When a mother is ill, it is important not to assume that she cannot breastfeed, but rather to objectively assess the risk to the baby as against the many benefits the baby will receive from breastfeeding. National guidelines, where available, should be consulted, and each mother and baby dyad assessed carefully. The decision not to breastfeed should never be made lightly, as even where the family can afford and correctly prepare infant formula, the risk of illnesses such as asthma and allergies may be increased. Where the ability to sustain adequate formula feeding is a challenge to the family, the effect on the child’s health can be disastrous.

13.8.8 Mothers in Formal Employment

Supportive workplaces (Baby Friendly Workplaces), extended paid maternity leave, effective use of hand expression, and good-quality breast pumps are some of the ways to help mothers who work outside the home to continue breastfeeding. Breast pump technology has evolved over the years so that there are, for example, wearable hands-free breast pumps which can discreetly pump breast milk whilst the mother is at work. However simple, correctly done hand expression of breast milk is very effective. Breast milk can then be stored at room temperature for 6 hours, in a good fridge with a temperature of 6-7oC for 24 hours, and in a deep freezer or fridge freezer at a temperature of -17oC and below for 6 months. The milk can then be fed to the baby by cup by whoever is caring for the child.

13.9 Counteracting Challenges to Breastfeeding

Barriers to breastfeeding in Ghana include:

  • Aggressive and inappropriate marketing and promotion of Infant Formula by companies that manufacture and sell Infant Formula.
  • Negative cultural attitudes to breastfeeding.
  • Lack of support from health professionals or family.

13.9.1 Solutions

  • Community education,
  • Health worker training,
  • Advocacy for breastfeeding-friendly policies.

13.10 Conclusion

Breastfeeding is a public health priority with far-reaching benefits for infants, mothers, and society. Despite its challenges, successful breastfeeding is achievable with informed support, early initiation, and continued advocacy. As science reveals more about the biology of breastmilk, our responsibility to protect and promote breastfeeding becomes ever more urgent.